STUDIES ON THE ILEAL POUCH-ANAL ANASTOMOSIS
Marie Louise Sunde
University of Oslo
Institute of Clinical Medicine Faculty of Medicine
© Marie Louise Sunde, 2018
Series of dissertations submitted to the Faculty of Medicine, University of Oslo
ISBN 978-82-8377-196-1
All rights reserved. No part of this publication may be
reproduced or transmitted, in any form or by any means, without permission.
Cover: Hanne Baadsgaard Utigard.
Print production: Reprosentralen, University of Oslo.
ACKNOWLEDGEMENTS:
Many people have been instrumental in conducting the studies this thesis is based on. I am especially grateful to Dr. Petr Ricanek and Professor Jørgen Jahnsen from the Department of Gastroenterology for collaborating on our third study, and I would like to extend special thanks to Dr. Ricanek for performing pouch endoscopies on all patients included. Likewise I would like to express my gratitude to Dr. Anne Negård, Dr. Njål Bakka, and Professor Jonn Terje Geitung from the Department of Radiology for collaborating on our fourth study. Again, a special thanks to Dr. Negård for overseeing the radiological aspects of the study. The
collaboration with both departments has been very fruitful, and I am thankful for the interest, engagement and positivity from our mentioned colleagues. I also want to thank Dr. Shafique, Dr. Schive, and Dr. Monteleone from the Department of Surgery for helping with the
manovolumetric examination of our study patients. Lastly, I want to thank nurses at the out- patient clinic and the radiographs at the MRI lab for coordinating and facilitating the
examination of patients. The statisticians at University of Oslo, campus Ahus, have been very helpful in advising the statistical analysis in the studies. I also want to thank my brother, Einar Sunde, for thoughtful help with calculations and statistical analysis, and my mother, Ingrid Stange, for proof reading.
This thesis would not have been possible without our patients agreeing to being interviewed and undergo further examinations. I want to express my gratitude to all patients included in the studies, and special thanks are due to the patients undergoing manovolumetric testing, endoscopy, and MRI. Our patients have been positive and happy to contribute to research on pouch surgery. I hope our results will improve the surgery and functional outcome in the future.
Last but not least, I want to thank my supervisors Dr. Arne Engebreth Færden and Professor Tom Øresland for supervising, advising, supporting and encouraging me throughout the research period. I am very grateful for your personal engagement and presence in each study, and for your support and trust ever since I was invited to join your research group as a
medical student.
CONTENTS:
THESIS AT A GLANCE……….. 7
PAPERS INCLUDED IN THE THESIS………. 8
1. BACKGROUND: 1.1 Introduction………. 9
1.2 History of ulcerative colitis………. 10
1.2.1 Aetiological understanding in a historic perspective……….. 10
1.3 History of IPAA surgery………... 12
1.3.1 The continent ileostomy – Kock’s pouch ………. 14
1.3.2 S-Pouch………... 14
1.3.3 J- and W-pouch………15
1.4 Ulcerative colitis………... 16
1.4.1 Epidemiology……….. 16
1.4.2 Aetiology………. 17
1.4.3 Pathogenesis……….... 17
1.4.4 Clinical manifestation………... 18
1.4.5 Medical treatment………... 18
1.4.6 Surgical intervention ……….. 19
1.5. IPAA physiology……….. 19
1.5.1 Sphincter function………... 19
1.5.2 Volume and compliance………... 20
1.5.3 Site of anastomosis………... 20
1.5.4 Type of anastomosis……….... 21
1.6. Complications›……… 21
1.6.1 Septic pelvic complications……….... 21
1.6.2 Pouchitis……….. 22
1.6.3 Other non-septic complications……….. 23
1.6.4 Laparoscopic versus open approach………... 23
1.7. Functional outcome and quality of life………... 24
1.7.1 Functional outcome……….... 24
1.7.2 Pouch design and functional outcome……… 25
1.7.3 Quality of life versus pouch function………. 26
1.7.4 Quality of life………. 27
1.8. Sexual function……… 27
2. AIM OF THE STUDY……….. 29
3. METHODS………. 30
3.1 Patients ……….... 30
3.2 Surgical technique ………..……….... 30
3.3 Questionnaires………... 31
3.4 Barostat………….………... 33
3.5 Pouch endoscopy……….………. 34
3.6 Biomarkers……….……….. 34
3.7 MRI……….………. 35
4. RESULTS ……….. 37
4.1 Study 1………... 37
4.1.1 Main findings……….. 37
4.1.2 Surgical outcome……….... 37
4.1.3 Functional outcome ……….... 38
4.1.4 Quality of life………. 39
4.1.5 Quality of life and functional outcome………... 40
4.2 Study 2……….. 41
4.2.1 Main findings……….. 41
4.2.2 Sexual function ……….. 41
4.2.3 Pouch function versus sexual function……… 43
4.3 Study 3……….. 44
4.3.1. Main findings………. 44
4.3.2 Barostat………... 45
4.3.3 Pouch endoscopy and biomarkers….………... 47
4.4 Study 4……….. 48
4.4.1 Main findings……….. 48
4.4.2 MRI………. 48
5. METHODOLOGICAL CONSIDERATIONS……….... 51
5.1 Study 1………... 51
5.2 Study 2………... 52
5.3 Study 3………... 54
5.4 Study 4………... 55
6. GENERAL DISCUSSION……….... 56
7. CONCLUSION ………. 60
8. FUTURE PERSPECTIVES………. 61
9. REFERENCES……….. 62
10 APPENDIXES……….. 72
Scores………. 73
Pouch functioning score………... 73
SF-36……… 74
PISQ………. 79
IIEf-5……… 80
Studies... 81 1. Restorative proctocolectomy with two different pouch
designs: few complications with good function.
2. Correlation between pouch function and sexual function in patients with IPAA.
3. Determinants of optimal bowel function in ileal pouch-anal anastomosis – physiological differences contributing to pouch function.
4. Morphological MRI with defecography of the ileal pouch anal anastomosis – Contributes little to the understanding of functional outcome.
THESIS AT A GLANCE:
STUDY 1 STUDY 2 STUDY 3 STUDY 4
AIM To investigate surgical outcome after IPAA at our unit, determine if there are differences in functional
outcome or QoL between patients with J and K pouches, and investigate the correlation between QoL and functional outcome.
To correlate postoperative bowel function with sexual function
To perform physiological tests and endoscopic examination on the well and poorly functioning pouches to determine factors contributing to functional outcome.
