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Orchard MR, Saracino A, Hooper J, Shabbir J. Ileorectal anastomosis in ulcerative colitis: what do surgeons and patients need to know? A systematic literature review. Ann R Coll Surg Engl 2024. [PMID: 38660816 DOI: 10.1308/rcsann.2024.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Ileal pouch-anal anastomosis (IPAA) is currently the gold standard for restoration of gastrointestinal continuity after colectomy for ulcerative colitis in the UK. However, with further experience of the risks relating to IPAA, the use of ileorectal anastomosis (IRA) is being revisited. Decisions regarding restorative surgery after colectomy are individual to every patient's circumstances, and this paper aims to provide a comprehensive review of the literature to guide a full discussion of the risks and benefits of IRA. METHODS A systematic literature review was conducted of papers published from 2000 onwards relating to IRA and ulcerative colitis, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The papers were reviewed by two independent surgeons for information it was felt that patients and surgeons would want to know about the operation (cancer risk, bowel function, sexual and urinary function, fecundity/fertility and postoperative complications). RESULTS Seventeen papers were identified for inclusion as they reported original data on one or more of the categories identified for discussion. The median ten-year cancer risk after IRA was 2.8% and the median failure rate at ten years was 21%. IRA was generally found to have lower postoperative complication rates and better bowel function than IPAA, with sexual function similar and fecundity not commented on in any paper. CONCLUSIONS For some patients, IRA can offer restorative surgery in the short or long term, with acceptable cancer risk, failure rate and postoperative complications, while avoiding the higher risks associated with IPAA.
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Affiliation(s)
- M R Orchard
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | | | - J Hooper
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - J Shabbir
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
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Pooni A, Brar MS, Kennedy E, Cohen Z, MacRae H, de Buck van Overstraeten A. Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis. Colorectal Dis 2024; 26:326-334. [PMID: 38169082 DOI: 10.1111/codi.16836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/11/2023] [Accepted: 10/01/2023] [Indexed: 01/05/2024]
Abstract
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.
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Affiliation(s)
- Amandeep Pooni
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mantaj S Brar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Erin Kennedy
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Zane Cohen
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Helen MacRae
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anthony de Buck van Overstraeten
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
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Maspero M, Lavryk O, Holubar SD, Lipman J, Qazi T, Cohen B, Steele SR, Hull T. Long-term quality-of-life and functional outcomes after redo ileal pouch-anal anastomosis. Br J Surg 2023; 110:1663-1667. [PMID: 37535972 DOI: 10.1093/bjs/znad244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Olga Lavryk
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jeremy Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Taha Qazi
- Department of Gastroenterology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Hassan Y, Connell WR, Rawal A, Wright EK. Review of long-term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease. ANZ J Surg 2023. [PMID: 37095321 DOI: 10.1111/ans.18490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/12/2023] [Accepted: 04/16/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND In medically refractory Ulcerative Colitis (UC), proctocolectomy with ileoanal pouch procedure (IAPP) is the preferred continence-preserving surgical option. Functional outcomes post-surgery and long-term complication rates in the biologic era remain ambiguous. This review primarily aims to provide an update on these outcomes. Secondarily, risk factors associated with chronic pouchitis and pouch failure are explored. METHODS Two online databases (MEDLINE and EMBASE) were searched on 4 October 2022 for English studies from 2011-present relating to long-term outcomes of IAPP in inflammatory bowel disease (IBD) patients. Adult patients with 12 month follow-up were included. Studies focused on 30-day post-operative outcomes, non-IBD patients or studies including less than 30 patients were excluded. RESULTS Following screening and full-text review of 1094 studies, 49 were included. Median sample size was n = 282 (IQR: 116-519). Median incidences for chronic pouchitis and pouch failure were 17.1% (IQR: 12-23.6%) and 6.9% (IQR: 4.8-10.8%), respectively. Upon multivariate analysis, chronic pouchitis development was most significantly associated with pre-operative steroid use, pancolitis and extra-intestinal IBD manifestations, whilst pouch failure was most significantly associated with pre-operative diagnosis of Crohn's disease (compared to UC), peri-operative pelvic sepsis and anastomotic leak. Overall patient satisfaction was very high with four included studies reporting greater than 90% satisfaction rates. CONCLUSION Long-term complications for IAPP were common. However, despite this, patient satisfaction post-IAPP was high. Up-to-date knowledge of complication rates and their risk factors improves pre-operative counselling, management planning and patient outcomes.
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Affiliation(s)
- Yusuf Hassan
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - William R Connell
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
| | - Alisha Rawal
- General HMO Stream, Grampians Health, Ballarat, Australia
| | - Emily K Wright
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
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Risto A, Nordenvall C, Deputy M, Hermanson M, Lindforss U, Block M, Faiz O, Myrelid P. Colectomy reconstruction for ulcerative colitis in Sweden and England: a multicenter prospective comparison between ileorectal anastomosis and ileal pouch-anal anastomosis after colectomy in patients with ulcerative colitis. (CRUISE-study). BMC Surg 2023; 23:96. [PMID: 37085812 PMCID: PMC10122388 DOI: 10.1186/s12893-023-01984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND There are no prospective trials comparing the two main reconstructive options after colectomy for Ulcerative colitis, ileal pouch anal anastomosis and ileorectal anastomosis. An attempt on a randomized controlled trial has been made but after receiving standardized information patients insisted on choosing operation themselves. METHODS Adult Ulcerative colitis patients subjected to colectomy eligible for both ileal pouch anastomosis and ileorectal anastomosis are asked to participate and after receiving standardized information the get to choose reconstructive method. Patients declining reconstruction or not considered eligible for both methods will be followed as controls. The CRUISE study is a prospective, non-randomized, multi-center, open-label, controlled trial on satisfaction, QoL, function, and complications between ileal pouch anal anastomosis and ileorectal anastomosis. DISCUSSION Reconstruction after colectomy is a morbidity-associated as well as a resource-intensive activity with the sole purpose of enhancing function, QoL and patient satisfaction. The aim of this study is to provide the best possible information on the risks and benefits of each reconstructive treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05628701.
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Affiliation(s)
- Anton Risto
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping, 581 85, Linköping, Sweden.
- Department of Surgery, County Council of Östergötland, Linköping, Sweden.
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Mohammed Deputy
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Maria Hermanson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Ulrik Lindforss
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Block
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Omar Faiz
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Pär Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping, 581 85, Linköping, Sweden
- Department of Surgery, County Council of Östergötland, Linköping, Sweden
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Transabdominal IPAA Revision: Does Indication Dictate Outcome? Dis Colon Rectum 2023; 66:559-566. [PMID: 35426379 DOI: 10.1097/dcr.0000000000002335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Following IPAA failure, select patients are eligible for IPAA revision. Presently, there is limited evidence describing long-term revision outcomes and predictors of revision failure. This represents an important knowledge gap when selecting and counseling patients. OBJECTIVE This study aimed to define long-term IPAA survival outcomes after transabdominal IPAA revision and identify preoperative clinical factors associated with revision failure. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a tertiary referral center. PATIENTS This study included all patients who underwent revisional IPAA surgery between 1982 and 2017 for pouch failure. INTERVENTION Transabdominal IPAA revision was included. MAIN OUTCOME MEASURES The primary outcome was pouch failure, defined as pouch excision or permanent pouch diversion, after IPAA revision. RESULTS A total of 159 patients (64.2% women) were included with a median age of 36 years (interquartile range, 28.5-46.5) at revision. Eighty percent of patients had a primary diagnosis of ulcerative colitis. The most common indication for revision was leak/pelvic sepsis, representing 41% of the cohort, followed by pouch-vaginal fistula (22.2%), mechanical factors (20.4%), and poor pouch function (14.6%). During the study period, 56 patients (35.2%) experienced pouch failure. The 3-year pouch survival probability was 82.3% (95% CI, 75.5%-87.5%), 5-year pouch survival probability was 77.2% (95% CI, 69.8%-83.0%), and 10-year pouch survival probability was 70.6% (95% CI, 62.6%-77.2%). Compared to mechanical factors, pouch failure was significantly associated with pelvic sepsis (HR, 4.25; 95% CI, 1.50-12.0) and pouch-vaginal fistula (HR, 4.37; 95% CI, 1.47-12.99). No significant association was found between revision failure and previous revision, redo ileoanal anastomosis, or new pouch construction. LIMITATIONS This study is limited by its retrospective design. CONCLUSIONS Revisional IPAA can be undertaken with favorable long-term outcomes at high-volume centers. Consideration should be given to indication for revision when counseling patients regarding the risk of failure. Further research on risk stratifying patients before revision is required. See Video Abstract at http://links.lww.com/DCR/B966 . REVISIN DE LA ANASTOMOSIS ANAL DE LA BOLSA ILEAL TRANSABDOMINAL LA INDICACIN DICTA EL RESULTADO ANTECEDENTES:Después de la falla en la anastomosis del reservorio ileoanal, los pacientes seleccionados son elegibles para la revisión de la anastomosis del reservorio ileoanal. Actualmente, hay evidencias limitadas que describen los resultados de la revisión a largo plazo y los predictores del fracaso de la revisión. Esto representa un importante vacío de investigación a la hora de seleccionar y asesorar a los pacientes.OBJETIVO:Definir los resultados de supervivencia a largo plazo de la IPAA después de la revisión de la anastomosis del reservorio ileoanal transabdominal e identificar los factores clínicos preoperatorios asociados con el fracaso de la revisión.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLINICO:Este estudio se realizó en un centro de referencia terciario.PARTICIPANTES:Todos los pacientes que se sometieron a una cirugía de revisión de la anastomosis ileoanal del reservorio entre 1982 y 2017, por falla del reservorio.INTERVENCIÓN:Revisión de la anastomosis de reservorio ileoanal transabdominal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario es el fracaso del reservorio, definido como escisión del reservorio o derivación permanente del reservorio, después de la revisión de la anastomosis del reservorio ileoanal.RESULTADOS:Se incluyeron un total de 159 pacientes (64,2% mujeres) con una mediana de edad a la revisión de 36 años (RIC: 28,5-46,5). El ochenta por ciento tenía un diagnóstico primario de colitis ulcerosa. La indicación más común para la revisión fue la fuga/sepsis pélvica, que representó el 41 % de la cohorte, seguida de la fístula vaginal del reservorio (22,2 %), factores mecánicos (20,4 %) y mala función del reservorio 14,6 %. Durante el período de estudio, 56 pacientes (35,2 %) experimentaron fallas en la bolsa. Las probabilidades de supervivencia de la bolsa a los 3, 5 y 10 años fueron del 82,3% (IC del 95%: 75,5%-87,5%), del 77,2% (IC del 95%: 69,8%-83,0%) y del 70,6% (IC del 95%: 62,6%- 77,2%), respectivamente. En comparación con los factores mecánicos, la falla de la bolsa se asoció significativamente con sepsis pélvica (HR = 4,25, IC del 95 %: 1,50 a 12,0) y fístula vaginal de la bolsa (HR = 4,37, IC del 95 %: 1,47 a 12,99). No hubo una asociación significativa entre el fracaso de la revisión y la revisión previa, el rehacer la anastomosis ileoanal o la construcción de una nueva bolsa.LIMITACIONES:El estudio está limitado por su diseño retrospectivo.CONCLUSIONES:La revisión de la anastomosis del reservorio ileoanal se puede realizar con resultados favorables a largo plazo en centros de alto volumen. Se debe considerar la indicación de revisión al asesorar a los pacientes sobre el riesgo de fracaso. Se requiere investigación adicional sobre la estratificación del riesgo de los pacientes antes de la revisión. Consulte Video Resumen en http://links.lww.com/DCR/B966 . (Traducción - Dr. Fidel Ruiz Healy ).
