Enteral nutrition combined with glutamine promotes recovery after ileal pouch-anal anastomosis in rats

AIM

To assess the effect of enteral nutrition (EN) supplemented with glutamine on recovery after ileal pouch-anal anastomosis (IPAA) in rats, to provide an experimental basis for nutritional support in patients with ulcerative colitis (UC) after IPAA.

METHODS

Male Sprague-Dawley (SD) rats were randomly divided into three groups (n = 8) after IPAA operation using a microsurgical technique. From the third postoperative day, rats in the control group, EN group, and immune nutrition (IN) group were fed standard rat chow, short peptide EN, and short peptide EN combined with glutamine ad libitum, respectively. The rats’ general condition was observed throughout the study. Serum levels of total protein (TP), albumin (ALB), prealbumin (PA), and transferrin (TF) were detected on the 30th postoperative day, using an automatic biochemical analyzer. The ileal pouch mucosa was stained with hematoxylin and eosin (HE), and occludin protein levels were detected by immunohistochemistry.

RESULTS

The body weight of rats in the EN group (359.20 ± 10.06 g) was significantly higher than that in the control group (344.00 ± 9.66 g) (P < 0.05) and lower than that in the IN group (373.60 ± 9.86 g) (P < 0.05) on the 30th postoperative day. The levels of serum TP, ALB, PA, and TF in the EN group were significantly higher than those in the control group (P < 0.01 for all) and lower than those in the IN group (P < 0.05 for all). Histopathological score (EN: 0.80 ± 0.37; IN: 0.60 ± 0.40; control group: 2.29 ± 0.18) and expression level of occludin protein (EN: 0.182 ± 0.054; IN: 0.188 ± 0.048; control group: 0.127 ± 0.032) were significantly lower in the control group compared with the EN and IN groups (P < 0.05 for all), but there were no significant differences between the latter two groups (P > 0.05 for all).

CONCLUSION

EN combined with glutamine may effectively improve nutritional status after IPAA. Our results suggest a benefit of glutamine supplementation in EN for UC patients undergoing IPAA, although human studies are required to confirm this finding.

De novo Crohn's Disease after Ileal Pouch-Anal Anastomosis for Ulcerative Colitis and Inflammatory Bowel Disease Unclassified: Long-Term Follow-Up of a Prospective Inflammatory Bowel Disease Registry

The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8-81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3-236), 63 patients (19%) developed CD within a median of 22 months (range: 1-213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up (P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.

Cancer arising from the remnant mucosa of the ileoanal anastomosis leading to pouchectomy

Ileal pouch-related adenocarcinoma remains a rarity; thus, guidelines on treatment are currently lacking. We present this case of a 54-year-old man who underwent restorative proctocolectomy with stapled ileal pouch–anal anastomosis formation for familial adenomatous polyposis during the 1980s. Despite undergoing annual surveillance endoscopy, the patient was noted to be anaemic and passing fresh blood per anus. Endoscopy and radiological investigation revealed the presence of a pouch-related adenocarcinoma. This was subsequently treated with short-course radiotherapy and pouch excision. The patient remains well until now and will follow six-monthly surveillance protocols with a transition to annual surveillance after 2 years.

Biofeedback Therapy After Perineal Rectosigmoidectomy or J Pouch Procedure

The aim of this study was to determine the outcome and to identify possible predictors of success for biofeedback therapy after perineal rectosigmoidectomy (PRS) or coloanal or ileoanal J pouch. A retrospective chart review of all patients with electromyography-based biofeedback therapy due to fecal incontinence after PRS or a J pouch procedure was undertaken. Follow-up was obtained by telephone survey. Fourteen patients (4 men and 10 women) were included in this study. In the 9 patients after PRS, the frequency of daily bowel movements was 3.6 2.8 preoperatively, 4.1 3.2 prebiofeedback, and 2.2 - 1.3 postbiofeedback (P < .05). The frequency of daily incontinent episodes was reduced from 2.4 2.2 preoperatively and 2.0 + 1.9 prebiofeedback to 0.26 0.3 postbiofeedback (P< .05). The incontinence scores decreased from 17 3.1 preoperatively to 16 + 2.1 prebiofeedback and to 8.2 5 postbiofeedback (P < .001). At a follow-up of 15.8 7.1 months, 5 patients after the J pouch had decreased daily bowel frequency from 6.6 4.2 prebiofeedback to 3.3 2 postbiofeedback and 3.1 2 at follow-up (P < .05). The frequency of daily incontinent episodes was reduced from 1.9 1.3 prebiofeedback to 0.9 0.7 postbiofeedback to 0.7 0.8 at followup (P < .05). The incontinence scores decreased from 13.4 2.7 prebiofeedback to 8.8 5.1 postbiofeedback to 6.8 5.5 at follow-up (P < 0.05). In both groups, the postbiofeedback incontinence score correlated with the prebiofeedback incontinence score. Furthermore, there was no correlation between outcome and age, interval between surgery and biofeedback therapy, frequency of biofeedback sessions, or manometry results in either group. Biofeedback therapy is an effective option for patients with fecal incontinence after perineal rectosigmoidectomy or colonic or ileal J pouch.

