TY - JOUR
AU1 - MD, Hagit Tulchinsky,
AU2 - MD, Iris Dotan,
AU3 - MD, Arik Alper,
AU4 - MD, Eli Brazowski,
AU5 - Klausner, Joseph M.
AU6 - MD, Zamir Halpern,
AU7 - MD, Micha Rabau,
AB - Background We designed and evaluated a novel concept in enhancing postoperative care of patients following restorative proctocolectomy (RPC) for ulcerative colitis (UC) and determined the risk factors, incidence, and nature of RPC-associated complications in this population. Methods The study cohort consisted of consecutive UC patients post-RPC attending a comprehensive pouch clinic run by a gastroenterologist and a colorectal surgeon in a tertiary care medical center (from January 2003 to December 2005). Data were collected on their medical history, physical examination, laboratory tests, pouch endoscopy and biopsies, and anonymous in-house patient satisfaction questionnaires mailed to the first 90 patients. Assessment was also done on data regarding risk factors, incidence, and nature of RPC-associated complications. Results A total of 120 UC patients with a functioning pouch visited the clinic: mean age 37 years, range 13–75; 57 males; mean disease duration 11 years; mean follow-up 65 months. Of the 55 patients who responded to the questionnaire, 48 (87%) felt that the comprehensive clinic significantly improved the quality of their care. The major complications were pouchitis (52%), extraintestinal manifestations, pouch-related fistula, and mechanical dysfunction. The risk factors for the development of pouchitis were time since surgery, >1-stage surgery, and reason for surgery (acute exacerbation/intractable disease more than dysplasia/cancer); the latter was the only independent risk factor. Conclusions The pouch clinic concept significantly enhanced patient satisfaction. The most common RPC-associated complication was pouchitis. Risk factors for developing pouchitis were duration since operation, >1-stage operation, and indication for surgery. ileoanal pouch, pouchitis, postoperative complications, ulcerative colitis, patient satisfaction Although most patients with ulcerative colitis (UC) can be managed medically, about 20%–30% will eventually require elective or emergent surgery. 1,–3 Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) has become well established as the surgical procedure of choice for patients with UC. The advantages of IPAA are complete removal of all diseased mucosa with preservation of continence, thereby avoiding a permanent ileostomy. 4,–8 IPAA is associated with low mortality and good quality of life with good long-term functional outcomes. 9,–11 It is, however, associated with various complications that may occur in 10%–60% of patients, depending on the duration of follow-up and the choice of diagnostic criteria. 12,13 Complications may appear early or late and may be surgical and/or medical, although a clear distinction between the 2 seems to be artificial. At present, the follow-up of patients after IPAA is usually conducted by colorectal surgeons. Since these patients often require both medical and surgical follow-up, we decided to establish a comprehensive multidisciplinary pouch clinic with the primary goal of improving the quality of patient care by standardized follow-up and treatment modalities. The primary objective of the present study was to appraise the clinic in terms of its contribution to the quality of patient care and patient satisfaction. We also aimed to determine the incidence and nature of IPAA-associated complications and their risk factors among our patients during the 3-year study period. Materials and Methods The specially designed pouch clinic was opened in January 2003 at the Tel Aviv Sourasky Medical Center (TASMC), a tertiary referral center for patients with inflammatory bowel disease (IBD). These outpatients were interviewed and examined by both a colorectal surgeon (H.T.) and an IBD-oriented gastroenterologist (I.D.) at the same time and in the same room from their first visit and throughout the selection phase for the operation and long-term follow-up. Diagnostic and treatment decisions, as well as management policies (such as selection of routine laboratory blood tests and the timing of pouch endoscopy) were taken jointly by the 2 physicians. Visits, laboratory tests, and pouch endoscopy and biopsies were performed at least once yearly even in asymptomatic patients or when indicated. All pouch endoscopies were carried out by an IBD-oriented gastroenterologist (I.D.). A nutritionist, a stoma care nurse, and a psychologist are members of the