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Xu W, Wang Y, Hua Z, Hu H, Chen W, Cai Z, Cui L, Wu X, Lian L, Ding Z, Du P. Risk Factors and Quality of Life in Patients with Diffuse Pouchitis After Ileal Pouch Anal Anastomosis According to the Chicago Classification for J Pouch: a Retrospective Multicenter Cohort Study in China. J Gastrointest Surg 2023; 27:766-776. [PMID: 36596961 DOI: 10.1007/s11605-022-05563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pouchitis is a common late complication in patients with ulcerative colitis (UC) who undergo ileal pouch-anal anastomosis (IPAA). The heterogeneous nature of the clinical and endoscopic presentations could affect the evaluation of therapeutic interventions for pouchitis. Thus, identifying the risk factors and clinical outcomes of pouch inflammation at different sites and severity is becoming increasingly important for colorectal surgeons. METHODS Data on patients who underwent IPAA January from 2008 to June 2022 in our three pouch centers affiliated with the China UC Pouch Center Union were retrospectively collected. Pouchitis was categorized as a different phenotype according to the Chicago Classification. J pouches were classified into short (14 ± 2 cm) and long pouches (22 ± 2 cm) according to the distribution of ileal pouch length in our institute. RESULTS Altogether, 143 patients with a median follow-up time of 5.0 years (interquartile range: 2.0-8.0) were enrolled. Among them, 41 patients (28.7%) developed pouchitis and 32 patients (78%) had diffuse inflammation of the pouch. Patients with diffuse pouchitis had a higher pouchitis disease activity index and more seriously impaired improvement of long-term quality of life than those with pouch phenotypes. A short J pouch, recurrent UC, and preoperative high white blood cell count were independent risk factors for diffuse pouchitis. Furthermore, a short J pouch could effectively predict the occurrence of diffuse pouchitis with an area under the receiver-operating characteristic curve of 0.614, a sensitivity of 62.5%, and a specificity of 60.4% (p = 0.049) and significantly decreased the overall diffuse pouchitis-free survival compared to a long J pouch (p = 0.0002). CONCLUSION Diffuse pouchitis is a common phenotype of pouchitis that seriously impairs long-term prognosis. For colorectal surgeons, decision-making regarding pouch construction with an appropriate length should be considered to prevent the development of diffuse pouchitis.
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Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Hang Hu
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Wenhao Chen
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Zerong Cai
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Xiaojian Wu
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Lei Lian
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China. .,China UC Pouch Center Union, Shanghai, China.
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China. .,China UC Pouch Center Union, Shanghai, China.
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Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the procedure of choice when colectomy is needed for medically refractory ulcerative colitis. Pouchitis is one of the most common complications among patients who have undergone IPAA and represents a spectrum of disease varying in both phenotype and clinical course. OBJECTIVE This study aimed to assist clinicians and surgeons in the treatment of both acute and chronic pouchitis, including newer therapies and future directions. DIAGNOSIS AND MANAGEMENT Diagnosis is made by endoscopy of the pouch with biopsy because other conditions may produce similar symptoms such as increased stool frequency, abdominal cramps, and urgency. Pouchitis is classified by duration (acute versus chronic), disease pattern (infrequent, relapsing, and continuous), and response to antibiotics (responsive, dependent, and refractory). The Pouchitis Disease Activity Index may be used to measure disease activity. The management of pouchitis is guided by the disease phenotype. Acute episodes are treated with an initial 2-week course of antibiotics (typically ciprofloxacin or metronidazole), although patients with relapsing or chronic pouchitis may require long-term antibiotic treatment or the cycling of different antibiotics. Certain probiotics may also be used for maintenance therapy in those with chronic symptoms. For patients with chronic antibiotic refractory pouchitis, oral budesonide, immunosuppressive agents (azathioprine), or biologic therapy (infliximab, adalimumab, vedolizumab, and ustekinumab) may be required for both induction and maintenance with close monitoring for potential side effects. In rare cases, diverting ileostomy or pouch excision may be required. CONCLUSION Pouchitis represents a spectrum of disease phenotypes, ranging from acute antibiotic responsive pouchitis to chronic antibiotic refractory pouchitis. The management of pouchitis is primarily directed by the disease phenotype.
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Stoma-less IPAA Is Not Associated With Increased Anastomotic Leak Rate or Long-term Pouch Failure in Patients With Ulcerative Colitis. Dis Colon Rectum 2022; 65:1342-1350. [PMID: 35001049 DOI: 10.1097/dcr.0000000000002274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is debate regarding the utility of diverting loop ileostomy with IPAA construction in patients requiring colectomy for ulcerative colitis. OBJECTIVE This study aimed to determine whether the omission of diverting loop ileostomy at the time of IPAA construction increases the risk of complications. DESIGN This was a retrospective study. SETTINGS The study was conducted in a high-volume, quaternary referral center with an IBD program. PATIENTS The patients, who underwent IPAA with or without ileostomy, were diagnosed for ulcerative colitis. MAIN OUTCOME MEASURES Anastomotic leak rate and pouch failure rates were determined between patients who either had a diverting ileostomy at the time of IPAA creation or had stoma-less IPAA. RESULTS Of the 414 patients included in this study, 91 had stoma-less IPAA. When compared to IPAA with diverting loop ileostomy, patients with stoma-less IPAA were less likely to be taking prednisone and had decreased blood loss. Short- and long-term outcomes were similar when comparing stoma-less IPAA and IPAA with diverting loop ileostomy, with no significant difference in anastomotic leak rate and long-term pouch failure rates. Diverting loop ileostomy was associated with a 14.6% risk of complication at the time of stoma reversal. LIMITATIONS The study is limited by its retrospective nature. CONCLUSIONS The results of this study suggest that the omission of a diverting ileostomy is feasible in select patients undergoing IPAA. Stoma-less IPAA does not have a statistically significant higher risk of anastomotic leak or pouch failure when compared to IPAA with diverting loop ileostomy in properly selected patients. Diverting loop ileostomies have their own risks, which partially offset their perceived safety. See Video Abstract at http://links.lww.com/DCR/B891 .LA ANASTOMÓSIS DE RESERVORIO ILEAL AL ANO SIN ESTOMA NO ESTÁ ASOCIADO CON UN AUMENTO EN LA TASA DE FUGA ANASTOMÓTICA O DISFUNCIÓN DE LA BOLSA A LARGO PLAZO EN PACIENTES CON COLITIS ULCERATIVA. ANTECEDENTES Existe debate en lo que respecta a la utilidad de efectuar una ileostomía en asa en la construcción de una anastomosis de reservorio ileal al ano en pacientes que requieren colectomía para colitis ulcerativa. OBJETIVO Determinar si el evitar una ileostomía de derivación en el momento de efectuar una anstomósis de reservorio ileal al ano aumenta el riesgo de complicaciones. DISEO Estudio retrospectivo. REFERENCIA Centro de referencia de cuarto nivel de grandes volúmenes con programa de enfermedad inflamatoria intestinal. PACIENTES Con diagnóstico de colitis ulcerativa sometidos a anastomosis de reservorio ileal al ano con o sin ileostomía derivative. PRINCIPALES MEDIDAS DE RESULTADOS Tasa de fuga anastomótica y disfunción del reservorio en pacientes sometidos a anastomosis de reservorio ileal al ano con ileostomía derivativa en el mismo evento y aquellos sin derivación de protección. RESULTADOS De los 414 pacientes incluídos en el estudio, 91 no contaban con ileostomía de protección de la anastomosis del reservorio ileal al ano. Al comprarse con aquellos con ileostomía derivativa, aquellos sin estoma requirieron menor dosis de prednisona y presentaron menor pérdida sanguínea. Los resultados a corto y largo plazo fueron similares al comprar ambos grupos sin haber evidencia significativa de fuga anastomótica o falla del reservorio a largo plazo. La derivación con ileostomía en asa se asoció en un 14.6% de riesgo de complicaciones al efectuar el cierre de la misma. LIMITACIONES Es una revision retrospectiva. CONCLUSIONES : Los resultados de este estudio sugieren que la omisión de una ileostomía de protección es posible en pacientes seleccionados sometidos a una anastomosis de reservorio ileoanal. La anastomosis sin derivación de protección no confiere un riesgo estadísticamente significativo de fuga anastomótica o disfunción de la misma al compararse con el procedimiento con estoma derivativo en pacientes seleccionados. Las ileostomías de derivación en asa tienen su propia morbilidad que cuestiona la perfección de su seguridad. Consulte Video Resumen at http://links.lww.com/DCR/B891 . (Traducción- Dr. Miguel Esquivel-Herrera ).
