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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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McKenna NP, Mathis KL, Pemberton JH, Lightner AL. The Impact of Age at Time of Ileal Pouch Anal Anastomosis on Short and Long-Term Outcomes in Adults. Inflamm Bowel Dis 2018; 24:1857-1865. [PMID: 29718243 DOI: 10.1093/ibd/izy087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is limited knowledge on ileal pouch anal anastomosis (IPAA) function when performed on patients older than age 50 years. The aim of this study was to determine if surgery on those older than age 50 years impacts short-term complications or long-term function. METHODS A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between 2002 and 2013 was conducted. Short-term postoperative complications and long-term function and quality of life were analyzed according to age at pouch formation (age >50 vs age ≤50 years). RESULTS A total of 911 patients who underwent IPAA (542 male) were included, with 178 patients (20%) age >50 years and 733 (80%) ≤50 years. Patients >50 years had higher American Society of Anesthesiology score (ASA) scores and increased rates of obesity and dysplasia or cancer at the time of colectomy, and were less often on steroids (all P < 0.01). Over a median follow-up of 5 years, older patients reported increased daytime incontinence (60% vs 37%, P < 0.01) and pad usage (34% vs 11%, P < 0.01) at up to 1.5 years post-IPAA, after which time the groups became similar. Other functional outcomes, including pouch failure and quality of life, were similar between the 2 groups across the follow-up periods. CONCLUSION Performing an IPAA on carefully selected patients older than age 50 years has minor, transient differences in pouch function compared with patients younger than age 50 years. Assuming appropriate patient selection, IPAA should continue to be offered to older patients without increased risk of compromised function or of pouch failure.
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Affiliation(s)
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Ramage L, Qiu S, Georgiou P, Tekkis P, Tan E. Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review. Int J Colorectal Dis 2016; 31:481-92. [PMID: 26754072 PMCID: PMC4773498 DOI: 10.1007/s00384-015-2475-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 02/04/2023]
Abstract
AIM Ileal pouch-anal anastomosis (IPAA) is performed in ulcerative colitis or familial adenomatous polyposis with a view to restoration of GI continuity and prevention of permanent faecal diversion. Debate exists as to its safety in older patients. This review aims to assess functional outcomes and safety of restorative proctocolectomy (RPC) in older compared to younger patients. METHODS Literature search was performed for age-stratified studies which assessed functional outcomes of IPAA. Twelve papers were included overall. Patients were categorized into 'older' and 'younger' groups. Analysis was split into three separate parts: 1. Age cut-off of 50 ± 5 years (with sensitivity analysis); 2. Age cut-off of 65 ± years; 3. Long-term outcomes (>10 years). RESULTS With an age cut-off of 50 years (4327 versus 513 patients), complication rates were comparable with the exception of an increased rate of small-bowel obstruction in the younger patients (p = 0.034). At 1 year, 24-h stool frequency was significantly higher in the older patient group (p < 0.0001). Daytime (p < 0.0001) and night-time (p < 0.0001) incontinence rates were also significantly higher in older patients. Overall, function deteriorated with time across all ages; however, after 10 years, there was no significant difference in incontinence rates between age groups. Dehydration and electrolyte loss was a significant problem in patients over 65 (p < 0.0001). Despite differences in postoperative function, quality of life was comparable between groups; however, only a few studies reported quality of life data. CONCLUSION IPAA is safe in older patients, although treating clinicians should bear in mind the increased risk of dehydration. Postoperative function is worse in older patients, but seems to level out with time and does not appear to significantly impact on overall quality of life and patient satisfaction. Assessment for suitability for RPC should not be based on chronological age in isolation. It is imperative that the correct support is given to older patients with worsened postoperative function in order to maintain patient satisfaction and adequate quality of life.
