What is the benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for benign diseases?

Short-term morbidity and quality of life from a randomized clinical trial of close rectal dissection and total mesorectal excision in ileal pouch–anal anastomosis

Background

Posterior rectal dissection during ileal pouch–anal anastomosis (IPAA) can be performed in the total mesorectal excision (TME) or close rectal dissection (CRD) plane. The aim of this study was to compare morbidity and quality of life (QoL) in patients having TME or CRD during proctectomy followed by IPAA for benign disease.

Methods

In this randomized clinical trial, patients undergoing IPAA were allocated to TME or CRD. Thirty-day morbidity was determined and QoL assessed using Short Form 36, GIQLI (GastroIntestinal Quality of Life Index) and COREFO (COloREctal Functional Outcome) questionnaires. The primary outcome (pouch compliance) of the trial is to be reported separately.

Results

Fifty-nine patients were included, 28 in the CRD and 31 in the TME group. Baseline data were similar, except for more previous abdominal surgery in the TME group. Operating time was longer for patients having CRD (195 min versus 166 min for TME; P = 0·008). More patients in the TME group had a primary defunctioning ileostomy (7 of 31 versus 1 of 28 for CRD; P = 0·055). Severe complications occurred more frequently in the TME group (10 of 31 versus 2 of 28 for CRD). QoL was better in the CRD group for several subscales of the questionnaires measured at 1, 3 and 6 months after surgery. At 12 months, QoL was similar in the two groups for all subscales.

Conclusion

CRD led to a lower severe complication rate and better short-term QoL than wide TME.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.