To evaluate the morphology and emptying in well and poorly functioning pouches with a pelvic MRI, and to establish a
reference of normal MRI findings in pelvic pouch patients.
PATIENTS AND
METHODS
All patients operated on between 2000- 2013 (N=103) were interviewed regarding QoL, sexual function and pouch function by a pouch functioning score (PFS) ranging from 0-16 (low numbers indicate good function) .
Based on pouch function, the best and worst functioning patients were invited to undergo manovolumetric testing, pouch endoscopy and a pelvic MRI
RESULTS There were few complications and no pouch failures. 88 responded to the QoL questionnaire and PFS. There were no differences in QoL or functional outcome, although a tendency towards better function in K patients. A PFS ≥ 8 was the best cut off to predict when functional outcome significantly impairs quality of life
68 responded to the questionnaire regarding sexual function and pouch function. Poor pouch function is negatively
correlated to sexual function in women, not in men.
N=47. Well functioning pouches have a
significantly larger volume. Sensibility thresholds are triggered by pressure and not by volume. More patients with poor function have histological pouchitis, hand sewn anastomosis and longer rectal cuff.
N = 43. There were no differences in MRI findings between the groups, and no findings correlated to malfunction. Pelvic volume was not correlated to pouch volume.
Inflammation signs on MRI seems to be normal also among well functioning pouches.
CON- CLUSION
Small improvements in function have an impact on the QoL.
Other designs than the J-pouch deserve further evaluation.
Pouch function has a stronger
correlation with sexual function in women compared to men.
In this study volume is the most prominent predictor of functional outcome.
The reason for variability in pouch volumes remains unexplained.
It seem MRI does not increase the understanding of factors contributing to functional outcome after IPAA surgery, unless septic pelvic complications are suspected.
PAPERS INCLUDED IN THE THESIS:
1. Restorative proctocolectomy with two different pouch designs: few complications with good function.
Sunde ML, Øresland T, Faerden AE.
Colorectal Disease. 2016. Vol 19. 363-371.
2. Correlation between pouch function and sexual function in patients with IPAA Sunde ML, Øresland T, Faerden AE.
Scandinavian Journal of Gastroenterology. 2015. Vol 51. 295-303.
3. Determinants of optimal bowel function in ileal pouch anal anastomosis – physiological differences contributing to pouch function.
Sunde ML, Ricanek P, Øresland T, Jahnsen J, Naimy N, Faerden AE.
Submitted to Scandinavian Journal of Gastroenterology, and resubmitted with minor revision.
4. Morphological MRI with defecography of the ileal pouch anal anastomosis – Contributes little to the understanding of functional outcome.
Sunde ML, Negård A, Øresland T, Bakka N, Geitung JT, Færden AE.
Submitted to Colorectal Disease.
1. BACKGROUND:
1.1. Introduction
Ulcerative colitis is an inflammatory bowel disease affecting the large bowel, causing bloody diarrhoea, frequent bowel movements, sometimes incontinence, and to a varying degree pain.
As a result of the disease, patients suffer from fatigue and malnutrition, and depending on the severity of the disease, the quality of life can be significantly impaired. The most feared complications are toxic megacolon and bowel perforation, leading to death unless surgical intervention is immediately undertaken. Today most patients can be successfully treated with drugs. However, around 20% will need at least a colectomy at some point. The disease incidence has steadily increased throughout the 20th and 21st century, but ulcerative colitis- like cases date back several hundred years. During the past hundred years physicians and scientists have had an increasing understanding of the disease manifestation, aetiology and treatment. Although the understanding of ulcerative colitis has improved drastically the past decades, we do not have a full understanding of the disease pathogenesis. Up until the late 80s great improvements were made in surgical treatment of ulcerative colitis. Quality of life was greatly improved with the introduction and refinement of pouch surgery. During the past decades we have had relatively little progression in refining surgical techniques improving functional outcome and patients’ quality of life. Colectomy is most life saving, further surgery with a pelvic pouch or an ileorectal anastomosis is done merely to improve the life quality by avoiding a permanent stoma. Thus QoL should after all be the most important parameter in determining surgical success.
1.2 History of ulcerative colitis:
Although ulcerative colitis (UC) was not described by its proper name until the 20th century, there are descriptions of non-contagious diarrhoea primarily affecting young adults dating back several centuries. As early as in the ancient Greece Hippocrates suggested diarrhoea had several different causes, and Roman physicians described non-contagious diarrhoea with similar presentations as we see in UC today. During the Civil War medical officers of the US army described clinical and pathological features resembling UC in patients with diarrhoea, and in 1875 S. Wilks and W. Moxon wrote3 “ We have seen a case affected by discharge of mucus and blood, where, after death, the whole internal surface of the colon presented a highly vascular soft, red surface covered with a tenacious mucus and adherent lymph. (…) In other examples there have been extensive ulcerations.” Ten years later, G.N Pitt and A.E Durham3 described a 29 year old female with a 5 year history of diarrhoea: “More than half of the area of the whole colon was covered with small friable villous polypi. (...) The intervening depressed white areas in the muscular coat, the mucous coat having entirely ulcerated away (…) the circumference of the bowel is only 1 1/3 – 2 inches, being narrower than the small intestine.” Hale-White3 at Guy’s Hospital reported 29 cases of an ulcerative colitis like diarrhoea stating “the origin of this ulceration is extremely obscure (…) it is not dysentery.”
Doctors throughout Europe reported several similar cases during the end of the 19th century.
In 1907 P. Lockhart-Mummery3 described a large number of colonic cancers in patients with UC with the newly invented electrically illuminated proctosigmoidoscope.
1.2.1 Aetiological understanding in a historic perspective:
Physicians speculated in several different causes of the disease, from pollen allergy, food and psychogenic disorders. Throughout the first part of the 20th century several attempts were
made to reproduce UC in animals by applying toxins, bacteria or by constricting the arterial supply to the colon without success. In the 30s, the attention was drawn towards the
psychogenic aspects of UC (C.D. Murray4), leading to intense psychiatric interest in the disease all through out the 60s. Murray et al described chronological relationship between emotional disturbances (in relation to marriage, home life, interpersonal relationships etc) happening prior to onset of UC symptoms. During the 30s, 40s and 50s there was talk of an
“ulcerative colitis personality” consisting of “immaturity of the patient, indecisiveness, over- dependence, inhibited interpersonal relationships, feelings of social rejection and maternal dominance.” For decades psychotherapy was hence regarded as an important part of UC treatment. Several studies during the 70s did however not prove any beneficial effect of psychotherapy on patients with UC, and the theory of a psychogenic aetiology of the disease was abandoned.
