Abstract
Background
Restorative proctocolectomy with an ileal pouch–anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery.
Methods
The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control.
Results
Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted.
Conclusion
Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B12 anemia and hypomagnesaemia.
Similar content being viewed by others
Reference
Park AG, Nicholls RJ (1978) Proctocolectomy without ileostomy for ulcerative colitis. Br J Surg 2:85–88
Martin LW, LeCoultre C, Schubert WK (1997) Total colectomy and mucosal proctocolectomy with preservation of continence in ulcerative colitis. Ann Surg 186:477–480
Utsunomiya J, Iwama T, Imajo M et al (1980) Total colectomy, mucosal proctectomy, and ileoanal anastomosis. Dis Colon Rectum 23:459–466
Keighley MR, Yoshioka K, Kmior W (1988) Prospective randomised trial to compare the stapled double lumen pouch and the sutured quadruple pouch for restorative proctocolectomy. Br J Surg 75:1008–1011
Tuckson WB, Fazio VW (1991) Functional comparison between double and triple ileal loop pouches. Dis Colon Rectum 34:17–21
Nicholls RJ, Pezim ME (1985) Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial polyposis: a comparison of three reservoir designs. Br J Surg 72:470—474
Tiainen J, Matikainen M (2000) Long-term clinical outcome and anemia after restorative proctocolectomy for ulcerative colitis. Scand J Gastroenterol 35:1170–1173
Mibu R, Oohata Y, Ishikawa M, Sakai M, Tanaka M (1998) Terminal ileal transport procedure in ileoanal anastomosis following proctocolectomy. Int J Colorect Dis 13:17–20
Christl SU, Schewppach W (1997) Metabolic consequences of total colectomy. Scand J Gastroent 32:20–24
Levitt MD, Kuan M (1998) The physiology of ileo-anal pouch function. Am J Surg 176:384–389
Kuisma J, Nuutinen H, Luukkonen P, Järvinen H, Kahri A, Färkkilä M (2001) Long term metabolic consequences of ileal pouch–anal anastomosis for ulcerative colitis. Am J Gastroenterol 96:3110–3116
Liljeqvist L, Lindquist K, Ljungdahl I (1988) Alterations in ileoanal pouch technique, 1980 to 1987. Complications and functional outcome. Dis Colon Rectum 31:929–938
Liljeqvist L, Lindquist K (1985) A reconstructive operation on malfunctioning S-shaped pelvic reservoirs. Dis Colon Rectum 28:506–511
Lindquist K, Nilsell K, Liljeqvist L (1987) Cuff abscesses and ileoanal anastomotic separation in pelvic pouch surgery. An analysis of possible etiologic factors. Dis Colon Rectum 30:355–359
Lindquist K (1990) Anal manometry with microtransducer technique before and after restorative proctocolectomy. Sphincter function and clinical correlations. Dis Colon Rectum 33:91–98
Lindquist K, Liljeqvist L, Sellberg B (1984) The topography of ileoanal reservoirs in relation to evacuation patterns and clinical functions. Acta Chir Scand 150:573–579
Veress B, Reinholt FP, Lindquist K, Liljeqvist L (1990) Different types of mucosal adaption in the ileal reservoir after restorative proctocolectomy. APMIS 98:786–796
Veress B, Reinholt FP, Lindquist K, Löfberg R, Liljeqvist L (1995) Long-term histomorphological surveillance of the pelvic ileal pouch: dysplasia develops in a subgroup of patients. Gastroenterology 109:1090–1097
Ståhlberg D, Gullberg K, Liljeqvist L, Hellers G, Löfberg Robert (1996) Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors. Dis Colon Rectum 39:1012–1018
Weinry RM, Gustavsson JP, Liljeqvist L, Poppen B, Rossel RJ (1995) A prospective study of quality of life after pelvic pouch operation. J Am Coll Surg 180:189–198
M’Koma AE, Lindquist K, Liljeqvist L (1994) Biochemical laboratory data before and after restorative proctocolectomy. A study on 83 patients with a follow-up of 36 months. Ann Chir 48:525–534
