Total colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis (IPAA) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to determine the short- and long-term outcomes of patients undergoing IPAA by a single surgeon, correlating intraoperative technical aspects with outcomes, and to characterize better the clinical syndrome of pouchitis. A retrospective review was performed of 114 consecutive patients who underwent IPAA by a single surgeon between December 1987 and August 1996. Clinical follow-up and operative notes were reviewed, and patient questionnaires were obtained for all patients. The mean follow-up was 3 years (range 0.5-8.0 years). The average age of the patients was 39 years (range 16-72 years). There were 64 males and 50 females. Indications for operation were ulcerative colitis (n = 101) and familial polyposis coli (n = 13). Long-term morbidity occurred in 41% of patients (small bowel obstruction 10%, anastomotic stricture 9%). Pouch excision was required in only three patients. Stool frequency (mean +/- SE) was 6.1 +/- 0.2 and did not change with duration of follow-up. Only 7% of patients reported fecal soilage. The incidence of pouchitis was 59% (n = 67), with 4.2 +/- 0.3 episodes of pouchitis per patient. Using multivariate analysis, the factors significantly associated with the incidence of pouchitis were gender (p = 0.008) and duration of follow-up (p = 0. 02). A total of 37 of 50 women (74%) but only 30 of 64 men (47%) developed pouchitis. The incidence of pouchitis increased with the duration of follow-up. The incidences of pouchitis in patients followed for 6 months, 1 year, and 3 years were 25%, 37%, and 50%, respectively. Of patients followed more than 6 years, the incidence of pouchitis was 94% (15/16). There was not a significant correlation between anastomotic tension or the extent of arterial dissection of the ileal mesentery required to achieve IPAA and the incidence of pouchitis. The best antibiotics for pouchitis were metronidazole (54% of patients) and ciprofloxacin (37%). Eleven patients have required nearly continuous antibiotics. Patient satisfaction with the outcome is high, with a mean satisfaction of 8. 4 (0, dissatisfied; 10, extremely satisfied). This review demonstrates a high incidence of pouchitis in patients after IPAA, which is due to the more liberal definition of the syndrome and the complete follow-up achieved in this report compared to previous series. This study also is unique in identifying the significantly higher incidence of pouchitis in women, although the overall satisfaction with the clinical outcome in patients undergoing IPAA remains high.

No abstract

Malignant esophageal stricture secondary to invasion from a tumor arising in a contiguous organ is a relatively rare finding; even more uncommon is a direct metastasis to the esophagus from a distant primary carcinoma. We present six cases, the largest current series, of esophageal strictures secondary to metastases from a separate primary cancer. We reviewed the records of 20 patients treated at Virginia Mason Medical Center between 1972 and 2000 with a diagnosis of malignant esophageal stricture secondary to an extraesophageal primary carcinoma. Patients whose stricture appeared to be secondary to esophageal invasion or compression from a contiguous tumor or lymph nodes were excluded. The remaining six patients who had metastases to the esophagus itself were reviewed with respect to the nature of the primary tumor, presentation, radiologic and endoscopic findings, and treatment. Among the 20 patients reviewed, 14 were excluded owing to either contiguous involvement from a nearby primary malignancy, regional nodal involvement, or complications of external beam radiation treatment. Six patients were considered to have direct metastasis to the esophagus from distant primary malignancies. The mean age of these patients was 72 years (range 68-74). Two of the primary lesions were lung carcinoma, while four primaries were breast cancers. The average time interval from the diagnosis of a primary tumor to esophageal involvement was 7 years in patients with breast cancer and 5 months in patients with lung cancer. Three patients were palliated with endoscopic dilation and stent placement. The other three patients have died secondary to upper gastrointestinal bleeding. Metastatic cancer to the esophagus is a rare occurrence. The process is usually submucosal and can be difficult to diagnose. The diagnosis should be considered when a patient presents with malignant dysphagia and has a background of distant carcinoma.

No abstract

No abstract