Outcome of pouch-related complications after ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis for ulcerative colitis: 30-year analysis on surgical evolution and patient outcome

BACKGROUND

Proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for patients with ulcerative colitis with medical refractory disease or dysplasia. The aim of this research was to describe the evolution of ileal pouch-anal anastomosis surgery and surgical outcomes over a three-decade interval in a high-volume referral centre.

METHODS

All consecutive patients undergoing ileal pouch-anal anastomosis for ulcerative colitis between 1990 and 2022 at the University Hospitals of Leuven were retrospectively included. Patients were divided into three interval arms (interval A 1990-2000, interval B 2001-2010 and interval C 2011-2022). The primary outcomes of interest were anastomotic leakage at 30 days and pouch failure.

RESULTS

Overall, 492 patients were included. The use of preoperative advanced therapies increased over time (P < 0.001). An increase in laparoscopic procedures (23.2% in interval A, 66.4% in interval B, 86.0% in interval C; P < 0.001) and a shift towards delayed ileal pouch-anal anastomosis (colectomy-first approach with delayed ileal pouch-anal anastomosis construction: 23.0% in interval A, 40.9% in interval B, 85.8% in interval C; P < 0.001) were observed. Anastomotic leakage rate decreased from 16.7% (interval A) to 8.4% (interval C) (P = 0.04). Delayed ileal pouch-anal anastomosis was the most relevant factor in limiting leakage (OR 0.49 (95% c.i. 0.27 to 0.87); P = 0.016). Median follow-up was 7.5 years (interquartile range 2.5-16). Cumulative pouch failure incidence was 8.2%, not significantly different between the three intervals (P = 0.580). Anastomotic leakage was the only significant risk factor for pouch failure (HR 2.82 (95% c.i. 1.29 to 6.20); P = 0.010).

CONCLUSION

Significant changes in the management of ulcerative colitis patients occurred. Despite the widespread use of advanced therapies and the expanded surgical indications, anastomotic leakage rate decreased over time. In the context of a delayed ileal pouch-anal anastomosis, diverting ileostomy could be avoided in selected cases. Anastomotic leakage remains the most relevant risk factor for pouch failure. Pouch failure incidence remained stable over the years.

Endoscopic Treatment of Ileal Pouch Sinus

BACKGROUND AND AIMS

Pouch sinus is a serious complication in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to verify the efficacy and safety of endoscopic needle knife sinusotomy (NKSi) in the management of pouch sinus.

METHODS

All consecutive patients with a pouch sinus treated with NKSi from 2008 to 2016 were identified. The primary outcomes were complete healing of the sinus and pouch survival.

RESULTS

A total of 109 patients were included. During a median follow-up of 2.1 years (interquartile range: 0.7-4.4), 54 (49.5%) patients achieved complete healing and 20 (18.3%) patients had partial healing, Twenty-two (20.2%) patients developed sinus-related pouch failure. In multivariable analysis for the sinus healing, Crohn's disease of the pouch was a risk factor [odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8), whereas a longer interval between NKSi (OR: 1.1, 95%CI: 1.0-1.1) and high body mass index (OR: 1.2, 95%CI: 1.0-1.3) were protective factors. In the multivariable analysis for surgery-free survival, previously documented acute anastomotic leak (OR:3.5, 95%CI: 1.2-10.4), toxic megacolon (OR: 7.4, 95%CI: 1.9-29.1), an increased length of sinus (OR: 1.4, 95%CI: 1.0-2.0), and increased duration from sinus diagnosis to NKSi (OR: 2.6, 95%CI: 1.1-6.2) were risk factors; and a longer interval between NKSis (OR: 0.9, 95%CI: 0.9-0.99), and concurrent use of dextrose 50% (OR: 0.2, 95%CI: 0.04-0.6) and doxycycline during the NKSi procedure (OR: 0.2, 95%CI: 0.04-0.7) were protective factors. NKSi-associated complications were reported in 6 (1.8% per procedure) cases.

CONCLUSIONS

NKSi is an effective and safe procedure for treating pouch sinus.