M’Koma AE (1994) Follow-up results of haematology data before and after restorative proctocolectomy. Clinical outcome. Dis Colon Rectum 37:932–937
M’Koma AE, Lindquist K, Liljeqvist L (1995) Adaptive returns to normal serum electrolytes after depletion following restorative proctocolectomy and ileal-pouch anal anastomosis. A controlled, prospective study. Int J Surg Sci 2:330–334
M’Koma AE, Lindquist K, Liljeqvist L (2000) Observations in the blood lipid profile in patients undergoing restorative proctocolectomy. Int J Surg Investig 2:227–235
M’Koma AE, Lindquist K, Liljeqvist L (2000) A study of plasma immunoglobulins profile in connection with restorative proctocolectomy. Int J Surg Investig 2:125–131
M’Koma AE, Lindquist K, Liljeqvist L (1999) Effect of restorative proctocolectomy on gastric acid secretion and serum gastrin levels. A prospective study. Dis Colon Rectum 42:398–402
Tiainen J, Matikainen M, Hiltunen KM (1999) Eleven years experience of postoperative morbidity and trends in handsewn ileal–anal anastomosis with pelvic J-pouch for ulcerative colitis. Ann Chir Gynaecol 88:118–121
Tiainen J, Matikainen M (1999) Health related quality of life after ileal J-pouch-anastomosis for ulcerative colitis: long-term results. Scand J Gastroenterol 34:601–605
Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH (1998) J ileal pouch–anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 85:800–803
Foidart M et al (1983) Hemopexin metabolism in patients with altered serum levels. J Lab Clin Med 102:838–846
Asofski R et al (1970) An extension of the nomenclature of immunoglobulins. J Biol Chem 245:3033–3034
Capra JD et al (1972) Recommendations for the nomenclature of human immunoglobulins. Immunochemistry 9:597–599
Raven JL, Barkhan P (1972) Assay of vitamin B12. J Clin Pathol 25:1101
Young S, Bomford A (1984) Transferrin and cellular iron exchange. Clin Sci 67:273–278
Ray AK (1972) A safe and inexpensive method for setting up the Westergren ESR. J Clin Pathol 25:366
Attallah AM, Johnson RP (1981) A simple highly sensitive method for the determination of cell viability using an electronic particle analyzer, Coulter counter. J Immunol Methods 41:155–162
Carey M (1978) Critical tables for calculating the cholesterol saturation of native bile. J Lipid Res 19:945–955
Carlson K (1977) Lipoprotein fractionation. J Clin Pathol 5:32–37
Lopes-Virella M, Stone P, Ellis S, Colwell J (1977) Cholesterol determination in high-density lipoproteins separated by three different methods. Clin Chem 23:882–884
Gräsbeck RN, Nyberg W, Siurala M (1956) Urinary excretion of radioactive vitamin B12 (“Schilling test”). Nord Med 56:1656–1658
Einarsson K, Björkhem I, Eklöf R, Blomstrand R (1983) 14C-triolein breath test as a rapid convenient screening test for fat malabsorption. Scand J Gastroenterol 18:9–12
Wallenstein S, Zucker CL, Fleiss JL (1980) Some statistical methods useful in circulation research. J Cir Res 47:1–9
Wilcoxon F (1945) Individual comparisons by ranking methods. Biometrics 1:80–83
University of Califonia BMDP (1986) BMDP Statistical Software, Los Angeles, CA
Fisher RA (1921) On the probable error of a coefficient of correlation deduced from a small sample. Metron 1:3–21
Merret MN, Soper N, Mortensen N, Jewell DP (1996) Intestinal permeability in the ileal pouch. Gut 39:226–230
Luukkonen P, Jarvinen H, Transkannen M et al (1994) Pouchitis: recurrence of the inflammatory bowel disease? Gut 35:243–246
Hurst RD, Molinari M, Chung T et al (1996) Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy. Arch Surg 131:497–500
Salemans JM, Nagengast FM, Lubbers EJ et al (1992) Postoperative and long-term results of ileal pouch–anal anastomosis for ulcerative colitis and familial polyposis coli. Dig Dis Sci 37:1882–1889
Malafosse M (2003) Familial adenomatous polyposis: long term follow-up of patients after surgical treatment. Prognostic factors. Bull Acad Natl Med 187:103–114