multidisciplinary team. Patients were charged for this service as for a single outpatient clinic, to the colorectal surgery unit. Pouch endoscopy was charged to the Division of Gastroenterology. Biopsies were blindly examined and scored by an IBD-oriented pathologist (E.B.). In addition, blinded evaluation of histological activity in the colectomy specimens was performed using the grading scale described by Geboes et al.14 Briefly, this is a 6-grade classification system for inflammation, where the grades are structural change, chronic inflammation, lamina propria neutrophils, neutrophils in epithelium, crypt destructions and erosions or ulcer. To that we added evaluation of the appendix (involved or not involved), pyloric gland metaplasia, and depth of inflammation. Data were prospectively collected on all consecutive patients who visited the clinic between January 2003 and December 2005. These data included demographics, family history of IBD, disease characteristics (e.g., age at disease onset, preoperative medical treatment, extent of disease, extraintestinal manifestations [EIM]), surgery-related data (indication for surgery, number of operation stages), pouch-related data, duration of follow-up, as well as late postoperative data (total number of visits to the clinic, delayed EIM, and long-term pouch status). The Helsinki Committee of the TASMC authorized the study. Normal pouch status was defined as 6–8 bowel movements per day, 1 or no bowel movements per night, full daytime continence (minimal night soiling), and no EIM. The definition of pouchitis was based on the Pouchitis Disease Activity Index (PDAI).15 Briefly, clinical, endoscopic, and histological criteria are graded according to a predefined scale, where each criterion can receive 6 points, to a total of 18 points. Pouchitis was defined as a PDAI score ≥7. Acute pouchitis was diagnosed when an episode of pouchitis had been resolved following short (usually 2 weeks) antibiotic treatment. Recurrent acute pouchitis was diagnosed when episodes of acute pouchitis were followed by normal pouch function. Chronic pouchitis was defined as persistence of symptoms for more than 3 months or the need for chronic antibiotic therapy. 16,17 A pouch-related fistula was defined as a fistula that originates either from the pouch, the ileoanal anastomosis, or the dentate line. An IPAA “true” stenosis was defined as a stricture at the IPAA that necessitated examination under anesthesia and dilation. EIM were documented and included joints, skin, and liver (including bile duct) symptoms, as well as anemia, vitamin deficiencies, and renal and electrolyte disturbances. Irritable pouch syndrome (IPS) was defined as an increase in bowel movements and abdominal complaints without sufficient endoscopic or histologic criteria for the diagnosis of pouchitis (i.e., PDAI <7). The study cohort was divided into a group of patients with normal pouch function and a group of patients with pouchitis. Anonymous in-house patient satisfaction questionnaires that included a 5-point scale and open-ended questions were mailed to the first 90 patients and the responses were studied by an independent researcher (A.A.). Statistical Analysis Clinical and demographic data were collected prospectively and entered into an Excel database using Microsoft Office software (Redmond, WA). Continuous parameters were presented as means and standard deviations or range. Comparisons between the 2 patient groups with regard to demographics, surgical parameters, and outcome variables were performed using 1-way analysis of variance, independent samples t-tests, chi-square, and Fisher's exact tests, as applicable. Multivariate analyses included step-wise techniques. Statistical significance was set at 0.05 and SPSS for Windows software (Chicago, IL) v. 12.0 was used for the analysis. Results Of the 241 patients who underwent RPC and IPAA at our institution between January 1986 and December 2005, 193 were operated on for UC, 2 for Crohn's disease (CD), and 46 for familial adenomatous polyposis (FAP). Of them, 143 patients, of whom 12 were referrals (125 UC, 16 FAP, 2 CD) were seen at the pouch clinic. The data of 23 patients were subsequently excluded from analysis: 5 UC patients with an ileostomy at the last follow-up visit, the 16 FAP patients, and 2 patients who underwent IPAA for CD. The remaining 120 patients comprise this case series cross-sectional cohort. Patient characteristics are presented in Table 1. Table 1. Patient Characteristics     View Large Table 1. Patient Characteristics     