Long-term functional outcome after ileal pouch anal anastomosis in 191 patients with ulcerative colitis

BACKGROUND

A long-lasting good functional outcome of the pelvic pouch and a subsequent satisfying quality of life (QoL) are mandatory. Long-term functional outcome and QoL in a single-center cohort were assessed.

PATIENTS AND METHODS

A questionnaire was sent to all patients with an IPAA for UC, operated between 1990 and 2010 in our department. Pouch function was assessed using the Öresland Score (OS) and the 'Pouch Functional Score' (PFS). QoL was assessed using a Visual Analogue Score (VAS).

RESULTS

250 patients (42% females) with a median age at surgery of 38 years (interquartile range (IQR): 29-48 years) underwent restorative proctocolectomy. Median follow-up was 11 years (IQR: 6-17 years). Response rate was 81% (n=191). Overall pouch function was satisfactory with a median OS of 6/15 (IQR: 4-8) and a median PFS of 6/30 (IQR: 3-11). 24-hour bowel movement is limited to 8 times in 68% of patients (n=129), while 55 patients (29%) had less than 6 bowel movements. 12 patients (6.5%) were regularly incontinent for stools, while 154 patients (82%) reported a good fecal continence. Fecal incontinence during nighttime was more common (n=72, 39%). Pouch function had little impact on social activity (4/10; IQR: 2-6) and on professional activity (3/10; IQR: 1-6). 172 patients (90%) reported to experience an overall better health condition since their operation. The OS and the PFS correlated well (Pearson's correlation coefficient=0.83). Overall pouch function was stable over time.

CONCLUSION

Majority of patients report a good pouch function on the long-term with limited impact on QoL.

Postoperative complications following colectomy for ulcerative colitis: a validation study

Background

Ulcerative colitis (UC) patients failing medical management require colectomy. This study compares risk estimates for predictors of postoperative complication derived from administrative data against that of chart review and evaluates the accuracy of administrative coding for this population.

Methods

Hospital administrative databases were used to identify adults with UC undergoing colectomy from 1996–2007. Medical charts were reviewed and regression analyses comparing chart versus administrative data were performed to assess the effect of age, emergent operation, and Charlson comorbidities on the occurrence of postoperative complications. Sensitivity, specificity, and positive/negative predictive values of administrative coding for identifying the study population, Charlson comorbidities, and postoperative complications were assessed.

Results

Compared to chart review, administrative data estimated a higher magnitude of effect for emergent admission (OR 2.52 [95% CI: 1.80–3.52] versus 1.49 [1.06–2.09]) and Charlson comorbidities (OR 2.91 [1.86–4.56] versus 1.50 [1.05–2.15]) as predictors of postoperative complications. Administrative data correctly identified UC and colectomy in 85.9% of cases. The administrative database was 37% sensitive in identifying patients with ≥ 1Charlson comorbidity. Restricting analysis to active comorbidities increased the sensitivity to 63%. The sensitivity of identifying patients with at least one postoperative complication was 68%; restricting analysis to more severe complications improved the sensitivity to 84%.

Conclusions

Administrative data identified the same risk factors for postoperative complications as chart review, but overestimated the magnitude of risk. This discrepancy may be explained by coding inaccuracies that selectively identifying the most serious complications and comorbidities.

Long-term functional outcome and quality of life after restorative proctocolectomy with ileo-anal anastomosis for colitis

AIM

The study aimed to evaluate long-term health-related quality of life (HRQOL) and functional outcome in patients who had undergone restorative proctocolectomy with ileo-anal anastomosis (IPAA) for ulcerative colitis and familial adenomatous polyposis.

METHOD

A total of 156 patients who underwent IPAA during the period 1984-2003 and who still had an intact pouch were included. The HRQOL score was compared with 4152 individuals from the general Norwegian population using the SF-36 questionnaire, and function was evaluated using the Wexner Continence Grading Scale.

