Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients

Complications and functional outcomes after ileo-anal pouch excision-a systematic review of 14 retrospective observational studies

PURPOSE

The ileo-anal pouch (IAP) has been the gold standard procedure for maintenance of bowel continuity after panproctocolectomy for ulcerative colitis, familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. However, the IAP has an estimated failure rate of 13% at 10 years post-procedure (Tulchinsky et al., Ann Surg 238(2):229-34, 2003), which can result in pouch excision (P.E.). This systematic review aims to synthesise all the available studies reporting post-operative outcomes of P.E. and its impact on patient quality of life (QoL), when available, which have not previously been summarised.

METHODS

PubMed, Embase, Medline and the Cochrane library databases were searched with terms 'Pouch AND excision' OR 'Pouch AND removal' OR 'Pouch AND remove' OR 'IAP AND excision'. All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. were included. Studies with < 5 patients, non-English studies and conference abstracts were excluded.

RESULTS

14 studies comprising 1601 patients were included. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9-40%) or surgical site infection (wound-2 to 30%; intra-abdominal collection-3 to 24%). The mortality rate was between 0.58 and 1.4%. QoL is generally lower in P.E. patients compared to the normal population across various QoL measures and P.E. patients often had urinary and sexual dysfunction post-operatively.

CONCLUSIONS

There is a substantial incidence of complications after P.E.; however, there is no evidence describing QoL pre- and post-P.E. Further longitudinal research comparing QoL in patients undergoing P.E. and other treatment options such as indefinite diversion is required to definitively assess QoL post-procedure.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on pouchitis in ulcerative colitis. Part 2: Treatment

Pouchitis treatment is a complex entity that requires a close medical and surgical relationship. The elective treatment for acute pouchitis is antibiotics. After a first episode of pouchitis it is recommended prophylaxis therapy with a probiotic mix, nevertheless it is not clear the use of this formulation for preventing a first episode of pouchitis after surgery. First-line treatment for chronic pouchitis is an antibiotic combination. The next step in treatment should be oral budesonide. Selected cases of severe, chronic refractory pouchitis may benefit from biologic agents, and anti-TNF α should be recommended as the first option, leaving the new biologicals for multi-refractory patients. Permanent ileostomy may be an option in severe refractory cases to medical treatment.

Ileal Pouch Excision: A Contemporary Observational Cohort

BACKGROUND

Pouch excision is required for many of those patients experiencing pouch failure in whom ileostomy alone is inadequate and revision surgery is not appropriate. The published rate of pouch failure is approximately 10% at 10 years, resulting in a growing cohort of patients requiring excision.

OBJECTIVE

In this article, we aim to describe the indications for excision and postoperative outcomes at our center since 2004.

DESIGN

This is a retrospective observational study.

SETTINGS

This study was conducted at a tertiary referral center for ileal pouch dysfunction. Cases were documented from 2004 to 2017.

PATIENTS

The cohort comprised 92 patients; 83% were diagnosed with ulcerative colitis, 15% with familial adenomatous polyposis, and 2% with indeterminate colitis.

INTERVENTIONS

Patients underwent excision of pelvic ileal pouches.

MAIN OUTCOME MEASURES

The primary outcomes measured were the time to perineal wound healing and healing at 6 months. Thirty- and 90-day morbidity and mortality were evaluated.

RESULTS

Postoperative histology was consistent with Crohn's disease in 1 patient. The median time from pouch creation to excision was 7 years. The rate of perineal wound healing at 6 months was 78%, and regression analysis demonstrated significantly improved chances of healing for noninfective indications for excision (p = 0.023; OR, 15.22; 95% CI, 1.45-160.27) and for more recent procedures (p = 0.032; OR, 12.00; 95% CI, 1.87-76.87).

LIMITATIONS

This study was limited because it was retrospective in nature, and it was a single-center experience.