View Large The patients' mean age at operation was 37 years (range 13–75). The mean disease duration before proctocolectomy was 11 years (range 0–36 years). Twenty-three (19%) patients were operated on before 1995, 61 (51%) in 1995–2002, and 36 (30%) in 2003–2005. Most patients had a staged surgery (64% 2 and 22% 3 stages) compared to 14% in 1 stage. Interestingly, 7/21 patients (33.3%) operated for dysplasia/cancer had a 1-stage surgery, compared to only 9/99 (9%) operated for active disease (acute or intractable; P = 0.008). This finding probably reflects the fact that patients with dysplasia/cancer came less ill into the procedure. Early postoperative complications occurred in 27% of the patients, without statistically significant differences between patients operated in 1 compared to multistage procedures. The mean interval between the formation of the IPAA and ileostomy closure was 8 months (range 2–294). The mean interval between ileostomy closure (for patients operated in more than 1 stage) and the first clinic visit was 54 months (range 3–182). The mean duration of follow-up since operation was 65 months (range 2–258). The mean number of visits to the clinic per patient was 3 (range 1–11). As can be seen in Table 1, most patients were operated on due to intractable disease (n = 86, 72%) after having pancolitis (n = 72, 60%). Long-term Complications Fifty out of 120 patients (42%) had a normal pouch. Sixty-three patients (52%) were diagnosed with pouchitis: 17 (14%) with acute, 29 (24%) with recurrent acute, and 17 (14%) with chronic pouchitis. Fifteen out of 23 (65%) patients operated on before 1995 had pouchitis, compared to 36/61 (59%) in 1995–2002 and to 11/36 (30%) in 2003–2005 (P < 0.001). Of note, patients with pouchitis were followed-up for a significantly longer time (mean 81 ± 64 months) compared to patients with a normal pouch (46 ± 45 months, P = 0.008). Five patients (4%) had IPS and the diagnosis was changed to CD in 2 patients (2%). Their data were not included in the group comparisons. Six patients had inflammation of the rectal cuff (cuffitis), and half of them also had chronic pouchitis. We compared the groups of patients with and without pouchitis in order to determine which demographic or disease characteristics may serve as a risk factor for the development of pouchitis. Univariate analysis (Table 2) revealed that significantly more patients who underwent RPC in 1 stage had a normal pouch compared to patients who underwent a staged operation. It also showed that significantly more patients with neoplastic lesions had a normal pouch compared to patients who were operated on due to chronic or acute intractable disease. Since a significantly higher percentage of dysplasia/cancer patients had a 1-stage operation compared with the active disease group, correlation between preoperative disease activity and pouch function is suggested. Pancolitis emerged as being a third significant risk factor for pouchitis. In order to determine which risk factors were independent factors for the development of pouchitis, we then performed a multivariate analysis: indeed, only intractable (acute or chronic) disease remained significant (P = 0.039, 95% confidence interval [CI] 1.06–10.68). Table 2. Comparison of Patients With and Without Pouchitis (n = 113)     View Large Table 2. Comparison of Patients With and Without Pouchitis (n = 113)     View Large In order to evaluate whether pathological features, not only clinical disease activity, were predictive of subsequent development of pouchitis, a representative sample of colectomy specimens of patients with normal pouch function or pouchitis (acute, recurrent, and chronic) were blindly assessed. Less structural changes and chronic inflammatory infiltrate were noticed in the normal pouch function group; however, no difference in the depth of inflammation or the nature of the inflammatory process (criteria which are associated with a higher histological grade) was observed. Six patients (5%) were diagnosed as having IPS. As a group, IPS patients tended to visit the clinic more often than the non-IPS patients (6.6 versus 3.2 visits, P = 0.08). This was true even when compared to patients with pouchitis (6.6 versus 3.3, P = 0.09). Pouch-related fistula was identified in 13 (11%) patients. The origin of the internal fistula opening was at the ileoanal anastomosis in 8 and below the anastomosis in 3 patients. The pouch team reassessed all fistula cases, including colectomy specimens and the pouch endoscopy biopsies: the diagnosis was not