As different bacteria were discovered as the cause of several infections in the early 1900 including gastrointestinal diseases, there was a great interest in bacteria as the possible cause of UC. Several attempts were made to inject different kinds of bacteria and other
microorganisms to animals, but none reproduced the clinical manifestation of Ulcerative Colitis. As sulfonamides (1938) and antibiotics (penicillin 1946) were introduced as treatment with some effect, the theory of a bacterial cause was re-visited. Up until today one has not succeeded in finding a given microbiological agent causing UC. However, the theory that gut microbiota play a role in the development of UC is still relevant.
Although the theory of a microorganism as a direct cause of UC seemed more unlikely as the years passed without any success of proving a link, several reports were given on patients not
recovering from food poisoning or bacterial intestinal infections, developing chronic ulcerative colitis like symptoms. During the 1900s one was increasingly aware that some infections might cause an extensive immune response. In the 1940s immune mechanisms were suggested for several diseases with unknown cause (such as rheumatoid arthritis)
including UC, and the possible association of such immunological diseases was discussed. In the 50’s steroids were introduced as a treatment with good response in many patients,
reinforcing this theory. The thought that immunological reactions are an important part of the UC aetiology remains today, although the exact mechanism is not yet understood. It is also known that patients with one autoimmune disease have an increased risk of other autoimmune diseases, confirming the theory of association between immunological diseases.
Already in 1909, the first published cases of possible familial inflammatory disease was presented, and several independent observations supported this theory throughout the
beginning of the 20th century. A link between Crohn’s disease (CD) and ulcerative colitis was also discussed as several families had increased incidences of both. As the field of genetics has evolved, it has become evident that there are genetic predispositions for CD and UC and that the two diseases indeed are linked4.
1.3. History of IPAA surgery:
The first attempts of surgical treatment of UC were made in the late 19th century. Mayo Robson described colonic irrigation already in 1893, further developed by Keetly in 1895 and Weir in 1902 with irrigation through an appendicostomy, at the time believing the disease was caused by a microorganism5. Irrigation was hence viewed as an important treatment as it
“washed” the deceased bowel, and it was used extensively for UC until the late 30s. From the
beginning of the 20th century, complete bowel rest was also introduced by the creation of an ileostomy (Brown, 1913)5. For many patients the bowel diversion became a permanent
solution as it often proved to be impossible to close the ileostomy, and many patients later had to have the large bowel removed due to persistent disease activity or complications. As a result, from the middle of the century surgeons started doing colectomy with ileostomy in one procedure (Miller et al 1949, Crile and Thomas Jr 1951)5. This was either done by removing both colon and rectum (proctocolectomy), or by leaving the rectum (colectomy), allowing for a later anastomosis of the distal ileum to the rectum (ileorectal anastomosis, IRA), hence allowing a normal route for defecation. IRA for colitis was first described by Wangsteen in 1948 (Wangsteen & Toon, 1948) and further by Stanley Aylett in the 60s, (Aylett SO, 1960 and 1966) but the procedure was never accepted as a gold standard for ulcerative colitis treatment as it did not eradicate the disease with the remaining rectum, thus increasing the risk of both disease recurrence and development of cancer5.
The goal for surgical treatment of ulcerative colitis was to preserve the anal route of
defecation, avoiding a permanent ileostomy. The first attempt of this kind was by Nissen et al in 19335, performing a direct ileoanal anastomosis attaching the small bowel directly to the anal canal in a young boy with familial adenomatous polyposis. This was further developed by Ravitch and Sabiston in 19476, who removed the large bowel and the mucosal layer of the rectum, leaving the rectal muscular layer, after which the small bowel was attached to the anal canal. Ravitch reported good functional outcome after the surgery. However, several other surgeons throughout the 40s and beginning of the 50s reported varying results with frequent bowel movements, faecal incontinence and perianal soreness. (Wangensteen and Toon (Am J.
Surg) Gogligher (Ann. R. Coll. Engl), Best (Jama))5. The dissection of rectal mucosa leaving
the muscular layer proved to be technically demanding resulting in an increased risk of surgical complications. As a result, this procedure was abandoned and the treatment of choice again became proctocolectomy with ileostomy.
During the 50s and 60s surgeons continued experimenting with ileoanal anastomosis in dogs.
Valiente MA and Bacon HE (1955). discovered that the functional results were drastically improved if a pouch was made by the distal ileum before attaching it to the anal canal
1.3.1 Continent ileostomy - Kock’s pouch
The next breakthrough in surgical treatment of ulcerative colitis and familial adenomatous polyposis was introduced by Koch in 19698 constructing a pouch of the distal part of the ileum (15x2 cm), using parts of the ileum to form a nipple valve that was used as a stoma.
The valve was continent so that the stoma was not emptied unless a catheter was inserted in the stoma, eliminating the need of a stoma bag. The patient was hence continent and could empty the pouch 4-6 times a day. This method was called Koch’s pouch or continent ileostomy, and is still in use today in patients not suitable for ileal-pouch anal anastomosis.
1.3.2 S- pouch
Ten years later, in 1978, Parks and Nicholls at St Mark’s hospital published the first paper on a series of patients operated on with an ileal-pouch anal anastomosis (IPAA), inspired by the results of Valiente’s dog experiments and Koch’s continent ileostomy9. The pouch was formed by folding the distal ileum as an S after which it was attached to the anal canal. This was later called an S-pouch. The patients had good functional outcome with regards to continence and frequency of bowel movements compared to the direct ileoanal anastomosis.
However, almost 50% reported emptying problems needing catheters to successfully empty the pouch. In addition there was a large number of severe complications with nearly 20%
septic pelvic complications. The high complication rates and emptying problems could be explained by two factors; firstly it was at the time considered important to preserve rectal muscular layers to maintain rectal sensibility. Secondly it was thought that the remaining rectum needed to be of a certain length so there would remain a distance between the pouch and the anal canal. Both factors were considered important to maintain continence and sexual function. As a result, an advanced mucosectomy (removal of rectal mucosa leaving the muscular layer) was done. The complicated nature of the procedure lead to high complication rates, and the remaining rectum resulted in emptying difficulties. Hence, the mucosectomy was replaced by removal of the whole rectum, resulting in fewer complications and less emptying problems, whereas the continence was hardly altered. These findings resulted in rejection of the theory that the rectal muscular layer was important to maintain sensibility and as a “barrier” between the pouch and the anal canal. However, even after improved surgery patients with S-pouch still experienced emptying difficulties, and the design was never fully embraced.