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Ileal Pouch–Anal Anastomosis and Pouchitis: The Role of the Microbiota in the Pathogenesis and Therapy. Nutrients 2022; 14:nu14132610. [PMID: 35807791 PMCID: PMC9268595 DOI: 10.3390/nu14132610] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, are life-long disorders characterized by the chronic relapsing inflammation of the gastrointestinal tract with the intermittent need for escalation treatment and, eventually, even surgery. The total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical intervention of choice in subjects affected by ulcerative colitis (UC). Although IPAA provides satisfactory functional outcomes, it can be susceptible to some complications, including pouchitis as the most common. Furthermore, 10–20% of the pouchitis may develop into chronic pouchitis. The etiology of pouchitis is mostly unclear. However, the efficacy of antibiotics in pouchitis suggests that the dysbiosis of the IPAA microbiota plays an important role in its pathogenesis. We aimed to review the role of the microbiota in the pathogenesis and as a target therapy in subjects who develop pouchitis after undergoing the surgical intervention of total proctocolectomy with IPAA reconstruction.
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11
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Endoscopic Phenotype of the J Pouch in Patients With Inflammatory Bowel Disease: A New Classification for Pouch Outcomes. Clin Gastroenterol Hepatol 2022; 20:293-302.e9. [PMID: 33549868 PMCID: PMC8339185 DOI: 10.1016/j.cgh.2021.02.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pouchitis is a common complication of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis who have undergone colectomy. Pouchitis has been considered a single entity despite a broad array of clinical and endoscopic patterns. We developed a novel classification system based on the pattern of inflammation observed in pouches and evaluated the contributing factors and prognosis of each phenotype. METHODS We identified 426 patients (384 with ulcerative colitis) treated with proctocolectomy and IPAA who subsequently underwent pouchoscopies at the University of Chicago between June 1997 and December 2019. We retrospectively reviewed 1359 pouchoscopies and classified them into 7 main pouch phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted 6 months after ileostomy takedown. Logistic regression analysis was used to assess factors contributing to each phenotype. Pouch survival was estimated by the log-rank test and the Cox proportional hazards model. RESULTS Significant contributing factors for afferent limb involvement were a body mass index of 25 or higher and hand-sewn anastomosis, for inlet involvement the significant contributing factor was male sex; for diffuse inflammation the significant contributing factors were extensive colitis and preoperative use of anti-tumor necrosis factor drugs, for cuffitis the significant contributing factors were stapled anastomosis and preoperative Clostridioides difficile infection. Inlet stenosis, diffuse inflammation, and cuffitis significantly increased the risk of pouch excision. Diffuse inflammation was associated independently with pouch excision (hazard ratio, 2.69; 95% CI, 1.34-5.41; P = .005). CONCLUSIONS We describe 7 unique IPAA phenotypes with different contributing factors and outcomes, and propose a new classification system for pouch management and future interventional studies.
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12
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Freund MR, Kent I, Agarwal S, Wexner SD. Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers. Tech Coloproctol 2022; 26:181-186. [PMID: 35091791 DOI: 10.1007/s10151-021-02557-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications. METHODS Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6 weeks after surgery via contrast enema and pouchoscopy. RESULTS One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks. CONCLUSION ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.
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Affiliation(s)
- M R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - I Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S Agarwal
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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13
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Ileal Pouch Anal Anastomosis (IPAA) for colitis; development of Crohn's and Pouchitis. Am J Surg 2022; 224:453-458. [DOI: 10.1016/j.amjsurg.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/07/2022] [Accepted: 01/19/2022] [Indexed: 11/23/2022]
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14
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Sriranganathan D, Kilic Y, Nabil Quraishi M, Segal JP. Prevalence of pouchitis in both ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis. Colorectal Dis 2022; 24:27-39. [PMID: 34800326 DOI: 10.1111/codi.15995] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
AIM Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis with its prevalence varying in the literature. Pouchitis is thought to occur more commonly in patients with ulcerative colitis (UC) than in patients with familial adenomatous polyposis (FAP). We conducted a systematic review with meta-analysis of all published literature to report the prevalence of pouchitis in all pouch patients as well as specifically in UC and FAP. We also investigated the prevalence of acute and chronic pouchitis in UC and FAP. METHODS A meta-analysis was conducted by searching the Embase, Embase Classic and PubMed databases between 1978 and 2021 exploring the prevalence of pouchitis in UC and FAP. We then performed a random effects model in order to find the pooled prevalence of pouchitis and used odds ratios to report differences in the prevalence of pouchitis in UC and FAP. RESULTS Fifty-nine full papers and conference abstracts were included in the meta-analysis comprising 18 117 patients with UC and 860 with FAP. The prevalence of pouchitis in UC was 0.32 (95% CI 0.27-0.37) and in FAP was found to be 0.06 (95% CI 0.03-0.15). The odds ratio of pouchitis in UC patients compared with FAP patients was 4.95 (95% CI 3.17-7.72, P < 0.0001). CONCLUSIONS Our findings support the consensus that the prevalence of pouchitis is higher in UC than in FAP. More significantly our findings suggest that the true prevalence of pouchitis is higher than commonly reported in the literature. This literature may help counsel patients prior to undergoing restorative proctocolectomy.
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Affiliation(s)
| | - Yakup Kilic
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohammed Nabil Quraishi
- Department of Gastroenterology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
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15
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Kővári B, Pai RK. Upper Gastrointestinal Tract Involvement in Inflammatory Bowel Diseases: Histologic Clues and Pitfalls. Adv Anat Pathol 2022; 29:2-14. [PMID: 34310370 PMCID: PMC8663524 DOI: 10.1097/pap.0000000000000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The upper gastrointestinal (UGI) manifestations of inflammatory bowel diseases (IBDs) are frequently obscured by classic ileal and colonic symptoms and are reported to involve only 0.5% to 4% of adult patients. However, because of the improvement of endoscopic techniques and the growing use of esophagogastroduodenososcopy with biopsy, both asymptomatic and clinically significant esophageal, gastric, and duodenal manifestations are increasingly recognized. The UGI involvement in IBD was historically synonymous with Crohn's disease (CD), but the doctrine of ulcerative colitis (UC) being limited to the colon has been challenged, and UC-related gastroduodenal lesions have been reported. The diagnosis of UGI IBD should ideally rely on a combination of the clinical history, endoscopic picture, and histologic features. Although endoscopic changes such as aphthoid or longitudinal ulcers and bamboo-joint-like pattern are suggestive of CD, histologic evaluation increases the sensitivity of the IBD diagnosis since histologic alterations may be present in endoscopically unremarkable mucosa. Conversely, in many cases, the histologic findings are nonspecific, and the knowledge of clinical history is vital for reaching an accurate diagnosis. The presence of epithelioid granuloma is highly suggestive of CD but is present in a minority of CD cases; thus, pathologists should be aware of how to diagnose UGI IBD in the absence of granulomata. This article reviews the most important clinical, endoscopic, and histologic features of IBD-associated esophagitis, gastritis, and duodenitis, as well as the IBD-related manifestations in the biliary tract and the postcolectomy setting.
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Affiliation(s)
- Bence Kővári
- Department of Pathology, Henry Lee Moffitt Cancer Center and Research Institute, Tampa, FL
- Department of Pathology, University of Szeged and Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Rish K. Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ
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16
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Melde M, Müller TM, Schneider I, Geppert CI, Mühl L, Besendorf L, Allner C, Becker E, Atreya I, Vitali F, Atreya R, Neurath MF, Zundler S. α4β7 integrin-dependent adhesion of T cells to MAdCAM-1 is blocked by vedolizumab in patients with chronic refractory pouchitis. Therap Adv Gastroenterol 2021; 14:17562848211054707. [PMID: 34868349 PMCID: PMC8640978 DOI: 10.1177/17562848211054707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/04/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The anti-α4β7 integrin antibody vedolizumab is an established therapeutic option for the treatment of inflammatory bowel disease (IBD). It has also been successfully used in patients with chronic antibiotic-refractory pouchitis following proctocolectomey with ileal pouch-anal anastomosis. However, the expression and function of gut-homing markers as well as strategies to predict the response to vedolizumab in pouchitis are understudied so far. METHODS We used flow cytometry and dynamic adhesion assays to study the expression and function of gut-homing integrins on T cells from patients with pouchitis and controls as well as longitudinally during therapy of pouchitis with vedolizumab. Moreover, we describe clinical effects of vedolizumab in a cohort of patients with pouchitis. RESULTS T cells from patients with pouchitis express a specific profile of gut-homing integrins. Integrin α4β7 on T cells from patients with pouchitis mediates adhesion to mucosal addressin cell adhesion molecule (MAdCAM)-1, which can be blocked by vedolizumab in vitro. Vedolizumab efficiently treats pouchitis in a portion of patients and response correlates with dynamic adhesion profiles to MAdCAM-1. CONCLUSION Our data suggest that T cell trafficking seems to be important for the pathogenesis of pouchitis and support the therapeutic use of vedolizumab. Integrin function might serve as a biomarker to predict response to vedolizumab.