changed to CD in any of these cases. In terms of severity, 9 patients were clinically symptomatic and 4 patients were asymptomatic or had very mild symptoms. All symptomatic patients were treated surgically. Four patients (3%) developed a pouch-vaginal fistula: 2 occurred early after a 1-stage IPAA and were successfully treated by a diverting ileostomy, while the other 2 patients had very mild symptoms and refused surgery. Pouch-perineal fistula occurred in 9 patients: 2 patients were treated by fistulotomy and a seton was inserted in 5 patients. Six (5%) patients developed ileoanal anastomotic strictures requiring dilatation under anesthesia on at least 1 occasion. In 1 patient the pouch was excised due to severe functional problems and 2 patients were dependent on self-dilatations once to twice a week. Thirty-eight patients (32%) had preoperative EIM that included mainly arthralgia/arthritis. As expected, fewer (19 patients, 16%) had postoperative EIM, and, interestingly, 4 of them had a normal pouch without pouchitis. Even more intriguing was the finding of new-onset EIM in 8 patients (7%) and included arthralgia, pyoderma gangrenosum, and deep vein thrombosis (DVT). One patient had pyoderma gangrenosum, arthralgia, and DVT. Importantly, out of 105 patients that had been screened endoscopically, none had cancer or dysplasia in the pouch or rectal cuff, including the 22 patients (18%) that had dysplasia or cancer in the colectomy specimen. Fifty-five patients (61%) completed the patient satisfaction questionnaires (Table 3). Table 3. Patient Satisfaction Questionnaire     View Large Table 3. Patient Satisfaction Questionnaire     View Large Fifty patients (50/55, 90%) who had been previously treated and followed-up in either a surgical or medical setting felt that the comprehensive clinic improved the quality of their care, of which 42 (76%) felt the improvement was very significant (Question 7, Table 4). When patients were grouped according to years of surgery to those operated before 1995 (n = 8), in 1995–2002 (n = 30) and in 2003–2005 (n = 17) similar results were obtained. Thus, patients with longstanding pouches and those treated in the comprehensive pouch clinic “de novo” had similarly high satisfaction. Importantly, patients felt that the combination of follow-up and treatment by both a gastroenterologist and a colorectal surgeon at the same visit was preferable to follow-up at either of the clinics separately or being seen at 1 clinic only. This was generally or completely true for 67%–76% of the responders (Questions 1, 3, and 5). As expected, patients found it more convenient to be followed-up at the comprehensive pouch clinic (Question 2) and believed that their medical as well as surgical problems were better dealt with by this approach (Questions 4, 5) compared with separate visits to gastroenterology or colorectal surgery clinics. Table 4. Patient Satisfaction Data (n = 55)     View Large Table 4. Patient Satisfaction Data (n = 55)     View Large Discussion While IPAA restores the natural route of defecation with good long-term functional outcomes, it may be associated with various surgical and/or medical complications. 13,18,19 The distinction between purely medical and purely surgical complications associated with the procedure is a moot one: the patient may require—and benefit from—the combined skills and know-how of a colorectal surgeon and an IBD-oriented gastroenterologist. This prompted us to establish a comprehensive pouch clinic. The concept behind this novel approach was the understanding that the problems and needs of this complicated and distinct patient population require a dedicated team with the appropriate expertise. Our pouch clinic has been functioning for the past 3 years: we now describe our experience and the complications that emerged as being specific to these patients. The complexity of treating pouch patients is demonstrated by the results of this study. A wide range of complications might develop in the short- and long-term after pouch operations in UC patients. In their extreme form, each one may lead to pouch dysfunction. Pouchitis is the most common long-term complication, 20,–22 with a reported incidence between 5%–59%. 17,23,–25 Clinically, the majority of patients have a single attack of pouchitis that rapidly resolves with treatment, followed by recurrent acute attacks. Pouchitis developed in 52% of our patients, and 38% of them had acute and recurrent acute attacks. Chronic refractory pouchitis may occasionally develop, requiring constant maintenance therapy: our 14% rate of chronic refractory pouchitis is comparable to that of previous reports from specialized centers. 