Clostridium difficile infection after restorative proctocolectomy and ileal pouch anal anastomosis for ulcerative colitis

AIM

Clostridium difficile infection (CDI) of the ileal pouch following restorative proctocolectomy (RPC) is becoming increasingly recognized. We aimed to understand better (i) the associated risk factors, (ii) treatment practices and (iii) the pouch diversion and failure rate in patients who developed CDI of the pouch after RPC for ulcerative colitis (UC).

METHOD

Patients who tested positive for C. difficile of the pouch between 2007 and 2010 were included in the analysis. Data collected included patient demographics, time from RPC to documented CDI, the treatment of CDI and rate of excision of the pouch.

RESULTS

Of 2785 patients recorded in the hospital CDI database, 15 had had an RPC with ileal pouch anal anastomosis. The median age was 44 years and the median interval from RPC to first documented episode of CDI was 3 years. Thirteen (81%) patients had had multiple episodes of pouchitis before and after CDI infection, and all were symptomatic at the time of testing for CDI. Within 30 days of the diagnosis of CDI, six (40%) patients were taking immunosuppressive medication, seven (47%) were taking a proton pump inhibitor and 12 (80%) had received antibiotics. Five patients required hospitalization for CDI and four had severe infections characterized by a serum creatinine more than 1.5 times baseline (n = 3) and a white cell count above 15 000 (n = 1). Six patients who underwent endoscopy had severe inflammation of the pouch including the presence of a pseudomembrane in one case. Ten patients were treated with metronidazole alone and five with vancomycin. Two patients had recurrent CDI of the pouch during a median follow-up period of 2.9 years and one had CDI refractory to medical management. This patient required diversion of the pouch with an ileostomy for refractory CDI but no patient required excision of the pouch.

CONCLUSION

All 15 patients developing CDI of the pouch were successfully treated with antibiotics and only one required surgery in the form of an ileostomy.

Infliximab to Treat Refractory Inflammation After Pelvic Pouch Surgery for Ulcerative Colitis

BACKGROUND

Inflammatory pouch complications refractory to first-line therapies remain problematic following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We evaluated infliximab efficacy and associations with therapeutic response.

METHODS

Data from individuals who underwent colectomy and IPAA for UC (2000-2014) were reviewed. Patients with chronic refractory pouchitis (CP) and Crohn's disease (CD)-like outcomes treated with infliximab were included. Pre-treatment parameters and response at median 8 (initial) and 48 weeks (sustained) were measured. Complete response was defined as symptomatic and endoscopic resolution with modified Pouchitis Disease Activity Index (mPDAI) <5. Partial response included mPDAI improvement >2. Serum was analysed for Anti-Saccharomyces cerevisiae antibodies (ASCA), anti-OmpC, anti-CBir1 and perinuclear Anti-Neutrophil Cytoplasmic Antibodies (pANCA).

RESULTS

One hundred and fifty-two patients with CP or a CD-like phenotype were identified. Forty-two were treated with infliximab (33% male; age 32.6±2.6 years, 28.5% CD-like). Post-induction response was achieved in 74% (48% complete) and sustained response in 62.6% (29.6% complete). Mean mPDAI and C-reactive protein declined from 8.5±0.3 to 2±3.4 (p < 0.002) and from 29.48±6.2 to 5.76±1.6mg/L (p < 0.001), respectively. Female gender, smoking and presence of anti-CBir1 were associated with infliximab use (p < 0.01) but not response. Pre-treatment mPDAI <10 (p < 0.01), resolution of rectal bleeding (p < 0.001 ) and week 8 endoscopic activity were associated with sustained response (p = 0.04; odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1-16.5]). More than 2 positive antimicrobial antibody titres were associated with non-response (p < 0.05), but did not retain significance in multivariate analysis (p = 0.197; OR 0.632; 95% CI 0.31-1.2).

CONCLUSIONS

Infliximab can effectively treat inflammatory pouch complications. Pre-treatment mPDAI <10 and early endoscopy may identify responders.

Clinical features and management of afferent limb syndrome after ileal pouch-anal anastomosis for ulcerative colitis

PURPOSE

Afferent limb syndrome (ALS) is a type of small bowel obstruction (SBO) caused by obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis (IPAA). The aim of this study was to reveal the clinical features and management of ALS.

METHODS

Of 320 patients undergoing IPAA for ulcerative colitis, we analyzed data from patients presenting with SBO.

RESULTS

Six of 19 patients with SBO were diagnosed with ALS. All patients with ALS presented with recurrent intermittent obstructive symptoms before admission, whereas 15 % of patients without ALS presented with these symptoms (P < 0.0005). Among the six patients with ALS, four patients required surgery, although they underwent transanal decompression for each episode of obstruction. The proportion of surgery was higher in the ALS group (P < 0.01). Acute angulation of the afferent limb was recognized in four cases and followed by fixation of the afferent limb. No further surgery was required in any patient following the last fixation.

CONCLUSIONS

SBO after IPAA may be caused by acute angulation of the afferent limb of the ileal J-pouch. Most patients with ALS may eventually require fixation of the afferent limb due to acute angulation of the afferent limb.