1.3.3 J-pouch and W-pouch
Throughout the 80s several different pouch designs were tested. Utsunomyia et al developed the “J” pouch in the early eighties, where two loops of the distal ileum were folded as a J to form the pouch, which was attached to the anal canal10. This was further developed to a quadruple pouch (W pouch) being formed of four ileum loops11. Up until today, the J pouch is still the most commonly used pouch design as it is technically the least demanding design12.
During the past two decades there has been little progression in the pouch surgery. After the introduction of laparoscopic surgery, more and more units strive to do most of the surgery laparoscopically. This has had little effect on the functional outcome for the patients. The rational behind the transition towards laparoscopic surgery is that this will reduce the intraabdominal scarring and formation of adhesions, hereby reducing postoperative
complications. Critics say the laparoscopic approach only means applying new techniques to old surgery without improving the results and the patient’s quality of life13,14 (see section 1.6.4).
1.4 Ulcerative Colitis 1.4.1 Epidemiology:
The incidence of UC varies between countries, and is more common in the Northern
hemisphere15. According to a large systemic review by Molodecky et al from 2012 the annual incidence in Europe is 24.3 per 100.000 person years, 19.3 in Northern America and 6.3 in Asia and the Middle East (Figure 1 – printed with permission from Dr. Kaplan – final author and corresponding author of the paper)2.
Figure 1:
Incidence of ulcerative colitis globally. The figure is from an article by Molodecky et al, printed with permission from Dr.
Kaplan2
The incidence of ulcerative colitis in Norway was estimated to be 13/100.000 according to Moum et al in the mid 90s16. A recent Danish study reports that the incidence might be as high as 23/100.00017, which is in accordance with Molodecky et al, reporting an increase in UC over the past decades2.
1.4.2 Aetiology:
The aetiology of ulcerative colitis is still not fully understood, however some contributing factors are known. A combination of genetic disposition, environmental triggers and changes in gut microbiota driving an inflammatory response in the colon and rectum is considered to be of relevance18,19.
1.4.3 Pathogenesis:
UC causes mucosal inflammation of the colon and rectum, usually starting distally, spreading proximally throughout the colon in a continuous pattern. It differs from CD in that CD results in a transmural inflammation that can affect any part of the gastrointestinal tractus, most commonly the ileo-coecal area and small intestine in a classic pattern of “skip-lesions” 20. In 5 - 15% of patients with inflammation of the colon only, it is not possible to distinguish between UC and CD, a condition known as IBD unclassified (IBDU). In patients where the diagnosis is still not clear from a full pathological examination after having undergone a colectomy, the condition is known as Indeterminate Colitis (IC)21.
1.4.4 Clinical manifestation:
UC is characterised by bloody diarrhoea and frequent bowel movements, often followed by abdominal pain in left-sided and extensive UC, and by urgency and tenesmus in proctitis21. The disease commonly presents in the early 20s (early onset), with a second smaller peak of onset after 50 years of age (late onset).22 Most patients experience a clinical course of
exacerbations and remissions.23 According to the Montreal classifications UC is divided into phenotypes depending on the extent and severity of the inflammation. Ulcerative proctitis includes inflammation limited to the rectum (distal to the rectosigmoid junction), left sided UC/distal UC refers to inflammation distal to the splenic flexure, and pancolitis refers to inflammation proximal to the splenic flexure. The extent of inflammation is correlated to disease activity, use of medication, hospitalization, need of colectomy and risk of colorectal malignancy, with higher morbidity in more extensive disease. The disease will often present distally, and as many as 50% may experience a proximal extension of disease with pancolits over time. The Montreal classification of severity divides UC into clinical remission, mild, moderate and severe UC based on the number of bowel movements, systemic illness and inflammatory markers 24,25.
1.4.5 Medical treatment:
According to the second European evidence-based consensus on the diagnosis and management of ulcerative colitis, medical treatment strategy should be based on disease activity, relapse frequency, response to previous medications, extra-intestinal manifestation, distribution (proctitis, left-sided, pancolitis), age, onset of disease, duration of disease and pattern of disease. Medical treatment consists of immunosuppressive drugs, and includes mesalazine, aminosalicylate, corticosteroids and anti-TNF therapy.26
1.4.6 Surgical intervention
10-30% of patients with UC will need surgery27-29, and 50% of them will get an ileal pouch- anal anastomosis (IPAA)30. Patients with CD are not considered suitable for IPAA surgery because of a significantly higher failure rate14,31,32. The results from IC patients with pelvic pouches are diverging. According to research from the Mayo Clinic significantly more patients with IC developed CD, and hence the failure rate among pouch patients with IC was higher than in UC patients. Others find no significant difference in failure rate, whereas they find impaired functional results 14,33,34. Based on this, there is consensus that patients with IBDU can undergo IPAA surgery provided they accept the slight risk increase35,36.
1.5. IPAA physiology
The rectum is a complex system ensuring storage, continence and evacuation of faeces37. IPAA is a technically demanding procedure seeking to maintain continence and ensure a low frequency of bowel movements after removal of almost all diseased large bowel mucosa, including the rectum. The physiological aspects contributing to functional outcome are still not fully understood. However some factors have been identified:
1.5.1 Sphincter function:
The sphincter complex is an important contributor to maintaining continence. The anal sphincter consists of an inner, involuntary smooth muscle maintaining the resting anal pressure (RAP), and an outer, voluntary sphincter contributing to the maximum sphincter pressure. RAP is known to be reduced after IPAA38 however the consequences of this reduction remains uncertain. The literature is conflicting, with several studies finding a correlation between leakage and low resting anal pressure39-48, while some do not find a
significant correlation38,49,50. All mentioned studies have few patients included. There are two larger studies including 1439 and 116 patients finding a significant correlation between RAP and leakage 51,52. This might suggest there is a correlation that smaller studies fail to find, as they are underpowered.
1.5.2 Volume and compliance
Nicholls et al described in 1985 the inverse relationship between frequency of defaecation and capacitance of the pouch11 . A Swedish study group have found that a large volume and high compliance is positively correlated to good functional outcome, and that these parameters can explain 20% of the variability in function. In their studies small volumes were correlated to a higher number of bowel movements and leakage, and were more common in patients with pouchitis38,53-55. Other studies have also found that pouch volume and compliance are predictors of functional outcome41,43,45,56,57, and that the volume is larger in well functioning pouches and in patients not experiencing urgency42,50,56. Others have not found a significant correlation between compliance and functional outcome.40
1.5.3 Site of anastomosis:
The level of the anastomosis is a known predictor of functional outcome, with a short length of preserved anal canal being associated with better pouch function. The ECCO guidelines state the anastamosis should be made no further than 2 cm from the dentate line26,36, as a long rectal cuff can cause inflammation, dysplasia and dysfunction in terms of evacuation
problems 58,59.