RESULTS

One hundred and ten (71%) patients answered the questionnaires, 60 (55%) of whom were men. All except five patients had ulcerative colitis. Median (range) age at interview was 47 (19-66) years, and time after surgery was 12 (2-22) years. The IPAA patients scored slightly, but significantly, lower in four of six SF-36 health domains than the control subjects, adjusted for age and gender. Multiple regression analysis showed frequency of nocturnal defaecation, faecal incontinence and urgency to be independent negative prognostic factors of quality of life. Frequency of defaecation was a median of 7 (3-12) bowel movements during the day and 2 (0-6) at night. The majority had some degree of faecal incontinence, median (range) Wexner score of 8 (0-17), and 40% reported urgency of defaecation necessitating alterations in lifestyle.

CONCLUSION

Patients with IPAA reported slightly lower HRQOL rates than the general population and had an inferior functional outcome.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

A longitudinal study of quality of life and functional outcome of patients with ulcerative colitis after proctocolectomy with ileal pouch-anal anastomosis

PURPOSE

Ileal pouch-anal anastomosis is considered the surgical treatment of choice for patients with ulcerative colitis. It is safe and effective but associated with long-term complications, making functional outcome and quality of life important factors in determining patient outcome. Longitudinal studies on long-term functional outcome and quality of life are sparse. The purpose of this study was to longitudinally evaluate the long-term functional outcome and quality of life of ulcerative colitis patients who underwent proctocolectomy with ileal pouch-anal anastomosis.

METHODS

The study group was composed of ulcerative colitis patients who underwent pouch operation in our institution between 1990 and 2001 who had filled in quality of life and functional outcome questionnaires 60 months (mean) after ileostomy closure and responded to the same questionnaires at 133 months (mean) after ileostomy closure. They served as their own controls. Quality of life was scored using the Medical Outcomes Study Short Form 36. Global Assessment of Functioning Scale was used to evaluate functional outcome.

RESULTS

Data were obtained for 63 of the 77 patients (82%) who had answered the first questionnaire. The mean interval between responding to the 2 questionnaires was 73 +/- 3 months. Functional outcome did not deteriorate over time. Some quality of life scores (bodily pain, general health perception, and the physical component summary) worsened over time, whereas the other scales of the Short Form 36 scores did not change.

CONCLUSION

The functional outcome of ulcerative colitis patients after a pouch operation did not change significantly over time. The overall quality of life was generally stable, however, some aspects did deteriorate over time. These findings merit further investigation.

Surgical site infection following surgery for inflammatory bowel disease in patients with clean-contaminated wounds

BACKGROUND

It is generally believed that the accompanying conditions in patients with inflammatory bowel disease (IBD) are associated with a high incidence of surgical site infection (SSI), and sometimes these patients are classified as compromised hosts without definitive clinical evidence. The aim of this study was to clarify the impact of IBD on the occurrence and features of SSI in patients with clean-contaminated wounds.

METHODS

We conducted prospective SSI surveillance of 580 patients with clean-contaminated wounds who underwent surgery between March 2006 and December 2007 using the National Nosocomial Infection Surveillance system. Multivariate analyses using stepwise logistic regression were performed to determine risk factors for SSI.

RESULTS

A total of 562 patients with clean-contaminated wounds who underwent surgery for IBD [ulcerative colitis (UC), n = 173; Crohn's disease (CD), n = 122] or colorectal cancer [(CA), n = 267] were identified for evaluation. SSI was observed in 12.6% of all patients and there was no significant difference in infection rate by type of disease (UC, 14.5%; CD, 13.9%; CA, 10.9%). Multivariate logistic regression analysis yielded an ASA score > or =3 [odds ratio (OR) = 2.04; 95% confidence interval (CI) = 1.06-3.93] and rectal surgery (OR = 2.35; 95% CI = 1.28-4.31) as independent risk factors for SSI. IBD surgery was not an independent risk factor for overall SSI (OR = 1.62; 95% CI = 0.94-2.80). However, there was a significant difference in the incidence of incisional SSI [IBD, 11.9% (UC, 12.7%; CD, 10.7%); CA, 4.9%, p = 0.003]. In the analysis of rectal surgery, the incidence of incisional SSI was 5.3% in CA patients, 12.0% in UC patients, and 26.3% in CD patients. In contrast to overall SSI data, IBD surgery was found to be an independent risk factor for incisional SSI (OR = 2.59; 95% CI = 1.34-5.03).

