Total Abdominal Colectomy and Ileorectal Anastomosis for Ulcerative Colitis: Long Term Results in 110 Patients
Abstracts
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Aim : Ileoanal J pouch anastomosis (IAA) is the gold standart of Ulcerative Colitis (UC) surgery. However,in selected patients whose proctitis was minimal, we have still favored ileorectal anastomosis (IRA) with an annual rectoscopy. We reviewed the incidence and severity of subsequent proctitis, the risk of cancer ,and long term functional outcomes. Patients and Methods : From 1967 to 1999, 118 patients (60F, 58M, mean age 36) underwent total colectomy with IRA for apparent UC. Eight cases (7 %) turned out later as Crohn s disease and were excluded. One patient was lost for follow up. Conversion to permanent ileostomy, with or without proctectomy or IAA were recorded as failure of IRA. Patients having functional IRA have been evaluated recently.The mean follow up period was 14 years for this population. Results: There were 4 perioperative deaths (3.6%, during the sixties) and 4 late deaths from non digestive diseases. Three patients refused ileostomy closure, 9 underwent a secondary proctectomy with IAA for severe proctitis (8%). Four patients (3.6%) developed rectal adenocarcinoma (1 death) ; two of them had not been compliant to the follow up program. One patient exhibited a lymphoma. Eighty four (76%) patients still have a functional IRA. In this population, the mean daily stool frequency is 4. Only 3 patients report urgencies. Endoscopic examination showed : absence or mild proctitis in 67 patients, moderate inflammation in 14 and severe proctitis in 3, corresponding to the three patients having a poor functional outcome. These are the only patients receiving oral steroids, for whom a decision of IAA is pending. The patients having moderate proctitis receive only local treatments to control symptoms. No dysplasia, nor carcinoma has been identified so far in these 84 patients. Seventy seven of them (91%) returned to their previous activity and declare satisfied about their quality of life. Eight out of 41 female patients (19%) became pregnant at least once. Conclusion : In selected patients, long term results of IRA are acceptable. Criteria to be respected are : mild proctitis , absence of extradigestive symptoms, absence of dysplasia on biopsies or colectomy specimen and short preoperative history. IRA may be especially valuable in circumstances that preclude IAA success such as anatomical limitations, doubt about a possible Crohn s disease and patients whose UC began late in life. |