1.5.4 Type of anastomosis:
The incidence of incontinence (especially nocturnal incontinence) is known to be increased in patients with a hand sewn anastomosis compared to stapled anastomosis60,61. The consensus is therefore that the anastomosis should be stapled unless there is an indication for
mucosectomy due to dysplasia or cancer36.
1.6. Complications:
1.6.1 Septic pelvic complications and failure:
IPAA is considered a safe procedure, with a mortality below 1%62-64. It is however associated with a short-term complication rate of 20-33% and a long-term complication rate of 30- 50%62,65-69. The most important complication is pelvic sepsis (anastomotic leaks, para-pouch abscesses (pelvic abscesses) and pouch-anal fistulas)70, as this is known to increase both the short- and long-term risk of poor function and pouch failure (pouch excision or indefinite diversion)71-73. The pelvic sepsis rate varies extensively in literature, ranging from 7.4 to as high as 37% 70,74-76 with a potential onset at any time during follow-up. Two major meta analyses on IPAA studies performed before74 and after75 2000 have found a pooled pelvic sepsis incidence of 9.5% and 7.4%, and a pooled failure incidence of 6.8% and 4.3%
respectively (median follow up time was 36 and 75 months respectively) . In large studies the ten-year failure rate varies between nine and 16%, with pelvic sepsis and impaired function being the most common causes of failure, and chronic pouchitis and CD being less common causes62,64,65,67,77,78. Some studies suggest that pelvic sepsis is more likely to impair function in hand-sewn anastomosis79,80.
Several recent publications have demonstrated that the volume of surgery and specialisation of the unit have a beneficial effect on the outcome in terms of failure and complications 32,81-84. Consequently, the 2015 ECCO guidelines recommend that institutions performing pouch surgeries should do at least 10 pouches per year36.
Fistula
As previously described, fistulas communicating with the pouch are associated with an increased risk of pouch failure, and occur in 2.9-7% of patients having undergone IPAA surgery62,66,75,85,86. Pouch-vaginal fistulas are the fistulas most often leading to pouch failure87. Patients with Crohn’s disease and previous pelvic sepsis are at higher risk of developing fistulas62. The treatment of fistulas ranges from conservative treatment to surgical intervention based on the extent of symptoms.
1.6.2 Pouchitis:
Pouchitis is often defined as an episode with increased frequency of defaecation and/or bloody stool, treated with antibiotics88, and should in addition include endoscopic and histological findings36. The risk of developing pouchitis increases with time. In large studies the 10 year accumulated risk varies from 20 up to 50%62,63,75,77,78. According to the ECCO guidelines of the European evidence based consensus on surgery for ulcerative colitis, 2015, the treatment of pouchitis should be metronidazol and/or ciprofloxazin. VSL#3 has proven some effect to maintain remission, and to prevent further episodes after treatment of antibiotics36. 10-15% of patients with pouchitis will develop chronic pouchitis89-91. As mentioned, chronic pouchitis is a well known but rather uncommon cause of pouch failure.
1.6.3 Other non-septic complications:
Small bowel obstruction
According to a large meta analysis of studies on IPAA patients after 2000 with median follow-up time 75 months (range 6-180), the pooled risk of small bowel obstruction is 11.4%, with the risk increasing with follow-up time75. At five and ten year follow-up the risk is reported to be 15-26% , and 22-31% respectively 63,66,77,92-94. The majority of cases are managed conservatively, but 5-10.6% of early small bowel obstruction and up to 36% of late small bowel obstruction need surgery66,92,93,95. There is hope that the incidence of small bowel obstruction will decline after the introduction of laparoscopic surgery as this is thought to reduce the development of adhesions.
Stricture:
Stricture of the pouch anal anastomosis is reported to occur in 5.2-11% of patients62,63,75, and may cause symptoms like diarrhoea, straining and anal or abdominal pain. In most cases, the problem can be treated with manual dilatation. Usually the procedure has to be repeated, and in a few cases stricture and evacuation problems lead to pouch failure14. A recent study finds a lower quality of life in patients with stricture96.
1.6.4 Laparoscopic versus open approach
Laparoscopic IPAA surgery has been assumed to reduce the postoperative morbidity
including incidence of small bowel obstruction and incisional hernia as it is less invasive and reduces the amount of adhesions developed after surgery. However the benefits are
controversial and evidence of the superiority of a laparoscopic approach is not yet available.
A large systematic review from 2013 including 2428 patients (1097 laparoscopic) concluded that there were no significant difference in adverse event rates and long term functional results97. Others find similar rates of incisional hernia and small bowel obstruction98, no difference in postoperative morbidity 99-101 and no difference in quality of life and functional outcome compared to open surgery99,101,102. Laparoscopic surgery is superior in terms of cosmetic outcome,100,101 but according to several studies the operation time is significantly longer97,99,100,102. All studies conclude that a laparoscopic approach is safe and feasible.
Several of the mentioned studies are underpowered. Larger high-quality trials are needed to compare the two approaches and finally conclude on the different outcomes in laparoscopic versus open IPAA surgery.
1.7. Functional outcome and quality of life:
1.7.1 Functional outcome
As pouch surgery is done to improve the patients quality of life, the functional outcome is of great importance, and is assessed by frequency of bowel movements, urgency, emptying difficulties, leakage, and in addition also often the use of pads, perinal soreness and use of anti-diarrhoeals. Pouch function stabilises around a year after surgery, and remains stable for many years until it declines slightly after 10-15 years62,65,103.
Large long term follow-up studies up to 20 years report an average of 5-7 daytime bowel movements, and 0-2 night time movements with a day to day variability, but remaining constant over long term follow-up. Urgency is reported to occur in 5-10% and in some studies increasing with follow-up. Depending on definition (the inability to defer defecation for 15 or 30 minutes), some studies report even up to 30% of patients experiencing urgency.