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Affiliation(s)
| | | | - Ines Schneider
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Carol-Immanuel Geppert
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Laura Mühl
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Laura Besendorf
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Clarissa Allner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Emily Becker
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Imke Atreya
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany,Deutsches Zentrum Immuntherapie (DZI), University Hospital Erlangen, Erlangen, Germany
| | - Francesco Vitali
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany,Deutsches Zentrum Immuntherapie (DZI), University Hospital Erlangen, Erlangen, Germany
| | - Raja Atreya
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany,Deutsches Zentrum Immuntherapie (DZI), University Hospital Erlangen, Erlangen, Germany
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany,Deutsches Zentrum Immuntherapie (DZI), University Hospital Erlangen, Erlangen, Germany
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17
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Worley G, Burling D, Corr A, Clark S, Baldwin-Cleland R, Faiz O, Jenkins J. MRI-enema for the assessment of pelvic intestinal anastomotic integrity. Colorectal Dis 2021; 23:1890-1899. [PMID: 33900000 DOI: 10.1111/codi.15688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/26/2021] [Accepted: 04/18/2021] [Indexed: 12/14/2022]
Abstract
AIM Anastomotic leak causes significant morbidity for patients undergoing pelvic intestinal surgery. Fluoroscopic assessment of anastomotic integrity using water-soluble contrast enema (WSCE) is of questionable benefit over examination alone. We hypothesized that MRI-enema may be more accurate. The aim of this study was to compare MRI-enema with fluoroscopic WSCE. METHOD Patients referred for WSCE with pelvic intestinal anastomosis and defunctioning ileostomy (including patients with suspected or known leaks) were invited to participate. WSCE and MRI-enema were undertaken within 48 h of each other. MRI sequences were performed before, during and immediately after the introduction of 400 ml of 1% gadolinium contrast solution per anus. MRI examinations were reported to protocol by two blinded gastrointestinal radiologists. A Likert-scale patient questionnaire was administered to compare patient experience. Follow-up was >12 months after ileostomy reversal. Anastomotic leak was determined by unblinded consensus of examination and radiological findings. RESULTS Sixteen patients were recruited, with a median age of 39 years (range 22-69). Ten were men, 11 had ileoanal pouch formation and five had low anterior resection. Five patients had anastomotic leak identified by MRI and four by WSCE. The radial location of the anastomotic defect was identified in all five patients by MRI versus two on WSCE. MRI revealed additional information including contents of a widened presacral space. Patient experience was equivalent. Eleven patients eventually had ileostomy reversal without complications. CONCLUSION MRI-enema is a feasible and tolerable alternative to WSCE and offers greater anatomical detail in the context of pelvic intestinal anastomotic leak. Larger prospective studies are required to define its potential role in the UK National Health Service.
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Affiliation(s)
- Guy Worley
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - David Burling
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Susan Clark
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Omar Faiz
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - John Jenkins
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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18
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Thompson DT, Hrabe JE. Staged Approaches to Restorative Proctocolectomy with Ileoanal Pouch-When and Why? J Laparoendosc Adv Surg Tech A 2021; 31:875-880. [PMID: 34182807 DOI: 10.1089/lap.2021.0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Restorative proctocolectomy (RPC) with ileal pouch anal-anastomosis (IPAA) is commonly performed for patients with ulcerative colitis, familial adenomatous polyposis, and selected phenotypes of Crohn's disease (CD). Due to concerns about the effects of surgical complications on pouch functional outcomes, debate remains surrounding when and whether RPC with IPAA should be performed in a staged manner. Particularly debated are the timings of the IPAA, whether it is constructed at time of the proctocolectomy and whether to utilize temporary fecal diversion with a loop ileostomy. RPC with IPAA can be performed in one, two, or three stages, with each stage typically separated by 3-6 months. Proponents of a staged approach argue that poor pouch function, which is often a result of IPAA complications, including leak and infection, can be difficult to overcome and mandate additional, major surgeries, and that staging pouch creation and pairing with a protective ileostomy reduce those complications. However, subjecting patients to multiple surgeries and prolonging their time with an ileostomy present unique risks as well. Surgeons' experience and preference and patient characteristics need to be considered when determining operative planning. Highly selected patients with CD can be considered for RPC with IPAA, although with an acknowledgment of inherently higher pouch failure rates. Understanding the short- and long-term consequences of RPC with IPAA construction can help surgeons determine the appropriate approach.
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Affiliation(s)
- Dakota T Thompson
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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19
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Ellebaek MB, Dilling Kjaer M, Spanggaard K, El-Faramawi M, Möller S, Qvist N. Protective loop-ileostomy in ileal pouch-anal anastomosis for ulcerative colitis - advantages and disadvantages. A retrospective study. Colorectal Dis 2021; 23:145-152. [PMID: 32779825 DOI: 10.1111/codi.15302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/02/2020] [Indexed: 12/30/2022]
Abstract
AIM The aim was to investigate the overall postoperative complication rate within 90 days following ileal pouch-anal anastomosis (IPAA), with or without a diverting stoma, together with complications 30 days after stoma closure and overall pouch failure rate. METHOD This was a retrospective chart review including IPAA patients with or without a diverting loop-ileostomy for ulcerative colitis (1 January 1983 to 31 December 2015). Demographic data and postoperative complications were retrieved and recorded. RESULTS A total of 434 patients were included. A diverting loop-ileostomy was performed in 348 patients (80%). Baseline data were similar in the two groups except for body mass index (BMI) and the ratio of women, which were significantly higher in the group without a protective ileostomy. Overall 90-day complication rate after IPAA [Clavien-Dindo (CD) > 2] was similar in the two groups. Clinical anastomotic leaks (CD > 2) were higher in patients without a diverting stoma (9.3% vs 1.7%) (P = 0.002). The odds ratio for leakage after adjustments (age, gender, immune-modulating medicine and BMI) was 5.0 for omitting a diverting stoma (P = 0.004). Complications (CD > 2) after loop-ileostomy closure were seen in 61 cases (14.1%). Omitting a diverting stoma at IPAA demonstrated a non-significant odds ratio of 1.04 (0.46, 2.38) (P = 0.924) for pouch failure after adjustments (age, gender, immune-modulating medicine, BMI, time from pouch formation and clinical leakage). CONCLUSION The overall postoperative surgical and medical complication rate within 90 days after IPAA was similar in the group with and without diverting stoma. Postoperative complication rate after reversal was 14%. Omitting a diverting stoma at IPAA demonstrated an increased risk of leaks but no significant risk of long-term pouch failure.
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Affiliation(s)
- M B Ellebaek
- Research Unit for Surgery, IBD-care, Odense University Hospital, University of Southern Denmark, Odense C, Denmark.,OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - M Dilling Kjaer
- Research Unit for Surgery, IBD-care, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
| | - K Spanggaard
- Research Unit for Surgery, IBD-care, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
| | - M El-Faramawi
- Research Unit for Surgery, IBD-care, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
| | - S Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - N Qvist
- Research Unit for Surgery, IBD-care, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
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20
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Seifarth C, Slavova N, Degro C, Lehmann KS, Kreis ME, Weixler B. Sacral nerve stimulation in patients with ileal pouch-anal anastomosis. Int J Colorectal Dis 2021; 36:1937-1943. [PMID: 34160664 PMCID: PMC8346414 DOI: 10.1007/s00384-021-03981-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results after proctocolectomy and ileal pouch-anal anastomosis (IPAA) are generally good. However, some patients suffer from high stool frequency or fecal incontinence. Sacral nerve stimulation (SNS) may represent a therapeutic alternative in these patients, but little is known about indication and results. The aim of this study was to evaluate incontinence after IPAA and demonstrate SNS feasibility in these patients. METHODS This retrospective study includes patients who received a SNS between 1993 and 2020 for increased stool frequency or fecal incontinence after proctocolectomy with IPAA for ulcerative colitis. Proctocolectomy was performed in a two- or three-step approach with ileostomy closure as the last step. Demographic, follow-up data and functional results were obtained from the hospital database. RESULTS SNS was performed in 23 patients. Median follow-up time after SNS was 6.5 years (min. 4.2-max. 8.8). Two patients were lost to follow-up. The median time from ileostomy closure to SNS implantation was 6 years (min. 0.5-max. 14.5). Continence after SNS improved in 16 patients (69%) with a median St. Marks score for anal incontinence of 19 (min. 4-max. 22) before SNS compared to 4 (0-10) after SNS placement (p = 0.012). In seven patients, SNS therapy was not successful. CONCLUSION SNS implantation improves symptoms in over two-thirds of patients suffering from high stool frequency or fecal incontinence after proctocolectomy with IPAA. Awareness of the beneficial effects of SNS should be increased in physicians involved in the management of these patients.
