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Comparison of Surgical Treatment of Ulcerative Colitis Associated With Primary Sclerosing Cholangitis: Ileal Pouch-Anal Anastomosis Versus Brooke Ileostomy

      Objective

      To compare the operative risks, operative complications, and late outcome of two homogeneous groups of patients with chronic ulcerative colitis (CUC) and primary sclerosing cholangitis (PSC) who underwent either Brooke ileostomy or ileal pouchanal anastomosis (IPAA).

      Material and Methods

      Between 1970 and 1990, 72 patients with CUC and PSC underwent proctocolectomy with either Brooke ileostomy (group I; N = 32) or IPAA (group II; N = 40). Postoperative data included operative mortality, need for blood transfusion, general postoperative complications, liver-related complications, and proctocolectomy-related complications.

      Results

      Eight group I patients and nine group II patients had a total of 12 and 11 general complications, respectively. Liver-related complications were diagnosed in 16% and 10% of group I and group II patients, respectively. Proctocolectomy-specific complications occurred in 34% of group I and 20% of group II patients. The overall need for blood transfusion was 94% in group I and 47% in group II ( P<0.001). The cumulative probability of proctocolectomy-related complications at 5 years was 23% for group I and 64% for group II patients ( P<0.002). The difference, however, was primarily due to the high frequency of pouchitis after IPAA, estimated at 57% at 4 years. The cumulative 5-year risk of liver-related complications was 37% and 28% for group I and group II, respectively. Peristomal varices and bleeding occurred in eight group I patients but in none of group II.

      Conclusion

      Because IPAA avoids bleeding problems, it is the surgical treatment of choice in patients with PSC and CUC.
      CUC ( chronic ulcerative colitis), IPAA ( ileal pouch-anal anastomosis), PSC ( primary sclerosing cholangitis)
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      References