CONCLUSIONS

In patients of surgery restricted to clean-contaminated wounds, IBD was shown to be an independent risk factor for incisional SSI. With the use of proper operative procedures and techniques, the incidence of organ/space SSI should not be high in patients who undergo an uncomplicated IBD surgical procedure.

Long-term outcome 10 years or more after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis

PURPOSE

The aim of this study was to assess quality of life (QOL) in a long-term follow-up of patients with ulcerative colitis (UC) 10 years and more after ileal pouch-anal anastomosis (IPAA) to correlate these results with pouch function and to assess the long-term pouch failure rate.

METHODS

In a unicentric study, 294 consecutive patients after IPAA between 1988 and 1996 were identified from a prospective database. QOL was evaluated according to the validated Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

Overall median follow-up was 11.5 years. Thirty-seven patients experienced pouch failure (12.6%). The rates of ileal pouch success after 5, 10 and 15 years were 92.3%, 88.7% and 84.5%. According to the GIQLI, patients with a functioning pouch achieved a mean score of 107.8, reflecting a decrease of QOL of 10.8% compared to a healthy population. There were significant negative correlations between QOL and an age of >50 years (p < 0.05), pouchitis, perianal inflammation and increased stool frequency (p < 0.0001).

CONCLUSIONS

QOL and functional results of patients with UC 10 years or more after IPAA were acceptable; however, those were reduced when compared to a healthy population. Pouch failure rate still increases up to 15.5% 15 years after IPAA. This result represents an important issue in providing patients with comprehensive preoperative information.

Outcomes for patients developing anastomotic leak after ileal pouch-anal anastomosis: does a handsewn vs. stapled anastomosis matter?

PURPOSE

Outcomes for patients developing a leak after ileal pouch-anal anastomosis have not been well investigated. This study explored whether the use of a stapled or handsewn anastomosis was associated with different outcomes when an anastomotic leak developed.

PATIENTS AND METHODS

Patients were identified from a prospectively maintained pouch database. Functional outcomes regarding bowel movements, urgency, continence, and seepage were evaluated. Quality of life was assessed by the Cleveland Global Quality of Life Score.

RESULTS

One hundred and seventy-five patients with anastomotic leak (141 stapled and 34 handsewn anastomosis) were identified. The two groups were similar in gender and diagnosis. Patients with handsewn anastomosis were younger (P = 0.04), had less perioperative steroid use (P = 0.05), more proximal diversion (P = 0.02), and S-pouch creation (P = 0.003). More handsewn cases had intraoperative transfusion (P = 0.04) and postoperative hemorrhage within the pelvis (P = 0.003). Long-term pouch failure was 35.3 percent in the handsewn group and 12 percent in the stapled group (P = 0.002), which was confirmed by Kaplan-Meier analysis (Log-rank P = 0.007). On multivariate analysis, leak after handsewn anastomosis was independently associated with pouch failure. Leak after stapled anastomosis carried a lower incontinence rate at 5 years (P = 0.03), while handsewn had higher nocturnal seepage rate at 3, 5, and 10 years, and most recent follow-up. Cleveland Global Quality of Life Score was comparable between the groups during follow-up.

CONCLUSION

Outcomes including functional results and pouch failure rates for patients developing a leak after stapled anastomosis at ileal pouch-anal anastomosis were significantly better than outcomes for patients who develop a leak after handsewn anastomosis.

Assessments of anal canal sensitivity in patients with soiling 5 years or more after colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis for ulcerative colitis

INTRODUCTION

To clarify the significance of anal canal sensitivity contribution to soiling in patients after ileal J pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), we studied the sensory function of the anal canal.

