Increasing experience of modified two-stage transanal ileal pouch-anal anastomosis for therapy refractory ulcerative colitis. What have we learned? A retrospective analysis on 75 consecutive cases at a tertiary referral hospital

Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques

BACKGROUND

Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques.

OBJECTIVE

To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy.

DATA SOURCE

Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

STUDY SELECTION

Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis.

INTERVENTION

IPAA technique.

MAIN OUTCOME MEASURES

Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function).

RESULTS

Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques.

LIMITATIONS

A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy.

CONCLUSIONS

Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.

Transanal ileal pouch-anal anastomosis: A systematic review and meta-analysis of technical approaches and clinical outcomes

PURPOSE

Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.

METHODS

Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.

RESULTS

Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.

CONCLUSIONS

Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.

Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review

OBJECTIVE

To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA].

BACKGROUND

Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials.

METHODS

Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs.

RESULTS

The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials.

CONCLUSIONS

Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.

Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis

AIM

The aim of this study was to compare modified 2-stage and 3-stage IPAA construction techniques to evaluate the effect of diverting loop ileostomy following completion proctectomy and IPAA for ulcerative colitis. In addition, our overall institutional experience was reviewed to describe long-term outcomes and changes in staging trends over time.

METHODS

Our institutional database was searched to identify all cases of IPAA for ulcerative colitis between 1981 and 2018. Patient, pouch and outcome characteristics were abstracted. Primary study outcomes were the incidence of primary pouch failure and pouch-related sepsis. Failure was evaluated by Kaplan-Meier estimates of survival over time. The adjusted effect of pouch stage was evaluated using multivariable Cox and logistic regression models. Exploratory analysis evaluated the effect of stage on failure in the pouch related sepsis subgroup.

RESULTS

A total of 2105 patients underwent primary IPAA over the study period. The 5, 10 and 20-year pouch survival probabilities were 95.2%, 92.7% and 86.6%. The incidence of pouch related sepsis was 12.3%. Adjusted analysis demonstrated no difference in pouch failure (HR = 0.64: 95% 0.39-1.07, p = 0.09) or post-operative sepsis (aOR = 0.79: 95% CI 0.53-1.17, p = 0.24) by stage of construction. Among patients experiencing pouch sepsis, there was no difference in Kaplan-Meier estimates of pouch survival by stage (p = 0.90).

CONCLUSIONS

Pouch related sepsis and IPAA failure did not differ between modified 2-stage and 3-stage construction techniques. Among the sub-group of patients experiencing pouch related sepsis, there was no difference in failure between groups. The results suggest diverting ileostomy may be safely avoided following delayed pouch reconstruction in appropriately selected patients.

Transanal ileal pouch anal anastomosis for ulcerative colitis in children and adults: a systematic review and meta-analysis

PURPOSE

The incidence of pediatric onset ulcerative colitis (UC) is increasing, with increasing rate of children eventually requiring surgical treatment. Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment. Although transanal IPAA (ta-IPAA) is becoming widely accepted for adult UC patients, data regarding this procedure in children are scarce. Nevertheless, some adult publications also include patients under 18 years old. This systematic review and meta-analysis aimed to summarize surgical and functional outcomes following ta-IPAA, and extract conclusion regarding pediatric UC patients.

METHODS

PubMed, Cochrane Library databases, Embase, Web of science and Google Scholar databases were searched, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. The final search was updated in April 2022. Four comparative cohorts (n = 868) and 11 non-comparative case series (n = 241) were included. Six reports included children. Anastomotic leak, complications, operative time, conversion rate, length of stay and functional outcomes were examined.

RESULTS

A total of 1103 patients, ranging 9-79 years were included in this review. We found no difference in risk for anastomotic leak (OR 1.36, 95% CI 0.46-4.06), minor and major complications (OR 0.92, 95% CI 0.48-1.76 and OR 0.78 95% CI 0.36-1.69, respectively) comparing ta-IPAA to transabdominal IPAA. Short- and long-term follow-up showed satisfying functional outcomes and quality of life.

CONCLUSIONS

Our review suggests that ta-IPAA is not inferior to transabdominal IPAA. Implementation of this method in children is technically feasible due to familiarity with the dissection plane. Long-term functional outcomes and quality of life are paramount in the pediatric population and should be particularly investigated. Multicenter prospective studies are required to investigate pediatric UC patients undergoing ta-IPAA.

Minimally Invasive and Robotic Surgery for Ulcerative Colitis

Significant advancements have been made over the last 30 years in the use of minimally invasive techniques for curative and restorative operations in patients with ulcerative colitis (UC). Numerous studies have demonstrated the safety and feasibility of laparoscopic and robotic approaches to subtotal colectomy (including in the urgent setting), total proctocolectomy, completion proctectomy, and pelvic pouch creation. Data show equivalent or improved short-term postoperative outcomes with minimally invasive techniques compared to open surgery, and equivalent or improved long-term bowel function, sexual function, and fertility. Overall, while minimally invasive techniques are safe and feasible for properly selected UC patients, surgeons must remember to abide by the principles of high-quality proctectomy and pouch creation and convert to open if necessary.

Proctocolectomy and ileal pouch-anal anastomosis for the treatment of collagenous colitis

The role of surgery for collagenous colitis (CC) is unexplored. Either diverting stoma, subtotal colectomy with ileo-rectal anastomosis, and proctocolectomy with ileal pouch-anal anastomosis (IPAA) have been proposed. However, the optimal surgical strategy still needs to be defined. The aim of this short report is to report our experience with two cases of IPAA for CC. Two patients affected by histologically proven CC with watery diarrhea refractory to several lines of medical treatment underwent a laparoscopic proctocolectomy with IPAA at a tertiary referral hospital for the treatment of Inflammatory Bowel Disease in Belgium. A longer rectal cuff was left in place because of the absence of macroscopic inflammation of the rectal mucosa and the consequent negligible risk of cuffitis. No postoperative complications (90 days) occurred. Definitive pathological examination confirmed the diagnosis of CC. At six months, pouchoscopy revealed no signs of inflammation. One year after surgery, mean Öresland and Pouch Functional Score were 10.5 (8-13) and 11.5 (9-14). Functional outcomes after IPAA for CC were barely satisfactory. A high stool frequency not responding to high doses of anti-diarrheals was observed. This has also previously been reported for CC patients receiving a diverting stoma. Proctocolectomy and IPAA for medical refractory CC leads to acceptable short-term gastrointestinal functional outcomes which seems to be particularly affected by high stool frequency. For this reason, pouch surgery might not be the optimal indication for collagenous colitis.