Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results

Current concepts and controversies in surgery for IBD

Surgery improves the quality of life in patients with Crohn's disease (CD) and cures patients with chronic ulcerative colitis (CUC). There are several surgical controversies primarily involving techniques and long-term outcomes. Some debates are long standing; whether to perform a double-stapled ileal pouch-anal anastomosis (IPAA) or a mucosectomy and hand-sewn anastomosis, and whether to divert or not to divert in patients with CUC undergoing an IPAA. Other issues are more recent, such as the effects of age, pregnancy, pouch salvage, and laparoscopic IPAA. In patients with Crohn's disease the anastomosis technique, the management of perianal disease, and the role of laparoscopic surgery are topics of debate. This review shows the current concepts and controversies in the surgical management of patients with CUC or CD.

Salvage surgery after restorative proctocolectomy

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. There are four causes of failure including acute and chronic sepsis, poor function for mechanical or functional reasons, mucosal inflammation (including pouchitis and retained rectal mucosa) and neoplastic transformation. Failure rates themselves range from 5% to nearly 20%. Followed over a period of 20 years, the failure rate can be summarised approximately as 5% at five years, 10% at ten years and 15% at 15 years.

Ileal pouch-vaginal fistula treated by abdominoanal advancement of the ileal pouch

Best approach for high fistulas

Tropomyosin expression in the ileal pouch: a relationship with the development of pouchitis in ulcerative colitis

OBJECTIVE

Human tropomyosin isoform 5 (hTM5) is a cytoskeletal protein expressed in normal epithelial cells, predominantly in the colon. An autoimmune response toward hTM5 has been reported in ulcerative colitis (UC). Whether hTM5 expression in the ileum is involved in pouchitis is unknown. We assessed hTM5 expression on ileal epithelial cells at surgery and subsequently on development of pouchitis in UC.

METHODS

In a prospective longitudinal study, 28 UC patients undergoing ileal pouch procedures were included. Biopsy samples were taken from the rectum at surgery, as well as from the ileal pouch at surgery and at 6 months. The specimens were stained by immunoperoxidase using the anti-hTM5 monoclonal antibody CG3. Pouchitis was assessed by the Pouchitis Disease Activity Index and hTM5 expression on a scale of 0-3.

RESULTS

At surgery, in rectal samples, hTM5 expression was strong in all epithelial cells including the luminal surface, whereas in ileal samples hTM5 was not expressed or focally expressed only in the goblet cells. At 6 months, the ileum was found to have undergone morphological changes, becoming similar to the colon and showing shortening or reduced number of villi. These changes were associated with a diffuse hTM5 staining in the goblet cells and in the nongoblet epithelial cells lining the crypts and the lumen. The hTM5 score was related to the Pouchitis Disease Activity Index at 6 months (r = 0.82; p = 0.01).

CONCLUSIONS

Expression of hTM5 shows a different pattern in the ileal pouch in UC after surgery. This event is associated with morphological changes of the ileum toward colonic epithelium, related to the development of pouchitis.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis

AIM

To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures.

RESULTS

Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab.

CONCLUSIONS

These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

Pouch reconstruction in the pelvis

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.

Surgery for inflammatory bowel diseases

Surgery is required in many patients with inflammatory bowel disease at some point in their disease. In patients with ulcerative colitis, surgery is potentially curative whereas recurrence of Crohn's disease following surgery is a common occurrence. As a result, the indications and surgical management of the two diseases may be quite different. Surgery is usually reserved for the management of complications or failure of medical treatment in Crohn's disease. Resection of the diseased segment is the usual procedure performed. While surgery usually results in an improvement in quality of life, recurrence of disease occurs frequently with reported rates of 5-90% at 1 year, depending on the criteria used. To date, there have been no surgical maneuvers which have been shown to decrease the risk of recurrence. Over the past few decades, several advances have been made in the surgical management of Crohn's disease: use of strictureplasty for extensive disease; use of laparoscopic techniques to perform surgery and the performance of the ileal pouch procedure in very selected patients. Significant advances in the surgical management of ulcerative colitis have been made in the past 50 years. Although there are several options available to patients, the preferred option now is the ileal pouch procedure. With technical modifications and with experience, this procedure can now be performed with a low complication rate, with good functional results and quality of life and excellent long-term outcome.