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Survival of ileal pouch anal anastomosis constructed after colectomy or secondary to a previous ileorectal anastomosis in ulcerative colitis patients: a population-based cohort study
Ryhov County Hospital, Sweden; Oxford University Hospital NHS Fdn Trust, England.
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för Kirurgi, Ortopedi och Onkologi. Linköpings universitet, Medicinska fakulteten. Suez Canal University, Egypt.
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för Kirurgi, Ortopedi och Onkologi. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US.
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för Kirurgi, Ortopedi och Onkologi. Linköpings universitet, Medicinska fakulteten. Ryhov County Hospital, Sweden.
2017 (engelsk)Inngår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 52, nr 5, s. 531-535Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objectives: Ileorectal anastomosis (IRA) affects bowel function, sexual function and reproduction less negatively than ileal pouch anal anastomosis (IPAA), the standard reconstruction after colectomy for ulcerative colitis (UC). In younger UC patients, IRA may have a role postponing pelvic surgery and IPAA. The aim of the present study was to investigate the survival of IPAA secondary to IRA compared to IPAA as primary reconstruction, as this has not previously been studied in UC. Patients and methods: All patients with UC diagnosis between 1960 and 2010 in Sweden were identified from the National Patient Registry. From this cohort, colectomized patients reconstructed with primary IPAA and patients reconstructed with IPAA secondary to IRA were identified. The survival of the IPAA was followed up until pouch failure, defined as pouchectomy and ileostomy or a diverting ileostomy alone. Results: Out of 63,796 patients, 1796 were reconstructed with IPAA, either primarily (n=1720) or secondary to a previous IRA (n=76). There were no demographic differences between the groups, including length of follow-up (median 12.6 (IQR 6.7-16.6) years and 10.0 (IQR 3.5-15.9) years, respectively). Failure of the IPAA occurred in 103 (6.0%) patients with primary and in 6 (8%) patients after secondary IPAA (P=0.38 log-rank). The 10-year pouch survival was 94% (95% CI 93-96) for primary IPAA and 92% (81-97) for secondary. Conclusions: Patients choosing IRA as primary reconstruction do not have an increased risk of failure of a later secondary IPAA in comparison with patients with primary IPAA.

sted, utgiver, år, opplag, sider
TAYLOR & FRANCIS LTD , 2017. Vol. 52, nr 5, s. 531-535
Emneord [en]
Ulcerative colitis; inflammatory bowel disease; ileal pouch anal anastomosis; ileoanal pouches; ileoanal reservoir; pelvic pouches; ileorectal anastomosis; restorative proctocolectomy; pouch failure; pouch survival
HSV kategori
Identifikatorer
URN: urn:nbn:se:liu:diva-136233DOI: 10.1080/00365521.2016.1278457ISI: 000395746800006PubMedID: 28102092OAI: oai:DiVA.org:liu-136233DiVA, id: diva2:1086220
Merknad

Funding Agencies|Bengt Ihres Fund; Medical Research Council of Southeast Sweden; Futurum - Academy for Health and Care; Region Jonkoping County, Sweden

Tilgjengelig fra: 2017-03-31 Laget: 2017-03-31 Sist oppdatert: 2019-11-04
Inngår i avhandling
1. Cancer and reconstructive surgery in Inflammatory bowel disease
Åpne denne publikasjonen i ny fane eller vindu >>Cancer and reconstructive surgery in Inflammatory bowel disease
2019 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

Ulcerative colitis (UC) is a chronic inflammatory disease that affects the colon. According to the literature, some thirty percent of UC patients may require a subtotal colectomy and ileostomy due to failure of medical treatment, acute toxic colitis or dysplasia/cancer diagnosis. Some patients choose to get continence restored with either an ileorectal anastomosis (IRA) or an ileal pouch-anal anastomosis (IPAA). Worldwide most surgeons prefer an IPAA to an IRA, despite reports of pouchitis, impaired fertility and fecundity. Fear of recurring proctitis and fear of rectal cancer in the remaining rectum is contributing to the choice of an IPAA. Little is known regarding the outcomes of IRA compared with IPAA in UC patients. We aimed to investigate the anorectal function, quality of life (QoL), risk of failure and rectal cancer in patients with UC restored with IRA and IPAA respectively.

Methods: Data about all Inflammatory bowel disease (IBD) patients was obtained from the Swedish National Patient Register (NPR) between 1964-2014 and in one study from the Linköping University Hospital medical records 2006-2012. Patients who developed cancer were identified from the Swedish National Cancer Register. We investigated the risk of cancer and inflammation, functional outcome and failure as well as the quality of life for IRA and IPAA patients. Investigation of risk for cancer in IRA and IPAA compared with the background population was performed using survival analytic techniques: uni-and multivariate regression, Kaplan Meier curves and standardized incidence ratio.

Results: Twelve percent (7,889 /63,795) of UC patients required colectomy according to the NPR. The relative risk for rectal cancer among patients with an IRA was increased (SIR 8.7). However, the absolute risk was 1.8% after a mean follow up of 8.6 years and the cumulative risk 10- and 20-years after IRA was 1.6% and 5.6%, respectively. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio 6.12), and severe dysplasia or cancer of the colon prior to subtotal colectomy in patients with a diverted rectum in place (hazard ratio 3.67). Regarding IPAA, the relative risk to develop rectal cancer was (SIR 0.4) compared with the background population and the absolute risk was only 0.06% after a mean of 12.2 years of follow up. Among patients operated at the Linköping University Hospital: IRA patients reported better overall continence according to the Öresland score with in median3 (IQR 2–5) for IRA (n=38) and 10 (IQR 5–15) for IPAA (n=39, p<0.001). There were no major differences regarding the QoL. According to the NPR, after a median follow up of 12.4 years failure occurred in 265(32%) out of 1112 patients, of which 76 were secondarily reconstructed with an IPAA. Failure of the IPAA occurred in 103 (6%) patients with primary and in 6 (8%) patients after secondary IPAA (log-rank p=0.38).

Conclusion: IRA is a safe restorative procedure for selected UC patients. Patients should be aware of the annual postoperative endoscopic evaluation with biopsies as well as the need to the use of local anti-inflammatory preparations. However, IRA should not be offered for UC patients with an associated primary sclerosing cholangitis diagnosis due to the increased risk to develop rectal cancer in their rectal mucosa. In such case, IPAA is probably the treatment of choice.  

sted, utgiver, år, opplag, sider
Linköping: Linköping University Electronic Press, 2019. s. 116
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1670
Emneord
Inflammatory bowel disease, Colorectal cancer, IRA, IPAA, Primary sclerosing cholangitis
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-161507 (URN)10.3384/diss.diva-161507 (DOI)9789176851098 (ISBN)
Disputas
2019-12-19, Hugo Theorell sal, Campus US, Linköpings Universitet, Linköping, 09:00 (engelsk)
Opponent
Veileder
Tilgjengelig fra: 2019-11-04 Laget: 2019-11-04 Sist oppdatert: 2019-11-04bibliografisk kontrollert

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