Early postoperative small bowel obstruction is an independent risk factor for subsequent adhesive small bowel obstruction in patients undergoing open colectomy

BACKGROUND

This prospective study was performed to investigate whether postoperative ileus (POI) or early postoperative small bowel obstruction (EPSBO) affects the development of adhesive small bowel obstruction (SBO) in patients undergoing colectomy.

METHODS

We prospectively enrolled 1,002 patients who underwent open colectomy by a single surgeon. POI was defined as the absence of bowel function for more than 5 days or as a delay in oral intake beyond 7 days postoperatively. EPSBO was defined as the clinical and radiologic identification of SBO after resuming oral intake between postoperative days 7 and 30. Adhesive SBO was defined as SBO developing after 30 days because of intraperitoneal adhesion. The associations between POI, EPSBO, patient- and surgery-related variables, and the development of adhesive SBO were analyzed.

RESULTS

A total of 85 (8.5 %) patients developed POI, and 42 patients (4.2 %) developed EPSBO, with seven patients experiencing both POI and EPSBO. During the follow-up period (median 51 months), 70 patients (7.0 %) developed adhesive SBO, six (8.6 %) of whom needed laparotomy. The occurrence of adhesive SBO was significantly higher in patients with EPSBO than in those without EPSBO (26.5 vs. 7.5 % at 5 years, P < 0.001), but not in patients with POI (13.4 vs. 7.8 % at 5 years, P = 0.158). Multivariable analysis showed colostomy (hazard ratio [HR] 2.530, P = 0.006) and EPSBO (HR 4.063, P < 0.001) as independent risk factors for adhesive SBO.

CONCLUSIONS

The development of adhesive SBO after colectomy is more frequent in patients with EPSBO and colostomy; however, POI does not increase the risk of adhesive SBO.

The functional outcomes of coloanal and low colorectal anastomoses with reservoirs after low rectal cancer resections

Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.

Surgical treatment of ulcerative colitis: Ileorectal vs ileal pouch-anal anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the current gold standard in the surgical treatment of ulcerative colitis (UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis (IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.

Cytomegalovirus pouchitis in a patient with Crohn's disease

Colectomy with ileoanal pouch formation is usually contraindicated in patients with Crohn's disease (CD) due to the risk of recurrent disease and pouch failure. We report the case of a patient, initially thought to have ulcerative colitis (UC), who underwent such surgery but subsequently developed perianal CD. She presented with diarrhoea and weight loss. Inflammatory markers were raised. Pouchoscopy revealed deep ulcers within the pouch. The main differential diagnoses were idiopathic pouchitis and recurrent CD. However, immunohistochemical staining demonstrated positivity for cytomegalovirus (CMV). Stool frequency, C reactive protein and albumin normalised within 48 h of starting oral valgancyclovir. At 15 weeks, pouch appearances were improved, no histological evidence of CMV was found and baseline pouch function had returned. This case highlights that CD can present many years after surgery for apparent UC. Also, CMV pouchitis should be considered as a differential cause of pouchitis especially as it is treatable with antiviral therapy.

Complications after ileal pouch-anal anastomosis in Korean patients with ulcerative colitis

AIM: To investigate the outcomes of treatments for complications after ileal pouch-anal anastomosis (IPAA) in Korean patients with ulcerative colitis.

METHODS: Between March 1998 and February 2013, 72 patients (28 male and 44 female, median age 43.0 years ± 14.0 years) underwent total proctocolectomy with IPAA. The study cohort was registered prospectively and analyzed retrospectively. Patient characteristics, medical management histories, operative findings, pathology reports and postoperative clinical courses, including early postoperative and late complications and their treatments, were reviewed from a medical record system. All of the ileal pouches were J-pouch and were performed with either the double-stapling technique (n = 69) or a hand-sewn (n = 3) technique.

RESULTS: Thirty-one (43.1%) patients had early complications, with 12 (16.7%) patients with complications related to the pouch. Pouch bleeding, pelvic abscesses and anastomosis ruptures were managed conservatively. Patients with pelvic abscesses were treated with surgical drainage. Twenty-seven (38.0%) patients had late complications during the follow-up period (82.5 ± 50.8 mo), with 21 (29.6%) patients with complications related to the pouch. Treatment for pouchitis included antibiotics or anti-inflammatory drugs. Pouch-vaginal fistulas, perianal abscesses or fistulas and anastomosis strictures were treated surgically. Pouch failure developed in two patients (2.8%). Analyses showed that an emergency operation was a significant risk factor for early pouch-related complications compared to elective procedures (55.6% vs 11.1%, P < 0.05). Pouchitis was related to early (35.3%) and the other late pouch-related complications (41.2%) (P < 0.05). The complications did not have an effect on pouch failure nor pouch function.

CONCLUSION: The complications following IPAA can be treated successfully. Favorable long-term outcomes were achieved with a lower pouch failure rate than reported in Western patients.

Perineal wound healing following ileoanal pouch excision

INTRODUCTION

There is paucity of information relating to perineal wound healing when pouch failure after ileal pouch anal anastomosis necessitates pouch excision (PE). The aim of this study is to evaluate perineal healing and factors associated with the development of persistent perineal sinus (PPS) after PE.

