Iron Deficiency Is Common after Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis in Patients with Ulcerative Colitis

Background

Micronutrient deficiencies may occur after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC), largely due to malabsorption and/or pouch inflammation.

Objectives

The objective of this study was to report the frequency of iron deficiency in patients with UC who underwent RPC with IPAA and identify associated risk factors.

Methods

We conducted a retrospective chart review of patients with UC or IBD-unclassified who underwent RPC with IPAA at Mount Sinai Hospital between 2008 and 2017. Patients younger than 18 years of age at the time of colectomy were excluded. Descriptive statistics were used to analyze baseline characteristics. Medians with interquartile range (IQR) were reported for continuous variables, and proportions were reported for categorical variables. Iron deficiency was defined by ferritin <30 ng/mL. Logistic regression was used to analyze unadjusted relationships between hypothesized risk factors and the outcome of iron deficiency.

Results

A total of 143 patients had iron studies a median of 3.0 (IQR 1.7-5.6) years after final surgical stage, of whom 73 (51.0%) were men. The median age was 33.5 (IQR 22.7-44.3) years. Iron deficiency was diagnosed in 80 (55.9%) patients with a median hemoglobin of 12.4 g/dL (IQR 10.9-13.3), ferritin of 14 ng/mL (IQR 9.0-23.3), and iron value of 44 μg/dL (IQR 26.0-68.8). Of these, 29 (36.3%) had a pouchoscopy performed within 3 months of iron deficiency diagnosis. Pouchitis and cuffitis were separately noted in 4 (13.8%) and 13 (44.8%) patients, respectively, and concomitant pouchitis-cuffitis was noted in 9 (31.0%) patients. Age, sex, anastomosis type, pouch duration, and history of pouchitis and/or cuffitis were not associated with iron deficiency.

Conclusion

Iron deficiency is common after RPC with IPAA in patients with UC. Cuffitis is seen in the majority of patients with iron deficiency; however, iron deficiency may occur even in the absence of inflammation.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes

BACKGROUND

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

AIMS

To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

METHODS

A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

RESULTS

34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

CONCLUSION

PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Hepatobiliary manifestations following two-stages elective laparoscopic restorative proctocolectomy for patients with ulcerative colitis: A prospective observational study

BACKGROUND

Hepatobiliary manifestations occur in ulcerative colitis (UC) patients. The effect of laparoscopic restorative proctocolectomy (LRP) with ileal pouch anal anastomosis (IPAA) on hepatobiliary manifestations is debated.

AIM

To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.

METHODS

Between June 2013 and June 2018, 167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study. Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study. The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.

RESULTS

The patients' mean age was 36 ± 8 years, and males predominated (67.1%). The most common hepatobiliary diagnostic method was liver biopsy (85.6%), followed by Magnetic resonance cholangiopancreatography (63.5%), Antineutrophil cytoplasmic antibodies (62.5%), abdominal ultrasonography (35.9%), and Endoscopic retrograde cholangiopancreatography (6%). The most common hepatobiliary symptom was Primary sclerosing cholangitis (PSC) (62.3%), followed by fatty liver (16.8%) and gallbladder stone (10.2%). 66.4% of patients showed a stable course after surgery. Progressive or regressive courses occurred in 16.8% of each. Mortality was 6%, and recurrence or progression of symptoms required surgery for 15%. Most PSC patients (87.5%) had a stable course, and only 12.5% became worse. Two-thirds (64.3%) of fatty liver patients showed a regressive course, while one-third (35.7%) showed a stable course. Survival rates were 98.8%, 97%, 95.8%, and 94% at 12 mo, 24 mo, 36 mo, and at the end of the follow-up.

CONCLUSION

In patients with UC who had LRP, there is a positive impact on hepatobiliary disease. It caused an improvement in PSC and fatty liver disease. The most prevalent unchanged course was PSC, while the most common improvement was fatty liver disease.

Outcomes after transanal proctectomy with ileal pouch-anal anastomosis in adolescents

PURPOSE

The aim of this study was to describe our initial surgical and functional outcomes of transanal ileal pouch anastomosis (Ta-IPAA) in adolescents.

METHODS

A total of 16 adolescents' age ≤ 19 underwent consecutive Ta-IPAA on the indication ulcerative colitis (UC) or familiar adenomatous polyposis (FAP), between January 2018 and September 2022. Primary outcomes were postoperative complications. Secondary outcomes were conversion rates, intraoperative complications, length of hospital stay (LOS), morbidity within 30 days, surgical characteristics, and functional outcomes.

RESULTS

Thirteen adolescents with UC and three with FAP underwent Ta-IPAA. The median age of UC patients was 16. They had a colectomy on the indication UC followed by a Ta-IPAA. Median operating time was 247 min, and there were no conversion or intraoperative complications. Median LOS was 7 days. No anastomotic leakage was observed, and three patients had complications within the first 30 days. Three had late complications. The median bowel movements were 5, and 50% had bowel movements during the night. Three children were operated on the indication FAP with proctocolectomy and Ta-IPAA. There were no conversion or intraoperative complications, and the median bowel movements was 4.

CONCLUSION

Ta-IPAA approach in children seems to be feasible, safe and offers acceptable functional results.

Transanal ileal pouch-anal anastomosis for ulcerative colitis: a single-center comparative study

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice in patients with ulcerative colitis (UC) requiring surgery. Advantages of laparoscopic IPAA (lap-IPAA) compared to open surgery have been investigated. However, laparoscopic dissection in the pelvis is still a challenge. A transanal approach provides better access to lower pelvis and avoids multiple staple firings, which could reduce the risk of anastomotic complications. The aim of this study was to compare short-term outcomes of transanal proctectomy with IPAA (ta-IPAA) with conventional lap-IPAA in patients with UC.

METHODS

A single-center retrospective study was conducted on consecutive UC patients, treated at Copenhagen University Hospital, Hvidovre, undergoing either laparoscopic or transanal IPAA in the period between January 2013 and December 2020. Exclusion criteria were Crohn's disease, previous extensive abdominal surgery and impaired sphincter function. Primary outcomes were overall postoperative complications. Secondary outcomes were length of hospital stay and re-admissions. For comparison between ta-IPAA and lap-IPAA, the Mann-Whitney U test was used for continuous variables, and Chi-square and Fisher's exact test for categorical variables.

RESULTS

A total of 65 patients with ta-IPAA (34 males, 31 females, median age 31 years [range 12-66 years]) and 70 patients with lap-IPAA (35 males, 35 females, median age 26 years [range 12-66 years]) were included. There was no difference between ta-IPAA and lap-IPAA regarding age, sex, body mass index or American Society of Anesthesiologists class. The primary colectomy procedure was performed laparoscopically in 95% of the ta-IPPA and 91% of the lap-IPAA patients (p = 0.493). The mean time between total colectomy and IPAA was 15 and 9 weeks for ta-IPAA and lap-IPAA, respectively (p = 0.048). A higher proportion of patients with ta-IPAA were treated with biologics preoperatively (98 vs. 82%; p = 0.002). Patients with ta-IPAA had a significantly higher mean operative time compared to lap-IPAA (277 min vs. 224 min; p = 0.001). There was no difference in the overall postoperative complication rate (ta-IPAA: 23% vs. lap-IPAA: 23%; p = 0.99). Pouch-related complications occurred in 13% of the ta-IPAA patients and 29% of lap-IPPA patients (p = 0.402). There was no difference in the anastomotic leakage rates. Readmission rates were similar in the ta-IPAA and lap-IPAA group (26 vs. 29%; p = 0.85), including IPAA-related readmissions. The mean follow-up time was 24 and 75 months for ta-IPAA and lap-IPAA, respectively (p = 0.001), and the ileostomy closure rate was similar in both groups of patients (p = 0.96).