METHODS

Forty patients with UC who had undergone IPAA with ileostomy closure at least 60 to 132 months (mean 103.6 months) previously, and who had no preoperative or postoperative complications were recruited. They were divided into two groups: group A [n = 26; patients without soiling (16 males, 10 females; ages 15-49 years, mean 36.6 years)] and group B [n = 14; patients with soiling (10 men, 4 women; ages 24-56 years, mean 40.9 years)] compared with group C [n = 28; control subjects (18 men, 10 women; aged 19-49 years, mean 38.5 years)]. Patients with soiling were also divided into three groups (B1, rare soiling; B2, occasional soiling; B3, frequent soiling). The anal canal sensitivity threshold was measured using an anal canal electrosensitivity test (ACEST). The measurement point of anal canal was divided into three parts: lower part [1 cm below the dentate line (DL), middle part (just on the DL), and upper part (1 cm above the DL]. A small electric current from a constant-current generator was passed between the electrodes until the patient felt a sensation often described as tingling or pulsing. The threshold of sensitivity was assessed in the upper, middle, and lower parts of the anal canal.

RESULTS

In patients of group C, recording at the middle part of the anal canal showed the best results. The anal canal sensitivity threshold of group B was significantly higher than those of groups A and C at the upper and middle parts (P < 0.0001, respectively). There were no significant differences at the lower part among groups. The anal canal sensitivity threshold of subgroup B3 was significantly higher than those of groups B1 or B2 at both the upper part (P = 0.0002, P = 0.0038, respectively) and middle part (P = 0.0001, P = 0.0480, respectively). There were no significant differences at the lower part among groups.

CONCLUSIONS

The ACEST shows significantly lower sensitivity in the proximal and middle anal canal in IPAA patients with soiling.

Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis

Ulcerative colitis, a chronic inflammatory disease of the rectal and colonic mucosa, affects approximately 250,000 to 500,000 people in the United States, with 30% to 40% of patients requiring some form of surgical intervention during the course of their disease. The predominant reason for total proctocolectomy is for symptoms refractory to currently available medical therapy. Less common reasons are dysplasia or cancer. The goal of colectomy is to prevent recurrence of systemic inflammatory disease. Consequently, surgery with total proctocolectomy and creation of an ileal J-pouch-anal anastomosis has become the procedure of choice for many patients without other therapeutic options. Health-related quality of life (QOL) in patients with severe ulcerative colitis is so poor that, after ileal J-pouch-anal anastomosis, QOL is considered to improve in most clinical studies (8 studies, improved QOL; 1 study, no change; 1 study, QOL worse than general population). However, QOL and bowel function after such surgery cannot be considered "normal" in all patients, because a substantial number still have problems with urgency, leakage, nocturnal soiling, sexual dysfunction, and pouchitis, and some require conversion to a permanent ileostomy after ileal J-pouch-anal anastomosis failure. Thus, despite the availability of ileal J-pouch-anal anastomosis, surgery does not always restore all aspects of QOL to normal.

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients

OBJECTIVE

Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.

BACKGROUND

The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes.

METHODS

Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone.

RESULTS

Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080).

CONCLUSIONS

Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

Ileal pouch-anal anastomosis (IPAA): functional outcome after postoperative pelvic sepsis. A prospective study of 100 patients

INTRODUCTION

The ileal pouch-anal anastomosis (IPAA) has become a standard procedure for patients with ulcerative colitis requiring surgical intervention. The technique has greatly improved and, since 1990, all patients at Huddinge University Hospital have been operated on with the double stapled technique. Pelvic sepsis is one of the most serious complications postoperatively, and, according to previous reports, leads to impaired function of the pouch and, in some cases, extirpation of the pouch.

AIM

The purpose of this study was to find out if pelvic sepsis postoperatively after IPAA leads to impaired functional outcome at long-term follow-up.

PATIENTS AND METHODS

One hundred consecutive patients with ulcerative colitis operated on between 1990 and 1997 with double stapled J-shaped pouches were followed prospectively with a standardised questionnaire, clinical follow-up and endoscopy of the pouch. The function of the pouch has been evaluated at a minimum of 2 years after surgery to compare the functional outcome between patients with and without pelvic sepsis postoperatively.