METHODS

Perineal wound-related outcomes for patients who underwent PE from 1985-2009 were evaluated by type of closure (extrasphincteric, intersphincteric, and sphincter-preserving (SP)) and other factors (presence of Crohn's disease (CD) and/or perineal fistulae). Primary outcomes were PPS and delayed healing (healing after PPS development).

RESULTS

One hundred ten patients (CD 48 %) underwent PE. PPS occurred in 39.8 % patients, 51 % had delayed perineal healing with further procedures, with an overall healing rate of 80.7 %. Closure technique was not associated with PPS (p = 0.37) or eventual healing (p = 0.94). For CD patients, risk of PPS (41 vs. 39 %, p = 0.83) and delayed healing (44 vs. 59 %, p = 0.61) was similar to non-CD patients, but uncomplicated healing took longer (p = 0.04). Four of 15 (26.7 %) patients who underwent SP closure developed PPS; all eventually healed with secondary sphincter excision.

CONCLUSIONS

Perineal healing may be prolonged after pouch excision. Since eventual healing can be achieved in most patients, perineal dissection and closure can be tailored to the individual circumstance. Sphincter preservation may be used in non-CD patients if future reconstruction is possible. Extrasphincteric closure is preferable with cancer or perineal sepsis. Sphincter resection allows for complete healing in patients who undergo SP dissection and develop PPS.

Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis

Restorative proctocolectomy is the most common surgical option for patients with familial adenomatous polyposis (FAP). However, adenomas may develop in the ileal pouch mucosa over time, and even carcinoma in the pouch has been reported. We therefore reviewed the prevalence, nature, and treatment of adenomas and carcinoma that develop after proctocolectomy in the ileal pouch mucosa in patients with FAP. In 25 reports that were reviewed, the incidence of adenomas in the ileal pouch varied from 6.7% to 73.9%. Several potential factors that favor the development of pouch polyposis have been investigated, but many remain controversial. Nevertheless, it seems certain that the age of the pouch is important. The risk appears to be 7% to 16% after 5 years, 35% to 42% after 10 years, and 75% after 15 years. On the other hand, only 21 cases of ileal pouch carcinoma have been recorded in the literature to date. The diagnosis of pouch carcinoma was made between 3 to 20 years (median, 10 years) after pouch construction. Although the risk of malignant transformation in ileal pouches is probably low, it is not negligible, and the long-term risk cannot presently be well quantified. Regular endoscopic surveillance, especially using chromoendoscopy, is recommended.

Surgery for inflammatory bowel disease in the era of laparoscopy

During the course of inflammatory bowel disease (IBD), surgery may be needed. Approximately 20% of patients with ulcerative colitis (UC) will require surgery, whereas up to 80% of Crohn’s disease (CD) patients will undergo an operation during their lifetime. For UC patients requiring surgery, total proctocolectomy and ileoanal pouch anastomosis (IPAA) is the operation of choice as it provides a permanent cure and good quality of life. Nevertheless a permanent stoma is a good option in selected patients, especially the elderly. Minimally invasive surgery has replaced the conventional open approach in many specialized centres worldwide. Laparoscopic colectomy and restorative IPAA is rapidly becoming the standard of care in the treatment of UC requiring surgery, whilst laparoscopic ileo-cecal resection is already the new gold standard in the treatment of complicated CD of terminal ileum. Short term advantages of laparoscopic surgery includes faster recovery time and reduced requirement for analgesics. It is, however, in the long term that minimally invasive surgery has demonstrated its superiority over the open approach. A better cosmesis, a reduced number of incisional hernias and fewer adhesions are the long term advantages of laparoscopy in IBD surgery. A reduction in abdominal adhesions is of great benefit when a second operation is needed in CD and this influences positively the pregnancy rate in young women undergoing restorative IPAA. In developing the therapeutic plan for IBD patients it should be recognized that the surgical approach to the abdomen has changed and that surgical treatment of complicated IBD can be safely performed with a true minimally invasive approach with great patient satisfaction.

The trans-sphincteric posterior sagittal repair of recto-urinary and recto-vaginal fistulae using Surgisis™ mesh and fibrin sealant

Recto-urinary, recto-vaginal and ileo-anal pouch-associated fistulae are rare yet a significant clinical problem due to their profound impact on patients' quality of life and are a challenge to repair. In this report, we describe repair of these complex fistulae using a modified trans-sphincteric posterior sagittal approach with Surgisis™ mesh and fibrin sealant and review our repair outcomes.

Histopathological evaluation and risk factors related to the development of pouchitis in patients with ileal pouches for ulcerative colitis

OBJECTIVE

Many changes in mucosal morphology are observed following ileal pouch construction, including colonic metaplasia and dysplasia. Additionally, one rare but potential complication is the development of adenocarcinoma of the reservoir. The aim of this study was to evaluate the most frequently observed histopathological changes in ileal pouches and to correlate these changes with potential risk factors for complications.