Michelassi F, Lee J, Rubin M, Fichera A, Kasza K, Karrison T, Hurst RD (2003) Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study. Ann Surg 238:433–441
Willis S, Lorken M, Holzl F, Fackeldey V, Schumpelick V (2003) Functional results and quality of life after proctocolectomy and ileal J-pouch–anal anastomosis for ulcerative colitis. Zentralbl Chir 128:663–668
Colombo PL, Tinozzi FP, Abelli M, Pini G, Benedetti M, Moglia P, Morone G, Albertario S, Forti P, Laera MR, Bianchi C, Tinozzi S (2002) Clinical and functional results after restorative proctocolectomy with ileal J reservoir in the treatment of ulcerative colitis. Ann Ital Chir 73:287–296
Regimbeau JM, Panis Y, Pocard M, Hautefeuille P, Valleur P (2001) Handsewn ileal pouch–anal anastomosis on the dentate line after total proctectomy: technique to avoid incomplete mucosectomy and the need for long-term follow-up of the anal transition zone. Dis Colon Rectum 44:43–50
Dunker MS, Bemelman WA, Slors JF, van Duijvendijk P, Gouma DJ (2001) Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum 44:1800–1807
Fichera A, Michelassi F (2001) Long-term prospective assessment of functional results after proctectomy with coloanal anastomosis. J Gastrointest Surg 5:153–157
Nilsson LO, Andersson H, Hulten L, Jagenburg R, Kock NG, Myrvold HE, Phillipson B (1979) Absorption studies in patients 6 to 10 years after construction of ileostomy reservoir. Gut 20:499–509
McIntyre PB, Pemberton JH, Wolff BC, Beart RW, Dozois RR (1994) Comparing functional results one year and ten years after ileal pouch–anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 34:303–307
Weinryb RM, Liljeqvist L, Poppen B, Gustavsson JP (2003) A longitudinal study of long-term quality of life after ileal pouch-anal anastomosis. Am J Surg 185:333–338
Fazio VW, O’Riordain MG, Lavery IC, Church JM, Lau P, Strong SA, Hull T (1999) Long-term functional outcome and quality of life after stapled restorative proctocolectomy. Ann Surg 230:575–584
Barrier A, Martel P, Gallot D, Dugue L, Sezeur A, Malafosse M (1999) Long-term functional results of colonic J pouch versus straight coloanal anastomosis. Br J Surg 86:1176–1179
Scarpa M, Angriman I, Ruffolo C, Ferronato A, Polese L, Barollo M, Martin A, Sturniolo GC, D’Amico DF (2004) Health-related quality of life after restorative proctocolectomy for ulcerative colitis: long-term results. World J Surg 28:124–129
Kalbassi MR, Winter DC, Deasy JM (2003) Quality-of-life assessment of patients after ileal pouch–anal anastomosis for slow-transit constipation with rectal inertia. Dis Colon Rectum 46:1508–1512
Yu CS, Pemberton JH, Larson D (2002) Ileal pouch–anal anastomosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 43:1487–1496
Heuschen U, Schmidt J, Allemeyer E, Stern J, Heuschen G (2001) The ileo-anal pouch procedure: complications, quality of life, and long-term results. Zentralbl Chir 126:36–42
Coffey JC, Winter DC, Neary P, Murphy A, Redmond HP, Kirwan WO (2002) Quality of life after ileal pouch–anal anastomosis: an evaluation of diet and other factors using the Cleveland Global Quality of Life instrument. Dis Colon Rectum 45:30–38
Dunker MS, Bemelman WA, Slors JF, van Duijvendijk P, Gouma DJ (2001) Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum 44:1800–1807
Ko CY, Rusin LC, Schoetz DJ Jr, Moreau L, Coller JC, Murray JJ, Roberts PL, Marcello PW (2001) Long-term outcomes of the ileal pouch anal anastomosis: the association of bowel function and quality of life 5 years after surgery. J Surg Res 98:102–107
Nicholls RJ, Belliveau P, Neill M, Wilks M, Tabaqchalis S (1981) Restorative proctocolectomy with ileal reservoir: a pathophysiological assessment. Gut 22:462–468
