Aspects on Long-term Outcome After Restorative Proctoclectomy

Aspects on Long-term Outcome After Restorative Proctocolectomy Abstract Background Restorative proctocolectomy is the preferred surgical alternative for reconstruction after proctocolectomy for ulcerative colitis. The majority of patients are satisfied with the functional outcome. However, a proportion of the patients suffer from complications and impaired pouch function. Furthermore, about 10% of the patients will have a definitive failure of the pouch. The aim of this thesis was to explore some of the long-term aspects of this surgical procedure. Methods Paper I: 42 patients were assessed with a pouch functional score and manovolumetry. The outcome after median 16 years were compared to two years after surgery in a paired analysis. Paper II: Grade of inflammation, possible dysplasia and pouch related problems were assessed in 13 patients with pouch failure and the pouch still in place but deviated with an ileostomy. Paper III: 36 patients with pouch failure were compared to 72, age and gender matched patients with functioning pouches, regarding sexual function, body image and health related quality of life. The instrument used for sexual function was the female sexual function index (FSFI) and the international index of erectile function (IIEF). Body image was assessed with the body image scale (BIS), and health related quality of life with SF-36. Swedish version. 2.0. Paper IV: is a randomized, placebo-controlled, double blind study on the effects of probiotics (Lactobacillus plantarum 299, Bifidobacterium infantis Cure21) on 31 patients with poor pouch function. Assessments were made with a pouch functional index, the pouchitis activity index (PDAI), endoscopy, histology and faecal biomarkers. Results The pouch functional score showed impairment at 16 year as well as the manovolumetric characteristics, except for resting anal pressure. Increased age and pouch volume were correlated to a worse functional score (Paper I). The majority of patients had no problems with the defunctioned pouch and dysplasia was not found (Paper II). Patients with pouch failure demonstrated lower scores in all domains in the FSFI and IIEF, as well as lower summary score in both instruments. However, the differences were not statistically significant. BIS summary score was significantly lower for both sexes in the patients with pouch failure. All domain SF-36 scores were lower for both sexes with pouch failure, though not statistically significant (Paper III). There was no significant difference between the probiotics and placebo groups regarding pouch functional score, PDAI or faecal biomarkers after treatment. Initial values of PDAI correlated significantly to all faecal biomarkers (Paoer IV). Conclusions A decline in pouch function at long-term, concurrent with alterations in pouch physiology as assessed with manovolumetry was demonstrated. The mucosa in the indefinitely deviated pouch showed no dysplasia. Furthermore, the majority of the deviated patients had no pouch related symptoms. This indicates that the pouch could be left in situ in case of pouch failure, but further follow-up is needed. Patients with pouch failure seem to have an impaired body image, but sexual function and health related quality of life were not significantly different compared to patients with functioning pouches. Probiotics did not improve poor pouch function compared to placebo

Appropriate maintenance treatment for Crohn's disease: results of a multidisciplinary international expert panel - EPACT II

Introduction: Biological. therapy has dramatically changed management of Crohn's disease (CD). New data have confirmed the benefit and relative long-term safety of anti-TNF alpha inhibition as part of a regular scheduled administration programme. The EPACT appropriateness criteria for maintenance treatment after medically-induced remission (MIR) or surgically-induced remission (SIR) of CD thus required updating. Methods: A multidisciplinary international expert panel (EPACT II, Geneva, Switzerland) discussed and anonymously rated detailed, explicit clinical indications based on evidence in the literature and personal expertise. Median ratings (on a 9-point scale) were stratified into three assessment categories: appropriate (7-9), uncertain (4-6 and/or disagreement) and inappropriate (1-3). Experts ranked appropriate medication according to their own clinical practice, without any consideration of cost. Results: Three hundred and ninety-two specific indications for maintenance treatment of CD were rated (200 for MIR and 192 for SIR). Azathioprine, methotrexate and/or anti-TNF alpha antibodies were considered appropriate in 42 indications, corresponding to 68% of all appropriate interventions (97% of MIR and 39% of SIR). The remaining appropriate interventions consisted of mesalazine and a "wait-and-see" strategy. Factors that influenced the panel's voting were patient characteristics and outcome of previous treatment. Results favour use of anti-TNF alpha agents after failure of any immunosuppressive therapy, while earlier primary use remains controversial. Conclusion: Detailed explicit appropriateness criteria (EPACT) have been updated for maintenance treatment of CD. New expert recommendations for use of the classic immunosuppressors as well as anti-TNF alpha agents are now freely available online (www.epact.ch). The validity of these criteria should now be tested by prospective evaluation. (C) 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved