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Akiyama S, Barnes EL, Onoda T, Ishikawa N, Shiroyama M, Ito Y, Rubin DT, Tsuchiya K. Endoscopic assessment of the J pouch in ulcerative colitis: A narrative review. DEN OPEN 2025; 5:e373. [PMID: 38694540 PMCID: PMC11058686 DOI: 10.1002/deo2.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 05/04/2024]
Abstract
Patients with ulcerative colitis sometimes need a total colectomy with ileal pouch-anal anastomosis due to medically refractory disease or colitis-associated neoplasia. Up to 50% of patients with ulcerative colitis postoperatively develop pouchitis and the rate of chronic inflammatory pouch conditions requiring pouch excision or diverting ileostomy is reported to be 10%. In order to diagnose and monitor pouchitis, pouchoscopy is essential to assess endoscopic inflammatory findings of the J pouch and to survey neoplasia development, particularly in the remnant distal rectum. However, endoscopic protocols for the evaluation of the pouch may not be standardized worldwide and the reliability of existing disease activity indices for pouchitis has been questioned due to the lack of validation. Recently, reliable endoscopic scoring systems based on an observation of the anatomical location of the J pouch were reported and a significant association between the distribution pattern of endoscopic inflammation (i.e., endoscopic phenotype) and pouch outcomes was also uncovered. In this review, we discuss how to survey the J pouch using pouchoscopy, endoscopic indices for pouchitis disease activity, endoscopic phenotypes and classification, and the pathological mechanisms of pouchitis phenotype in patients with ulcerative colitis.
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Affiliation(s)
- Shintaro Akiyama
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Edward L Barnes
- Division of Gastroenterology and HepatologyUniversity of North Carolina at Chapel HillChapel HillUSA
| | - Tsubasa Onoda
- Department of GastroenterologyNHO Mito Medical CenterIbarakiJapan
- Doctoral Program in Medical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Naoki Ishikawa
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Doctoral Program in Medical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Mamiko Shiroyama
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Doctoral Program in Medical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Yuka Ito
- Department of GastroenterologyNHO Mito Medical CenterIbarakiJapan
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease CenterChicagoUSA
| | - Kiichiro Tsuchiya
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
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Weber AT, Lichtenstein GR. Evidence-Based Approach to Chronic Antibiotic Refractory Pouchitis: A Review. Dis Colon Rectum 2024; 67:S99-S105. [PMID: 38363696 DOI: 10.1097/dcr.0000000000003207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND Chronic antibiotic refractory pouchitis after restorative proctocolectomy with IPAA, characterized by at least 4 weeks of pouchitis symptoms that have not responded to standard antibiotic therapy, presents a therapeutic challenge for patients and health care providers. OBJECTIVE The aim of this narrative review was to summarize the current evidence regarding the management of chronic antibiotic refractory pouchitis. DATA SOURCES Studies were identified through a search of the PubMed database from the National Library of Medicine. STUDY SELECTION We included case series, cohort studies, randomized controlled trials, and systematic reviews with meta-analyses that addressed chronic antibiotic refractory pouchitis management, with prioritization of data published within the past 3 to 5 years. INTERVENTION Studies examining pharmacologic and select nonpharmacologic interventions were included. MAIN OUTCOME MEASURE Outcomes measures included clinical, endoscopic, and histologic end points. RESULTS Mesalamine has demonstrated efficacy in symptom improvement but no improvement in quality of life. Budesonide has demonstrated high rates of clinical remission that have mostly been sustained in a small number of patients. Anti-tumor necrosis factor therapies have demonstrated efficacy in reaching clinical and even endoscopic end points, although rates of treatment discontinuation were not insignificant. Limited evidence is encouraging for the use of ustekinumab in achieving clinical response. Data for vedolizumab are favorable across clinical, endoscopic, and histologic end points, including one of the only randomized, placebo-controlled trials. Nonmedication therapies, including hyperbaric oxygen therapy and fecal microbiota transplant, have undergone limited evaluation, and concerns about the ultimate accessibility of these therapies remain. LIMITATIONS Overall, studies assessing therapeutic options for chronic antibiotic refractory pouchitis are mostly limited to case series and retrospective studies with small sample sizes. CONCLUSIONS Biologic therapies have demonstrated efficacy in the management of chronic antibiotic refractory pouchitis and offer a steroid-sparing option for refractory disease. Nonpharmacologic therapies, including hyperbaric oxygen and fecal microbiota transplant, require further exploration. See video from symposium .