CONCLUSIONS

The ta-IPAA approach for UC is a safe procedure and offers acceptable short-time outcomes.

Association Between Portal Vein Thrombosis and Pouchitis in Patients with Ulcerative Colitis

BACKGROUND

Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis.

AIM

To evaluate the association between PVT and other demographic and clinical factors and pouchitis.

METHODS

We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis.

RESULTS

We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04-16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02-1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23-1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28-1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33-0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis.

CONCLUSIONS

We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis.

Nurse-led surveillance of ileoanal pouch patients post-stoma reversal: outcomes at 12-month review

Restorative proctocolectomy with pouch anal anastomosis is the accepted treatment for suitable patients with ulcerative colitis, yet surveillance following stoma reversal remains contentious and involves several issues. While most patients are discharged from routine follow-up between 6 weeks and 3 months, some remain on surveillance pathways indefinitely. A high volume of patients require advice for many months or years after the stoma has been reversed, with the burden of surveillance on consultant-led clinics. Nurse-led follow-up after restorative proctocolectomy has been recognised for decades but has not been validated. This study reports the first protocol-based pathway for nurse-led follow-up. Using validated questionnaires, suitable pouch patients were followed up in nurse-led clinics over a 12-month period then sent an online survey to report on the service they received. Overall, most patients were satisfied with the nurse-led follow-up; however, further engagement and investment in the workforce and infrastructure is required to offer sustainable services.

Postoperative complications, bowel function, and prognosis in restorative proctocolectomy for ulcerative colitis-a single-center observational study of 320 patients

PURPOSE

To determine the selection criteria, postoperative complications, bowel function, and prognosis of stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA for ulcerative colitis (UC).

METHODS

We defined our surgical indications and strategy, and compared the postoperative complications, bowel function, and prognoses between patients who underwent stapled and hand-sewn IPAA for UC at the Yokohama City University Medical Center between 2004 and 2017.

RESULTS

Among 320 patients enrolled, 298 patients underwent stapled IPAA while 22 underwent hand-sewn IPAA. There was no significant difference in the postoperative complications between the two groups. Regarding postoperative bowel function, stapled IPAA caused significantly less soiling (stapled vs hand-sewn: 9.1% vs 41.0%, odds ratio (OR) = 0.14, p < 0.0002), spotting (stapled vs hand-sewn: 23.2% vs 63.6%, OR = 0.17, p < 0.0001), and difficulty in distinguishing feces from flatus (stapled vs hand-sewn: 39.9% vs 63.6%, OR = 0.36, p < 0.026). No postoperative neoplasia was observed at the final follow-up in all patients.

CONCLUSION

In this study, there was no clear difference in the postoperative complications between stapled and hand-sewn IPAA, but stapled IPAA resulted in better postoperative bowel function. Postoperative oncogenesis from the residual mucosa is rare. However, future cancer risk remains; thus, careful follow-up is required.

Functional outcomes, quality of life, sexual function, and fertility of adult patients undergoing ileo-anal pouch anastomosis in childhood

BACKGROUND

We conducted a questionnaire-based study of pouch function, quality of life, sexual function, and fertility among patients who had undergone ileal pouch anal anastomosis (IPAA) in childhood and who are now more than 18 years old.

METHODS

A consecutive series of patients were asked to complete the following questionnaires: Pouch function score (PFS), short form 36 (SF-36), International index of erectile function (IIEF) (males), and Female sexual function index (FSFI) (females). Fertility in females was also assessed. Data are quoted as a median (SD).

RESULTS

Of 144 patients who had IPAA, 101 were eligible, and 70 responded. Mean age at surgery was 14 years, and mean current age is 26 years. Most patients had either ulcerative colitis or familial adenomatous polyposis. The questionnaire was completed by 38/70 (54%). Median PFS score was 6 (5). SF-36 were lower than previous reports. Median FSFI was 30 (7.6), 84% of possible maximum. Median IIEF was 69, 92% of possible maximum. Successful conception was reported in 5/7 women who had tried. However, there were several miscarriages and two surgical emergencies during pregnancies.

CONCLUSIONS

IPAA can be performed in childhood with similar pouch function to reported adult series. Quality of life appears poorer, but sexual function is maintained. There may be an association with adverse events in pregnancy.

LEVEL OF EVIDENCE

IV.

Laparoscopic robotic-assisted restorative proctocolectomy and ileal J-pouch-anorectal anastomosis in children

PURPOSE

Total proctocolectomy with ileal J-pouch-anorectal anastomosis (IPAA) remains the preferred surgical treatment for ulcerative colitis (UC) in children. Considering the well-known advantages of minimally invasive approach, and its main application for the deep pelvis, robotic surgery may be used in UC reconstructive procedures. The aim of the study is to report our experience with Robotic IPAA in children.

METHODS

Single surgeon experience on Robotic IPAA were prospectively included. Data on patient demographics, surgical details, complications, and length of stay (LOS), were collected.

RESULTS

Fifteen patients were included. Median age was 13.2 years, median body weight 45 kg. Median operative time was 240 min. Median LOS was 7 days and mean follow-up time 1 year. No intraoperative complication occurred. Five postoperative complications happened: 3 minors treated conservatively (CD I-II), 2 majors needing reintervention under anesthesia (CD IIIb). No mortality was observed.

CONCLUSION

Our preliminary experience reveals that Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. A bigger patient sample and a long-term follow-up are needed to confirm our findings.

Single-stage restorative proctocolectomy for ulcerative colitis in pediatric patients: a safe alternative

BACKGROUND

Surgical management for refractory ulcerative colitis (UC) has been restorative proctocolectomy (RP) with ileal-pouch-anal-anastomosis (IPAA) done as one to three stages, with safety and effectiveness of a single-stage operation unclear.

METHODS

Pediatric UC patients from 2004 to 2019 who underwent RP/IPAA in the initial operation were retrospectively reviewed. 1-stage operations were matched 1:2 to 2-stage operations using age, duration of disease, and disease severity.

RESULTS

Ninety-nine patients (33 1-stage, 66 2-stage) were identified. The median total operative time was shorter in the 1-stage group (6 h:00 min vs. 7 h:47 min, p = 0.004). Total length of stay was shorter in the 1-stage group (9 vs. 17 days, p = 0.001). Rates of readmission were higher in 2-stage group (30 vs. 9%, p = 0.02). There was no difference in pouch leak rates (p = 1.00). Stricture rates were higher in the 2-stage group (50 vs. 16%, p = 0.005). Functional outcomes including pouchitis (p = 0.13), daily bowel movements (p = 0.37), and incontinence (p = 0.77) were all similar.

CONCLUSIONS

Restorative proctocolectomy with IPAA in children with UC can be performed as a 1- or 2-stage operation with equivalent short-term, long-term, and functional outcomes in similar risk population. Our findings suggest 1-stage RP/IPAA operations without ileostomy are a safe alternative for patients considered for a 2-stage operation.

