Medical management of patients with ileal pouch anal anastomosis after restorative procto-colectomy

Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.

Ileal pouch dysfunction: diagnosis and management

Restorative proctocol ectomy is the elective surgical procedure of choice for most patients who have ulcerative colitis or familial adenomatous polyposis. This major advance has offered an alternative to permanent ileostomy in these patients.

Use of a monoclonal antibody to sucrase-isomaltase for evaluation of the columnar cuff after stapled restorative proctocolectomy

PURPOSE

Restorative proctocolectomy with a double-stapled pouch-anal anastomosis retains a cuff of diseased columnar mucosa (columnar cuff) in the upper anal canal that may require biopsy. Biopsying this can be difficult and colonic phenotypic change in the pouch can lead to errors interpreting the histology. This study was designed to investigate the use of a monoclonal antibody to sucrase-isomaltase for differentiating ileal pouch from columnar cuff mucosa. Then, by using this antibody, the ability to accurately take and report biopsies from the anal canal was examined.

METHODS

The technique of staining for sucrase-isomaltase was developed. From 113 patients who had a double-stapled pouch-anal anastomosis, 467 formalin-fixed biopsies and 177 fresh-frozen biopsies were taken from the ileal pouch, columnar cuff, or anal transitional zone. Biopsies were stained with a monoclonal antibody to sucrase-isomaltase, and fixed biopsies were routinely reported after staining with hematoxylin and eosin.

RESULTS

A monoclonal antibody to sucrase-isomaltase reliably discriminated between ileal from rectal mucosa. A biopsy of columnar cuff mucosa as reported by routine histology was obtained during 72 percent of attempted outpatient examinations. Sucrase-isomaltase staining of reported columnar cuff biopsies showed that biopsies were of pouch rather than columnar cuff in 4.4 percent (95 percent confidence interval, 2-8) of outpatient examinations.

CONCLUSIONS

The monoclonal antibody to sucrase-isomaltase used in this study may have a clinical role when interpreting columnar cuff biopsies from patients being investigated for pouch dysfunction, or in patients having surveillance biopsies to exclude neoplasia in the columnar cuff.

Does smoking influence the risk of pouchitis following ileal pouch anal anastomosis for ulcerative colitis?

OBJECTIVE

According to epidemiological studies, smoking habit is strongly associated with inflammatory bowel disease. Non-smokers, and especially recent ex-smokers, have an increased risk of ulcerative colitis (UC). Conversely, concerning Crohn's disease, the risk is increased among smokers. Pouchitis is the major long-term complication of restorative proctocolectomy for UC, and seems to be pathogenetically related to this condition. The aims of this study were to test the hypothesis that smoking reduces the risk of pouchitis, and to investigate whether cessation of smoking precedes the onset of the inflammation.

MATERIAL AND METHODS

All living patients operated on for UC with proctocolectomy and ileal pouch anal anastomosis (IPAA) between November 1982 and November 1996 at Sahlgren's University Hospital were included in the study (n=410). Data concerning smoking habits and pouchitis were obtained from questionnaires and from medical records. The correlation between smoking habits and incidence of pouchitis was statistically evaluated by means of a survival test and a multivariate analysis, i.e. a Poisson model.

RESULTS

In all, 327 patients (80%) completed the questionnaires. Ninety-six (29%) of these patients had had at least one episode of pouchitis. Smoking habits during follow-up did not significantly influence the risk of pouchitis (p=0.29). Nor did smoking habits before and at the time of IPAA correlate with the incidence of pouchitis. Women had a decreased risk of pouchitis, compared to men (p=0.014). There was a non-significant tendency for smoking to increase the risk, which was more pronounced in women.

CONCLUSIONS

Smoking does not decrease the risk of pouchitis following IPAA for UC, and in this respect the pathogenetic model of pouchitis, suggested to be a manifestation of UC, is not supported.

The role of scintigraphic defecography in the assessment of bowel function after restorative proctocolectomy for ulcerative colitis

BACKGROUND

The aim of the study was to evaluate the efficiency of defecation in patients with ileal pouch for ulcerative colitis by using the mean of scintigraphic defecography.

METHODS

Sixteen patients were classified into two groups according to the presence of good (group A) or poor (group B) pouch function. Emptying efficiency was calculated by scintigraphic defecography and measured as percentage of evacuation. This involves the use of up to 200 ml of an artificial stool made up of methyl cellulose paste labeled with 180 MBq of technetium-99 m (Tc-99 m) methylene diphosphonate. Potential causes of increased frequency in the absence of additional associated symptoms of dysfunction were excluded in all patients. Maximum tolerated volume (MTV) and balloon expulsion tests were also performed on all patients.

RESULTS

No patient in both groups showed evidence of organic pouch dysfunction. Percentage of emptying was higher in patients of group A (n=6) than in group B (n=10) (81+/-9 vs 71+/-9%, respectively, P<0.05; correlation, -0.51, P<0.04). Mean MTV was similar in the two groups (group A: 361+/-118 ml and group B: 338+/-77 ml, P=0.7). Results of the balloon expulsion test were normal in all patients except for one individual in group B.

CONCLUSION

In patients with ileal pouch for ulcerative colitis, increased frequency of defecation without any evidence of pouch dysfunction may be correlated with an alteration of emptying efficiency. Scintigraphic defecography is appropriate to use for investigation of this condition with no disadvantages for the patients.