METHODS

A total of 41 patients were enrolled in the study and divided into the following three groups: a non-pouchitis group (group 1) (n = 20; 8 males; mean age: 47.5 years) demonstrating optimal outcome; a pouchitis without antibiotics group (group 2) (n = 14; 4 males; mean age: 47 years), containing individuals with pouchitis who did not receive treatment with antibiotics; and a pouchitis plus antibiotics group (group 3) (n = 7; 3 males; mean age: 41 years), containing those patients with pouchitis who were administered antibiotics. Ileal pouch endoscopy was performed, and tissue biopsy samples were collected for histopathological analysis.

RESULTS

Colonic metaplasia was found in 15 (36.6%) of the 41 patients evaluated; of these, five (25%) were from group 1, eight (57.1%) were from group 2, and two (28.6%) were from group 3. However, no correlation was established between the presence of metaplasia and pouchitis (p = 0.17). and no differences in mucosal atrophy or the degree of chronic or acute inflammation were observed between groups 1, 2, and 3 (p>0.45). Moreover, no dysplasia or neoplastic changes were detected. However, the degree of mucosal atrophy correlated well with the time of postoperative follow-up (p = 0.05).

CONCLUSIONS

The degree of mucosal atrophy, the presence of colonic metaplasia, and the degree of acute or chronic inflammation do not appear to constitute risk factors for the development of pouchitis. Moreover, we observed that longer postoperative follow-up times were associated with greater degrees of mucosal atrophy.

Successful management of urethro-ileal pouch fistula by cynoacrylate glue instillation

Uro-enteric fistulae are difficult clinical conditions that have a significant bearing on the patient's quality of life. Surgical correction, though challenging, is the usual mode of treatment offered to these patients. We describe a case of urethro-ileal pouch fistula which could be managed successfully without surgery with the help of cynoacrylate glue instillation.

Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

OBJECTIVE

The objective of this study is to provide a comprehensive update of the outcome of the ileo-pouch anal anastomosis (IPAA).

DATA SOURCES

An extensive search in PubMed, EMBASE, and The Cochrane Library was conducted.

STUDY SELECTION AND DATA EXTRACTION

All studies published after 2000 reporting on complications or functional outcome after a primary open IPAA procedure for UC or FAP were selected. Study characteristics, functional outcome, and complications were extracted.

DATA SYNTHESIS

A review with similar methodology conducted 10 years earlier was used to evaluate developments in outcome over time. Pooled estimates were compared using a random-effects logistic meta-analyzing technique. Analyses focusing on the effect of time of study conductance, centralization, and variation in surgical techniques were performed.

RESULTS

Fifty-three studies including 14,966 patients were included. Pooled rates of pouch failure and pelvic sepsis were 4.3% (95% CI, 3.5-6.3) and 7.5% (95% CI 6.1-9.1), respectively. Compared to studies published before 2000, a reduction of 2.5% was observed in the pouch failure rate (p = 0.0038). Analysis on the effect of the time of study conductance confirmed a decline in pouch failure. Functional outcome remained stable over time, with a 24-h defecation frequency of 5.9 (95% CI, 5.0-6.9). Technical surgery aspects did not have an important effect on outcome.

CONCLUSION

This review provides up to date outcome estimates of the IPAA procedure that can be useful as reference values for practice and research. It is also shows a reduction in pouch failure over time.

Efficacy and safety of endoscopic treatment of ileal pouch strictures

BACKGROUND

Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients with ileal pouches and to identify risk factors for pouch failure for those patients.

METHODS

Consecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0-3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses.

RESULTS

A total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range [IQR] 1-2); the median stricture length was 1 (IQR 0.5-1.25) cm, and the median balloon size was 20 (IQR 18-20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6-17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model.

CONCLUSIONS

Endoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.

The continent ileostomy: an alternative to end ileostomy? Short and long-term results of a single institution series

INTRODUCTION

Total proctocolectomy, ensuring eradication of all diseased colorectal mucosa is the treatment of choice for ulcerative colitis, familial adenomatous polyposis. Before the era of ileal pouch anal anastomosis, definitive ileostomy was required. The aim of this study is to define both early and late morbidity and the functional result of continent ileostomy.

METHODS

All patients' chart who had a continent ileostomy in our department were reviewed. The functional result was evaluated in 43 patients.

RESULTS

Forty-nine patients (34 women) with a mean age of 42 years (range: 17-69) underwent a continent ileostomy, 32 following a restorative proctocolectomy. The mean follow-up was 20.5 (range: 3-34) years. Seventeen patients (35%) experienced an early postoperative complication requiring reintervention in two patients. There was no mortality, and conversion to an end ileostomy was not required. Twenty-two patients developed late complications requiring 50 reoperations. The mean number of catheterisations per 24h was 4.4. The SF36 questionnaire showed values close to those of the general population.

CONCLUSION

Continent ileostomy carries a significant risk of non-severe complications. In selected patients, it represents a valuable alternative to an end ileostomy, in particular when restorative proctocolectomy has failed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative infliximab is not associated with an increased risk of short-term postoperative complications after restorative proctocolectomy and ileal pouch-anal anastomosis

INTRODUCTION

Considerable controversy exists over whether the preoperative use of infliximab (IFX) for refractory ulcerative colitis (UC) increases the risk for surgical complications after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to assess the association between preoperative IFX use and short-term surgical complications in a single-surgeon cohort at a tertiary care academic center.