Development of a systematic approach to conversion of the ileoanal pouch into continent ileostomy

Based on practical experience, a systematic approach to conversion of ileal J-pouches into continent ileostomies is developed by defining three types of conversion surgery, each with two subtypes. Type 1 refers to conversion without pouch reconstruction, type 2 to partial pouch reconstruction, and type 3 to complete pouch reconstruction. The subdivisions (a and b) take into account whether the afferent loop of the former pelvic pouch (a) or a higher ileal/jejunal segment of the small intestine (b) is used in conversion and/or reconstruction. The six resulting surgical variants are shown in schematic illustrations with accompanying descriptions of technical details to provide the specialized surgeon with comprehensive technical guidance.

Severity of complications following restorative proctocolectomy in children is related to staging not diagnosis

BACKGROUND

Restorative proctocolectomy (RPC) is performed using a variety of staged procedures for several diseases. Our aim was to assess whether the severity of complications, classified according to Clavien-Dindo, was related to the diagnosis or the procedure.

METHODS

A consecutive series of children receiving an ileoanal pouch was prospectively recorded. Complications were scored by two blinded observers. Major complications were Clavien-Dindo ≥3b. Procedures were classified as: colectomy, proctectomy and pouch or proctocolectomy and pouch. Diagnoses were classified as: ulcerative colitis, familial adenomatous polyposis or other: idiopathic constipation, total colonic Hirschsprung's disease, juvenile polyposis, Crohn's colitis, fibrosing colonopathy or necrotising enterocolitis.

RESULTS

128 children underwent 191 procedures: 61 colectomies, 63 proctectomies and 67 proctocolectomies. 84 children had ulcerative colitis, 20 had FAP and 24 had other indications. Major complications were significantly more likely with proctocolectomy (16/67, 24%) than with either colectomy (4/61, 7%) or proctectomy (8/63, 13%), p = 0.01. There was no association between diagnosis and major complications: ulcerative colitis (18/133, 14%), FAP (5/20, 25%), other (5/38, 13%) p = 0.4. There was no increase in major complications following proctectomy if a major complication had occurred during prior colectomy. Overall, 15% of procedures experienced a major complication. 6/9 stoma related complications required operative intervention.

CONCLUSIONS

The severity of complications after RPC in children is related to use of a two stage rather than three stage sequence of surgery, not the underlying diagnosis.

TYPE OF STUDY

Case control study.

LEVEL OF EVIDENCE

Level III.

Robotic versus laparoscopic ileal pouch-anal anastomosis (IPAA): a systematic review and meta-analysis

BACKGROUND

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is a curative and cancer preventative procedure in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). It can be technically difficult laparoscopically, and hence the robotic platform has been suggested as a way to enable minimally invasive surgery in more patients. This systematic review examines robotic proctectomy or proctocolectomy with IPAA. A limited meta-analysis was performed on data comparing the robotic approach to laparoscopy.

METHODS

We searched MEDLINE, EMBASE and the Cochrane database for case series of robotic IPAA procedures and studies comparing the robotic to laparoscopic or open procedures. Data examined includes operating time, conversion to open, length of stay, complications, blood loss, return of bowel function, reoperation rate and functional outcomes.

RESULTS

Five non-randomised studies compared robotic to laparoscopic techniques; one compared robotic to open surgery and three case series are included. Operating time was significantly longer in robotic cases. Estimated blood loss was significantly less in three of four studies which reported this; hospital stay was significantly less in two. There were nonsignificant reductions in complications and readmission rates. Pooled analysis of four papers with adequate data showed a nonstatistically significant trend to less complications in robotic procedures. Three studies assessed functional and quality of life outcomes, with little difference between the platforms.

CONCLUSIONS

Available data suggests that the robotic platform is safe to use for IPAA procedures. There is minimal evidence for clinical advantages, but with little data to base decisions and significant potential for improvements in technique and cost-effectiveness, further use of the platform for this operation is warranted. It is vital that this occurs within an evaluation framework.

Acute abdomen due to J-pouch outlet obstruction: A case report and review of literature

Introduction

Ileal pouch–anal anastomosis is the procedure of choice for re-establishing intestinal continuity for patients undergoing total proctocolectomy. Despite growing experience with this procedure, it is still associated with considerable morbidity rates.

Presentation of case

Herein, we report the case of a 14-year-old boy with familial adenomatous polyposis who underwent total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy. The patient developed early postoperative complications; on postoperative day 1, he developed bleeding from the pouch staple line, which was managed endoscopically. On postoperative day 15, he developed intestinal obstruction due to adhesions. One year after proctocolectomy, ileostomy closure was performed uneventfully. From postoperative day 3, the patient presented with obstructive signs such as abdominal distention, bloating, abdominal pain, and fever. Computed tomography identified diffuse intense intestinal distension with pouch dilatation. Digital rectal examination identified the pouch filled with liquid stool and no signs of anal canal anastomosis stenosis. The patient was considered to have pouch outlet obstruction and was successfully managed using bedside evacuation anoscopy. After 3 days, oral nutrition was re-established, and appropriate stool evacuation and fecal continence were achieved.

Discussion

Proctocolectomy with ileal pouch–anal anastomosis still carries a considerable complication rate. Proper identification of causative factors is mandatory for appropriate treatment. Pouch outlet obstruction can present as acute abdomen after diverting ileostomy closure. In this case, outlet obstruction was identified and treated by pouch evacuation, avoiding morbidity of a new surgical procedure.

Conclusion

We presented an unusual case of acute intestinal obstruction due to pouch outlet obstruction that was managed nonoperatively with bedside pouch evacuation.

•

Proctocolectomy with ileal pouch-anal anastomosis is the main treatment for APC

•

The procedure is technically demanding and carries considerable complications rate

•

Intestinal obstruction is frequent early complication, mostly due to intestinal adhesions

•

Pouch outlet obstruction can promote acute abdomen and can be managed conservatively

D-pouch: a modified ileal J-pouch for patients with ulcerative colitis and familial adenomatous polyposis

BACKGROUND

Ileal J-pouch anal anastomosis (J-IPAA) is the standard approach for patients requiring restorative proctocolectomy due to familial adenomatous polyposis (FAP) or ulcerative colitis (UC). To obviate the risk of a J-tip leak, we modified the J-pouch with a D-pouch anal anastomosis (D-IPAA) designed to eliminate the ileal stump. The aim of our study was to evaluate the feasibility, safety and medium-term functional outcomes of D-IPAA.

METHODS

A retrospective comparison was made between D-IPAA and J-IPAA constructions after a restorative proctocolectomy. Clinical data were collated between October 2014-March 2018 recording operation duration, pouch construction time, pouch volume, intraoperative estimated blood loss, complication rates, readmissions and cumulative length of hospitalization. Continence was assessed at the final visit with the Wexner Cleveland Clinic Score along with the Cleveland Global Quality of Life (CGQL) scale.

RESULTS

A total of 97 patients with FAP (n = 28) and UC (n = 69) who had J-IPAA (n = 54) or D-IPAA (n = 43) after proctocolectomy were identified. Patients were well matched with no differences noted in the intraoperative variables between the J- and D-pouch groups. The D-pouch construction time was shorter than that for a standard J-pouch. There was no difference in major or minor complications between groups. A pouch leak developed in each group: a cutaneous fistula from J tip leak in the J-IPAA group and a pouch-vaginal fistula from the IPAA the D-IPAA group. Clinical outcomes (the number of bowel movements) were equivalent in the two groups with the Wexner score significantly improving within each group up to 2.5 years and with improvement in the CGQL after surgery.

