Measurement of quality of life, especially in pouch patients is fraught by methodological problems . Quality of life varies on a daily basis and depends on mood, expectations and anal function. The instruments of measurements are usually based on questionnaires which attempt to quantify abstract issues .
Even though pouch surgery is generally successful, there is always a fear of incontinence, which would require a permanent stoma. High bowel frequency, which is not uncommon following pouch surgery, is less demoralizing than urgency. The most debilitating symptom, however, is passive incontinence .
Quality of life is said to be normal in well-motivated individuals who are treated by proctocolectomy and permanent ileostomy; although it is accepted that patients make considerable adjustments to their life . Consequently pouch surgery has to ensure that imperfections of continence, bowel frequency and sexual dysfunction do not compromise the generally better image and social ease of patients who no longer require a permanent stoma [5, 6]. Pouch surgery for dysplasia or malignancy often is performed in a rather older population with quiescent colitis and the functional results may not be as good as pouch surgery for patients with chronic relapsing colitis where medical treatment has failed. Nevertheless, even minor imperfections of incontinence do not appear to have a major impact on quality of life after pouch surgery [6-9].
Data from three large North American series has indicated that all of those patients who held a job prior to the pouch operation returned to their original place of employment afterwards . However, it has been reported  that 13% had to change their employment, a finding almost mirrored in a study from Vancouver . Another study reported that 75% of those in military service were able to return to the armed services after pouch surgery . Normal sporting activities could be pursued by all patients after pouch surgery. Furthermore, children and adolescents were able to complete their education without any detriment to their academic achievement .
Pezim and Nicholls  conducted a questionnaire survey among patients with a pouch to assess their preferences compared to their life when they had a protecting ileostomy. This is not an entirely fair comparison as loop stomas are usually more troublesome than an end ileostomy. Furthermore, patients were self selected, having undergone a major operation to avoid a stoma. Nevertheless, 87% said that they were more confident, 89% felt that they were cleaner and 87% said that their sex image was better than it had been with a stoma. Similarly, 87% said that they were more at ease socially and 87% that they were more able to pursue normal sporting interests. In our own series, the functional outcome and quality of life was as follows: 73% said that they had unquestionably improved, 89% stated that having a pouch operation was definitely worth the effort, none regretted the pouch but 16% were uncertain whether this was the best operation for them. Despite this, 73% would definitely recommend the operation to a friend. When this cohort of patients was interviewed by an independent assessor, 38% stated that they were concerned about going out, 32% said that they were often worried about taking holidays, 26% had minor concerns about normal sexual activity and 7% had severe sexual morbidity.
The impact of having a permanent intestinal stoma must be acknowledged. Quite apart from the cost of the ileostomy appliance and the surgical complications that often occur, the impact of a stoma on social well being, sexual fulfilment and religious acceptability is often not fully recognised . A study of attitudes amongst Asian migrants and the endogenous public in the United Kingdom has highlighted the anxieties expressed in both groups in relation to having an abdominal stoma . This morbidity is largely eliminated by a modern pouch-anal reconstruction, provided that patients are appropriately counselled and properly selected. Naturally, quality of life is seriously impaired if there are major complications following pouch surgery. Any assessment of the impact of pouch surgery on quality of life must include a thorough pre-operative assessment as well as a thorough pre-operative counselling process .
Sagar et al.  compared the quality of life of patients in Leeds treated by restorative proctocolec-tomy with a matched group of quiescent colitics in remission. Bowel frequency was lower in those with quiescent colitis, but even in the absence of severe active disease, urgency was a serious problem in 72% of those with colitis, compared with only 12% after pouch construction. There was more anxiety and depression in the colitics compared with the pouch patients, but there was no difference between the groups in terms of leakage, use of pads, perianal irritation or time spent in the lavatory.
Perhaps some of the most interesting data on quality of life in pouch patients emanate from longitudinal studies . Berndtsson and Oresland  from Göteborg, used a modified Olbrisch adjustment scale and found that the initial subtotal colectomy and ileostomy provided little improvement for patients within the group when medically treated for colitis. Only after pouch construction was there a sig nificant improvement in quality of life. Sexual satisfaction improved, there was much greater freedom to move about and travel without urgency, there was greater confidence and self respect, patients enjoyed a normal social life and there was improved work performance. Perhaps this was somewhat surprising given that 51% reported perianal soreness, 40% nocturnal evacuation and 58% consumed regular anti-diarrhoea medication. The Cork Group  showed that parous patients and those with repeated pouchi-tis had a compromised quality of life after pouch surgery. They showed that despite a favourable quality of life, some form of dietary restriction was reported by 93%, especially the avoidance of eating late in the day. Elderly patients studied at the Cleveland Clinic had a higher incidence of impaired continence compared with the younger pouch patients . Quality of life parameters when compared between indeterminate colitis and ulcerative colitis at the Cleveland Clinic were indistinguishable . However, the impact of a diagnosis of Crohn's disease, especially if complicated by sepsis, fistula and failure, has a devastating impact on quality of life after pouch surgery . Impaired fertility may also tarnish the image of the apparently successful pouch. Weinryb et al.  followed 40 patients for seven years and showed that quality of life improved with time and that there was remarkably little individual variation from day to day. The Amsterdam group reported a better global quality of life when laparoscopic pouch surgery was compared with conventional pouch construction
. We believe that this is a particularly important issue in asymptomatic individuals having prophylactic pouch surgery for familial adenomatous polyposis
If a patient is dissatisfied with the functional outcome of restorative proctocolectomy or is dissatisfied because of repeated episodes of pouchitis, then the question of pouch excision and conversion to a conventional ileostomy or a reservoir ileostomy must be addressed. Patients must be counselled carefully and be warned that, although it is sometimes possible to salvage some ileum from the pouch, generally the whole pouch must be sacrificed, resulting in a rather liquid ileostomy and the loss of 40-50 cm of ileum. Nevertheless, for well-counselled patients who have had a poor functional outcome following pouch surgery, quality of life may be greatly improved by conversion to a conventional ileostomy and excision of the anorectum. However, there is a risk of pelvic nerve damage with potential impotence or retrograde ejaculation in men and urinary dysfunction as well after pouch excision. A quality of life survey was undertaken in patients who had had a pouch excision for ulcerative colitis compared with the responses of those of age and sex-matched patients having con ventional proctocolectomy over the same time span. The results of the survey showed that the quality of life was broadly comparable, the only exception was the increased ileostomy losses from the stoma in the pouch-excision patients compared with conventional proctocolectomy . Despite this optimistic report, the Helsinki group reported that pouch failures have a compromised quality of life with impaired general health and emotional well being, reduced energy, increased pain and disordered sexual function .
Generally pouch surgery results in improved quality of life, provided there is minimal soiling and a bowel frequency of less than seven or eight stools per day. If there are serious complications or if the underlying diagnosis proves to be Crohn's disease, then the quality of life is generally much worse with pouch surgery and the majority of these individuals would be better served by a conventional ileostomy.
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