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Affiliation(s)
- Andrew T Weber
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Shen B, Yao Q, Scherl EJ. Management of Primary Sclerosing Cholangitis and Extraintestinal Disorders in Patients With Ileal Pouches: A Systematic Review. Dis Colon Rectum 2024; 67:S106-S114. [PMID: 38411984 DOI: 10.1097/dcr.0000000000003231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joints, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis, can persist after colectomy. OBJECTIVES A systematic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and IPAA for ulcerative colitis. DATA SOURCES PubMed, Google Scholar, and Cochrane database. STUDY SELECTION Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between January 2001 and July 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and IPAA were included. MAIN OUTCOME MEASURES Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management. RESULTS Primary sclerosing cholangitis and extraintestinal manifestations are associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with chronic pouchitis, enteritis, and possible pouch neoplasia. However, the disease severity and course of primary sclerosing cholangitis and pouchitis do not appear to be parallel. Despite the fact that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may also be beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking. LIMITATIONS This is a qualitative, not quantitative, review of case series and case reports. CONCLUSIONS Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. Although the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See video from the symposium .
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Affiliation(s)
- Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
| | - QingPing Yao
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, New York
| | - Ellen J Scherl
- Division of Gastroenterology and Hepatology, Department of Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York, New York
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Ahmed Ali U, Kiran RP. Conversion of Failed J-Pouch to Kock Pouch: Indications, Contraindications, and Outcomes. Dis Colon Rectum 2024; 67:S46-S51. [PMID: 38276945 DOI: 10.1097/dcr.0000000000003182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND The IPAA has been successful in restoring intestinal continuity and preserving continence in the majority of patients requiring a proctocolectomy. However, a subset of individuals experience significant complications that might result in pouch failure. The conversion of the J-pouch to a continent ileostomy pouch represents a significant surgical procedure. In this article, we discuss the indications and contraindications, present the technical principles applied for the conversion, and describe the outcomes of such conversion in the literature. OBJECTIVE The main objective during the conversion of the J-pouch to a continent ileostomy is the creation of a sufficiently sized reservoir with a high-quality valve mechanism while preserving as much small bowel as possible. CONCLUSIONS The conversion of the J-pouch to a continent ileostomy represents a significant surgical procedure. When performed in centers of expertise, it can be a good option for patients who otherwise will require an end ileostomy. Indications for conversion include most cases of J-pouch failure, with a few important exceptions. See video from symposium .
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Affiliation(s)
- Usama Ahmed Ali
- Division of Colorectal Surgery, Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York
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Shen B. Endoscopic Evaluation of the Ileal Pouch. Dis Colon Rectum 2024; 67:S52-S69. [PMID: 38276962 DOI: 10.1097/dcr.0000000000003269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described. DATA SOURCES PubMed, Google Scholar, and Cochrane databases. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES Accurate characterization of the ileal pouch in healthy or diseased states. RESULTS The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series. CONCLUSIONS Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.
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Affiliation(s)
- Bo Shen
- The Global Integrated Center for Colorectal Surgery and Interventional Endoscopy and Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
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Lee KE, Sizemore JA, Kim G, Shen B, Sands BE. Impact of Biologics and Small-Molecule Agents on Postoperative Complications in IBD: A Systematic Review. Dis Colon Rectum 2024; 67:S11-S25. [PMID: 38294838 DOI: 10.1097/dcr.0000000000003222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Patients with IBD may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. The question of the impact of biologic use on postoperative complications is a topic of active investigation. OBJECTIVE A systematic literature review was performed to describe the current state of knowledge of the impact of perioperative biologic and tofacitinib use on postoperative complications in patients with IBD. DATA SOURCES PubMed and Cochrane databases were searched. STUDY SELECTION Studies between January 2000 and January 2023, in any language, were searched, followed by a snowball search identifying further studies in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Articles regarding pediatric or endoscopic management were excluded. INTERVENTIONS Preoperative or perioperative exposure to biologics in IBD was included. MAIN OUTCOME MEASURES Infectious and noninfectious complications, including anastomotic leaks, surgical site infections, urinary tract infections, pneumonia, sepsis, septic shock, postoperative length of stay, readmission, and reoperation, were the main outcomes measured. RESULTS A total of 28 studies were included for analysis in this review, including 7 meta-analyses or systematic reviews and 5 randomized studies. Snowball search identified 11 additional studies providing topical information. Overall, tumor necrosis factor inhibitors likely do not increase the risk of postoperative adverse outcomes, while data on other biologics and small-molecule agents are emerging. LIMITATIONS This is a qualitative review including all study types. The varied nature of study types precludes quantitative comparison. CONCLUSIONS Although steroids increase postoperative infectious and noninfectious complications, tumor necrosis factor inhibitors do not appear to increase postoperative infectious and noninfectious complications. There is a need for further perioperative data for other agents. See video from symposium .