Moskowitz RL, Shephered NA, Nocholls RJ (1986) An assessment of inflammation in the reservoir after restorative proctocolectomy with ileal reservoir. Int J Colorect Dis 1:167–174
Main AN, Morgan RJ, Russel RI (1981) Magnesium deficiency in chronic inflammatory bowel disease and requirements during intravenous nutrition. J Parent Ent Nutr 5:15–19
Hessov I, Hasselblad C, Fasth S, Hulten L (1983) Magnesium deficiency after ileal resection for Crohn’s disease. Scand J Gastroenterol 18:643–649
Stewart JS, Pollock DJ, Hoffbrand AV, Mollin DL, Booth CC (1967) A study of proximal and distal intestinal structure and absorptive function in idiopathic steatorrhoea. Quart J Med 36:425–444
MacFadyen DA, Akre OH, Duncan J, Flesch F, Mauser M (1954) Electrolyte metabolism in ulcerative colitis patients before and after surgery. 55th annual meeting of the American Gastroenterological Association, San Francisco, California, June 18–19
Kimberg DV, Baerg RD, Gershon E, Graudusius RT (1971) Effect of cortisone treatment on the active transport of calcium by the small intestine. J Clin Invest 50:1309–1321
Moore CV (1961) Iron metabolism and nutrition. Harvey Lect 55:67–101
Naiman JL, Oski FA, Diamond LK et al (1964) The gastrointestinal effects of iron deficiency anemia. Paediatrics 33:83–99
Moore CV, Duback R (1956) Metabolism and requirement of iron in the human. JAMA 162:197–204
Stewart JS, Pollock DJ, Hoffbrand AV, Mollin DL, Booth CC (1967) A study of proximal and distal intestinal structure and absorptive function in idiopathic steatorrhoea. Quart J Med 36:425–444
Miettinen TA, Peltokallio P (1971) Bile salt, fat, water and vitamin B12 excretion after ileostomy. Scand J Gastroenterol 6:543–552
Castle WB. Gastric intrinsic factors and vitamin B12 absorption. In (ed) Hand book of physiology, vol. III, sec. 6. The Williams and Wilkins Co, Baltimore, Maryland, pp 1529–1552
Schjonsby H, Hofstand T (1972) Effect of bacteria on intestinal uptake of vitamin B12. II. The consequences of in vitro preincubation of B12 with pure bacterial population. Scand J Gastroenterol 7:353–359
Pedersen BH, Simonsen L, Hansen LK et al (1985) Bile acid malabsorption in patients with an ileum reservoir with a long efferent leg to an anal anastomosis. Scand J Gastroenteol 20:995–1000
Steizner M, Buddington RK, Phillips JD, Diamond JM, Fonkalsrud EW (1990) Changes in mucosal nutrient transport in small and large ileal reservoir after endorectal ileal pullthrough. J Surg Res 49:344–349
Nasmyth DG, Godwin PG, Dixon MF, Williams NS, Johnston D (1989) Ileal ecology after pouch–anal anastomosis or ileostomy. A study of mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationship. Gastroenterology 96:817–824
Natori H, Utsunomiya J, Yamamura T, Benno Y, Uchida K (1992) Fecal and stomal bile acid composition after ileostomy or ileoanal anastomosis in patients with chronic ulcerative colitis and adenomatosis coli. Gastroenterology 102:1278–1288
Kramer P, Kearney MM, Ingelfinger FJ (1962) The effect of specific foods and water loading on the ileal excreta of ileostomized human subjects. Gastroenterology 42:535–546
Percy-Robb IW, Jalan KN, McManus JP, Sircus W (1969) Bile salt metabolism in patients with an ileostomy. Br J Surg 56:694–695
Schjonsby H, Halvorsen JF, Hofstand T, Hovdennak N (1977) Stagnant loop syndrome in patients with continent ileostomy (intra-abdominal ileal reservoir). Gut 18:796–799
Heppell J, Kelly KA, Phillips SF (1982) Physiologic aspect of continence after colectomy, mucosal proctectomy and endorectal ileo-anal anastomosis. Ann Surg 195:435–443
Kuisma J, Luukkonen P, Jarvinen H, Kahri A, Farkkila M (2002) Risk of osteopenia after proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Scand J Gastroenterol 37:171–176
Jensen MB, Houborg KB, Vestergaard P, Kissmeyer-Nielsen P, Mosekilde L, Laurberg S (2002) Improved physical performance and increased lean tissue and fat mass in patients with ulcerative colitis four to six years after ileoanal anastomosis with a J-pouch. Dis Colon Rectum 45:1601–1607