CONCLUSIONS

This study represents the most contemporary cohort of patients undergoing pouch excision surgery. The procedure retains a relatively high postoperative morbidity, but this study demonstrates a learning curve with improving perineal healing over time associated with a high institutional volume. Defunctioning ileostomy may improve perineal wound healing in patients with infective indications for excision. Further investigation is required to establish the quality-of-life benefits of pouch excision in this modern cohort. See Video Abstract at http://links.lww.com/DCR/A804.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease

Inability to distinguish Crohn's colitis from ulcerative colitis leads to the diagnosis of indeterminate colitis. This greatly effects medical and surgical care of the patient because treatments for the two diseases vary. Approximately 30 percent of inflammatory bowel disease patients cannot be accurately diagnosed, increasing their risk of inappropriate treatment. We sought to determine whether transcriptomic patterns could be used to develop diagnostic biomarker(s) to delineate inflammatory bowel disease more accurately. Four patients groups were assessed via whole-transcriptome microarray, qPCR, Western blot, and immunohistochemistry for differential expression of Human α-Defensin-5. In addition, immunohistochemistry for Paneth cells and Lysozyme, a Paneth cell marker, was also performed. Aberrant expression of Human α-Defensin-5 levels using transcript, Western blot, and immunohistochemistry staining levels was significantly upregulated in Crohn's colitis, p< 0.0001. Among patients with indeterminate colitis, Human α-Defensin-5 is a reliable differentiator with a positive predictive value of 96 percent. We also observed abundant ectopic crypt Paneth cells in all colectomy tissue samples of Crohn's colitis patients. In a retrospective study, we show that Human α-Defensin-5 could be used in indeterminate colitis patients to determine if they have either ulcerative colitis (low levels of Human α-Defensin-5) or Crohn's colitis (high levels of Human α-Defensin-5). Twenty of 67 patients (30 percent) who underwent restorative proctocolectomy for definitive ulcerative colitis were clinically changed to de novo Crohn's disease. These patients were profiled by Human α-Defensin-5 immunohistochemistry. All patients tested strongly positive. In addition, we observed by both hematoxylin and eosin and Lysozyme staining, a large number of ectopic Paneth cells in the colonic crypt of Crohn's colitis patient samples. Our experiments are the first to show that Human α-Defensin-5 is a potential candidate biomarker to molecularly differentiate Crohn's colitis from ulcerative colitis, to our knowledge. These data give us both a potential diagnostic marker in Human α-Defensin-5 and insight to develop future mechanistic studies to better understand crypt biology in Crohn's colitis.

Quality of life following ileoanal pouch failure

This article describes a novel qualitative study exploring the lived experience of participants having undergone ileoanal pouch failure, on a background of ulcerative colitis (UC). It focuses on the impact of living with indefinite diversion of the pouch and a permanent end ileostomy. Six participants were interviewed with an aim to establish their experience of pouch failure and the support they required. Five pertinent themes emerged that suggested participants did not expect pouch failure and were unprepared for the regression towards UC. Some participants recommenced drug therapy, wore pads to manage leakage from the diverted pouch, avoided certain social settings or manipulated diet and lifestyle in order to gain an acceptable quality of life with a permanent ileostomy. Pouch failure potentially presents adverse effects on patients' quality of life, but currently there is a deficit in support and resources available in order to provide acceptable outcomes for patients experiencing pouch failure.

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

[Current status of elective surgical treatment of ulcerative colitis. A systematic review]

Despite recent advances in the medical treatment of ulcerative colitis (UC), approximately 25-40% of patients will need surgery during their disease. The aim of elective surgical treatment of UC is to remove the colon/and rectum with minimal postoperative morbidity, and to offer a good long-term quality of life. There are several technical options for the surgical treatment of UC; at present, the most frequently offered is restorative proctocolectomy and ileal pouch-anal anastomosis. Both the surgeon and patient should be aware of the risks associated with a technically demanding procedure and possible postoperative complications, including the possibility of infertility, permanent stoma, or several surgical procedures for pouch-related complications. A precise knowledge of each surgical technique, and its indications, complications, long-term risks and benefits is useful to offer the best surgical option tailored to each patient. We searched in PubMed, MEDLINE, and EMBASE for all kinds of articles (all the publications until April 2012). Papers on Crohn's disease, indeterminate colitis, or other forms of colitis were excluded from the review. We reviewed the abstracts and identified potentially relevant articles. MeSH words were used as search, "ulcerative colitis", "surgery", "indications", "elective surgery", "colectomy," "proctocolectomy," "laparoscopy", "Complications," "outcome", "results" "quality of life". One hundred and four articles were included in this review.