RESULTS

Twelve patients developed pelvic sepsis postoperatively. No significant differences were found in pouch evacuation frequency, incontinence, deferral time, usage of protecting pads, skin irritation, evacuation problems, diet, usage of medication or social handicap. There was one failure in the control group.

CONCLUSION

In this study, no evidence was found that suggested pelvic sepsis postoperatively impairs functional outcome after IPAA at long-term follow-up.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis

OBJECTIVE

The aim of this study was to evaluate functional outcome and quality of life (QOL) in patients undergoing proctocolectomy ileal pouch anal anastomosis (IPAA), to assess the correlation between functional outcome and QOL, and to identify factors influencing functional outcome and QOL in these patients.

BACKGROUND

IPAA is now considered the procedure of choice for ulcerative colitis. Functional outcome and QOL are important factors in evaluating operative outcome.

METHODS

All patients with UC who had undergone IPAA at our institute during the period 1990-2001 were included. QOL and functional outcome were evaluated by mailed questionnaires. QOL was scored using the Short Form 36 (SF-36). Global Assessment of Function Scale was used to evaluate functional outcome.

RESULTS

Data were obtained in 77 of 99 patients (78%), with the median age of 38 years. Median follow up time was 4.25 years. The QOL in patients after pelvic pouch procedure was excellent, with scores equal to published norms for the Israeli general population in most scales. Functional outcome and QOL scores correlated strongly (r > 0.5; P < 0.0001) in all dimensions. Older age was associated with lower scores in both functional outcome and QOL scales (P < 0.0001).

CONCLUSIONS

This study demonstrates a strong association between functional outcome and QOL in patients after IPAA. These patients, however, have a QOL that is comparable with the general population. Age at time of surgery strongly influences both functional outcome and QOL. This finding has to be taken into consideration in pre-operative counseling.

Pouch reconstruction in the pelvis

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.

Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results

PURPOSE

Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients.

METHODS

All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database.

RESULTS

Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent.

CONCLUSION

Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.

Anal Complications after Restorative Proctocolectomy (J-Pouch)

A prospective assessment was performed to determine the incidence of anal complications after ileoanal J-pouch anastomosis procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). From 1989 to 2000, 75 patients (50 male and 25 female) underwent proctocolectomy and ileal pouch-anal anastomosis with temporary loop ileostomy for UC (N = 68) and FAP (N = 7). Overall 33 patients (44%) developed anal complications postoperatively. Nineteen patients (25%) had mild anal stenosis amenable to digital dilatation in the office. Ten patients (13%) had severe anal stenosis requiring operative dilatation. Ileostomy closure was delayed longer than 3 months in four patients because of anal stenosis. One patient never had his ileostomy closed secondary to severe anal stenosis. Anal fissures developed in one patient that resolved with conservative treatment. Three patients developed fistula-in-ano and one patient developed a pouch-vaginal fistula. Of these four patients two later manifested signs of Crohn's disease. Four patients developed perirectal abscesses (three without fistulas) that were treated with incision and drainage. Two patients had presacral (anastomotic) abscesses; one patient was treated with temporary anastomotic diversion and the other underwent a permanent ileostomy and pouch resection. Both of these patients were later diagnosed with Crohn's disease. Anal complications developed in 17 of 41 (41%) handsewn anastomoses, 16 of 34 (47%) stapled anastomoses, three of seven (43%) patients with FAP, and 30 of 68 (44%) patients with UC. Operative technique and disease type did not significantly correlate with the type of anal complication. However, hand-sewn anastomoses had a higher incidence of severe strictures and FAP patients did not develop anal abscesses, fistulas, or fissures. Forty-five per cent of our patients with abscesses/fistulas and all of our patients with presacral abscesses from anastomotic dehiscence were later diagnosed with Crohn's disease. Anal complications after ileoanal J-pouch anastomosis are relatively common.

Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis

OBJECTIVE

To analyze the association between pre- and perioperative factors and pouch-related septic complications (PRSC) in ulcerative colitis (UC) and in familial adenomatous polyposis (FAP) after ileal pouch-anal anastomosis (IPAA).