METHODS

UC patients who underwent IPAA from September 2005 through May 2009 were retrospectively identified. Twenty-nine patients treated with IFX within 12 weeks of surgery and 52 non-IFX control subjects were identified. Short-term postoperative outcomes were compared between groups occurring within 30 days of loop ileostomy closure.

RESULTS

Patients were similar with respect to demographics, co-morbidities, rate of emergency surgery, hand-sewn anastomosis, and preoperative use of cyclosporine, azathioprine, and high-dose steroids. IFX patients were more likely to have received a laparoscopic hand-assisted IPAA, low-, medium-, and any-dose steroids, 6-mercaptopurine (6-MP), methotrexate, and to have failed medical therapy. There was no short-term mortality. Overall postoperative and infectious complications were similar between IFX and non-IFX groups. Multivariate regression models revealed no independent predictors for postoperative complications when including IFX [odds ratio (OR) 0.78, p = 0.67], laparoscopic hand-assisted IPAA, 6-MP, methotrexate, steroids, failure of medical therapy, and body mass index.

CONCLUSIONS

Preoperative IFX use was not associated with an increased risk of short-term postoperative complications after IPAA.

[Factors associated with ileal-pouch related fistulas in 100 consecutives patients who underwent restorative proctocolectomy]

OBJECTIVE

The pouch-related fistulas range in literature from 2% to 16% and they can be cause of failure of the intervention of restorative proctocolectomy. Aim of this study was to examine factors associated with theirs development and to identify theirs possible etiology and pathogenesis.

MATERIALS AND METHODS

Retrospective study focusing on 100 consecutive patients who underwent restorative proctocolectomy with pouch-anal anastomosis (IPAA). Patients with fistula and patients without fistula have been identified and the fistula type, the time from surgery and the site relative to IPAA have been recorded. Patients' demographics, co-morbidity or related medical history, clinical indication for treatment, surgical method, histological diagnosis, length of follow-up, early and late postoperative complications have been reviewed, and data collected have been compared among the two groups through univariate analysis.

RESULTS

The overall incidence of fistulas was of 10% (10 cases); 8 cases had pouch-vaginal fistulas, involving the distal tract of the vagina, and associated with pouch-perineal fistulas in 2 cases; 1 case had pouch-vulval fistula; 1 case had a complex pouch-perineal fistula. Three fistulas were precocious, all associated with an IPAA leak; 2 of these cases also had pelvic sepsis while the third had delayed diagnosis of Crohn’s disease. Seven fistulas had a late development. Four fistulas occurred at the level of the IPAA; 5 fistulas were located below the IPAA, and 1 fistula originated above and below the IPAA. When the two groups of patients were compared we found that there was an higher percentage of perineal or anal disease (40.0% vs 2.2%; p <0.001), of extraintestinal manifestations of inflammatory bowel disease (IBD) (40.0% vs 3.3%, p <0.001), and of leak of the IPAA (40.0% vs 11.1%; p <0.05) in the group with fistula vs the group without fistula.

CONCLUSIONS

A direct link with the leak of the IPAA appears in all the early fistulas, while the cryptoglandular infection was suggested as a possible cause of the late fistulas located below the IPAA; the association with the extraintestinal manifestations of IBD could show a correlation between the fistulas and an higher specific activity of the underlying chronic inflammatory disease.

Functional outcome and quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with dysplasia or cancer, or familial adenomatous polyposis (FAP). The aim of this study is to report our 6-year experience of restorative proctocolectomy and IPAA at a tertiary referral centre. Chart review was performed for 7 patients undergoing IPAA from 2006 to 2010. Preoperative histopathological diagnoses were ulcerative colitis (n=5), FAP (n=1) and other (n=1). We collected data regarding patient demographics, type and du-ration of the disease, previous operations and indications for surgery. We analysed the operative protocols and postoperative pathological diagnoses. Early (within 30 days after surgery) and late complications were noted. Follow-up was conducted upon annual function and a quality of life questionnaire, physical examination and endoscopic evaluation of the pouch. Postoperative histopathological diagnoses were: ulcerative colitis (n=3), indeterminate colitis (n=2), FAP (n=1) and colonic necrosis and gangrene (n=1). The average age of the operated patients was 48, with a female predomination of 71%. The mean duration of the follow-up was 4 years. We report 2 cases of steroid use prior to operation as well as 2 cases of extraintestinal manifestations. We report no septic complications and 3 cases of pouchitis. Functional results and quality of life were good to excellent in all 7 cases of IPAA. Restorative proctocolectomy with IPAA is a safe procedure with a low morbidity rate. Functional results are generally good and patient satisfaction is high.