Intestinal stomas: indications, management, and complications

The ability to appropriately construct and care for an ostomy is crucial to good colorectal surgical practice. Enterostomal therapy is critical to the successful management of ostomies and their complications. Although associated with morbidity, a well-constructed ostomy can provide our patients with a good, durable QoL.

Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision?

BACKGROUND

The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized.

OBJECTIVE

This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure.

DESIGN

This study is a retrospective review of prospectively gathered data.

SETTINGS

This investigation was conducted at a tertiary center.

PATIENTS

Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study.

MAIN OUTCOME MEASURES

The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires.

RESULTS

One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.

Sexual function after failed ileal pouch-anal anastomosis

BACKGROUND AND AIMS

Failure of ileal pouch-anal anastomosis (IPAA) occurs in around 10% of the patients. Compared to patients with functioning pouches, health related quality of life is deteriorated after failure. Sexual function in patients with pouch failure is however poorly studied. The aim was to study sexual function in patients with pelvic pouch failure; patients with functioning pouches were used as controls. The hypothesis was that patients with pouch failure have worse sexual function.

METHODS

36 patients with pouch failure were compared with 72 age and sex-matched controls with ulcerative colitis and functioning pouches. The patients answered a set of questionnaires concerning sexual function (Female Sexual Function Index [FSFI] and International Index of Erectile Function [IIEF]), body image (BIS-scale) and health-related quality of life (SF-36).

RESULTS

Both women and men with pouch failure scored lower than controls in the FSFI and IIEF questionnaires. However, none of the observations were statistically significant. The scores in the failure group (for both sexes) were below the cut-off level for sexual dysfunction. Scores for the BIS instrument were significantly lower for both sexes in the failure group. Women and men in the failure group scored lower than the controls in all domains of the SF-36, however statistically significant only for the social function domain in men.

CONCLUSIONS

The hypothesis, that a failed IPAA is associated with worse sexual function, was not confirmed. Compared to patients with functioning pouches, patients with pouch failure have inferior body image.

Inflammatory bowel disease-associated colorectal cancer: proctocolectomy and mucosectomy do not necessarily eliminate pouch-related cancer incidences

BACKGROUND

Colorectal cancer (CRC), the most lethal long-term complication of inflammatory bowel disease (IBD), is the culmination of a complex sequence of molecular and histologic derangements of the colon epithelium that are initiated and at least partially sustained by prolonged chronic inflammation. Dysplasia, the earliest histologic manifestation of this process, plays an important role in cancer prevention by providing the first clinical alert that this sequence is under way and by serving as an endpoint in colonoscopic surveillance of patients at high risk for CRC. Restorative proctocolectomy (RPC) is indicated for patients with IBD, specifically for ulcerative colitis that is refractory to medical treatment, emergency conditions, and/or in case of neoplastic transformation. Even after RPC with mucosectomy, pouch-related carcinomas have recently been reported with increasing frequency since the first report in 1984. We review IBD-associated CRC and pouch-related neoplasia prevalence, adverse events, risk factors, and surveillances.

METHODS

Literature of IBD-associated CRC patients and those undergoing RPC surgeries through 2010 were prospectively reviewed.

RESULTS

We found 12 studies from retrospective series and 15 case reports. To date, there are 43 reported cases of pouch-related cancers. Thirty-two patients had cancer in the anal transit zone (ATZ); of these, 28 patients had mucosectomy. Eleven patients had cancer found in the pouch body.

CONCLUSION

RPC with mucosectomy does not necessarily eliminate risks. There is little evidence to support routine surveillance of pouch mucosa and the ATZ except for patients associated with histological type C changes, sclerosing cholangitis, and unremitting pouchitis.