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Affiliation(s)
- C. Seifarth
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - N. Slavova
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - C. Degro
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - K. S. Lehmann
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - M. E. Kreis
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - B. Weixler
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
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21
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Short-term and Long-term Outcomes Following Pelvic Pouch Excision: The Mount Sinai Hospital Experience. Dis Colon Rectum 2020; 63:1621-1627. [PMID: 33149024 DOI: 10.1097/dcr.0000000000001761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Few studies have reported surgical outcomes following pouch excision and fewer have described the long-term sequelae. Given the debate regarding optimal surgical management following pouch failure, an accurate estimation of the morbidity associated with this procedure addresses a critical knowledge gap. OBJECTIVE The objective of this study was to review our institutional experience with pouch excision with a focus on indications, short-term outcomes, and long-term reintervention rates. DESIGN This was a retrospective cohort study. SETTING This study was conducted at Mount Sinai Hospital, Toronto, Ontario Canada. PARTICIPANTS Adult patients registered in the prospectively maintained IBD database with a diagnosis of pelvic pouch failure between 1991 and 2018 were selected. INTERVENTION The patients had undergone pelvic pouch excision was measured. MAIN OUTCOMES AND MEASURES Indications for excision, incidence of short-term and long-term complications, and long-term surgical reintervention were the primary outcomes. In addition, multivariable logistic regression models were fitted to identify predictors of chronic perineal wound complications and the effect of preoperative diversion. The positive predictive value of a clinical suspicion of Crohn's disease of the pouch was also evaluated. RESULTS One hundred forty cases were identified. Fifty-nine percent of patients experienced short-term complications and 49.3% experienced delayed morbidity. Overall, one-third of patients required long-term reoperation related to perineal wound, stoma, and hernia complications. On multivariable regression, immunosuppression was associated with increased odds of perineal wound complications, and preoperative diversion was not associated with perineal wound healing. Crohn's disease was suspected in 24 patients preoperatively but confirmed on histopathology in only 6 patients. LIMITATIONS This is a retrospective chart review of a single institution's experience, whereby complication rates may be underestimates of the true event rates. CONCLUSIONS Pouch excision is associated with high postoperative morbidity and long-term reintervention due to nonhealing perineal wounds, stoma complications, and hernias. Further study is required to clarify risk reduction strategies to limit perineal wound complications and the appropriate selection of patients for diversion alone vs pouch excision in IPAA failure. See Video Abstract at http://links.lww.com/DCR/B348. RESULTADOS A CORTO Y LARGO PLAZO DESPUÉS DE LA EXTIRPACIÓN DE LA BOLSA PéLVICA: LA EXPERIENCIA DEL HOSPITAL MOUNT SINAÍ: Pocos estudios han informado resultados quirúrgicos después de la escisión de bolsa pélvica (reservorio ileoanal) y menos han descrito las secuelas a largo plazo. Dado el debate sobre el manejo quirúrgico óptimo después de la falla de la bolsa, una estimación precisa de la morbilidad asociada con este procedimiento aborda una brecha crítica de conocimiento.El objetivo de este estudio fue revisar nuestra experiencia institucional con la extirpación de la bolsa con un enfoque en las indicaciones, los resultados a corto plazo y las tasas de reintervención a largo plazo.Estudio de cohorte retrospectivo.Hospital Mt Sinaí, Toronto, Ontario, Canadá.Pacientes adultos registrados en la base de datos de EII mantenida prospectivamente con un diagnóstico de falla de la bolsa pélvica entre 1991 y 2018.Escisión de bolsa pélvica.Las indicaciones para la escisión, la incidencia de complicaciones a corto y largo plazo y la reintervención quirúrgica a largo plazo fueron los resultados primarios valorados. Además, se ajustaron modelos de regresión logística multivariable para identificar predictores de complicaciones de la herida perineal crónica y el efecto de la derivación preoperatoria. También se evaluó el valor predictivo positivo de una sospecha clínica de enfermedad de Crohn de la bolsa.Se identificaron 140 casos. El 59% de los pacientes desarrollaron complicaciones a corto plazo y el 49,3% con morbilidad tardía. En general, 1/3 de los pacientes requirieron una reoperación a largo plazo relacionada con complicaciones de herida perineal, estoma y hernia. En la regresión multivariable, la inmunosupresión se asoció con mayores probabilidades de complicaciones de la herida perineal y la derivación preoperatoria no se asoció con la cicatrización de la herida perineal. La enfermedad de Crohn se sospechó en 24 pacientes antes de la operación, pero se confirmó por histopatología en solo 6 pacientes.Revisión retrospectiva del cuadro de la experiencia de una sola institución por la cual las tasas de complicaciones pueden ser subestimadas de las tasas de eventos reales.La escisión de la bolsa se asocia con una alta morbilidad postoperatoria y una reintervención a largo plazo debido a complicaciones de heridas perineales, complicaciones del estoma y hernias. Se requieren más estudios para aclarar las estrategias de reducción de riesgos para limitar las complicaciones de la herida perineal y la selección adecuada de pacientes para la derivación sola versus la escisión de la bolsa en caso de falla de reservorio ileoanal. Consulte Video Resumen en http://links.lww.com/DCR/B348.
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Akiyama S, Rai V, Rubin DT. Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment. Intest Res 2020; 19:1-11. [PMID: 33138344 PMCID: PMC7873408 DOI: 10.5217/ir.2020.00047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) occasionally need a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) because of medically refractory colitis or dysplasia/cancer. However, pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. About 10% of patients with IBD who develop pouchitis require pouch excision, and several risk factors of the failure have been reported. A phenotype that has features similar to Crohn’s disease may develop in a subset of ulcerative colitis patients following proctocolectomy with IPAA and is the most frequent reason for pouch failure. In this review, we discuss the diagnosis and prognosis of pouchitis, risk factors for pouchitis development, and treatment options for pouchitis, including the newer biological agents.
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Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Victoria Rai
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
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Reporting Templates for MRI and Water-Soluble Contrast Enema in Patients With Ileal Pouch-Anal Anastomosis: Experience From a Large Referral Center. AJR Am J Roentgenol 2020; 217:347-358. [PMID: 32936014 DOI: 10.2214/ajr.20.24031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Ileal pouch-anal anastomosis (IPAA) surgery is the reference standard surgical procedure for treatment of ulcerative colitis and most patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of workup for pouch dysfunction. The purpose of this article is to propose structured reporting templates for MRI and water-soluble contrast enema (WSCE), based on our referral pouch center's experience, in patients who have undergone IPAA surgery. We review salient surgical technique, pouch anatomy, and imaging protocols, with an emphasis on a systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting templates for MRI and WSCE.
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Abstract
Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with medically-refractory ulcerative colitis or ulcerative colitis with associated dysplasia. Although most patients after ileal pouch-anal anastomosis experience good functional outcomes, a number of complications may develop. Of the long-term complications, pouchitis is most common. Although most respond to antibiotic treatment, some patients develop chronic pouchitis, leading to substantial morbidity and occasionally pouch failure. In patients with pouchitis who are not responsive to conventional antimicrobial therapy, secondary causes of chronic pouchitis need to be considered, including Crohn's disease of the pouch. In recent years, more literature has become available regarding the medical management of chronic pouchitis and Crohn's disease of the pouch, including the use of newer biologic agents. We herein provide a concise review on inflammatory complications involving the ileal pouch, including a focused approach to diagnosis and medical management.
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Lightner AL. Inflammation of the Ileal Anal Pouch: Do Biologics Really Change the Trajectory? Inflamm Bowel Dis 2020; 26:1087-1088. [PMID: 31587041 DOI: 10.1093/ibd/izz229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Indexed: 12/09/2022]
Abstract
Inflammatory conditions of the ileal pouch are relatively common after ileal pouch anal anastomoses. Although biologics can induce mucosal healing and may have decreased rates of colectomy for medically refractory ulcerative colitis in recent years, they have not decreased rates of pouch failure due to inflammatory conditions of the pouch.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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26
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Ileal pouch-anal anastomosis for ulcerative colitis: long-term outcomes and trends over time in a low-volume institution. Ir J Med Sci 2020; 190:143-149. [PMID: 32472241 DOI: 10.1007/s11845-020-02262-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) can restore bowel continuity for patients with ulcerative colitis (UC) who have needed total colectomy with end ileostomy. Internationally, this surgery is recommended for centralisation focussing reflection on Irish outcomes. METHODS Retrospective study examining patient outcomes after IPAA in our institution over a 15-year period using data from inflammatory bowel disease database, HIPE codes and clinical charts review between January 2002 and January 2018. Cohorts were analysed overall and in 5-year cohorts as well as by access modality of pouch operation. Contextualising Irish data were identified from published literature review. RESULTS Thirty-four patients (average age 34.8, 21/64% male) had IPAA for UC locally with 64-month mean follow-up. Overall laparoscopic procedure rate was 39.4% (85% 2013-17) being associated with lower lengths of stay (10.6 ± 8 vs 12.7 ± 6.5 days open access). The mean total duration of ileostomy was 27.3 ± 22.5 months, being longest most recently and with an open index procedure. Overall pouchitis affected 53% (n = 18) with rates at 1, 5, 10 and 15 years being 17.6%, 38.2, 50.0% and 52.9%, respectively. Pouch failure rates at 1, 5 and 10 years were 2.9%, 11.8% and 17.6%. Outcomes were similar with other centres publishing from Ireland although none met modern criteria for high-volume practice. CONCLUSIONS Overall outcomes and practice in this study are consistent with previously published studies on IPAA nationally and internationally. While acceptable, the opportunity from surgical centre collaboration outside of the National Cancer and Acute Surgery Strategies is to offer still better outcomes for our patients.
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Continent Ileostomy as an Alternative to End Ileostomy. Gastroenterol Res Pract 2020; 2020:9740980. [PMID: 32382274 PMCID: PMC7199532 DOI: 10.1155/2020/9740980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/30/2019] [Indexed: 02/07/2023] Open
Abstract
Continent ileostomy (CI) was once a prevalent surgical technique for patients who required total proctocolectomy but then gave way to ileal pouch-anal anastomosis (IPAA) after 1980. Although IPAA has been the gold standard procedure preferred by most patients when total proctocolectomy is required, due to its imitation of physiological function of rectum and preserved function of anus, various complications have been observed with a relatively high rate of morbidity that could affect pouch longevity. Once serious complications such as pelvic abscesses and/or fistula occur, the pouch often needs to be removed. In addition, for some patients with a shortened small intestine or foreshortened mesentery, it is impossible for the ileal pouch to reach the pelvic floor, thus making the creation of an IPAA difficult. Previously, most of these patients would be referred for an end ileostomy, with an associated poor quality of life. In this circumstance, we propose that CI may deserve a reappraisal and serve as an alternative. In this article, we review the indications, contraindications, technique evolution, and outcomes of CI.