Diagnosis and management of pouchitis and ileoanal pouch dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia and for the majority of patients with familial adenomatous polyposis. However, UC patients with IPAA are susceptible to inflammatory and noninflammatory sequelae, such as pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome, in addition to common surgery-associated complications, which adversely affect the surgical outcome and compromise health-related quality of life. Pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. Pouchitis may be classified based on the etiology into idiopathic and secondary types, and the management is often different. Pouchoscopy is the most important tool for the diagnosis and differential diagnosis in patients with pouch dysfunction. Antibiotic therapy is the mainstay of treatment for active pouchitis. Some patients may develop dependency on antibiotics, requiring long-term maintenance therapy. Although management of antibiotic-dependent or antibiotic-refractory pouchitis has been challenging, secondary etiology for pouchitis should be evaluated and modified, if possible.

Ileoanal pouch dysfunction and the use of a Medena catheter following hospital discharge

With the advent of new surgical techniques to manage colorectal disease, the number of ileoanal pouch operations has amplified and therefore increased numbers of pouch patients are being discharged into the community setting. Community nurses will now encounter the ileoanal pouch patient and may be required to manage related complications. Restorative proctocolectomy with ileoanal pouch anastomosis (RPC) has become established as the gold standard operation for patients with ulcerative colitis (UC) and selected patients with familial adenomatous polyposis (FAP). Using a reservoir constructed from small bowel as a substitute rectum is a medical triumph which in the majority of cases improves the quality of life for patients, not only by eradicating disease and preserving anal sphincter function but also by avoiding a permanent ileostomy. Recent investigation into the use of Medena catheterization for pouch dysfunction has found that it is tolerated in the long-term and is associated with satisfactory quality of life in pouch patients with outflow obstruction.

[Prospective, double-blind study of topical phenylephrine treatment for nocturnal fecal incontinence in patients after ileoanal pouch construction]

PATIENTS

Fecal incontinence has been reported in 5.5% to 45% of patients after ileoanal pouch construction, predominantly at night. It has been shown that alpha1-adrenergic agonists as phenylephrine increase anal sphincter pressure in healthy volunteers and in patients with idiopathic fecal incontinence. The median duration of action of topical phenylephrine is seven hours. Carapeti et al have demonstrated its usefulness in patients after ileoanal pouch construction.

OBJECTIVE

To demonstrate that the administration of a single dose of topical 10% phenylephrine at night is effective for the treatment of nocturnal anal incontinence in this group of patients.

PATIENTS AND METHODS

We randomized 12 patients in two groups. Group A (control) received a placebo cream and group B received a 10% phenylephrine cream. The study was prospective, randomized and double-blind.

RESULTS

There were no significant differences between the two groups in age, follow-up time since the closure of ileostomy and pre-treatment and intra-treatment leaks. Control group had 7 episodes of incontinence pre-treatment and 9 intra-treatment. Treated group had 3 and 5.4, respectively. (p = NS) No patient had side effects.

CONCLUSIONS

Given the small number of patients included, we can not yet rule out that topical 10% phenylephrine is useful for the treatment of nocturnal fecal incontinence in patients after ileoanal pouch construction. It would be necessary to continue with studies, increasing the number of patients treated with this drug, in order to have a better evidence of its clinical utility.

Ano-neorectal function using manometry on patients with soiling at 10 years or more after ilheal J pouch-anal anatomosis for ulceraitive colitis

BACKGROUND/AIMS

Physiological assessments of the ano-neorectum in patients with soiling at long-term period after total colectomy, mucosal protectomy, and ileal J pouch-anal anastomosis with short rectal cuff (IPAA) are still inconclusive. The purpose of this study was to clarify the pathophysiology of ano-neorectal functions in patients with or without soiling at 10 years or more after IPAA for ulcerative colitis (UC).

METHODOLOGY

Twenty-five patients after IPAA for UC were mamometrically studied. There were 17 men and 8 women, aged 38-58 years (mean 48.3 years). Patients after IPAA were divided into 2 groups [15 patients without soiling (10 men and 5 women, aged 38 to 52 years with a mean age of 47.9 years), 10 patients with soiling (7 men and 3 women, aged 42 to 58 years with a mean age of 49.3 years)]. The median follow-up time from closure of the diverting ileostomy was 126.9 months (range 120-136). No patients experienced any major complaints in the postoperative course.

RESULTS

Ten patients (40.0%) did experience an occasional soiling (a small amount of soiling in day time; 1 to 2 times per week, nocturnal soiling;1 time per 1 to 2 nights). Patients with soiling showed the worst results in the ano-neorectal manometry (anal sphincter dysfunction; lower resting and squeeze pressure, neorectal sensory dysfunction; increase of sensory threshold volume) compared with patients without soiling. Neorectal capacity function (maximamum neorectal tolerated threshold volume and neorectal compliance) and ano-neorectal inhibitory reflex showed no difference between patients without soiling and patients with soiling. These results are probably due to the injury to the internal anal sphincter, external anal sphincter, and rectal cuff caused during the operation.

CONCLUSIONS

Patients with soiling at 10 years or more after IPAA showed anal sphincter dysfunction and neorectal sensory dysfunction. The IPAA should not cause damage to the ano-rectal apparatus during rectal mobilization, making short rectal cuff, and mucosectomy.