Emptying difficulties are reported in 5-16% of patients. Mild incontinence during the day is reported to occur in 14-45% of patients and severe daily incontinence in 4-14% patients, depending on age, follow-up and how broadly soiling is defined. 11-21% suffer from frequent nightly incontinence, and up to 48% occasional nightly incontinence. Several large studies have found that continence deteriorates slightly after 15-20 years of follow-up. Around 70%
can distinguish gas from stool, 20-45% of patients use pads and 50-80% use medication to control function. About half report dietary restrictions, and 10-20% report their pouch as a social handicap 60,62,65,67,75,77,78,88,103-112. Several studies have shown a marginal worsening in function in patients over 50 years of age78,113,114, however not enough as to consider age an absolute contra indication for IPAA surgery according to recent ECCO guidelines36.
1.7.2 Pouch design and functional outcome:
There is little recent research on pouch construction and how this affects function. As earlier mentioned some studies have indicated that pouch volume most likely contributes to the postoperative functional outcome38,55,57. Due to the difference in construction, the more spherical K-pouch should have a larger pouch volume than a J pouch with the same length of ileum, which should suggest better function in patients with K pouches. Several studies report K pouches to have a larger volume and better compliance than J pouches (factors known to predict functional outcome, see section about pouch physiology), but have failed to show a statistical difference in pouch function53-55. Others again have found K pouches to have better long-term function and a lower failure incidence64,105. A study from 2010 found that there was a large variation in pouch volumes in patients with J pouches formed of the same lengths of ileum,45 suggesting that other factors than pouch design alone predicts the
pouch volume. The reasons as to why volume varies extensively in pouches although they supposedly are made of the same lengths of ileum are not known.
A meta-analysis by Lovegrove et al from 2006, comparing J, W and S pouches, found W and S pouches to have a lower frequency of defecation than J pouches, and confirmed the S pouch’s shortcoming in evacuation difficulties and the need of catheterizing the pouch.
However, they found no significant difference in volume between W and J pouches57. Tekkis et al also found W pouches to have fewer bowel movements than J pouches, and J pouches to have more urgency and leakage than W pouches.65 A randomized controlled trial comparing W pouches and J pouches from 2012 (N=94) found no differences in bowel movements, continence or quality of life between the two designs115. J pouches remain the most
commonly used pouch design as it is technically easier to construct and no other design has been proven to have superior functional results13,14.
1.7.3 Quality of life versus pouch function:
Functional outcome is known to affect quality of life. Berndtsson et al found in 2007 a significant correlation between functional outcome and SF-36 scores in all domains, with a pouch functioning score ≥ 8 significantly impairing quality of life107. This finding indicates that small changes in bowel habit, lowering the pouch functioning score can significantly influence a patient’s quality of life for the better.
Lovegrove et al also found in a study from 2010 that increased 24-hours and nocturnal stool frequency, urgency, incontinence and use of antidiarrhoeal medication had a statistically
significant negative impact on quality of life116. Other studies confirm the correlation between functional outcome and quality of life117,118
1.7.4 Quality of life:
The IPAA procedure is done to avoid a permanent stoma and improve patient’s quality of life.
Many studies have investigated life quality postoperatively. However, as studies use different measures to assess the life quality, they are not always comparable. The literature generally reports life quality to be good after IPAA surgery. This is also found in long term follow-up studies of 20 years, also reporting that although pouch function deteriorates slightly with time, quality of life remains unchanged62,103,107,110,117,119-121. When comparing pouch patients with the normal populations results are conflicting, some finding the life quality to be comparable with normal population 107,117 and others find it to be slightly inferior to the normal
population122. When comparing quality of life before and after surgery, most patients report an improvement 123.
1.8. Sexual function:
As with any form of pelvic surgery there is a risk of altering sexual function. The impact of IPAA on sexual function is probably multifactorial. With all pelvic surgery, there is a risk of pelvic nerve damage, resulting in retrograde ejaculation and impotence in men and vaginal dryness in women, leading to reduced sexual function. Furthermore, anatomical changes as a result of the surgery can lead to vaginal adhesions in women resulting in dyspareunia. In addition, it is reasonable to hypothesize that bowel function also affects sexual function and that poor pouch function may be a contributing factor in patients with a poor sexual function postoperatively. Whereas several studies have evaluated sexual function after IPAA on a
general level, only one has looked at the impact of pouch function on sexual function. This particular study only included women, and found no association between pouch function and sexual function, but a trend towards significant association between impaired sexual function and interference of stool leakage during intercourse 124.
The literature is conflicting regarding sexual function after IPAA. Several studies find that sexual function in both men and women remains relatively unchanged
postoperatively14,68,88,110,125-130, and may even improve after surgery 78,125,127. The most common indication for IPAA is ulcerative colitis. Patients with inflammatory bowel disease (IBD) with colon and rectum in situ are more likely than the average population to have reduced sexual function131-133, and the tendency is stronger in patients with active disease than patients in remission132-134. The reason why some studies report an improvement in sexual function after surgery is probably found in an improvement in the patients’ general health and may be due to better stool control postoperatively. This would also suggest a correlation between bowel/pouch function and sexual function. 64
Others again find reduced sexual function with increased risk of vaginal dryness and dyspareunia in women, and impotence, and retrograde ejaculation in men124,135,136
2. AIMS OF THE STUDY
Restorative proctocolectomy is the treatment of choice for most patients with ulcerative colitis and familial adenomatous polyposis, and is often performed on relatively young patients who will live with the results of the operation for many years. The functional outcome is therefore of great importance. However there is a considerable variation in functional outcome, and the reasons are to a large extent unexplained. The objective of this thesis was to undertake a thorough investigation of patients having undergone IPAA surgery at our unit the past decade to increase the understanding of contributors to functional outcome. Our specific aims were:
1. To investigate surgical results, and the effect of septic pelvic complications on functional outcome.
2. To determine whether there are differences in function and quality of life among patients undergoing IPAA having two different pouch designs (J and K pouch).
3. To investigate the effect of functional outcome on quality of life.
4. To correlate postoperative bowel function with sexual function in male and female patients.
5. To perform physiological tests and endoscopic examination on IPAA-patients with well and poorly functioning pouches and two different pouch designs to determine factors contributing to functional outcome.
6. To evaluate the morphology and emptying patterns of the ileal pouch with a pelvic MRI in well and poorly functioning pouches, comparing the results with findings from
manovolumetric analysis and pouch endoscopy.
7. To establish a reference of normal MRI findings in pelvic pouch patients, as this is the first study published on MRI-findings of pouch patients with a well functioning control group.
