HRQL after RPC in UC Patients

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Total proctocolectomy and IPAA is often advocated as the definitive treatment for UC [36,4]. In fact, RPC with IPAA guarantees complete excision of the diseased bowel, reduction of cancer risk and preserves the natural route of defecation, so it can be fully considered as the first choice for the elective treatment of patients affected by UC who need surgical therapy [38, 39].

Amelioration of the technique and the increased surgical experience reduced procedure morbidity; nevertheless, some unsatisfactory functional results may affect quality of life, which has led several authors to consider the importance of quality of life [39, 40] after this treatment.

The relatively young age of such patients and their subsequent life expectancy imposed an accurate analysis of quality of life that became the measure of thefor efficiency of the procedure. .

In fact the relatively young age of such patients and their subsequent life expectancy imposed an accurate analysis of quality of life that became the measure for efficiency of the procedure. So HRQL questionnaires are the indispensable instruments to assess the quality of surgery.

Although long-term functional results described by some authors, are excellent, there is a relevant incidence of complications related to ileal pouch [41]. Several authors reported a high level of satisfaction in patients submitted to colectomy in general [42-44] and in particular to RPC [44-47].

However, despite dramatic improvement of patients' general conditions, functional results are not always perfect. In fact, some patients complains of occasional episodes of soiling or urgency, elevated number of daily bowel movements, difficulties in pouch emptying or dietary restrictions. And even more, also without such complications, patients with IPAA may refer a conspicuous number of daily stool and a certain degree of incontinence or urgency [47].

The difficulty of quantifying such dysfunction, and its impact on HRQL, make it necessary to use an investigative instrument, that not only explores clinical parameters of each patient but also his/ or her emotional and social function [48,49].

Several authors report excellent long-term functional results of RPC with IPAA and HRQL comparable to those of healthy subjects, probably for the different consideration given to the emotional function, which is among the least important components of the Cleveland Global Quality of Life Score (CGQL), which is one of the most affirmed instrument used for HRQL analysis in RPC patients [44] .

On the contrary, according to some other authors , patients submitted to RPC for UC experience a long-term quality of life similar to those of UC patients, with mild or remission of disease activity because of long-term pouch complications, conspicuous number of daily stool or a certain degree of incontinence or urgency [42-44].

In particular, RPC patients reported HRQL scores similar to to those with moderate UC for intestinal and systemic symptoms and similar to those with mild remission UC for emotional and social function. The global scores indicate that RPC patients obtained similar scores to those with mild/ remission UC, so once again, we emphasise the role and weight of emotional and social function for HRQL [44]. RPC

patients have similar scores to healthy controls for actual quality of life and for energy levels as well as to moderate UC for actual quality of life to patients with mild/remission UC for quality of health and to mild/remission UC for energy levels.

Once again, this result emphasises the role and the weight of the emotional and social function for HRQL [44, 49].

Age, gender, marriage status, education, job, fertility after the operation, type of anastomosis, elective or urgent surgery, 3two- or three-stage surgery, number of operations, age at stoma closure and duration of UC have not anyno actual role in predicting long-term HRQL outcome. There are some other critical factors for a good HRQL outcome: use of drugs, number of daily bowel movements, presence of pouchitis, rectal stenosis, sinus tracts or occasional incontinence, and age at UC diagnosis or at ileostomy closure.

The subjective perception of being ill is still present in many patients, and it may be reinforced, in part, by the medical follow-up that patients undergo but even more by the use of drugs that some patients still must take. Furthermore, the emotional function of patients who had their UC diagnosed and were operated in late childhood did not improve even 10.3 ± 7.0 years after their last operation. Only this item gives them a lower HRQL outcome (even if in the group of younger operated patients the difference is not statistically significant, probably because of the small number). Probably, this is not only due to more severe or fulminating onset of UC and higher incidence of pancolitis or postoperative pouchitis in childhood [50, 51] but also to the psychological trauma they suffered at this particularly fragile age.

So it is possible that they have grown up with the idea of being ill. These results should be considered by physicians when they are preparing a patient for the impact of RPC.

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