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Re-operation surgery following IPAA: is there a role for laparoscopy? Surg Endosc 2020; 35:1591-1596. [PMID: 32266546 DOI: 10.1007/s00464-020-07537-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Restorative proctocolectomy with ileal J pouch anal anastomosis (IPAA) has become the standard of care for mucosal ulcerative colitis and Familial Adenomatous Polyposis. Some patients require re-operation, including pouch revision, advancement, or excision. Re-operative procedures are technically demanding and usually performed only by experienced colorectal surgeons in a small number of referral centers. There is a paucity of data regarding feasibility, safety, and outcomes of laparoscopic re-operative IPAA surgery. This study aimed to determine the safety and feasibility of laparoscopic approach for re-operative IPAA, trans-abdominal surgery. METHODS Retrospective analysis of IRB-approved prospective database for patients who underwent trans-abdominal re-operative IPAA from 2011 to 2018. Patient demographics and operative reports were reviewed to classify type of re-operation into pouch excision, revision, or advancement and further classify as laparoscopic, laparoscopic converted to open, or open surgery. Main outcome measures were post-operative morbidity and mortality. RESULTS Seventy-six patients met the inclusion criteria: 19 underwent attempted laparoscopic re-operative IPAA surgery, 12 of whom underwent successful laparoscopic surgery while 7 were converted to laparotomy, for an overall laparoscopic intent to treat 63% success rate. The remaining operations (n = 57) were performed through midline laparotomy. Length of stay (LOS) for patients who underwent laparoscopic surgery was significantly shorter (5.5 vs 9.7 days, p < 0.001) as were abdominal superficial surgical site infections (SSI) (0% vs 18%, p < 0.001) and deep SSI (0% vs 17%, p < 0.001). Laparotomy was performed by 6 colorectal surgeons at our institution while laparoscopy was successfully performed only by the senior author. There was no significant difference in overall complications, re-admission, re-operation, or mortality. CONCLUSION Re-operative, trans-abdominal, laparoscopic IPAA is both feasible and safe and has clear benefits compared to laparotomy in terms of LOS and superficial and deep SSI. However, this approach needs to be undertaken only by very experienced, high-volume laparoscopic IPAA surgeons.
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Pellino G, Keller DS, Sampietro GM, Carvello M, Celentano V, Coco C, Colombo F, Geccherle A, Luglio G, Rottoli M, Scarpa M, Sciaudone G, Sica G, Sofo L, Zinicola R, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis. Tech Coloproctol 2020; 24:397-419. [PMID: 32124113 DOI: 10.1007/s10151-020-02175-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/09/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, Portsmouth, UK.,University of Portsmouth, Portsmouth, UK
| | - C Coco
- UOC Chirurgia Generale 2, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - A Geccherle
- IBD Unit, IRCCS Sacro Cuore-Don Calabria, Negrar Di Valpolicella, VR, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Scarpa
- General Surgery Unit, Azienda Ospedaliera Di Padova, Padua, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - R Zinicola
- Department of Emergency Surgery, University Hospital Parma, Parma, Italy
| | - S Leone
- Associazione Nazionale Per Le Malattie Infiammatorie Croniche Dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
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30
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Helavirta I, Lehto K, Huhtala H, Hyöty M, Collin P, Aitola P. Pouch failures following restorative proctocolectomy in ulcerative colitis. Int J Colorectal Dis 2020; 35:2027-2033. [PMID: 32592093 PMCID: PMC7541371 DOI: 10.1007/s00384-020-03680-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Restorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision. METHODS The number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016. RESULTS Out of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn's disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn's disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I-II). CONCLUSIONS Eleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn's disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.
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Affiliation(s)
- Ilona Helavirta
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland.
| | - Kirsi Lehto
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, FI-33014, Tampere, Finland
| | - Marja Hyöty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Petri Aitola
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1184] [Impact Index Per Article: 236.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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33
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Die J, Ocaña J, Abadía P, García JC, Moreno I, Pina JD, Rodrígez G, Devesa JM. Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study. Cir Esp 2019; 98:64-71. [PMID: 31735363 DOI: 10.1016/j.ciresp.2019.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/12/2019] [Accepted: 09/20/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. METHODS A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. RESULTS The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors. CONCLUSION Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.
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Affiliation(s)
- Javier Die
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Ocaña
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - Pedro Abadía
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Carlos García
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Irene Moreno
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Diego Pina
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Gloria Rodrígez
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - José Manuel Devesa
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
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Abstract
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.
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Rossi C, Beyer-Berjot L, Maggiori L, Prost-À-la-Denise J, Berdah S, Panis Y. Redo ileal pouch-anal anastomosis: outcomes from a case-controlled study. Colorectal Dis 2019; 21:326-334. [PMID: 30565821 DOI: 10.1111/codi.14484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/23/2018] [Indexed: 12/09/2022]
Abstract
AIM To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA. METHOD This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index. RESULTS Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51 (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function. CONCLUSION The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.
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Affiliation(s)
- C Rossi
- Department of Gastrointestinal Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - L Beyer-Berjot
- Department of Gastrointestinal Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - L Maggiori
- Department of Colorectal Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - J Prost-À-la-Denise
- Department of Colorectal Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - S Berdah
- Department of Gastrointestinal Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Y Panis
- Department of Colorectal Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
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Sahami S, Wildenberg ME, Koens L, Doherty G, Martin S, D'Haens GRAM, Cullen G, Bemelman WA, Winter D, Buskens CJ. Appendectomy for Therapy-Refractory Ulcerative Colitis Results in Pathological Improvement of Colonic Inflammation: Short-Term Results of the PASSION Study. J Crohns Colitis 2019; 13:165-171. [PMID: 30285094 DOI: 10.1093/ecco-jcc/jjy127] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The objective of this study was to examine the modulating effect of an appendectomy on the disease course of therapy-refractory ulcerative colitis [UC] patients, and to analyse appendiceal pathological characteristics predictive of pathological response. METHODS Patients with therapy-refractory UC, and referred for proctocolectomy, were invited to undergo laparoscopic appendectomy first. The primary end points were clinical response after 3 and 12 months. Secondary end points were endoscopic remission, failure, and pathologic response. Appendiceal specimens, and pre- and post-operative biopsies were histologically graded according to the validated Geboes score. RESULTS Thirty patients [53% male] with a median age of 40 (interquartile range [IQR], 33-47) underwent appendectomy, with a median preoperative total Mayo score of 9 [IQR, 8-11]. After 12 months, 9 patients [30%] had lasting clinical response, of whom 5 [17%] were in endoscopic remission. Pathological evaluation was possible in 28 patients. After a median of 13.0 weeks [range 7-51], pathological response was seen in 13 patients [46%], with a median decrease of 2 points [range 1-3]. Appendiceal inflammation was highly predictive of pathological response when compared with no inflammation or extensive ulcerations [85% vs 20%, p = 0.001]. CONCLUSIONS Appendectomy was effective in one-third of therapy-refractory UC patients, with a substantial proportion of patients demonstrating complete endoscopic remission after 1 year. Pathological response was seen in almost 50% of patients and was related to active inflammation in the appendix, limited disease, and shorter disease duration. These early results suggest that there is a UC patient group that may benefit from appendectomy.
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Affiliation(s)
- S Sahami
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - M E Wildenberg
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - L Koens
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - G Doherty
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Dublin, Ireland
| | - S Martin
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Dublin, Ireland
| | - G R A M D'Haens
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - G Cullen
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Dublin, Ireland
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - D Winter
- Department of Surgery, St. Vincent's Hospital, Dublin, Ireland
| | - C J Buskens
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Characterization of megapouch in patients with restorative proctocolectomy. Surg Endosc 2018; 33:2293-2303. [PMID: 30327916 DOI: 10.1007/s00464-018-6523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Megapouch is a rare functional complication of restorative proctocolectomy with ileal pouch-anal anastomosis characterized by pouch ± small bowel dilatation with no evidence of obstruction on endoscopy and imaging. Little is known about clinical characteristics and outcomes of this entity. METHODS We included all patients diagnosed with megapouch at our institution, identified from a pouch database. Data on baseline characteristics, management, and outcomes were documented and analyzed from electronic medical records. Appropriate statistical measures were used. p < 0.05 was considered significant. RESULTS Twenty-three patients with megapouch were identified. The mean age was 40.7 years; 95.6% had underlying ulcerative colitis; most common indication for colectomy was medically refractory disease (56.5%). Abdominal pain (82.6%) and bloating (52.2%) were most common presenting symptoms. Most common finding on pouchoscopy was pouch dilatation (81.8%), while barium or gastrografin enemas and MRI/CT mostly revealed dilatation of pouch and/or small bowel. Fourteen (66.7%) patients required some forms of surgery-six patients required pouch excision and three required either pouch redo or revision. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically versus those managed medically (p = 0.007 and 0.024, respectively), while need for escalation of IBD-therapy was comparable between the groups (p = 0.133). No deaths were reported and no patient had recurrence of megapouch. IPAA revision or redo did not lead to more IBD-related morbidity. CONCLUSIONS Majority of our patients with megapouch required surgery. In selected patients, redo pouch offered cure. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically.