3. METHODS:
3.1 Patients
All patients undergoing IPAA between 2000 and 2013 were identified from hospital medical records (N=103). Preoperative, perioperative, and postoperative information was gathered retrospectively by an independent investigator, and quality of life, sexual functioning and pouch function was assessed using questionnaires. The best and worst functioning patients were identified, and invited to undergo examination with manovolumetric testing, pouch endoscopy and MRI. Figure 2 illustrates how the patients were included in each study. To ensure the well and poorly functioning groups were comparable, the groups were stratified by pouch design.
3.2 Surgical technique and follow up:
The majority were operated on in a three-stage procedure having undergone an initial subtotal colectomy before pouch formation. Most of these were performed laparoscopically, many in
Figure 2:
Inclusion of patients for Study 1-4. The arrows indicate that some of the patients were included in several studies.
other hospitals before undergoing IPAA in our unit. IPAA was performed through a low midline incision in all patients. Four consultant surgeons were part of the “pouch team”
during the study period, and at least two were present at every operation. All patients were diverted with a loop ileostomy. Patients operated on before 2008 were given a stapled J-pouch.
All patients operated on in 2008 and onwards had a hand-sewn, double folded K-pouch according to the technique of continent ileostomy (Kock pouch) (Figure 3). Both pouch types were constructed from two 15 cm segments of terminal ileum. The pouch anal anastomosis was created within a maximum of two centimetres above the dentate line, and stapled in the majority of the patients.
3.3 Questionnaires
All patients were sent questionnaires regarding their quality of life (Short Form Health Survey 36; SF-36137), and sexual function (International Index of Erectile Function 5; IIEF 5138 for male, Pelvic organ prolapse/urinary Incontinence Sexual Function Questionnaire 12; PISQ 12139 for female). The questionnaires regarding sexual function and quality of life are given as
J-Pouch K-Pouch
Figure 3:
Formation of a J-pouch and a K-pouch. For each reconstruction the distal 30 cm of the ileum is folded into two loops. These are then sutured longitudinally to form a J-pouch. In the case of a K-pouch, the apex of the two loops is folded as in the figure and the pouch is completed by a transverse suture as shown. The drawings are printed with the permission of Prof. Leif Hulten.
appendixes. The results were compared to the average Norwegian population (SF-361, male sexual function140 and female sexual function141). All patients were also interviewed
regarding their pouch function using a pouch functioning score (PFS) according to Oresland et al106. (Table 1).
During the telephone interview, the patients were asked about all complications, including those treated at other hospitals or by their general practitioner, and specifically about pouchitis and reoperations. Previous episodes of pouchitis were defined as an episode with increased frequency of defecation and/or bloody stool, responding on with antibiotics88.
Table 1: Oresland pouch function score (PFS)
Score
0 1 2
Daytime ≤ 4 5 ≥6
No. of bowel movements
At night 0 > 1/week ≥ 2/night Urgency
(inability to defer evacuation > 30 min)
No Yes
Evacuation difficulties
(>15 min spent in toilet on any occasion during the week)
No Yes
Daytime No >1/week
Soiling or seepage
At night No >1/week
Inability to release flatus safely No Yes
Perianal soreness No Occasional Permanent
Daytime No >1/week
Protective pad
At night No >1/week Dietary restrictions
(avoid certain items that interfere with pouch function)
No Yes
Medication
(continuous or occasional)
No Yes
Social handicap
(not able to resume full-time occupation or participate in social life)
No Yes
*Score range 0-16: Overall good function scores 0 points, overall poor function scores 16 points.
3.4 Barostat
The manovolumetric tests were conducted using a barostat (G&J Electronics Inc, Toronto, Canada) simultaneously measuring volume (V) of the pouch at present pressures (P1), and pressure (P2) of the anal canal. The barostat was connected to a non-distensible plastic tube (Ch 18) with a thin-walled, disposable, flaccid, noncompliant plastic bag hermetically tied to the end of the tube and placed in the pouch, measuring pouch volume (V). A tracheal tube (7 mm Mallinckrodt®) was placed over the Ch18 tube, and the cuff was connected to the barostat, measuring anal pressure (P2). The distensions of the bag were started at increasing pressures (P1), measuring V and P2 at each distension. P1 was lowered to zero after each distension.
There was no bowel preparation, but patients were asked to empty the pouch and bladder before examination. Patients were lying in a left lateral position.
The following parameters were investigated: resting anal pressure (RAP), maximum squeeze pressure, pouch sensibility (first sensation, urge to defecate and discomfort), pouch
compliance (Delta V/ Delta P), rectoanal inhibitory reflex and pouch motility patterns during the distensions. Motility fell into four subtypes; initial pouch contraction, initial and
unchanged volume readings, gradual adaption to increased volumes, and motility waves throughout the distension period. (Figure 4).
Figure 4:
Pouch motility was categorised in as one of four motility patterns;
initial pouch contraction, initial and unchanged volume readings, gradual adaption to increased volumes, and motility waves throughout the distension period.
3.4. Pouch Endoscopy:
The patients were invited back to the outpatient clinic within six months for a pouch endoscopy, performed by an independent gastroenterologist. The endoscopy findings were scored after the pouchitis disease activity index (PDAI)142. In addition the following was noted; presence of pre-pouch ileitis and the level of the anastomosis (distance from the
anstomosis to linea dentate). Biopsies were taken from the lower posterior and anterior part of the pouch for histological analysis. The biopsies where investigated by pathologists at the hospital describing the presence of inflammation (no, mild, moderate or severe acute inflammation).
3.5 Biomarkers:
Patients also delivered faecal samples to test for enteric pathogens and calprotectin
(Calprotectin ELISA; Buhlmann Laboratories AG, Basel, Switzerland), and they had general blood tests taken (Hb, LPK and CRP).
3.6 MRI:
The MRIs were undertaken the same day as the endoscopies and performed prior to the endoscopy to avoid any irritation of the pouch. There was no bowel preparation before the MRI scans, but the patients were asked to empty the pouch before imaging. Before the examination started, the patients were instructed how to perform squeezing, straining and evacuation. The first part of the examination consisted of morphological MRI sequences, after which contrast (methylcellulose) was installed in the pouch from the anal canal through a continent ileostomy catheter. The amount of gel was individualised, installing the volume at which the patients reported an urge to defecate. Finally, the dynamic sequences were done while the patients were squeezing, straining and emptying the pouch. Two independent radiologist consultants assessed the MRI scans separately to validate the findings; both were blinded for the patient histories. The different parameters evaluated are given in Table 13 (see section 4.4.2).
