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P346. The experience of restorative proctocolectomy for ulcerative colitis during 1985–2009

I. Nieminen1, H. Huhtala2, M. Hyöty1, P. Collin1, P. Aitola1, 1Tampere University Hospital, Gastroenterology and alimentary tract surgery, Tampere, Finland, 2University of Tampere, Finland

Background

Restorative proctocolectomy (RPC) has become the operation of choice for most of the ulcerative colitis (UC) patients who require surgery. The aim of this study was to determine the operative technique, early and late complications, and pouch excision rate of the patients undergoing RPC.

Methods

Retrospective review of the medical records of all the patients with UC over 18 years of age who underwent RPC in our institution between March 1985 and December 2009; comprising a total of 352 patients, median age 36 (18–72) of which 149 (42.3%) were women.

Results

The most frequent indication for surgery was active chronic colitis in 168 (47.7%); acute colitis in 159 (45.2%) and cancer or dysplasia 25 (7.1%). During the early years all anastomosis were handsewn and covering ileostomy was constructed only when considered necessary, whereas today, we perform mainly stapler anastomosis with a routine covering ileostomy. In the whole series, handsewn anastomoses were performed in 283 (80.4%) patients and stapled anastomoses in 69 (19.6%); Covering ileostomy was carried out in 133 (37.8%) patients. Urgent colectomy with end ileostomy was performed before RPC in 170 (48.3%) patients.

The total number of any early complications (30 days after operation) was 184 (in 52.3% patients); of these 82 (23.3% of all) were J-pouch related complications. The operative mortality was 0.3%. When covering ileostomy was used there were significantly less leakages (6.0% vs. 16.9%, p = 0.003) and early reoperations (4.5% vs. 11. 9%, p = 0.02).

The median follow up was 5 years. Pouchitis was the most common late complication occurring as at least once in 134 (38.1%) patients. Forty-two (11.9%) patients experienced pouch failure leading to pouch excision in all but one. During the first year pouch excision rate was 2.2%. Seven patients were afterwards found to have confirmed and one probable Crohn's disease; four of these had had their pouch excised.

Conclusion

The technique used in RPC in our hospital has changed over the past years. Covering ileostomy seems to protect from major complications. RPC is still associated with significant morbidity, pouchitis being the most common problem in follow up. Pouch failure is common but not inevitable in patients with a later diagnosis of Crohn's disease.