CONCLUSIONS

The D-pouch construction is safe and feasible for patients with UC and FAP with good functional outcome over the medium term and the potential to reduce the risk of pouch leaks.

Risk factors for non-reaching of ileal pouch to the anus in laparoscopic restorative proctocolectomy with handsewn anastomosis for ulcerative colitis

Background/Aims

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis and handsewn anastomosis for ulcerative colitis requires pulling down of the ileal pouch into the pelvis, which can be technically challenging. We examined risk factors for the pouch not reaching the anus.

Methods

Clinical records of 62 consecutive patients who were scheduled to undergo RPC with handsewn anastomosis at the University of Tokyo Hospital during 1989–2019 were reviewed. Risk factors for non-reaching were analyzed in patients in whom hand sewing was abandoned for stapled anastomosis because of non-reaching. Risk factors for non-reaching in laparoscopic RPC were separately analyzed. Anatomical indicators obtained from presurgical computed tomography (CT) were also evaluated.

Results

Thirty-seven of 62 cases underwent laparoscopic procedures. In 6 cases (9.7%), handsewn anastomosis was changed to stapled anastomosis because of non-reaching. Male sex and a laparoscopic approach were independent risk factors of non-reaching. Distance between the terminal of the superior mesenteric artery (SMA) ileal branch and the anus > 11 cm was a risk factor for non-reaching.

Conclusions

Laparoscopic RPC with handsewn anastomosis may limit extension and induction of the ileal pouch into the anus. Preoperative CT measurement from the terminal SMA to the anus may be useful for predicting non-reaching.

Surgical Management of Ulcerative Colitis

Ulcerative colitis can be managed by surgical resection of the colon and rectum. The final reconstruction options of traditional end ileostomy, continent ileostomy, ileorectal anastomosis, or ileal pouch anal anastomosis (IPAA). We maintain that the IPAA is the gold standard management of ulcerative colitis and should be performed in stages. This article includes descriptions of technique, management alternatives, and intraoperative and postoperative management of pouch issues.

Pouch wall thickness and floppy pouch complex

BACKGROUND

Floppy pouch complex (FPC) consists of disease phenotypes in patients with ileal pouches, including pouch prolapse, afferent limb syndrome, enterocele, redundant loop, and pouch folding. Our recent study demonstrated that lower body weight, lower peripouch fat, family history of inflammatory bowel disease (IBD), female gender, and dyschezia are risk factors for FPC patients with IBD. The aims of this study were to assess the relationship between pouch wall thickness and FPC, and to investigate the association between inflamed and non-inflamed pouch wall thickness.

METHODS

This case-control study included all eligible patients with FPC from our prospectively maintained, IRB-approved Pouchitis Registry from 2011 to 2017. We measured pouch wall thickness of fully distended pouches on cross-sectional abdominal and pelvic imaging. Patients with stoma and non-distended pouches were completely excluded. Risk factors for FPC were analyzed.

RESULTS

A total of 140 out of 451 patients from our were found to have fully distended pouches on imaging. Of the 140 patients, 36 (25.7%) were diagnosed as having FPC. We analyzed pouch wall thickness for each subcategory of FPC as well as non-FPC conditions. The thickness of pouch wall was follows: pouch prolapse (N = 19): 1.5 mm (1.5-2.0), afferent limb syndrome (N = 12): 1.5 mm (1.1-2.0), folded pouch (N = 4): 1.5 mm (1.1-1.9), and redundant pouch (N = 2): 1.3 mm (1.0-1.3). The control group (N = 104) consisting of normal pouch, pouchitis, cuffitis, Crohn's disease of the pouch, and pouch sinus with median pouch wall thickness of 1.5 mm, 2.3 mm, 2.0 mm, 2.0 mm, and 1.5 mm, respectively. There were significant differences in pouch wall thickness between normal or non-inflamed pouch versus pouchitis versus cuffitis versus Crohn's disease of the pouch with p values of 0.01, 0.04, 0.05, and 0.049, respectively.

CONCLUSION

Patients with FPC were shown to have thin pouch wall, which those with inflammatory conditions of the pouch tended to have thick pouch wall. These findings will have implications in both diagnosis and investigation of etiopathogenesis of these disorders.

Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons

Purpose

Anastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons.

Methods

A cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon’s preference for the use of diverting stomas, rectal tubes, and pelvic drains.

Results

There were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouches

Conclusion

There is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Better characterization of operation for ulcerative colitis through the National surgical quality improvement program: A 2-year audit of NSQIP-IBD

INTRODUCTION

There is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail.

METHODS

We queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity.

RESULTS

430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity.

CONCLUSIONS

Our data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity.

SHORT SUMMARY

We applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.

Short-term Outcomes of Elective 2-Stage Restorative Proctocolectomy for Ulcerative Colitis in Korea: Does Laparoscopy Have Benefits?

Purpose

This study aimed to compare the short-term outcomes of the open and laparoscopic approaches to 2-stage restorative proctocolectomy (RPC) for Korean patients with ulcerative colitis (UC).

Methods

We retrospectively analyzed the medical records of 73 patients with UC who underwent elective RPC between 2009 and 2016. Patient characteristics, operative details, and postoperative complications within 30 days were compared between the open and laparoscopic groups.

Results

There were 26 cases (36%) in the laparoscopic group, which had a lower mean body mass index (P = 0.025), faster mean time to recovery of bowel function (P = 0.004), less intraoperative blood loss (P = 0.004), and less pain on the first and seventh postoperative days (P = 0.029 and P = 0.027, respectively) compared to open group. There were no deaths, and the overall complication rate was 43.8%. There was no between-group difference in the overall complication rate; however, postoperative ileus was more frequent in the open group (27.7% vs. 7.7%, P = 0.043). Current smoking (odds ratio [OR], 44.4; P = 0.003) and open surgery (OR, 5.4; P = 0.014) were the independent risk factors for postoperative complications after RPC.

Conclusion

Laparoscopic RPC was associated with acceptable morbidity and faster recovery than the open approach. The laparoscopic approach is a feasible and safe option for surgical treatment for UC in selective cases.

Pouch failures following restorative proctocolectomy in ulcerative colitis

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.

Ileo-anal pouch excision and permanent ileostomy - Indications and outcomes from a tertiary centre

PURPOSE

Pouch excision is a major complication of ileoanal pouch surgery. Current practice is for this type of surgery to be performed in a specialist centre. We present a series of patients undergoing pouch excision surgery in a high volume centre in the UK and assess the outcomes in these patients.

METHODS

All patients undergoing pouch excision at the Royal Liverpool Hospital between 1995 and 2015 under the care of a single surgeon were included. Demographics and outcomes were taken from patients' notes and a dedicated retrospectively compiled database.

RESULTS

35 patients underwent pouch excision surgery during this period. Around half the patients had their original pouch surgery elsewhere and were referred for management of complications. Median time to pouch excision was 13 years from the original operation. Overall complication rate was 31% with 11% requiring re-intervention post-operatively. There was no mortality in this series.