The pelvic volume was calculated from standardised pelvimetric measurements of the bony pelvis143-145 (Figure 5-8). The measurements were used to calculate the pelvic inlet (π X anatomical transverse distance X the distance from the promontory to the upper border of the pubic symphysis), pelvic outlet (π X the intertuberous distance) and height (distance from superioposterior pubis to the posterior anorectal junction, at the level of tuber). The volume was then calculated using a formula for frustrum 143,144.
3.7 Ethical approval:
All studies have been approved by the Regional Ethics Committee (REK no. 2012/363 and 2014/2206).
Figure 5: The anatomical limitations in the axial plane used to measure the Interischial distance (IS).
Figure 6: The anatomical limitations in the axial plane used to measure the intertuberous distance (IT).
Figure 7: The anatomical limitations in the coronal plane used to measure the transverse distance of the pelvis (IP; the cranial line) and the interacetabular distance (IA; the caudal line).
Figure 8: The anatomical limitations in the sagital plane used to measure the distance between the promontory (Pr) and the upper border of the pubic symphysis (SyU), the line distance is referred to as PrSyU, and the angle between PrSyU and a line drawn along the upper border of the pubic symphysis.
Figure 6 Figure 5
Figure 7 Figure 8
4 RESULTS 4.1 Study 1
4.1.1 Main findings:
1 RPC is a safe procedure with few complications
2 Our patients have good functional outcome with no significant difference between J and K pouches, although with a tendency towards better function in K patients.
3 Septic pelvic complications were negatively correlated with pouch function.
4 A PFS of ≥ 8 was the best cut-off to predict when functional outcome significantly impairs quality of life.
5 Our patients have good life quality with a tendency towards better function in K patients. Compared to the average Norwegian population the IPAA patients score slightly worse in general health.
4.1.2 Surgical outcome:
There was no postoperative death. Short-term complications are given in Table 2, and long- term complications are given in Table 3.
Table 2: Complications within 30 days of stoma closure (N=103)
After RPC After stoma closure
Reoperations Total: 9
Anastomotic leakage: 1 Small bowel obstruction: 6 Possible peritonitisa: 2
Total: 3
Small bowel perforation: 2 Intraabdominal bleeding: 1 Abdominal
complications
Other: Intraabdominal abscessb: 1 Pelvic abscessb: 1
Intraabdominal abscessb: 2
Infection
(Non-pouch related include pneumonia, urinary tract infection, wound infections etc)
Total: 20
Excessive drainage from the pouch: 9 Ileitis: 1
Non-pouch related: 10
Total: 7 Perianal abscess: 2
Non-pouch related: 5
Small bowel obstruction 12 5
Readmission due to dehydration 36 3
Anastomotic stricture requiring dilatation
9 2
Venous thrombosis 6 1
Other Complications not requiring surgery
Other 13 8
a: Both patients were operated on with no finding of peritonitis. b: Drained percutaneously.
No patient had the pouch removed or the intestine diverted. One patient had the pouch excised owing to local recurrence of cancer, and two died from metastatic disease from colonic cancer. The remaining 100 patients are alive with anal function.
4.1.3 Functional outcome Eighty-eight patients agreed to being interviewed regarding their function, the results given in Table 4. Of the 88 patients 97.3% would have had the surgery again.
In a multivariate analysis of the PFS with age at surgery, gender, duration of follow- up perianal disease, pouchitis and septic pelvic complications, only the
latter correlated significantly with PFS (p=0.027).
Table 3: Long-term complications (N=103)
J
N = 56
K N = 47 Median follow-
up
11 years 3 years
Median age 47 [14,66] 38 [12,64]
Pouchitis 19 (33.9%) 10 (21.3%) Reoperations 13
Small bowel obstruction :6 Perianal abscess/fistula : 3 Pelvic abscess: 1 Ventral hernia : 2 Other : 1
3
Small bowel obstruction 3
Pouch removal or defunction
0 1 (for malignancy)
Table 4: Function of patients with a J- and K-pouch PFS=pouch functional score
Total (88) K (44) J (44) p-value
Median follow up (years) 8 3 11
PFS median (range) (Mean)
5.5 [0-11]
5.35
6 [2 -10]
5.27
5 [0-11]
5.43
0.766
PFS ≤ 5 44 (50%) 21 (47.7%) 23 (52.3%) 0.67 PFS ≥ 8 18 (20.5%) 7 (16%) 11 (25%) 0.29
Day 5 [3-15]
6.48
5 [3-17]
6.26
5.5[4-15]
6.70
0.217 No of bowel
movements (median) (mean)
Night 1/ week (0.75)
1/week (0.68)
1/week (0.82)
0.512
Urgency 6 (6.8%) 3 (6.8%) 3 (6.8%) 1
Evacuation difficulty 7 (8.0%) 2 (4.5%) 5 (11.4%) 0.253 Day 10 (11.4%) 4 (9.1%) 6 (13.6%) 0.504 Soiling/seepage/
leakage Night 17 (19.3%) 8 (18.2%) 9 (20.5%) 0.787 Inability to release flatulence
safely
52 (59.1%) 28 (63.6%) 24 (54.5%) 0.387 occasionally 49 (55.7%) 26 (59.1%) 23 (52.3%) Perianal
soreness Always 11 (12.5%) 5 (11.4%) 6 (13.6,0%) Day 11 (12.5%) 4 (9.1%) 7 (16.0%) 0.339 Protective pad
Night 18 (20.5%) 7 (15.9%) 11 (25.0%) 0.294 Dietary restriction 54 (38.6%) 19 (43.2%) 15 (34.1%) 0.382 Antidiarrhoeal medication 38 (43.1%) 21 (47.7%) 17 (38.6%) 0.390 Social handicap 18 (20.5%) 5 (11.4%) 13 (29.5%) 0.041
4.1.4 Quality of life
Seventy-eight patients answered the questionnaire regarding quality of life. There were no significant differences in SF 36 - scores, although there was a tendency towards better function in K
patients (Table 5). The results are compared to those reported for the average Norwegian population1 (Figure 9).
Table 5: SF-36 score (mean)
Total (78) K (40) J (38 ) p-value
General Health 64.7 69.0 60.2 0.069
Physical function 91.9 92.3 91.4 0.794
Role Physical 71.4 73.1 69.7 0.868
Bodily pain 75.5 77.4 73.6 0.518
Role Emotional 81.4 88.9 73.7 0.113
Social Function 78.5 80.1 76.8 0.570
Vitality 56.3 59.9 52.6 0.205
Mental Health 79.1 79.9 78.4 0.730
Figure 9:
Quality of life of patients in the present study and of the average Norwegian population assessed by SF- 361.
RPC = Restorative proctocolectomy.