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Worley GHT, Fearnhead NS, Brown SR, Acheson AG, Lee MJ, Faiz OD. Review of current practice and outcomes following ileoanal pouch surgery: lessons learned from the Ileoanal Pouch Registry and the 2017 Ileoanal Pouch Report. Colorectal Dis 2018; 20:913-922. [PMID: 29927537 DOI: 10.1111/codi.14316] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/16/2018] [Indexed: 12/13/2022]
Abstract
AIM The second Association of Coloproctology of Great Britain and Ireland (ACPGBI) Ileoanal Pouch Registry (IPR) report was released in July 2017 following a first report in 2012. This article provides a summary of data derived from the most recent IPR report (2017 Ileoanal Pouch Report. https://www.acpgbi.org.uk/content/uploads/2016/07/Ileoanal-Pouch-Report-2017-FINAL.compressed.pdf). METHOD The IPR is an electronic database of voluntarily submitted data including patient demographics, disease, intra-operative and postoperative factors submitted by consultant surgeons or delegates. Data up to 31 March 2017 have been analysed for this report. RESULTS A total of 5352 pouch operations were carried out at 76 UK and four European centres by 154 surgeons over four decades. Recorded procedures have increased over time but data submission is voluntary and underestimates actual volume. Significant variation exists in institutional volume; 73 centres entered data on patients undergoing pouch surgery during the past 5 years. Of these, 44 centres have submitted ≤ 10 cases, with 10 centres submitting one patient and nine centres two cases. Since 2013, minimal access surgery has been employed in 54% of cases. Rectal dissection was undertaken in the total mesorectal excision plane in 69%. J-pouch configuration was used in 99% of cases and 90% of pouch-anal anastomoses were performed using a stapled technique. Including all years, the IPR rate of pelvic sepsis was 9.4% and the rate of pouch failure was 4.7%. CONCLUSION The IPR holds the largest voluntary repository of data on ileoanal pouch surgery. The second report from the IPR records marked refinements in surgical technique over time but also highlights wide variation in institutional caseload and outcome across the UK.
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Affiliation(s)
- G H T Worley
- St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - N S Fearnhead
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- ACPGBI Inflammatory Bowel Disease Clinical Advisory Group, UK
| | - S R Brown
- ACPGBI Inflammatory Bowel Disease Clinical Advisory Group, UK
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A G Acheson
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - M J Lee
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - O D Faiz
- St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- ACPGBI Inflammatory Bowel Disease Clinical Advisory Group, UK
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Revisional and Reconstructive Surgery for Failing IPAA is Associated with Good Function and Pouch Salvage in Highly Selected Patients. Dis Colon Rectum 2018; 61:920-930. [PMID: 29944583 DOI: 10.1097/dcr.0000000000001130] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Revisional and reconstructive surgery for IPAA is rare given the high success of pouch surgery for chronic ulcerative colitis. Limited data exist on both surgical and functional outcomes in patients with chronic ulcerative colitis who undergo IPAA revision or reconstruction. OBJECTIVE This study aimed to determine the surgical and functional outcome in patients with chronic ulcerative colitis who undergo IPAA revision or reconstruction. DESIGN A prospectively collected surgical database was accessed for this study. SETTING This study was conducted at an IBD referral center. PATIENTS Patients with chronic ulcerative colitis who underwent IPAA revision or reconstruction were selected. MAIN OUTCOME MEASURES The primary outcomes measured were 30-day postoperative outcomes and long-term pouch function. RESULTS Eighty-one patients were identified. Original IPAA was performed for chronic ulcerative colitis (n = 71; 88%) and indeterminate colitis (n = 11; 12.%), and the most common configuration was a J-pouch (n = 69; 86%) with handsewn anastomosis (n = 41;68%). No independent predictors of 30-day postoperative complications following reconstructive/revisional surgery were identified. Pelvic abscesses and Crohn's disease of the pouch were independently associated with ultimate pouch excision. Median follow-up following revision/reconstruction was 40 months (range, 1-292 months) during which 15 patients (23%) had pouch failure. The 5- and 10-year pouch survival rates following revision were 85 ± 5% and 65 ± 9% by Kaplan-Meier estimation; age <30 years was significantly associated with pouch survival. Long-term function (n = 30; 35%) compared with a matched control cohort of primary IPAA was characterized by significantly increased daytime bowel incontinence (p = 0.0119), liquid stool (p = 0.0062), and medication to thicken stools (p = 0.0452). LIMITATIONS This was a single-center series, and response rate for functional data was 35%. CONCLUSIONS In properly selected patients with a failing pouch, originally made for chronic ulcerative colitis or indeterminate colitis, revisional and reconstructive surgery is associated with low complication rates, high pouch salvage, and acceptable long-term pouch function. See Video Abstract at http://links.lww.com/DCR/A640.
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Simillis C, Afxentiou T, Pellino G, Kontovounisios C, Rasheed S, Faiz O, Tekkis PP. A systematic review and meta-analysis comparing adverse events and functional outcomes of different pouch designs after restorative proctocolectomy. Colorectal Dis 2018; 20:664-675. [PMID: 29577558 DOI: 10.1111/codi.14104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/12/2018] [Indexed: 02/08/2023]
Abstract
AIM There is no consensus as to which ileoanal pouch design provides better outcomes after restorative proctocolectomy. This study compares different pouch designs. METHOD A systematic review of the literature was performed. A random effects meta-analytical model was used to compare adverse events and functional outcome. RESULTS Thirty comparative studies comparing J, W, S and K pouch designs were included. No significant differences were identified between the different pouch designs with regard to anastomotic dehiscence, anastomotic stricture, pelvic sepsis, wound infection, pouch fistula, pouch ischaemia, perioperative haemorrhage, small bowel obstruction, pouchitis and sexual dysfunction. The W and K designs resulted in fewer cases of pouch failure compared with the J and S designs. J pouch construction resulted in a smaller maximum pouch volume compared with W and K pouches. Stool frequency per 24 h and during daytime was higher following a J pouch than W, S or K constructions. The J design resulted in increased faecal urgency and seepage during daytime compared with the K design. The use of protective pads during daytime and night-time was greater with a J pouch compared to S or K. The use of antidiarrhoeal medication was greater after a J reservoir than a W reservoir. Difficulty in pouch evacuation requiring intubation was higher with an S pouch than with W or J pouches. CONCLUSION Despite its ease of construction and comparable complication rates, the J pouch is associated with higher pouch failure rates and worse function. Patient characteristics, technical factors and surgical expertise should be considered when choosing pouch design.
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Affiliation(s)
- C Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - T Afxentiou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - G Pellino
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - C Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - S Rasheed
- Department of Surgery and Cancer, Imperial College, London, UK
| | - O Faiz
- St Mark's Academic Institute, Surgical Epidemiological Trials and Outcomes Centre, London, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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Worley GHT, Segal JP, Warusavitarne J, Clark SK, Faiz OD. Management of early pouch-related septic complications in ulcerative colitis: a systematic review. Colorectal Dis 2018; 20:O181-O189. [PMID: 29768701 DOI: 10.1111/codi.14266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/22/2018] [Indexed: 12/26/2022]
Abstract
AIM It is well established that ileo-anal pouch-related septic complications (PRSC) increase the risk of pouch failure. There are a number of publications that describe the management of early PRSC in ulcerative colitis (UC) in small series. This article aims to systematically review and summarize the relevant current data on this subject and provide an algorithm for the management of early PRSC. METHOD A systematic review was undertaken in accordance with PRISMA guidelines. Studies published between 2000 and 2017 describing the clinical management of PRSC in patients with UC within 30 days of primary ileo-anal pouch surgery were included. A qualitative analysis was undertaken due to the heterogeneity and quality of studies included. RESULTS A total of 1157 abstracts and 266 full text articles were screened. Twelve studies were included for analysis involving a total of 207 patients. The studies described a range of techniques including image-guided, endoscopic, surgical and endocavitational vacuum methods. Based on the evidence from these studies, an algorithm was created to guide the management of early PRSC. CONCLUSION The results of this review suggest that although successful salvage of early PRSC is improving there is little information available relating to methods of salvage and outcomes. Novel techniques may offer an increased chance of salvage but comparative studies with longer follow-up are required.
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Affiliation(s)
- G H T Worley
- St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - J P Segal
- St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - J Warusavitarne
- St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - S K Clark
- St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - O D Faiz
- St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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Sunde ML, Negård A, Øresland T, Bakka N, Geitung JT, Færden AE. MRI defecography of the ileal pouch-anal anastomosis-contributes little to the understanding of functional outcome. Int J Colorectal Dis 2018. [PMID: 29520456 DOI: 10.1007/s00384-018-3011-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients. METHODS From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy. RESULTS Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores. CONCLUSION It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.
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Affiliation(s)
- M L Sunde
- Department of Colorectal Surgery, Akershus University Hospital, 1478, Lørenskog, Norway. .,Division of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - A Negård
- Department of Radiology, Akershus University Hospital, Lørenskog, Norway
| | - T Øresland
- Department of Colorectal Surgery, Akershus University Hospital, 1478, Lørenskog, Norway.,Division of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - N Bakka
- Department of Radiology, Akershus University Hospital, Lørenskog, Norway
| | - J T Geitung
- Department of Radiology, Akershus University Hospital, Lørenskog, Norway.,Division of Medicine and Laboratory Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - A E Færden
- Department of Colorectal Surgery, Akershus University Hospital, 1478, Lørenskog, Norway
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44
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Sunde ML, Ricanek P, Øresland T, Jahnsen J, Naimy N, Færden AE. Determinants of optimal bowel function in ileal pouch-anal anastomosis - physiological differences contributing to pouch function. Scand J Gastroenterol 2018; 53:8-14. [PMID: 29043868 DOI: 10.1080/00365521.2017.1390601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Variability in functional outcome after ileal-pouch anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to perform multiple physiological and biochemical tests including an endoscopic examination with histology on IPAA patients with well and poorly functioning pouches to determine factors, or combinations thereof, contributing to functional outcome. METHODS All patients with ulcerative colitis undergoing restorative proctocolectomy between 2000 and 2013 (N = 108) were interviewed using a pouch functioning score. The best and worst functioning quartiles were invited to undergo examination with a barostat measuring pouch volume at preset variable distension pressures, and a pouch endoscopy. RESULTS Forty five of 58 eligible patients agreed to participate. The most significant physiological parameter differing between the well and poorly functioning pouches was pouch volume at first sensation, urge and discomfort (p value <.001). Urge volumes were 213 (CI 171-256) ml for poorly and 352 (CI 305-401) ml for well functioning pouches. Pouchitis episodes were negatively correlated to function. The poorly functioning patients had a higher prevalence of histological signs of inflammation and hand-sewn anastomosis, and a longer remaining rectal cuff, however, nonsignificant. The pouch pressure at sensation thresholds did not differ between the groups. CONCLUSIONS Pouch volume is the most dominant predictor of pouch function in this study. The present comprehensive study of a multitude of different factors that possibly could be contributing to functional outcome, failed to shed much further light on the functional variability among pouch patients. The pouch physiology remains to a large extent unexplained.