CONCLUSION

Pouch excision is a complex, high-risk procedure that should be carried out in specialist centres. Our series shows that in such settings, good outcomes can be achieved for these patients.

Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study

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.

A Nationwide 17-year Cohort Study

BACKGROUND AND AIMS

Fertility decreases in women following restorative proctocolectomy for ulcerative colitis. The use and success of in vitro fertilisation [IVF] after restorative proctocolectomy for ulcerative colitis is not systematically studied. We aimed to estimate the use and success of in vitro fertilisation treatment in female ulcerative colitis patients, with and without restorative proctocolectomy.

METHODS

Women of fertile age [15-49 years] with restorative proctocolectomy for ulcerative colitis were compared with females with ulcerative colitis without restorative proctocolectomy. Data from the IVF registry from 1994-2010 were cross-linked with data from the National Danish Patient Registry and the Medical Birth Registry.

RESULTS

In vitro fertilisation is significantly more frequent in females with restorative proctocolectomy compared with females without restorative proctocolectomy, adjusted hazard ratio 3.2, 95% confidence interval [CI] [2.5;4.0]. The odds for having a live birth after in vitro fertilisation are no different in females with restorative proctocolectomy compared with females without restorative proctocolectomy, adjusted odds ratio 0.8, 95% CI [0.6;1.1]. The percentage of children born as a result of in vitro fertilisation is significantly higher in females with restorative proctocolectomy compared with females without restorative proctocolectomy (31.0%, 95% CI [24.1; 37.7] vs 5.0%, 95% CI [4.4; 5.6]).

CONCLUSIONS

Females with restorative proctocolectomy for ulcerative colitis have increased incidence of in vitro fertilisation by more than a factor three, the odds that a treatment results in a live birth are similar and six times more children are born as a result of in vitro fertilisation compared with females without restorative proctocolectomy.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak

BACKGROUND

The safety of undiverted restorative proctocolectomy (RPC) is debated. This study compares long-term outcomes after pouch leak in diverted and undiverted RPC patients.

METHODS

Data were obtained from a prospectively maintained registry from a single surgical practice. One-stage and staged procedures with an undiverted pouch were considered undiverted pouches; all others were considered diverted pouches. The outcomes measured were pouch excision and long-term diversion defined as the need for loop ileostomy at 200 weeks after pouch creation. Regression models were used to compare outcomes.

RESULTS

There were 317 diverted and 670 undiverted pouches, of which 378 were one-stage procedures. Pouch leaks occurred in 135 patients, 92 (13.7%) after undiverted, and 43 (13.6%) after diverted pouches. Eighty-six (64%) leaks were diagnosed within 6 months of pouch creation. Undiverted patients underwent more emergent procedures within 30 days of pouch creation (p < 0.01). Pouch excision occurred in 14 (33%) diverted patients and 13 (14%) undiverted patients (p = 0.01). Thirteen (32%) diverted patients and 18 (21%) undiverted patients (p = 0.17) had ileostomies at 200 weeks after surgery. In multivariable analyses, diverted patients had a higher risk of pouch excision (HR 3.67 p < 0.01), but similar rates of ileostomy at 200 weeks (HR 1.8, p = 0.19) compared to undiverted patients.

CONCLUSIONS

Despite a likely selection bias in which "healthier" patients undergo an undiverted pouch, our data suggest that diversion does not prevent pouch excision and the need for long-term diversion after pouch leak. These findings suggest that undiverted RPC is a safe procedure in appropriately selected patients.

The current state of the transanal approach to the ileal pouch-anal anastomosis. Surg Endosc. 2019;. [PMID: 30675660 DOI: 10.1007/s00464-019-06674-5]

BACKGROUND

The transanal approach to pelvic dissection has gained considerable traction and utilization continues to expand, fueled by the transanal total mesorectal excision (TaTME) for rectal cancer. The same principles and benefits of transanal pelvic dissection may apply to the transanal restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)-the TaPouch procedure. Our goal was to review the literature to date on the development and current state of the TaPouch.

MATERIALS AND METHODS

We performed a PubMed database search for original articles on transanal pelvic dissections, IPAA, and the TaPouch procedure, with a manual search from relevant citations in the reference list. The main outcomes were the technical aspects of the TaPouch, clinical and functional outcomes, and potential advantages, drawbacks, and future direction for the procedure.

RESULTS

The conduct of the procedure has been defined, with the safety and feasibility demonstrated in small series. The reported rates of conversion and anastomotic leakage are low. There are no randomized trials or large-scale comparative studies available for comparative effectiveness compared to the traditional IPAA.

CONCLUSIONS

The transanal approach to ileal pouch-anal anastomosis is an exciting adaption of the transanal total mesorectal excision for refining the technical steps of a complex operation. Additional experience is needed for comparative outcomes and defining the ideal training and implementation pathways.

A prospective study on safety, efficacy and long-term results

BACKGROUND

Laparoscopic ileo-pouch-anal anastomosis (IPAA) has been reported as having low morbidity and several advantages.

AIMS

To evaluate safety, efficacy and long-term results of laparoscopic IPAA, performed in elective or emergency settings, in consecutive unselected IBD patients.

METHODS

All the patients received totally laparoscopic 2-stage (proctocolectomy and IPAA - stoma closure) or 3-stage (colectomy - proctectomy and IPAA - stoma closure) procedure according to their presentation.

RESULTS

From July 2007 to July 2016, 160 patients entered the study. 50.6% underwent a 3-stage procedure and 49.4% a 2-stage procedure. Mortality and morbidity were 0.6% and 24.6%. Conversion rate was 3.75%. 8.7% septic complications were associated with steroids and Infliximab treatment (p = 0.0001). 3-stage patients were younger (p = 0.0001), with shorter disease duration (p = 0.0001), minor ASA scores of 2 and 3 (p = 0.0007), lower inflammatory index and better nutritional status (p = 0.003 and 0.0001), fewer Clavien-Dindo's grade II complications (p = .0001), reduced rates of readmission and reoperation at 90 days (p = 0.03), and shorter hospitalization (p = .0001), but with similar pouch and IPAA leakage, compared to 2-stage patients. 8 years pouch failure and definitive ileostomy were 5.1% and 3.7%.

CONCLUSION

A totally laparoscopic approach is safe and feasible, with very low mortality and morbidity rates and very low conversion rate, even in multi-stage procedures and high-risk patients.

Anxiety, depression, and inflammation after restorative proctocolectomy

PURPOSE

Anxiety and depression (A&D) are more common in inflammatory bowel disease (IBD) and in IBD patients who undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). Our aim was to test the hypothesis that chronic inflammatory conditions in IPAA are associated with increased incidence of A&D.

METHODS

Retrospective cohort study at a single tertiary care referral center using a consented IBD and colon cancer natural history registry. Demographic and clinical factors, including surgical and psychiatric history, were abstracted.