SUMMARY BACKGROUND DATA

For patients with UC and FAP, IPAA is the surgical therapy of choice, but in some patients the outcome is compromised by PRSC.

METHODS

A total of 706 consecutive patients (494 UC, 212 FAP) were assessed in a study aimed at identifying subgroups of patients who were at high risk for PRSC. The rate of PRSC was analyzed as a time-dependent function (Kaplan-Meier estimation). Patients with UC and FAP were stratified separately according to associated factors (age, sex, surgeon's experience, temporary ileostomy, colectomy before IPAA, anastomotic tension, and several factors specific for UC).

RESULTS

In all, 131 (19.2%) patients had PRSC (23.4% UC, 9.4% FAP). In patients with UC, the estimated 1-year PRSC rate was 15.6% and the estimated 3-year PRSC rate was 24.2%. In patients with FAP, the estimated 1-year and 3-year PRSC rates were 9.2%. The difference between the estimated rates of PRSC was significant (P <.001). In the univariate analysis, patients with UC younger than 50 years, with severe proctitis, with preoperative hemoglobin levels less than 10 g/L, or receiving corticoid medication had a significantly higher risk for PRSC (P =.039, P =.037, P =.047, P =.003, respectively). Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P <.001). Patients with FAP proved to have a significantly higher risk for PRSC in the univariate and multivariate analyses if anastomotic tension had occurred (RR 3.60, P =.0086).

CONCLUSIONS

Pouch-related septic complications occur as late complications and should therefore be considered in regular, specific long-term follow-up examinations. The authors identified significant risk factors for PRSC specific to patients with UC and FAP; these must be considered for each individual surgical strategy.

Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis

BACKGROUND

The introduction of surgical stapling instruments has widened the use of restorative proctocolectomy. Too high a distal transection of the rectum can, however, produce a retained rectal stump, which may cause symptoms. A study of the operative and functional data in a consecutive series of patients undergoing salvage surgery for retained rectal stump was undertaken.

METHODS

Twenty-five patients referred between January 1990 and September 2000 for pouch dysfunction were identified as having a retained rectal stump. Twenty-two underwent abdominoanal revision. The hospital notes were reviewed and function was assessed during outpatient visits, by postal questionnaire and by telephone interview.

RESULTS

Median operating time was 225 (range 170-340) min and median hospital stay was 15 (range 8-48) days. There was no operative death. Five pouches were excised. Seventeen patients were available for functional assessment. Median follow-up was 22.5 (range 4-114) months. Median 24-h frequency before and after operation was 12 (range 4-20) and 6 (range 3-12) respectively, and median night-time frequency was 4 (range 0-8) and 0.5 (range 0-4) respectively. Fifteen patients reported marked subjective improvement in pouch function and quality of life.

CONCLUSION

Major revisional surgery for symptomatic retained rectal stump after restorative proctocolectomy with stapled anastomosis was successful in 15 of 22 patients. These results are worse than the outcome following first-time restorative proctocolectomy with anastomosis constructed at the anal level. Pouch-rectal anastomosis should be avoided.

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.

Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery

BACKGROUND

Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery.

METHODS

A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted.

RESULTS

Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak.

CONCLUSION

There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.

Pouch and pouchitis

Pouchitis is an inflammation of unknown origin occurring in the ileal pouch after IPAA. It is considered by many to be a form of ulcerative colitis that recurs in the pouch and rarely, if ever, occurs in patients with FAP. Most patients respond to a short course of antibiotics. When remission cannot be maintained or the disease is nonresponsive to prolonged treatment with antibiotics, anti-inflammatory agents or steroids may be useful. A variety of alternative drugs have been tried with mixed success and should be considered as experimental. Rarely, when pouchitis is refractory to medical management, excision of the pouch may be required.

Redo ileal pouch-anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy?

BACKGROUND

Pouch complications after ileal pouch-anal anastomosis (IPAA) can result in morbidity and pouch loss. Recent reports describe success with redo IPAA. This study was conducted to assess the outcome of malfunctioning pouches treated by redo IPAA.