Adenocarcinoma arising in the middle of ileoanal pouches: report of five cases

Restorative proctocolectomy with ileal pouch-anal anastomosis with or without mucosectomy has become the procedure of choice in patients with long-standing ulcerative colitis complicated by malignancy or medically refractory disease and for familial polyposis syndrome. Some reports have demonstrated the development of malignancy at the ileoanal anastomosis. We present a recent series of five patients who developed adenocarcinoma in the middle of their ileal pouch including the first case of pouch carcinoma in a patient who underwent pouch formation for ulcerative colitis. We discuss their presentation and management. Development of ileal pouch cancers, while rare, has been seen with increasing frequency in our practice. Patients with long-standing ileal pouches may benefit from routine surveillance of the pouch as often as every six months, which can be performed quickly and easily in the office using flexible endoscopy.

Pouchitis: an evolving clinical enigma--a review

While the overall incidence of pouchitis is low, extensive research continues at clinical and experimental levels in attempts to unravel its etiology. The ileal pouch and pouchitis together represent a unique in vivo opportunity to study mucosal adaptation and inflammation in depth. In the recent past, molecular data relating to pouchitis has significantly expanded. These data provide invaluable insight into intracellular and extracellular events that underpin mucosal adaptation and inflammation. Advances in classification, risk factor evaluation, and prevention have meant that a review of this data, as well as its relationship to our current understanding of pouchitis, is both timely and warranted. Therefore, the aim of this review is to summarize recent data in the context of the established literature.

[Treatment of fistulating pouchitis with tumour necrosis factor-alpha-inhibitor (infliximab)]

The surgical first choice treatment for patients with ulcerative colitis (UC) involves total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Postoperative development of pouch-related fistula is a rare complication, but it is associated with significant morbidity, a high recurrence rate and is a major cause of pouch failure. We report the use of infliximab, a monoclonal antibody to tumour necrosis factor-alpha, in three patients who developed pouch-related fistula after undergoing IPAA surgery for UC.

Outcome of pouch surgery for ulcerative colitis: single center experience

AIM

The purpose of the present study is to present the experience and evaluate the outcome of pouch surgery for patients with ulcerative colitis (UC).

METHODOLOGY

Fifty eight patients underwent surgery for UC between 1996 and 2007 at Mansoura Gastroenterology Center. A retrospective analysis has been done of all patients with UC undergoing surgery which includes details of the patient's history, indication of surgery, type of operation, postoperative morbidity, and functional outcome.

RESULTS

The main indication for operation was failed medical treatment (n=42, 72.4%). Pouch surgery was performed in 25/58 patients (43.1%). The majority of patients, 23/25 (92%) had J-shaped pouch and most patients, 19 (76%), underwent a stapled anastomosis. Twenty patients (80%) had a defunctioning ileostomy. There was one postoperative death after pouch surgery. Early complications after pouch surgery included pelvic sepsis (n=4), small bowel obstruction (n=2), pouch hemorrhage (n=1), wound sepsis (n=3). Long-term follow-up data were available for 14 patients. The most common long-term complication was anastomotic stricture (n=9, 42.6%). Five patients (35.7%) presented with pouchitis. Median daytime stool frequency was 5.1. Three patients (21.4%) presented with fecal incontinence.

CONCLUSION

Pouch surgery is a major one that attains many complications. However, the long term results and patient's satisfaction are reasonable.

Thirty years of the ileal-anal pouch and beyond

Still referred to as a new surgical procedure, the ileal-anal pouch or restorative proctocolectomy is now in its 30th year. Over this time the procedure has become the standard of care for patients with ulcerative colitis and familial adenomatous polyposis who require surgery. For many patients it not only eradicates disease, but also preserves the anal sphincter, therefore enabling the patient to defecate in the normal way. Much research over the years has explored optimum surgical techniques, pouch function/capacity, pouch failure and pouch satisfaction and its long-term follow-up. This article reviews literature relating to the ileal-anal pouch and traces its journey through the past three decades, providing an overview of how the pouch has evolved and considers its future development.

[Organisation and early outcome of restorative proctocolectomy and ileal pouch-anal anastomosis]

INTRODUCTION

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become the operation of choice for patients with ulcerative colitis and familial polyposis. However, the procedure is complex with a long learning curve, and carries a risk of both early and late complications. The purpose of this study was to evaluate the early outcomes (within 30 days after surgery) and organisation of IPAA surgery in Denmark between January 2001 and December 2005.

MATERIALS AND METHODS

IPAA patients >18 years old were drawn from the Danish National Patient Registry from 2001 through 2005. Hospital stay and the primary operation were recorded as well as re-operations and readmissions within the first 30 postoperative days. Mortality was recorded from the National Civic Register.

RESULTS

385 patients underwent IPAA surgery during the study period (77/year) in six centres. One centre performed 31% of the operations. The mean postoperative hospital stay (primary - and readmission within 30 days) was 13.5 days. 24% were readmitted within 30 days and 8% were re-operated. The mortality rate was 0.3%.

CONCLUSION

Based upon the limited number of operations, the high risk of early readmissions and re-operations, the well-known steep learning curve and the potential improvement with the technically demanding laparoscopic technique, a reorganisation of the procedure to fewer centres is suggested.