RESULTS

We compared A&D rate in three cohorts: (1) ulcerative proctocolitis with IPAA (UC) (n = 353), (2) Crohn's disease/indeterminate proctocolitis with IPAA (CDIC) (n = 49), and (3) familial adenomatous polyposis with IPAA (FAP) (n = 33). Forty-six CDIC patients (93.9%) demonstrated pouch-related inflammation, while 126 UC patients (35.7%) and 2 FAP patients (6.1%) developed pouchitis. CDIC had a higher rate of A&D co-diagnosis compared to UC and FAP (20.4 vs.12.7 vs.12.1% respectively; p < 0.05). UC patients with pouchitis also exhibited a higher rate of A&D than UC without pouchitis (19.8 vs.8.8%; p < 0.05). Multivariable analysis demonstrated that pre-operative corticosteroid use (OR = 4.46, CI = 1.34-14.87, p < 0.05), female gender (OR = 2.19, CI = 1.22-3.95, p < 0.01), tobacco use (OR = 2.92, CI = 1.57 = 5.41, p < 0.001), and pouch inflammation (OR = 2.37, CI = 1.28-4.39, p < 0.05) were each independently associated with A&D in these patients.

CONCLUSIONS

Anxiety and depression were more common in patients experiencing inflammatory conditions of the pouch. UC without pouchitis and FAP patients demonstrated lower rates of A&D (that were comparable to the general population), implying that having an IPAA alone was not enough to increase risk for A&D. Factors independently associated with A&D in IPAA included an inflamed pouch, corticosteroid use, smoking, and female gender.

A systematic review and meta-analysis comparing adverse events and functional outcomes of different pouch designs after restorative proctocolectomy

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.

Neoterminal Ileal Polyposis and Ulceration after Restorative Proctocolectomy with a Current Review of the Literature

After ileal pouch anal anastomosis, one of the frequently encountered complications is polyposis of the pouch. We describe a case of proximal neoterminal ileal polyposis associated with deep ulceration suggestive of Crohn's disease and review the available literature. A 36-year-old male presented with resistant pouchitis 11 years after surgery for ulcerative colitis. With all-negative initial workup, pouchoscopy showed multiple deep ulcers in the proximal ileum with some polyps. Biopsy of polyps showed inflammatory polyps with negative immunohistological staining for IgG pouchitis. With no treatable etiology for pouchitis and the presence of inflammatory polyps, there are no guidelines for surveillance of this condition. Definitive diagnosis is challenging and there is no consensus or recommended guidelines on the management.

Pouch functional outcomes after restorative proctocolectomy with ileal-pouch reconstruction in patients with ulcerative colitis: Japanese multi-center nationwide cohort study

BACKGROUND

Although several complications capable of causing pouch failure may develop after restorative proctocolectomy (RPC) for ulcerative colitis (UC), the incidences and causes are conflicting and vary according to country, race and institution. To avoid pouch failure, this study aimed to evaluate the rate of pouch failure and its risk factors in UC patients over the past decade via a nationwide cohort study.

METHODS

We conducted a retrospective, observational, multicenter study that included 13 institutions in Japan. Patients who underwent RPC between January 2005 and December 2014 were included. The characteristics and backgrounds of the patients before and during surgery and their postoperative courses and complications were reviewed.

RESULTS

A total of 2376 patients were evaluated over 6.7 ± 3.5 years of follow-up. Twenty-seven non-functional pouches were observed, and the functional pouch rate was 98.9% after RPC. Anastomotic leakage (odds ratio, 9.1) was selected as a risk factor for a non-functional pouch. The cumulative pouch failure rate was 4.2%/10 years. A change in diagnosis to Crohn's disease/indeterminate colitis (hazard ratio, 13.2) was identified as an independent risk factor for pouch failure.

CONCLUSION

The significant risk factor for a non-functional pouch was anastomotic leakage. The optimal staged surgical procedure should be selected according to a patient's condition to avoid anastomotic failure during RPC. Changes in diagnosis after RPC confer a substantial risk of pouch failure. Additional cohort studies are needed to obtain an understanding of the long-standing clinical course of and proper treatment for pouch failure.

Clinical Implication of Enlarged Prostate in Patients with the Ileal Pouch-anal Anastomosis for Inflammatory Bowel Disease

Background

Enlarged prostate is often noticed in patients with ileal pouch-anal anastomosis (IPAA) in our clinical practice. The aims were to identify the factors associated with enlarged prostate and to investigate its clinical implications.

Methods

IPAA patients with available prostate imaging after IPAA were included. Prostate length and width were measured in the axial plane and height in coronal plane. Prostate volume was calculated with the formula (length × width × height) × π/6. A volume greater than 40 cm³ was used to define enlarged prostate.

Results

Prostate enlargement was found in 58 (24.8%) out of 234 patients. Factors associated with prostate enlargement included advanced age at imaging examination (55.6 ± 11.5 vs. 41.3 ± 13.6 years, P < 0.0001), age at pouch surgery (46.0 ± 11.8 vs. 32.5 ± 12.9 years, P<0.0001), and the presence of an S-pouch (6.9% vs. 1.1%, P = 0.03). Postoperative use of biologics was less common in patients with enlarged prostate (5.2% vs. 17%, P = 0.03). However, pouch duration was comparable (10.0 ± 5.9 vs. 8.8 ± 6.8 years, P = 0.2) and pouch failure rate was similar. A trend towards an increased risk for acute pouchitis in patients with enlarged prostate was noticed (19% vs. 9.1%, P = 0.06). The association of S-pouch (odds ratio: 7.2, 95% confidence interval: 1.1 - 46.4) and enlarged prostate remained significant after adjusting for age, acute pouchitis, and redo pouch on multivariate analysis.

Conclusions

Prostate enlargement appears to be uncommon after IPAA and it was associated with S-pouch configuration and advanced age. Enlarged prostate in the setting of IPAA does not seem to have adverse impact on pouch outcomes, although there is a trend in correlation between enlarged prostate and acute pouchitis.

Primary fecal diversion and bowel dysfunction in restorative proctocolectomy for ulcerative colitis: a nationwide cross-sectional study

PURPOSE

The aim of this study was to explore the effects of primary fecal diversion on the risk of pouch dysfunction.

METHODS

Patients operated with an ileal pouch-anal anastomosis in Denmark in 2000-2010 were identified and validated bowel function questionnaires retrieved from a cross-sectional study. Multivariate logistic regression analysis was performed to determine the effect of primary fecal diversion on pouch dysfunction. A diagnostic or procedural code for intraabdominal abscesses and fistulas, occurring within 1 year after pouch creation, and anastomotic leakage or extremely early-onset pouchitis within 30 days of surgery defined a pelvic complication.

RESULTS

The questionnaire response rate was 85.6% (504 of 589), with no relevant differences in clinical characteristics between responders and non-responders. Pelvic complications, pouch failure, and death prior to the questionnaire date were more common for patients without primary fecal diversion. Among patients without primary fecal diversion, the prevalence of pouch dysfunction was 48% (95% CI: 34-62%), compared to 30% (95% CI: 26-35%) for those with [adjusted odds ratio = 2.23 (95% CI: 1.20-4.14)]. This difference was primarily caused by a higher risk of 'urgency', 'incomplete emptying', and a higher number of bowel movements per day.

CONCLUSION

Omission of primary fecal diversion in ileal pouch-anal anastomosis for ulcerative colitis may have a negative impact on bowel function. Prospective studies are warranted to elaborate these findings and to determine causality with pelvic complications.