        • Wiesner RH
        • LaRusso NF
        Clinicopathologic features of the syndrome of primary sclerosing cholangitis.
        Gastroenterol-ogy. 1980; 79: 200-206
        • Wiesner RH
        • Ludwig J
        • LaRusso NF
        • MacCarty RL
        Diagnosis and treatment of primary sclerosing cholangitis.
        Semin Liver Dis. 1985; 5: 241-253
        • Wiesner RH
        • Grambsch PM
        • Dickson ER
        • Ludwig J
        • MacCarty RL
        • Hunter EB
        • et al.
        Primary sclerosing cholangitis: natural history, prognostic factors and survival analysis.
        Hepatology. 1989; 10: 430-436
        • Chapman RW
        • Arborgh BA
        • Rhodes JM
        • Summerfield JA
        • Dick R
        • Scheuer PJ
        • et al.
        Primary sclerosing cholangitis: a review of its clinical features, cholangiography, and hepatic histology.
        Gut. 1980; 21: 870-877
        • Ludwig J
        • Barham SS
        • LaRusso NF
        • Elveback LR
        • Wiesner RH
        • McCall IT
        Morphologic features of chronic hepatitis associated with primary sclerosing cholangitis and chronic ulcerative colitis.
        Hepatology. 1981; 1: 632-640
        • LaRusso NF
        • Wiesner RH
        • Ludwig J
        • MacCarty RL
        Current concepts: primary sclerosing cholangitis.
        N Engl J Med. 1984; 310: 899-903
        • Helzberg JH
        • Petersen JM
        • Boyer JL
        Improved survival with primary sclerosing cholangitis: a review of clinicopathologic features and comparison of symptomatic and asymptomatic patients.
        Gastroenterology. 1987; 92: 1869-1875
        • Dowis RR
        Ulcerative colitis: surgical alternatives.
        in: Fazio VW Current Therapy in Colon and Rectal Surgery. Decker,, Philadelphia1990: 166-174
        • Eade MN
        • Williams JA
        • Cooke WT
        Bleeding from an ileostomy caput medusae.
        Lancet. 1969; 2: 1166-1168
        • Graeber GM
        • Ratner MH
        • Ackerman NB
        Massive hemorrhage from ileostomy and colostomy stomas due to mucocu-taneous varices in patients with coexisting cirrhosis.
        Surgery. 1976; 79: 107-110
        • Ackerman NB
        • Graeber GM
        • Fey J
        Enterostomal varices secondary to portal hypertension: progression of disease in conservatively managed cases.
        Arch Surg. 1980; 115: 1454-1455
        • Cooper MJ
        • Mackie CR
        • Dhorajiwala J
        • Backer AL
        • Moossa AR
        Hemorrhage from ileal varices after total procto-colectomy.
        Am J Surg. 1981; 141: 178-179
        • Wang MM
        • McGrew W
        • Dunn GD
        Variceal bleeding from an ileostomy stoma.
        South Med J. 1985; 78: 733-737
        • Wiesner RH
        • LaRusso NF
        • Dozois RR
        • Beaver SJ
        Peristomal varices after proctocolectorny in patients with primary sclerosing cholangitis.
        Gastroenterology. 1986; 90: 316-322
        • MacCarty RL
        • LaRusso NF
        • Wiesner RH
        • Ludwig J
        Primary sclerosing cholangitis: findings on cholangiography and pancreatography.
        Radiology. 1983; 149: 39-44
        • Ludwig J
        • LaRusso NF
        • Wiesner RH
        Primary sclerosing cholangitis.
        Contemp Issues Surg Pathol. 1986; 8: 193-213
        • Child III, CG
        • Turcotte JG
        Surgery and portal hypertension.
        Major Probl Clin Surg. 1964; 1: 50-52
        • Pugh RN
        • Murray-Lyon LM
        • Dawson JL
        • Pietroni MC
        • Williams R
        Transection of the oesophagus for bleeding oesophageal varices.
        Br J Surg. 1973; 60: 646-649
        • Nugent FW
        • Kolack PF
        Differential diagnosis of chronic ulcerative colitis and Crohn's disease of the colon.
        in: Kirsner JB Shorter RG Inflammatory Bowel Disease. 3rd ed. Lea & Febiger,, Philadelphia1988: 185-207
        • Astler VB
        • Coller FA
        The prognostic significance of direct extension of carcinoma of the colon and rectum.
        Ann Surg. 1954; 139: 846-851
        • Broders Ae
        Squamous-cell epithelioma of the lip: a study of five hundred and thirty-seven cases.
        JAMA. 1920; 74: 656-664
        • Kaplan EL
        • Meier P
        Nonparametric estimation from incomplete observations.
        J Am Stat Assoc. 1958; 53: 457-481
        • Cox DR
        Regression models and life-tables.
        J R Stat Soc [B]. 1972; 34: 187-202
        • Penna C
        • Dowis RR
        • LaRusso NF
        • Tremaine WJ
        Pouchitis after ileal pouch anal anastomosis for chronic ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis [abstract].
        Gastroenter-ology. 1994; 106: A751
        • Conte JV
        • Arcomano TA
        • Naficy MA
        • Holt RW
        Treatment of bleeding stomal varices: report of a case and review of the literature.
        Dis Colon Rectum. 1990; 33: 308-314
        • Roberts PL
        • Martin FM
        • Schoetz Jr, DJ
        • Murray JJ
        • Coller JA
        • Veidenheimer Me
        Bleeding stomal varices: the role oflocal treatment.
        Dis Colon Rectum. 1990; 33: 547-549
        • Pemberton JH
        • Kelly KA
        • Beart Jr, RW
        • Dowis RR
        • Wolff BG
        • Ilstrup DM
        Ileal pouch-anal anastomosis for chronic ulcerative colitis: long-term results.
        Ann Surg. 1987; 206: 504-513
        • Dowis RR
        • Kelly KA
        • Welling DR
        • Gordon H
        • Beart Jr, RW
        • Wolff BG
        • et al.
        Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis.
        Ann Surg. 1989; 210: 268-271
        • Keighley MR
        • Winslet MC
        • Flinn R
        • Kmiot W
        Multivariate analysis of factors influencing the results of restorative proctocolectomy.
        Br J Surg. 1989; 76: 740-744
        • Lohmuller JL
        • Pemberton JH
        • Dowis RR
        • Ilstrup D
        • van Heerden J
        Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomo-sis.
        Ann Surg. 1990; 211: 622-627
        • Shepherd NA
        • Hulten L
        • Tytgat GN
        • Nicholls RJ
        • Nasmyth DG
        • Hill MJ
        • et al.
        Pouchitis.
        Int J Colorectal Dis. 1989; 4: 205-229