Geerling BJ, Stockbrugger RW, Brummer RJ (1999) Nutrition and inflammatory bowel disease: an update. Scand J Gastroenterol 230:95–105
Krasinski SD, Russell RM, Furie BC, Kruger SF, Jacques PF, Furie B (1985) The prevalence of vitamin K deficiency in chronic gastrointestinal disorders. Am J Clin Nutr 41:639–643
Brandtzaeg P, Halstensen TS, Ktee P, Krajci P, Kvale D, Rognum TO, Scott H, Sollid LM (1989) Immunobiology and immunopathology of human gut mucosa: humoral immunity and intraepithelial lympocytes. Gastroenterology 97:1562–1564
Elson CO (1988) The immunology of inflammatory bowel disease. In: Kirsner JB, Shorter PC (eds) Inflammatory bowel disease. Lea & Febiger, Philadelphia, pp 97–164
Brandtzaeg P (1985) Immunopathology of Crohn’s disease. Ann Gastroenterol Hepatol 21:201–220
Brandtzaeg P, Halstensen TS, Kett K, Rognum TO (1987) Local immunopathology in inflammatory bowel disease. In: Järnerot G (ed) Inflammatory bowel disease. Raven, New York, pp 21–35
Dearing WH, McGuckin WF, Eiveback LR (1969) Serum alpha 1-acid glycoprotein in chronic ulcerative colitis. Gastroenterology 56:295–303
Carey JB Jr, Wilson ID, Zaki FG, Hanson RF (1966) The metabolism of bile acids with special reference to liver injury. Medicine (Baltimore) 45:461–470
Sherr HP, Nair PP, White JJ, Banwell JG, Lockwood DH (1974) Bile acid metabolism and hepatic disease following small bowel bypass for obesity. Am J Clin Nutr 27:1369–1379
Payne JH, Dewind LT (1969) Surgical treatment of obesity. Am J Surg 118:141–147
Besterman HS, Adrian TE, Mallinson CN, Christofides ND, Sarson DL, Pera A, Lombardo L, Modigliani R, Bloom SR (1982) Gut hormone release after intestinal resection. Gut 23:854–861
Pietroletti R, Slors FJ, Mariani P, Leardi S, Simi M, Brummelkamp WH (1990) Enteroglucagon and peptide YY response after construction of a pelvic reservoir in humans. Dis Colon Rectum 33:966–969
Ternent CA, Staab P, Thorson AG, Blatchford GJ, Christensen MA, Thompson JS, Lanspa SJ, Meade PG, Cali RA, Falk PM, Sentovich SM, Adrian TE (1998) Ileoanal pouch function and release of peptide YY. Dis Colon Rectum 41:868–874
Dubé S, Heyen F (1990) Pouchitis and gastric hyposecretion: cause or effect? Int J Colorectal Dis 5:142–143
Barton JG, Paden MA, Lane M, Postier RG (2001) Comparison of postoperative outcomes in ulcerative colitis and familial polyposis patients after ileoanal pouch operations. Am J Surg 182:616–620
Heuschen UA, Hinz U, Allemeyer EH, Autschbach F, Stern J, Lucas M, Herfarth C, Heuschen G (2002) Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 235:207–216
Stallmach A, van Look M, Scheiffele F et al (1999) IgG, albumin, and sCD44 in whole-gut lavage fluid are useful clinical markers for assessing the presence and activity of pouchitis. Int J Colorectal Dis 14:35–40
Parc YR, Mosleim G, Pemberton JH, Wolff BG, King JE (2000) Familial adenomatous polyposis: results after ileal pouch–anal anastomosis in teenagers. Dis Colon Rectum 43:893–898
Acknowledgements
Dr. Christian Löwbeer, MD, is acknowledged for offering statistic guidelines and suggestions. This study was supported by grants from the Karolinska Institute.*This paper was presented in parts at the XVII Biennial Congress of The International Society of University Colon and Rectal Surgeons (ISUCRS), Malmö, Sweden, June 7–11, 1998, and at The Congress of the European Society for Surgical Research (ESSR), Corfu, Greece, May 18–21, 1997.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
M’Koma, A. Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy. Int J Colorectal Dis 21, 711–720 (2006). https://doi.org/10.1007/s00384-005-0076-3
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-005-0076-3