17,26,27 The variation in the rate of pouchitis between different series depends on the criteria used for diagnosing the condition, the length of the follow-up period, and the composition of the study population. As such, it is important to point out that there could have been potential referral or selection bias in our study. In addition to the routine follow-up of the majority of patients operated on in our hospital, our pouch clinic is a referral clinic for patients operated on in other centers who were often sent to us because they had disease of the pouch that was difficult to manage. The data on clinical, laboratory, and histological predictive factors for subsequent pouchitis are controversial. We identified an association between the extent of disease, the indication for surgery, the number of surgical stages, and the duration of follow-up with the development of pouchitis (Table 2). Thus, the parameters of pancolitis, intractable disease as the indication for surgery, staged surgery, and longer follow-up were associated with a greater chance of developing pouchitis (univariate analysis: P = 0.05, 0.002, 0.03, and 0.008, respectively). Our finding that patients who are preoperatively assessed to have extensive disease appear to be at greater risk for the development of pouchitis is in accordance with previous studies. 28,–30 When independent effects were analyzed by multivariate analysis, however, only the indication for surgery was highly related to the tendency of the pouch to develop inflammation. If the indication was acute exacerbation or intractability, the chance of developing pouchitis was higher compared to patients who were operated on because of dysplasia or colorectal cancer (CRC) (P = 0.039). Contrary to previous findings, 31,32 additional factors such as preoperative EIM did not predispose to pouchitis. Staged surgery was predictive of subsequent pouch inflammation, an association that is documented here for what we believe to be the first time. The explanation for the observed advantage of a 1-stage procedure is not clear-cut. Having noted that patients with pancolitis also had an increased risk of developing pouchitis compared to patients with left-sided colitis, we speculate that patients operated on in 1 stage came less ill into surgery. This is further supported by the observation that within the active (acute or intractable) disease group significantly fewer patients were operated on in 1 stage compared to the dysplasia/cancer group. An alternative explanation might have been that 1-stage surgery is associated with fewer early postoperative complications. However, our experience is similar to previously published results,33 where complications of 1-stage were comparable, and not less than multistage procedures. Thus, the better pouch function after 1-stage surgery cannot be attributed to fewer early postoperative complications We asked whether specific pathologic findings in the colectomy specimens may be predictive of the development of pouchitis, as controversial reports in the literature exist. 34,35 Using the grading system reported by Geboes et al14 and adding criteria such as depth of the inflammatory infiltrate, involvement of the appendix, and pyloric gland metaplasia, we found that less structural changes and chronic inflammatory infiltrate were noticed in the normal pouch function group; however, no difference in the depth of inflammation or the nature of the inflammatory process was observed. As these last criteria have more weight in the histological grading system that we used, we could not determine significant specific features that predict pouchitis. This is in agreement with a previously published study by Fogt et al,34 who did not demonstrate a correlation between involvement of the appendix, fissuring ulcers, and ileitis in colectomy specimens with the development of pouchitis. On the other hand, Yantiss et al35 were able to show that the presence of superficial fissuring ulcers and active appendicitis were highly associated with pouchitis. The discrepancies between these studies might be attributed to the different grading systems used and to interobserver variability. Regarding pathologic features, our findings are consistent with multiple previously published studies showing that clinical pouchitis does not correlate well with histopathological findings in the colectomy specimen. Our patients with pouchitis were followed-up