METHODS

All patients undergoing redo IPAA between 1983 and 1999 were identified and clinical records studied. Redo IPAA was defined as an operation for malfunctioning pouch with pelvic dissection and disconnection, pouch revision, and reanastomosis. Analyzed were etiology, presentation, diagnostic modalities, surgical management, pouch loss, and outcome. Follow-up was obtained by telephone or mailed survey.

RESULTS

Between 1983 and 1999, 650 IPAA procedures were performed, 6 (0.9%) of which required redo IPAA. Ten referred patients required redo IPAA. These 16 cases included 7 anastomotic disruptions, 3 pouch-vaginal fistulae, 2 recurrent polyps after stapled IPAA, 2 megapouches, 1 cuff abscess, and 1 straight pullthrough. All patients underwent redo IPAA with pouch salvage 100% in this series. Twelve had the original pouch repaired and 4 new pouches. Six patients (37%) had complications and outcome was acceptable with 7.8 stools per day and nighttime incontinence "rarely" or "never" in 7 patients. Eight described results as "good," 6 as "fair.".

CONCLUSION

Redo IPAA can be performed with few complications, an acceptable outcome, and should result in low pouch loss.

Surgery of the small intestine

This article reviews both clinical and scientific advances in surgery of the small intestine that have been reported in the last year. The management of both pediatric and adult intussusception is considered. Multiple studies on the evolving role of ileal pouch-anal anastomosis are assessed. The treatment and epidemiology of a wide variety of intestinal neoplasms are reviewed. Advances in small bowel transplantation are also reported. The cause of small bowel obstruction is considered as well as new strategies to prevent adhesion formation. Finally, a number of diverse topics relating to intestinal surgery, including new data on laparoscopic surgery, treatment of enterocutaneous fistulas, reconstruction after total gastrectomy, intestinal transit after ileocecal segment transposition, and ischemia/reperfusion and anastomotic healing, are reviewed.

Reconstruction for chronic dysfunction of ileoanal pouches

OBJECTIVE

A retrospective review was performed to determine the results after surgical reconstruction for chronic dysfunction of ileal pouch-anal procedures for ulcerative colitis and familial colonic polyposis at a university medical center.

METHODS

During the 20-year period from 1978 to 1998, 601 patients underwent colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, familial colonic polyposis, or Hirschsprung's disease. A J pouch was used for 351 patients, a lateral pouch for 221, an S pouch for 6, and a straight pull-through for 23. Acute complications after pouch construction have been detailed in previous publications and are not included in this study. Chronic pouch stasis with diarrhea, frequency, urgency, and soiling gradually became more severe in 164 patients (27.3%), associated with pouch enlargement, an elongated efferent limb, and obstruction to pouch outflow, largely related to the pouch configuration used during the authors' early clinical experience. These patients were sufficiently symptomatic to be considered for reconstruction (mean 68 months after IPAA). Transanal resection of an elongated IPAA spout was performed on 58 patients; abdominoperineal mobilization of the pouch with resection and tapering of the lower end (AP reconstruction) and ileoanal anastomosis on 83; pouch removal and new pouch construction on 7; and conversion of a straight pull-through to a pouch on 16.

RESULTS

Good long-term results (mean 7.7 years) with improvement in symptoms occurred in 98% of transanal resections, 91.5% of AP reconstructions, 86% of new pouch constructions, and 100% of conversions of a straight pull-through to a pouch. The average number of bowel movements per 24 hours at 6 months was 4.8. Complications occurred in 11.6% of reconstructed patients. Five of the 164 patients (3.1%) required eventual pouch removal and permanent ileostomy. The high rate of pouch revision in this series of patients undergoing IPAA is due to a policy of aggressive correction when patients do not experience an optimal functional result, or have a progressive worsening of their status.

CONCLUSIONS

Although occasionally a major undertaking, reconstruction of ileoanal pouches with progressive dysfunction due to large size or a long efferent limb has resulted in marked improvement in intestinal function in >93% of patients and has reduced the need for late pouch removal.