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Preoperative exposure to biologics and surgeons' attitude toward the surgical approach in ulcerative colitis
Full text linkOutcomes of salvage surgery for ileal pouch complications and dysfunctions. the experience of a referral centre and review of literature
No full textBACKGROUND AND AIMS:
Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction.
METHODS:
We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre- and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3).
RESULTS:
Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003).
CONCLUSIONS:
Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction
Education and imaging. Gastrointestinal: Symmetric lymphangitis of lower limbs originating from a perianal abscess.
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From colon-sparing techniques to pelvic ileal pouch: history and evolution of surgery for ulcerative colitis
No full textBackground
Since the first decription of ulcerative colitis(UC) by Sir Wilkins from the London Guy’s Hospital in 1859, medical and surgical management have gradually evolved. Aims of this review are to describe the milestones and pioneers of surgery for UC, taking the readers on a journey through the steps that led to the development of restorative proctocolectomy with ileal pelvic pouch.
Methods
This is an historical, narrative review. We reviewed scientific literature and historical archives, seeking for documentation of surgery of UC. Information were integrated with our personal experience, taking into accout patients’ perspective.
Results
Different surgical approaches have been attempted over time, grounding on different concepts. As long as pathophysiology of UC has become clearer, surgeons have profoundly modified their attitudes toward this disease. Early approaches aimed at preserving organs, with “damage-control” surgery. Advances in knowledge and surgical skills led surgeons to demolitive treatments, which proved to be very effective, but with poor quality of life in most patients, especially in young, due to permanent stoma—even if continent ileostomy ameliorated patient satisfaction. On the other hand, straight ileoanal anastomosis, despite preserving trans-anal defaecation, resulted in inacceptably high bowel frequency. Restorative proctocolectomy was the turning point. By combining the concepts of disease removal, continence, and physiological evacuation, it has become the surgical treatment of choice in most UC patients.
Conclusion
Choice and timing of treatment of UC need to be individualized. Besides surgical knowledge and techniques, the patient’s perspective must be examined closely. Restorative proctocolectomy is the mainstay
Book review on E. Lezoche, A.M. Paganini, A. Cuschieri Minimally invasive colorectal surgery
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