for a significantly longer period of time compared to patients without pouchitis. This finding was also reported by other authors 26,36 and supports our clinical observation that the incidence of pouchitis tends to increase with the duration of follow-up. This may raise the issue of “the aging pouch” reflected in the significantly increased incidence of pouchitis in longstanding pouches and may dictate closer follow-up or even preventive intervention (e.g., probiotics) as the interval of time after surgery increases. A stapled ileoanal anastomosis without mucosectomy is done routinely at the level of the anorectal junction, and so a 1–2 cm strip of rectal columnar cuff is retained. Some degree of persistent inflammation of the rectal cuff is common. This may be severe enough to cause local symptoms of bleeding, burning sensation, and urgency, and disordered evacuation. 37,38 The diagnosis, as in pouchitis, is based on clinical symptoms, endoscopy, and histology taken from the rectal cuff mucosa. In some patients, cuffitis coexists with pouchitis. In our group of patients, symptomatic inflammation of the retained anorectal mucosa that necessitated local treatment occurred in only 6 patients (5%). Other groups reported an incidence of cuffitis ranging between 2%–15%. 37,39,40 As in pouchitis, the variation in the reported incidence could be due to the choice of diagnostic criteria, the intensity and duration of follow-up, and whether cuff inflammation had been an isolated finding or if it coexisted with pouchitis. IPS is a functional disorder, diagnosed in symptomatic patients that suffer mainly from an increased bowel frequency, urgency, and abdominal pain, without endoscopic or histologic evidence of rectal cuff or pouch inflammation (thus yielding a PDAI <7). In our cohort the incidence of IPS was 8%—relatively low compared to the 30%–43% reported by 1 center, 41,42 possibly due to the careful exclusion of patients with confounding conditions (such as abdominal wall hernias, adhesions, and bacterial overgrowth) in our cohort. It is crucial to understand that the clinical features of pouchitis, cuffitis, and IPS may overlap and that they may well require different treatment approaches. Therefore, accurate diagnosis using didactic surgical as well as gastroenterological insights is of major importance for appropriate therapeutic management. In addition to more efficient medical and surgical care of patients, patient satisfaction and confidence increased (as demonstrated by the satisfaction questionnaire data) thanks to the availability of a novel joint consultation facility. Indeed, 90% of the patients of whom most were previously followed-up in surgical outpatient clinics, expressed their satisfaction with the unique setting, noting that the pouch clinic improved the quality of their care. Importantly, satisfaction was similarly high in the “longstanding-pouch” group (operated before 1994) and the group operated on in 2003–2005 in which patients were treated in the comprehensive pouch clinic “de novo.” We believe that patient satisfaction is directly related to the comprehensive approach. This is based on patients' comments, as well as on the results from the anonymous patients' satisfaction questionnaire. One may ask whether satisfaction correlated with pouch outcome rather than with the comprehensive approach. However, as the prevalence of pouchitis in our cohort (52%) is similar to that reported in the literature,43 and still 90% of the patients responding to the anonymous questionnaire felt that the comprehensive pouch clinic improved the quality of their care, no correlation seems to exist between pouch function and patient satisfaction. The comprehensive pouch clinic concept may also have economic consequences and professional advantages to the institution and its staff beyond the clinic itself. The follow-up of these patients prior to the establishment of the pouch clinic was episodic and infrequent. Since the establishment of the clinic, patients have at least a yearly visit to the clinic and a yearly pouch endoscopy. Therefore, providing clinical support and easily accessible medical and surgical solutions to these patients is associated with increased income to the institution. Since this is a referral clinic, patients that otherwise would be followed-up elsewhere are now being followed-up at our medical center and all investigations such as pouch endoscopies, abdominal CTs, and pelvic MRIs when required are also being done here, increasing not only income, but also expertise of