Surgical options in the treatment of ulcerative colitis

Children and young adults with ulcerative colitis tend to present with more extensive colonic disease than an adult population. The need for surgical intervention in the pediatric population with ulcerative colitis occurs earlier after diagnosis and has a greater incidence than a comparably matched adult population with an estimated need for colectomy at 5 years following diagnosis of 14-20%. Perhaps, even more than the adult population, there is a desire to restore intestinal continuity for the pediatric patient to achieve as healthy and normal quality of life as possible. With surgery playing such a prominent role in the treatment of ulcerative colitis in this age group, an understanding of the surgical treatment options that are available is important. The surgeon's awareness of the complexities of the different operations associated with proctocolectomy and reestablishing intestinal continuity may help to avoid early complications and minimize the risk of less than ideal long-term outcomes.

Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care

AIM

Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes.

METHOD

Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed.

RESULTS

In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06).

CONCLUSION

IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

A systematic review of sacral nerve stimulation for faecal incontinence following ileal pouch anal anastomosis

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.

Postoperative changes of manometry after restorative proctocolectomy in Korean ulcerative colitis patients

AIM

To investigate the changes of postoperative anal sphincter function and bowel frequency in Korean patients with ulcerative colitis (UC).

METHODS

A total of 127 patients with UC who underwent restorative proctocolectomy (RPC) during 20 years were retrospectively analyzed. The parameters of anal manometry and bowel frequency were compared according to the 6-mo intervals until 24 mo postoperatively. Manometry was used to measure the maximal squeezing pressure (MSP) and maximal resting pressure (MRP).

RESULTS

MSP decreased after surgery until 6 mo (157 to 142 mmHg); thereafter, it improved and was recovered to and maintained at the preoperative value at 12 mo postoperatively (142-170 mmHg, P < 0.001). Although the decreased MRP (65 to 56 mmHg) improved after 18 mo (62 mmHg), it did not completely recover to the preoperative value. The decreased rectal capacity after surgery (90 to 82 mL) gradually increased up to 150 mL at 24 mo. Although bowel frequency showed significant gradual decreases at each interval, it was stabilized after 12 mo postoperatively (6.5 times/d).

CONCLUSION

Postoperative changes of manometry and bowel frequency after restorative proctocolectomy in Korean patients with UC were not different from those in Western patients with UC.

An unusual haemorrhagic complication of an anastomotic leak and a novel method of controlling the haemorrhage

Introduction Restorative proctocolectomy (RP) is undertaken for patients with familial adenomatous polyposis (FAP) and ulcerative colitis, but is associated with a risk of anastomotic leak. Case history A 20-year-old male with a family history of FAP had a RP with a double-stapled J-pouch and covering loop ileostomy. At ileostomy reversal 21 months later, he presented with significant anal bleeding. He proceeded to theatre for endoscopy. Pouchoscopy showed a pouch full of blood and a foreign object trapped in a diverticulum. The foreign object (an undigested tablet) was removed with grasping forceps and the bleeding spot identified. Hemospray^® (Cook Medical, Winston-Salem, NC, USA) was deployed in the bleeding cavity to enable immediate control of haemorrhage. Recovery was uneventful and he was discharged home 72 hours later. Conclusions This case: (i) demonstrates a successful and novel method of controlling haemorrhage not amenable to use of conventional haemostatic mechanisms; (ii) highlights the potential problems of using prolonged-release medications in patients with gastrointestinal strictures/diverticulae.

Endoscopic closure instead of surgery to close an ileal pouch fistula with the over-the-scope clip system

An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and has a high risk compared to endoscopic treatment. The over-the-scope clip (OTSC) system was initially developed for hemostasis and leakage closure in the gastrointestinal tract during flexible endoscopy. There have been many successes in using this approach to apply perforations to the upper gastrointestinal tract. However, this approach has not been used for ileal pouch fistulas until currently. In this report, we describe one patient who suffered a leak from the tip of the “J” pouch and was successfully treated with endoscopic closure via the OTSC system. A 26-year-old male patient had an intestinal fistula at the tip of the “J” pouch after an ileal pouch anal anastomosis procedure. He received endoscopic treatment via OTSC under intravenous anesthesia, and the leak was closed successfully. Endoscopic closure of a pouch fistula could be a simpler alternative to surgery and could help avoid surgery-related complications.

Variables associated with loss of ileoanal pouches constructed in childhood

AIMS

To quantify the incidence of loss of an ileoanal pouch in children and to identify variables associated this event.

METHODS

Logistic regression of possible explanatory variables: age, sex, indication for procto-colectomy, pre-operative continence status, use of immunosuppressive drugs, open or laparoscopic surgery, number of stages, anastomotic leak, operative complication excluding anastomotic leak, performance of revisional surgery, albumin concentration and platelet count at time of surgery, rank order in series. Univariate logistic regression was used to identify significant variables which were then assessed in a multivariate model and construction of Kaplan-Meier graphs.

RESULTS

103 children, 56 girls, underwent ileoanal pouch at median age 14years (SD 3.7). Indications and mean age were: ulcerative colitis (n=71, 14years), polyposis syndromes (n=13, 15years), chronic idiopathic constipation (n=9, 11years), Hirschsprung's disease (n=4, 1year), Crohn's disease (n=2, 16years), and fibrosing colonopathy (n=2, 11years). 13 patients had their pouch excised or permanently diverted. Three patients had successful revisional pouch surgery. Only pre-operative fecal incontinence and anastomotic leak were significantly associated with pouch excision/diversion, however on multivariate analysis, only fecal incontinence remained significant, odds ratio 21 (95%CI 1.8-235, p=0.01). Pouch survival was significantly worse where there was fecal incontinence pre-operatively, p<0.0001 or an anastomotic leak, p<0.001.

CONCLUSIONS

13% of children subjected to restorative procto-colectomy ultimately receive a permanent ileostomy. Fecal incontinence prior to surgery is a relative contra-indication. Anastomotic leak increases the probability of later pouch excision.

LEVEL OF EVIDENCE

IV.

Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: investigation of a simple predictive method using computed tomography

AIM

This study aimed to assess the ability of preoperative axial computed tomography (CT) to predict surgical difficulty in bringing the ileal pouch to the level of the anus during restorative proctocolectomy (RPC).

METHOD

Patients who underwent RPC with an ileal pouch-anal anastomosis (or ileal pouch-anal canal anastomosis) in our institution between January 2008 and April 2014 were enrolled. The patients were divided into two groups, including those in whom CT indicated potential difficulty in extending the pouch downwards (extension difficult (ED) group) and patients with no CT evidence of potential difficulty (normal group). The groups were compared for clinical factors and the thickness of the slices of CT showing the root of the superior mesenteric artery, the point of communication of the ileocaecal artery with the marginal artery (tICA) and the anal verge (AV). Receiver-operating characteristic analysis was performed, and a cut-off value was calculated for predicting the degree of difficulty in bringing the ileal pouch down to the anal canal.

RESULTS

Thirty-four patients were entered in the study. The ED group included significantly taller patients and more with familial adenomatous polyposis than the normal group. The distance between tICA and AV was significantly longer in the ED group, with a cut-off of 21 cm giving a sensitivity of 100% and a specificity of 83.3%.

CONCLUSION

The distance between tICA and AV measured by axial CT can be a useful predictor for the difficulty in bringing the ileal pouch down to the anus during RPC.

Long-Term Outcomes in Indeterminate Colitis Patients Undergoing Ileal Pouch-Anal Anastomosis: Function, Quality of Life, and Complications

INTRODUCTION

It is uncertain whether the outcomes of patients with indeterminate colitis (IC) undergoing ileal pouch-anal anastomosis (IPAA) deteriorate over time. The aim of this study was to determine the long-term pouch function, quality of life, complications, and incidence of Crohn's disease after IPAA for patients with IC compared to ulcerative colitis (UC).