Pouch-related dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

BACKGROUND

Restorative proctocolectomy (RPC) is the criterion standard surgical treatment for ulcerative colitis (UC). Restorative proctocolectomy is indicated for UC that is refractory to medical treatment, for emergency conditions, and in case of neoplastic transformation. The procedure substantially reduces the risk of UC-associated dysplasia/neoplasia. However, after RPC surgery, even with mucosectomy, cancers of the pouch and/or the anal-transitional zone (ATZ) have been reported with increasing frequency since the first report in 1984. This review highlights pouch-related dysplastic and neoplastic transformation, prevalence and adverse events, risk factors and surveillance following surgery for UC.

METHODS

Reports in the literature about patients undergoing pouch surgery from different institutions reported through May 2010 were reviewed to identify patients who developed these complications, and an attempt was made to develop a rational follow-up policy based on the data available.

RESULTS

To date, there are 43 reported cancers of the pouch or inlet after RPC for UC: 16 from retrospective series, 1 from a prospective study, and 26 in case reports. Thirty patients underwent mucosectomy and 13 had stapled anastomoses. To date, the number of 28 patients has been diagnosed with dysplasia after RPC for UC. Mucosectomy was performed in 27 of them and in 1 a stapled anastomosis was constructed without mucosectomy. In all cases reviewed, the time interval from the onset of UC to dysplasia/neoplasia was over 10 years.

CONCLUSION

Neoplastic lesions occurring in UC patients after RPC have been shown to be absolutely inevitable. Even mucosectomy does not completely eliminate the risk. There is little evidence to support routine biopsy of the ileal mucosa or the anal-transition zone except in patients with histological type C changes, sclerosing cholangitis, and unremitting pouchitis in the ileal mucosa. Such patients should be selected for endoscopic surveillance to detect dysplasia preceding pouch adenocarcinoma.

Polyps in the ileal pouch

Total proctocolectomy and ileal pouch-anal anastomosis is the operation of choice for patients with familial adenomatous polyposis. With this operation comes the risk of developing ileal pouch polyps. Although rare, ileal pouch carcinomas may also occur within the pouch. Periodic endoscopic surveillance of the retained rectum and ileal pouch is recommended. Endoscopic polypectomy of medium and large polyps should be performed. Sulindac is effective in the reduction and often in the elimination of numerous smaller pouch polyps. Future studies are necessary to determine the role of sulindac and other chemotherapeutic agents in preventing the development of these polyps.

Assessment of the mucosa of the indefinitely diverted ileo-anal pouch

OBJECTIVE

One surgical option to treat failure after restorative proctocolectomy (RPC) is indefinite diversion (ID) without excision of the pouch. The study aimed to assess the mucosal morphology of the pouch and ileoanal anastomosis (IAA) over time after ID with particular reference to inflammation, dysplasia and carcinoma.

METHOD

Patients with ID were identified from the hospital's Ileal Pouch Database. Individuals were invited by mail to attend for flexible pouchoscopy and biopsy from the ileal pouch and immediately distal to the IAA.

RESULTS

Of 1822 patients on the database, 28 had undergone ID. Of these, 20 patients (18 ulcerative colitis, one familial adenomatous polyposis, one pseudo-obstruction) of median age 42 (18-67) years took part. There were eight males. The median (range) intervals from diagnosis of primary disease, pouch surgery and ID to the time of study were 221 (63-410), 146 (31-314) and 44 (10-159) months respectively. One patient had dysplasia in the original resection specimen. Five patients developed type C changes in the pouch. Of these three were identified between RPC and ID, one developed between ID and the present assessment and one was identified for the first time at the present assessment. No case of dysplasia or cancer was found in any of the biopsies. Rectal mucosa was found in biopsies from the IAA in four patients (three stapled; one handsewn); this was inflamed in three patients.

CONCLUSION

At a median follow-up of 12 years after RPC and 3.6 years after indefinite diversion no instance of dysplasia or carcinoma in the ileal reservoir or distal to the IAA was found in any of the 20 patients having ID. Type C changes occurred at some time in five (25%) patients, indicating the importance of continued follow up.