additional specialists. In conclusion, IBD patients after IPAA may present with both medical and surgical complications. A comprehensive pouch clinic is a novel approach in their management. In our experience, it facilitated follow-up and management and provided more efficient and beneficial care to the patients. It also provided an excellent environment for closer teamwork between colorectal surgeons and gastroenterologists. We believe that this multidisciplinary approach should be considered in everyday practice in all major centers treating IBD patients post-IPAA. In addition, our study into the incidence and nature of IPAA-associated complications and their risk factors confirmed that duration since operation and indication for surgery were risk factors for developing pouchitis. Finally, staged surgery was shown for the first time to be predictive of subsequent pouch inflammation. Acknowledgements We thank Esther Eshkol for editorial assistance. References 1. Blumberg D, Beck DE. Surgery for ulcerative colitis. Gastroenterol Clin North Am.  2002; 31: 219– 235. CrossRef Search ADS PubMed  2. Marion JF, Present DH. Indications for surgery in inflammatory bowel disease from the gastroenterologist's point of view. In: Sartor RB, Sandborn WJ, eds. Kirsner's inflammatory bowel diseases , 6th ed. New York: WB Saunders; 2004.: 585– 596. 3. Farmer RG, Easley KA, Rankin GB. Clinical patterns, natural history, and progression of ulcerative colitis. A long-term follow-up of 1116 patients. Dig Dis Sci.  1993; 38: 1137– 1146. CrossRef Search ADS PubMed  4. Wexner SD, Wong WD, Rothenberger DA, et al.   The ileoanal reservoir. Am J Surg.  1990; 159: 178– 183. CrossRef Search ADS PubMed  5. Melville DM, Ritchie JK, Nicholls RJ, et al.   Surgery for ulcerative colitis in the era of the pouch: the St Mark's Hospital experience. Gut.  1994; 35: 1076– 1080. CrossRef Search ADS PubMed  6. Kelly KA. Anal sphincter-saving operations for chronic ulcerative colitis. Am J Surg.  1992; 163: 5– 11. CrossRef Search ADS PubMed  7. Dozois RR, Goldberg SM, Rothenberger DA, et al.   Restorative proctocolectomy with ileal reservoir. Int J Colorectal Dis.  1986; 1: 2– 19. CrossRef Search ADS PubMed  8. Williams NS. Restorative proctocolectomy is the first choice elective surgical treatment for ulcerative colitis. Br J Surg.  1989; 76: 1109– 1110. CrossRef Search ADS PubMed  9. Michelassi F, Lee J, Rubin M, et al.   Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study. Ann Surg.  2003; 238: 433– 441. PubMed  10. Wheeler JM, Banerjee A, Ahuja N, et al.   Long-term function after restorative proctocolectomy. Dis Colon Rectum.  2005; 48: 946– 951. CrossRef Search ADS PubMed  11. Muir AJ, Edwards LJ, Sanders LL, et al.   A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis. Am J Gastroenterol.  2001; 96: 1480– 1485. CrossRef Search ADS PubMed  12. Fazio VW, O'Riordain MG, Lavery IC, et al.   Long-term functional outcome and quality of life after stapled restorative proctocolectomy. Ann Surg.  1999; 230: 575– 584. CrossRef Search ADS PubMed  13. Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg.  2003; 238: 229– 234. PubMed  14. Geboes K, Riddell R, Ost A, et al.   A reproducible grading scale for histological assessment of inflammation in ulcerative colitis. Gut.  2000; 47: 404– 409. CrossRef Search ADS PubMed  15. Sandborn WJ, Tremaine WJ, Batts KP, et al.   Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc.  1994; 69: 409– 415. CrossRef Search ADS PubMed  16. Stahlberg D, Gullberg K, Liljeqvist L, et al.   Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors. Dis Colon Rectum.  1996; 39: 1012– 1018. CrossRef Search ADS PubMed  17. Heuschen UA, Autschbach F, Allemeyer EH, et al.   Long-term follow-up after ileoanal pouch procedure: algorithm for diagnosis, classification, and management of pouchitis. Dis Colon Rectum.  2001; 44: 487– 499. CrossRef Search ADS PubMed  18. Fazio VW, Ziv Y, Church JM, et al.   Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg.  1995; 222: 120– 127. CrossRef Search ADS PubMed  19. Meagher AP, Farouk R, Dozois RR, et al.   J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg.  1998; 85: 800– 803. CrossRef Search ADS PubMed  20. Mahadevan U, Sandborn WJ. Diagnosis and management of pouchitis. Gastroenterology.  2003; 124: 1636– 1650. CrossRef Search ADS PubMed  21. Penna C, Dozois R, Tremaine W, et al.   Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Gut.  1996; 38: 234– 239. CrossRef Search ADS PubMed  22. Shen B, Fazio VW, Remzi FH, et al.   