METHODS

A case matched analysis was performed on patients undergoing IPAA for pathologically confirmed IC or UC, between 1985 and 2014. Patients were case matched for age ± 5 years, gender, date of surgery ± 3 years, type of anastomosis and presence of a diverting loop ileostomy. All patients were followed up for greater than six months.

RESULTS

448 patients were case matched, the average age was 36.8 year old and 52.7 % of patients were male. Mean follow-up was 122.06 months (+/- 80.77 months). There were statistically and clinically comparable number of daytime bowel movements (5.7 v 5.5, p = 0.45), rates of incontinence (26.1 % v 18.3 %, p = 0.09) and nighttime seepage in patients (23.1 % v 28.4 %, p = 0.28) with IC and UC. Quality of life markers and patient restrictions were comparable between the two groups. Rates of pelvic sepsis (IC 8.5 %, UC 8.5 %, p = 0.99) and anastomotic leak (IC 3.1 %, UC 4.0 %, p = 0.61) were similar but fistula formation (IC 15.6 %, UC 8.0 %, p = 0.01) and IPAA Crohn's disease rates (IC 6.7 %, UC 2.7 %, p = 0.04) were significantly increased in IC patients. There was no statistically significant difference in pouch failure rates for IC and UC (5.8 % vs.4.9 %, p = 0.58).

CONCLUSION

Patients undergoing IPAA for IC have a higher risk of post-operative fistulae and development of Crohn's disease, but comparable morbidity, functional outcomes, quality of life scores and pouch failure rates when compared to UC patients. Long-term data confirms that IPAA is a good surgical option in patients with IC.

Management of pouch dysfunction in a tertiary centre

AIM

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the operation of choice for ulcerative colitis (UC) and some cases of familial adenomatous polyposis (FAP). Although it offers improvement in quality of life and high patient satisfaction, pouch surgery is also associated with significant morbidity. The aim of this study was to describe the management of patients referred to a tertiary centre with pouch dysfunction.

METHOD

All patients referred with pouch dysfunction from other institutions between October 2006 and November 2014 were included in this retrospective study. Information regarding initial diagnosis before RPC, type of procedure, symptoms leading to referral, relation of the appearance of symptoms to the ileostomy closure, investigations, final diagnosis, treatment and follow-up was reviewed.

RESULTS

One hundred and twenty-one patients were included, having had RPC mostly for UC (94%), and with diverting ileostomy (83%). The most frequent reasons for referral were high frequency of defaecation in 83 (69%) patients, abdominal pain and incontinence in 45 (37%) each and perianal pain in 44 (36%). The principal investigations performed were pouchoscopy in 97 (80%) patients, examination under anaesthesia (EUA) in 62 (51%), pelvic magnetic resonance imaging (MRI) in 56 (46%) and contrast radiology of the pouch (pouchogram) in 45 (35%). The commonest diagnoses were pouchitis (primary and secondary) in 24 (21%) patients and anastomotic leakage in 26 (22%). After full investigation a cause for the symptoms could not be found in 24 (20%) patients, resulting in the diagnosis of exclusion of 'irritable pouch syndrome' or functional disorder. The treatments given were long-term antibiotic therapy in 29 (25%) patients, ileostomy in 19 (16%), use of a Medena catheter to promote anal evacuation in 17 (15%) and dilatation of a stenosis under anaesthetic in 12 (10%). Six (5%) patients underwent major revision surgery of the pouch with a defunctioning ileostomy and the pouch was excised in another six (5%).

CONCLUSION

Patients with ileoanal pouch dysfunction often have multiple symptoms. This study shows that a wide range of investigations and treatment modalities need to be available to manage such patients, with a specialized approach in a multidisciplinary setting.

Ileal pouch-anal anastomosis 20 years later: is it still a good surgical option for patients with ulcerative colitis?

PURPOSE

Short-term results after ileo-pouch anal anastomosis (IPAA) are well established; data are conflicting in long-standing patients. We retrospectively evaluated long-term complications and functional results after follow-up longer than 20 years.

METHODS

Two hundred five patients with follow-up longer than 20 years have been identified out of 1112 IPAA performed in our institution; of these, 20 cases were lost at follow-up or decline to take part at the study. We evaluated long-term complications and failure rate also according to changes in histological diagnosis. Changes in functional results and quality of life (QoL) were analyzed at 5 and 20 years after IPAA.

RESULTS

Pouch failure rate was 10.8 % (35 % due to misdiagnosed Crohn). Incidences of fistulas, anastomotic stenosis, chronic pouchitis, and pre-pouch ileitis were 17.3, 12.9, 28.6, and 7.6 %, respectively. Most of the patients reported good functional outcomes. Day-time evacuations at 5 and after 20 years were 4.3 and 4.8 (p = n.s.) while during night-time were 0.8 and 1.2 (p < 0.05). Urgency was 6 and 9.4 % (p = n.s.), respectively; need of antimotility drugs was 16 and 35 % (p < 0.001). Dietary limitations and work restrictions were similar over time. Only sexuality got worse during follow-up. Satisfaction for surgery was always high and it did not change over time.

CONCLUSION

IPAA is still an excellent surgical option for UC with a low rate of pouch failure even after more than 20 years. Despite a slight worsening of functional results over time, the QoL remained high and most patients expressed satisfaction with the procedure and were willing to recommend it to others.

The Evaluation of Postoperative Patients with Ulcerative Colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the standard surgical treatment modality for patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Normally staged pouch surgery is performed. Endoscopy plays an important role in postoperative monitoring of disease status and delivery of therapy, if necessary. Therefore, ileal pouch surgery significantly alters bowel anatomy, with new organ structures being created. Endoscopy of the altered bowel includes the evaluation of end ileostomy, Hartmann pouch or diverted rectum, loop ileostomy, diverted pouch, and pouchoscopy. Each segment of the bowel has unique landmarks.

Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for Peutz-Jeghers syndrome with synchronous rectal cancer

We report on a patient diagnosed with Peutz-Jeghers syndrome (PJS) with synchronous rectal cancer who was treated with laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). PJS is an autosomal dominant syndrome characterized by multiple hamartomatous polyps in the gastrointestinal tract, mucocutaneous pigmentation, and increased risks of gastrointestinal and nongastrointestinal cancer. This report presents a patient with a 20-year history of intermittent bloody stool, mucocutaneous pigmentation and a family history of PJS, which together led to a diagnosis of PJS. Moreover, colonoscopy and biopsy revealed the presence of multiple serried giant pedunculated polyps and rectal adenocarcinoma. Currently, few options exist for the therapeutic management of PJS with synchronous rectal cancer. For this case, we adopted an unconventional surgical strategy and ultimately performed laparoscopic restorative proctocolectomy with IPAA. This procedure is widely considered to be the first-line treatment option for patients with ulcerative colitis or familial adenomatous polyposis. However, there are no previous reports of treating PJS patients with laparoscopic IPAA. Since the operation, the patient has experienced no further episodes of gastrointestinal bleeding and has demonstrated satisfactory bowel control. Laparoscopic restorative proctocolectomy with IPAA may be a safe and effective treatment for patients with PJS with synchronous rectal cancer.