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Affiliation(s)
- Marie Louise Sunde
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway.,b Division of Surgical Sciences, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Petr Ricanek
- c Department of Gastroenterology , Akershus University Hospital , Lørenskog , Norway
| | - Tom Øresland
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway.,b Division of Surgical Sciences, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Jørgen Jahnsen
- c Department of Gastroenterology , Akershus University Hospital , Lørenskog , Norway.,d Division of Medicine and Laboratory Sciences, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Nazir Naimy
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway
| | - Arne Engebreth Færden
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway
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Watanabe K, Nagao M, Suzuki H, Karasawa H, Ohnuma S, Musha H, Funayama Y, Kamei T, Naitoh T, Unno M. The functional outcome and factors influencing the quality of life after ileal pouch anal anastomosis in patients with ulcerative colitis. Surg Today 2017; 48:455-461. [PMID: 29234962 DOI: 10.1007/s00595-017-1613-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/13/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to assess the bowel function and quality of life (QOL) in patients with ulcerative colitis (UC) after total proctocolectomy with ileal pouch anal anastomosis (IPAA). METHODS Two questionnaires ["Questionnaire sheet on the bowel function" and "Inflammatory bowel disease questionnaire (Japanese IBDQ)"] were sent to 121 patients with UC who underwent IPAA at Tohoku University Hospital. Seventy-nine patients (65%) participated in the study. RESULTS The median number of daily bowel movements was 6.5, which significantly decreased with postoperative time (≤ 1, 1-5, 5-15 years) and increased with age (< 45, ≥ 45 years at colectomy). The ratio of patients who usually had bowel movements at night also significantly decreased with postoperative time and increased with age. The median total IBDQ score was 180. A multivariate analysis showed that "trip activity", "care about where the restroom is", and "bowel movements in the day" were significant independent risk factors for the daily life satisfaction score. CONCLUSIONS The bowel function and QOL were acceptable in patients with UC after IPAA; however, patients with a short postoperative time or older age had a lower functional outcome than others.
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Affiliation(s)
- Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan.
| | - Munenori Nagao
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Hideyuki Suzuki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Hideaki Karasawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Shinobu Ohnuma
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Hiroaki Musha
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Yuji Funayama
- Department of Surgery, Sendai Red Cross Hospital, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Takeshi Naitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
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46
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Affiliation(s)
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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47
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Kong E, Nikolaou S, Qiu S, Pellino G, Tekkis P, Kontovounisios C. A systematic review of sacral nerve stimulation for faecal incontinence following ileal pouch anal anastomosis. Updates Surg 2017; 70:1-5. [PMID: 29086238 PMCID: PMC5866279 DOI: 10.1007/s13304-017-0496-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/04/2017] [Indexed: 12/20/2022]
Abstract
Faecal incontinence is a common complication of ileal pouch anal anastomosis (IPAA) and seems to worsen with time. The aim of this paper is to review the evidence of the use of sacral nerve stimulation (SNS) for patients with faecal incontinence after IPAA. A literature search was performed on PubMed and Cochrane databases for all relevant articles. All studies, which reported the outcome of SNS in patients with faecal incontinence after IPAA, were reviewed. Three papers were identified, including a case report, cohort study and retrospective study. The total number of patients was 12. The follow-up duration included 3 months, 6 months and 24 months. After peripheral nerve evaluation, definitive implantation was performed in 10 (83.3%) patients. All three studies reported positive outcomes, with CCF scores and incontinence episodes improving significantly. Preliminary results suggest good outcome after permanent SNS implant. Studies with larger sample sizes, well-defined patient characteristics and standardized outcome measures are required to fully investigate the effect of SNS in IPAA patients.
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Affiliation(s)
- E Kong
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - S Nikolaou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK. .,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK.
| | - S Qiu
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - G Pellino
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - C Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
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48
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The Experience of Living With an Ileoanal Pouch: An Interpretative Phenomenological Analysis. Gastroenterol Nurs 2017; 40:401-409. [PMID: 28505054 DOI: 10.1097/sga.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to explore the lived experiences of individuals living with an ileoanal pouch. A qualitative, phenomenological methodology was used to elicit detailed accounts of the impact of living with an ileoanal pouch. Ten individuals having an ileoanal pouch, formed as a consequence of ulcerative colitis, participated in the study. Semistructured interviews were conducted and analyzed using interpretative phenomenological analysis. The following 4 themes emerged from the analysis: "a flood of emotions"; "changed body image"; "changes in lifestyle"; and "intimacy and sexual relationships." Participants indicated that their quality of life after surgery has improved because they were no longer suffering from the devastating symptoms of ulcerative colitis. However, a considerable number of these participants disclosed that they are still living a restricted lifestyle and reported profound changes not only in their physical self but also in their social and sexual relationships. By acknowledging these experiences, healthcare professionals have the potential to improve the psychological, sexual, and social care that these individuals receive.
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49
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Landerholm K, Abdalla M, Myrelid P, Andersson RE. Survival of ileal pouch anal anastomosis constructed after colectomy or secondary to a previous ileorectal anastomosis in ulcerative colitis patients: a population-based cohort study. Scand J Gastroenterol 2017; 52:531-535. [PMID: 28102092 DOI: 10.1080/00365521.2016.1278457] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Ileorectal anastomosis (IRA) affects bowel function, sexual function and reproduction less negatively than ileal pouch anal anastomosis (IPAA), the standard reconstruction after colectomy for ulcerative colitis (UC). In younger UC patients, IRA may have a role postponing pelvic surgery and IPAA. The aim of the present study was to investigate the survival of IPAA secondary to IRA compared to IPAA as primary reconstruction, as this has not previously been studied in UC. PATIENTS AND METHODS All patients with UC diagnosis between 1960 and 2010 in Sweden were identified from the National Patient Registry. From this cohort, colectomized patients reconstructed with primary IPAA and patients reconstructed with IPAA secondary to IRA were identified. The survival of the IPAA was followed up until pouch failure, defined as pouchectomy and ileostomy or a diverting ileostomy alone. RESULTS Out of 63,796 patients, 1796 were reconstructed with IPAA, either primarily (n = 1720) or secondary to a previous IRA (n = 76). There were no demographic differences between the groups, including length of follow-up (median 12.6 (IQR 6.7-16.6) years and 10.0 (IQR 3.5-15.9) years, respectively). Failure of the IPAA occurred in 103 (6.0%) patients with primary and in 6 (8%) patients after secondary IPAA (P = 0.38 log-rank). The 10-year pouch survival was 94% (95% CI 93-96) for primary IPAA and 92% (81-97) for secondary. CONCLUSIONS Patients choosing IRA as primary reconstruction do not have an increased risk of failure of a later secondary IPAA in comparison with patients with primary IPAA.
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Affiliation(s)
- Kalle Landerholm
- a Department of Surgery , Ryhov County Hospital , Jönköping , Sweden.,b Department of Surgery, Colorectal unit , Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Maie Abdalla
- c Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden.,d Faculty of Medicine , Suez Canal University , Ismailia , Egypt
| | - Pär Myrelid
- c Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden.,e Department of Surgery , County Council of Östergötland , Linköping , Sweden
| | - Roland E Andersson
- a Department of Surgery , Ryhov County Hospital , Jönköping , Sweden.,c Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
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50
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Sunde ML, Øresland T, Faerden AE. Restorative proctocolectomy with two different pouch designs: few complications with good function. Colorectal Dis 2017; 19:363-371. [PMID: 27496246 DOI: 10.1111/codi.13478] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023]
Abstract
AIM The object of this study was to compare function and quality of life after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) surgery having two different pouch designs. METHOD Patients having RPC in an academic unit from 2000 who had had the loop-ileostomy closed by June 2013 were identified from the hospital medical records. They were sent a questionnaire regarding quality of life and interviewed using a pouch function score (PFS) described by Oresland (score 0-16, higher scores denote worse function). RESULTS One hundred and three patients underwent surgery, of whom 56 had a J-pouch design and 47 a K-pouch design, this being a double-folded Kock pouch without the nipple valve. No patients have had the pouch removed or defunctioned due to failure at a mean of 8 years. The reoperation rate was 11.6%. The mean PFS was 5.43 and 5.27 for J- and K-pouches, respectively (P = 0.766). More patients with a J-pouch reported a social handicap due to poor bowel function (P = 0.041). Patients with a PFS ≥ 8 had a poorer quality of life. A score of ≥ 8 was reported by 16% of K-pouch and 25% of J-pouch patients (P = 0.29). CONCLUSION RPC is a safe procedure with a low complication rate and good functional outcome. Small improvements in function have an impact on a patient's quality of life. Although the J-pouch is the most commonly used, the K-pouch has some advantages. Other pouch designs deserve further evaluation.
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Affiliation(s)
- M L Sunde
- Department of Colorectal Surgery, Akershus University Hospital, Lørenskog, Norway.,Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - T Øresland
- Department of Colorectal Surgery, Akershus University Hospital, Lørenskog, Norway.,Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - A E Faerden
- Department of Colorectal Surgery, Akershus University Hospital, Lørenskog, Norway
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