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Affiliation(s)
- Kate E Lee
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | - Grace Kim
- Duke University School of Medicine, Durham, North Carolina
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Division of Digestive and Liver Diseases, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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Schwartzberg DM, Kayal M, Barnes EL. The Ileal Pouch-Anal Anastomosis: Identifying Structural Disorders. Inflamm Bowel Dis 2024; 30:863-867. [PMID: 38253467 PMCID: PMC11063547 DOI: 10.1093/ibd/izad320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Indexed: 01/24/2024]
Abstract
Lay Summary
Chronic disorders of a pelvic pouch may result from structural complications secondary to postoperative surgical complications which manifest as a variety of symptoms. Knowing the crucial pitfalls of pouch construction can guide treatment options in patients suffering from signs of pouch failure.
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Affiliation(s)
- David M Schwartzberg
- Division of Colon and Rectal Surgery, Inflammatory Bowel Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Maia Kayal
- Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Anto VP, Ramos AE, Mollen KP. Ouch, my pouch! a clinician's guide to pouchitis. Semin Pediatr Surg 2024; 33:151406. [PMID: 38636151 DOI: 10.1016/j.sempedsurg.2024.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.
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Affiliation(s)
- Vincent P Anto
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna E Ramos
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Posner H, Lombard R, Akiyama S, Cohen NA, Rubin DT, Dubinsky MC, Dalal S, Kayal M. Extensive Disease and Exposure to Multiple Biologics Precolectomy Is Associated with Endoscopic Cuffitis Post-Ileal Pouch-Anal Anastomosis in Patients With Ulcerative Colitis. Inflamm Bowel Dis 2024:izae029. [PMID: 38521548 DOI: 10.1093/ibd/izae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 03/25/2024]
Abstract
INTRODUCTION To better inform the risk of cuffitis in patients with ulcerative colitis (UC), we aimed to identify its occurrence and associated precolectomy factors in a large multicenter cohort of patients who underwent restorative proctocolectomy (RPC) with stapled ileal pouch-anal anastomosis (IPAA). METHODS This study was a retrospective cohort analysis of individuals diagnosed with UC or indeterminate colitis who underwent RPC with IPAA for refractory disease or dysplasia at Mount Sinai Hospital or the University of Chicago followed by at least 1 pouchoscopy with report of the pouch-anal anastomosis. The primary outcome was cuffitis defined as ulceration of the cuff as reported in each pouchoscopy report. RESULTS The pouch-anal anastomosis was mentioned in the pouchoscopy reports of 674 patients, of whom 525 (77.9%) had a stapled anastomosis. Among these, cuffitis occurred in 313 (59.6%) patients a median of 1.51 (interquartile range 0.59-4.17) years after final surgical stage. On multivariable analysis, older age (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01-1.02), extensive disease (HR, 1.34; 95% CI, 1.01-1.78), exposure to biologics before colectomy (HR, 2.51; 95% CI, 1.93-3.27), and exposure to at least 2 or more biologics before colectomy (HR, 2.18; 95% CI, 1.40-3.39) were significantly associated with subsequent cuffitis. CONCLUSIONS In this multicenter study of patients who underwent RPC with stapled IPAA and at least 1 follow-up pouchoscopy, cuffitis occurred in approximately 60% and was significantly associated with extensive disease and exposure to multiple biologics precolectomy.
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Affiliation(s)
- Hannah Posner
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Lombard
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Shintaro Akiyama
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
- Department of Gastroenterology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Nathaniel A Cohen
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - David T Rubin
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Marla C Dubinsky
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sushila Dalal
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis. BMC Gastroenterol 2023; 23:32. [PMID: 36755253 PMCID: PMC9906904 DOI: 10.1186/s12876-023-02667-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Double-stapled ileal pouch-anal anastomosis (DS-IPAA) is easy to construct and has a good functional outcome in patients with ulcerative colitis (UC). However, retention of the anorectal mucosa may lead to a subsequent risk of inflammation and neoplasia. This study aimed to identify factors associated with the retention of a large amount of anorectal mucosa after DS-IPAA. METHODS The medical records of 163 patients who had undergone one-stage total proctocolectomy and DS-IPAA for UC between 2007 and 2020 were retrospectively reviewed. The patients were divided into two groups according to the length of the retained mucosa. The high anastomosis group was defined as having a retained mucosal length of ≥ 30 mm in the anterior or posterior wall. Clinical factors were compared between the high and low anastomosis groups. RESULTS The high anastomosis group showed a significantly higher body mass index (BMI) (high vs. low: 23.2 vs. 19.0), longer operation time (304 vs. 263) and greater blood loss (357 vs. 240). In the multivariate analysis, high BMI was the only factor significantly associated with high anastomosis (odds ratio 1.32). There was a positive correlation between BMI and the length of the retained mucosa. CONCLUSIONS In DS-IPAA, BMI showed the strongest association with the retention of a large amount of the anorectal mucosa. In high BMI patients, although the risk of inability of anastomosis is little than that of IPAA with mucosectomy, the possible retention of a large amount of mucosa should be considered.
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