Reoperative abdominal and perineal surgery in ileoanal pouch patients

PURPOSE

Complications of the ileal pouch with ileoanal anastomosis are associated with poor function and diminished quality of life; often, these complications may require surgery to salvage the pouch. The aims of this study were to review our experience with reoperative ileoanal pouch surgery and to define any predictors of pouch salvage surgery.

METHODS

Between 1991 and 1999, the medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision were reviewed; any minor local procedures were excluded. Successful ileoanal pouch salvage was considered to be an intact and functioning pouch, with acceptable patient satisfaction and good control.

RESULTS

Thirty-two patients underwent reoperative ileoanal pouch surgery, 25 for attempted pouch salvage and 10 for pouch excision (3 patients were included in both groups). Five patients (20 percent) had pouch reconstruction, 1 of which was successful; 8 (32 percent) had pouch advancement, with a 62 percent success rate; and 16 (64 percent) had local perianal procedures for control of perianal sepsis, with a 75 percent success rate (4 of these required further surgery). The overall success rate of ileoanal pouch salvage surgery was 84 percent, with 64 percent of patients having acceptable function. There was no correlation between the number of ileoanal pouch salvage procedures and failure. Four (40 percent) of the 10 patients who had pouch excision were ultimately diagnosed with Crohn's disease.

CONCLUSIONS

Ileoanal pouch salvage surgery is often successful and, in motivated patients without Crohn's disease, is worthwhile. Pouch advancement or local perianal repair yielded better results than did pouch reconstruction. Patients diagnosed with Crohn's disease after ileoanal pouch construction may be best suited for pouch excision when complications occur.

Ulcer associated cell lineage glands expressing trefoil peptide genes are induced by chronic ulceration in ileal pouch mucosa

BACKGROUND

Chronic ulcerative conditions in the gastrointestinal tract result in the appearance of the ulcer associated cell lineage (UACL). The glands of this new cell lineage secrete epidermal growth factor, transforming growth factor alpha, and the trefoil factor family (TFF) peptides, which are known to participate in repair processes. Pouchitis is the most frequent complication of ileal pouch-anal anastomosis.

AIM

Our aim was to determine whether the mucosal ulceration present in pouchitis can induce the development of UACL glands.

METHODS

Biopsies from ileal pouches with pouchitis (n=10), healthy pouches (n=5), and normal terminal ileum (n=5) were studied. Expression of TFF mRNA was assessed by in situ hybridisation. TFF1 and TFF2 proteins were localised by immunochemistry.

RESULTS

UACL glands containing TFF1 and TFF2 were observed in six patients with pouchitis. In some glands, there was TFF3 mRNA as has been reported for Crohn's UACL. None of the biopsies from ileal reservoirs without pouchitis showed UACL glands (p<0.05). Neither TFF1 nor TFF2 expression was detected in ileal reservoirs without pouchitis.

CONCLUSION

UACL glands arise de novo in ileal pouch mucosa of patients with pouchitis and express all three TFF peptide genes. Chronic inflammation alone, present in healthy pouches, is not enough to stimulate the growth of the UACL, and additional stimuli consequent on ulceration may be needed.

An audit of quality of life and functional outcome following restorative proctocolectomy and ileoanal pouch surgery in familial polyposis coli

We have audited the quality of life and functional outcome from restorative proctocolectomy and ileoanal pouch surgery in patients with familial adenomatous polyposis coli (FAP). By assessing the effect on employment, leisure activity, social life, and sexual function using a questionnaire derived from a modified McMaster Inflammatory Disease Questionnaire we have assessed the functional outcome of the pouch [ 1]. We have shown that although quality of life is maintained from the results of the questionnaire, over 50% of the patients felt that the pouch had not improved their lives. It has been shown that colitic patients have less complete function than polyposis patients, although the former were more satisfied with the results of their surgery [ 2]. Perhaps then the realization of the nature of FAP is not an incentive to surgery, when your life is to be ruled by your bowels. Therefore perhaps we should consider the outcomes in patients with FAP to be different from those in patients who have lived with colitis.

"Cuffitis" and inflammatory changes in the columnar cuff, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis

PURPOSE

During the past eight to ten years most surgeons have adopted the double-stapled technique to accomplish the pouch-anal anastomosis in restorative proctocolectomy for ulcerative colitis. Little attention has been focused on the functional implications of retaining a segment of diseased columnar mucosa in the upper anal canal. The aim of this study was to investigate clinically significant inflammation in the columnar cuff.

METHOD

In all, 113 patients were studied and 715 biopsies were performed during a 2.5-year period. Biopsy specimens were taken from two or three sites, including the columnar cuff, ileal pouch, and anal transitional zone. Acute and chronic inflammation was scored for biopsy specimens from all three sites and compared with endoscopic assessment and pouch function.

RESULTS

In the columnar cuff acute histologic inflammation was found in 13 percent of patients, and in 9 percent this was symptomatic during follow-up and was accompanied by evidence of endoscopic inflammation. Most patients had mild inflammation in the cuff that persisted over time. Inflammation in the pouch, pouch frequency, and anastomotic height were not related to columnar cuff inflammation.

CONCLUSIONS

Cuffitis is a cause of pouch dysfunction after a double-stapled restorative proctocolectomy. We propose a triad of diagnostic criteria, including symptoms and endoscopic and histologic inflammation.