Clinical approach to diseases of ileal pouch-anal anastomosis. Am J Gastroenterol.  2005; 100: 2796– 2807. CrossRef Search ADS PubMed  23. Stahlberg D, Gullberg K, Liljeqvist L, et al.   Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors. Dis Colon Rectum.  1996; 39: 1012– 1018. CrossRef Search ADS PubMed  24. Stocchi L, Pemberton JH. Pouch and pouchitis. Gastroenterol Clin North Am.  2001; 30: 223– 241. CrossRef Search ADS PubMed  25. Hurst RD, Molinari M, Chung TP, et al.   Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy. Arch Surg.  1996; 131: 497– 500. CrossRef Search ADS PubMed  26. Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg.  2000; 24: 851– 856. CrossRef Search ADS PubMed  27. Sengul N, Wexner SD, Hui SM, et al.   Anatomic extent of colitis and disease severity are not predictors of pouchitis after restorative proctocolectomy for mucosal ulcerative colitis. Tech Coloproctol.  2006; 10: 29– 34. CrossRef Search ADS PubMed  28. Schmidt CM, Lazenby AJ, Hendrickson RJ, et al.   Preoperative terminal ileal and colonic resection histopathology predicts risk of pouchitis in patients after ileoanal pull-through procedure. Ann Surg.  1998; 227: 654– 662. CrossRef Search ADS PubMed  29. Luukkonen P, Jarvinen H, Tanskanen M, et al.   Pouchitis—recurrence of the inflammatory bowel disease? Gut.  1994; 35: 243– 246. CrossRef Search ADS PubMed  30. Samarasekera DN, Stebbing JF, Kettlewell MG, et al.   Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease. Gut.  1996; 38: 574– 577. CrossRef Search ADS PubMed  31. Lohmuller JL, Pemberton JH, Dozois RR, et al.   Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg.  1990; 211: 622– 627. PubMed  32. Oresland T, Fasth S, Nordgren S, et al.   The clinical and functional outcome after restorative procetocolectomy. A prospective study in 100 patients. Int J Colorectal Dis.  1989; 4: 50– 56. CrossRef Search ADS PubMed  33. Remzi FH, Fazio VW, Gorgun E, et al.   The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum.  2006; 49: 470– 477. CrossRef Search ADS PubMed  34. Fogt F, Deren JJ, Nusbaum M, et al.   Pouchitis in ulcerative colitis: correlation between predictors from colectomy specimens and clinico-histological features. Eur Surg Res.  2006; 38: 407– 413. CrossRef Search ADS PubMed  35. Yantiss RK, Sapp HL, Farraye FA, et al.   Histologic predictors of pouchitis in patients with chronic ulcerative colitis. Am J Surg Pathol.  2004; 28: 999– 1006. CrossRef Search ADS PubMed  36. Cheifetz A, Itzkowitz S. The diagnosis and treatment of pouchitis in inflammatory bowel disease. J Clin Gastroenterol.  2004; 38: S44– 50. CrossRef Search ADS PubMed  37. Lavery IC, Sirimarco MT, Ziv Y, et al.   Anal canal inflammation after ileal pouch-anal anastomosis. The need for treatment. Dis Colon Rectum.  1995; 38: 803– 806. CrossRef Search ADS PubMed  38. Shen B, Lashner BA, Bennett AE, et al.   Treatment of rectal cuff inflammation (cuffitis) in patients with ulcerative colitis following re storative proctocolectomy and ileal pouch-anal anastomosis. Am J Gastroenterol.  2004; 99: 1527– 1531. CrossRef Search ADS PubMed  39. Schmitt SL, Wexner SD, Lucas FV, et al.   Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis. Dis Colon Rectum.  1992; 35: 1051– 1056. CrossRef Search ADS PubMed  40. Thompson-Fawcett MW, Mortensen NJ, Warren BF. “Cuffitis” and inflammatory changes in the columnar cuff, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis. Dis Colon Rectum.  1999; 42: 348– 355. CrossRef Search ADS PubMed  41. Parsi MA, Shen B, Achkar JP, et al.   Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch anal anastomosis. Gastroenterology.  2004; 126: 1280– 1286. CrossRef Search ADS PubMed  42. Shen B, Achkar JP, Lashner BA, et al.   Irritable pouch syndrome: a new category of diagnosis for symptomatic patients with ileal pouch-anal anastomosis. Am J Gastroenterol.  2002; 97: 972– 977. CrossRef Search ADS PubMed  43. Ferrante M, Declerck S, De Hertogh G, et al.   Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Inflamm Bowel Dis.  2008; 14: 20– 28. CrossRef Search ADS PubMed  Copyright © 2008 Crohn's & Colitis Foundation of America, Inc.
TI - Comprehensive pouch clinic concept for follow-up of patients after ileal pouch anal anastomosis: Report of 3 years' experience in a tertiary referral center
JF - Inflammatory Bowel Diseases
DO - 10.1002/ibd.20430
DA - 2008-08-01
UR - https://www.deepdyve.com/lp/oxford-university-press/comprehensive-pouch-clinic-concept-for-follow-up-of-patients-after-gVAnMIdlKF
SP - 1125
EP - 1132
VL - 14
IS - 8
DP - DeepDyve
ER -