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Affiliation(s)
- Lisa Ramage
- />Colorectal Surgery, Imperial College London, London, UK , />Department of Surgery and Cancer, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH UK
| | - Sheng Qiu
- />Colorectal Surgery, Imperial College London, London, UK , />Department of Surgery and Cancer, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH UK
| | - Panagiotis Georgiou
- />Colorectal Surgery, Imperial College London, London, UK , />Department of Surgery and Cancer, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH UK
| | - Paris Tekkis
- />Colorectal Surgery, Imperial College London, London, UK , />Department of Surgery and Cancer, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH UK
| | - Emile Tan
- />Colorectal Surgery, Imperial College London, London, UK , />Department of Surgery and Cancer, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH UK
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Perrault J. Pouchitis in Children: Therapeutic Options. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:389-397. [PMID: 12207862 DOI: 10.1007/s11938-002-0027-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pouchitis is an unfortunate common complication of the ileal pouch-anal anastomosis procedure, an otherwise very attractive surgical option in patients with ulcerative colitis (UC). The fact that the same pouch in familial polyposis is hardly complicated by pouchitis suggests that the basic inflammatory process in UC might participate in the pathophysiology. We review the clinical features of pouchitis, the diagnostic approach, and the many therapeutic considerations, including more recent data on prebiotics and probiotics.
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Affiliation(s)
- Jean Perrault
- Montreal Children's Hospital, McGill University Health Center, 2300 Tupper Street, Montreal, Quebec H3H 1P3, Canada.
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Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is a technically demanding, lengthy procedure with substantial associated morbidity. Some have suggested that this procedure should not be performed in older patients. This study was conducted to evaluate whether older patients have a poorer functional outcome and higher complication rate than younger patients who undergo IPAA. METHODS The 455 patients who have undergone IPAA at this institution were stratified according to age (< 55 versus > 55) to compare functional outcome and complication rates. The data were prospectively collected. The groups included 32 patients > 55 (7%) and 423 patients < 55. Comparisons were made with regard to stool frequency, incontinence rates, post-IPAA complications, postileostomy closure complications, and results 12 months postileostomy closure. RESULTS Preoperative anal sphincter resting and squeeze pressures were significantly lower in the > 55 group. Most complication rates were similar after IPAA except dehydration rates, which were higher in the older patients than the younger ones (27% versus 11%, respectively). Pre-ileostomy closure anal sphincter resting and squeeze pressures were not significantly lower in patients older than 55. Twenty-four hour daytime and nighttime stool frequencies were significantly higher in the > 55 group, as were daytime and nighttime stool incontinence. CONCLUSION Although functional outcome is poorer and some complications are higher in the > 55 group, the procedure can be safely performed with acceptable results and is greatly preferred by this population over permanent ileostomy.
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Affiliation(s)
- M T Dayton
- Department of Surgery, University of Utah School of Medicine, Salt Lake City 84132-0001, USA
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Abstract
This review assesses whether the risk of ileoanal pouch construction in patients with ulcerative colitis, compared with that of 'less dangerous' operations, is compensated by a better postoperative outcome. Even though the mortality rate is not greater for pouch construction, the risk of pelvic sepsis and pouchitis increase morbidity. Bowel function after construction of the ileal pouch, although better than that before operation, is not as good as that of normal controls and does not, in itself, justify increased morbidity. Quality of life measurements suggest that the benefit of the ileal pouch procedure is not much greater than that of ileostomy, even though some dimensions of quality of life are improved. However, most patients wish to avoid an ileostomy and surgeons should respect this wish, remembering that the pouch procedure has some risks and that the gain for the patient may be small.
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Affiliation(s)
- L Köhler
- Second Department of Surgery, University of Cologne, Germany
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Gemlo BT, Belmonte C, Wiltz O, Madoff RD. Functional assessment of ileal pouch-anal anastomotic techniques. Am J Surg 1995; 169:137-41; discussion 141-2. [PMID: 7817983 DOI: 10.1016/s0002-9610(99)80122-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent advances in ileal pouch-anal anastomotic (IPAA) technique include the substitution of a double stapled anastomosis for a mucosectomy and hand-sewn pouch-anal anastomosis, and the use of staples to construct a "J" shaped pouch rather than a hand-sewn "S" pouch in most cases. METHOD To determine the impact these technical changes have had on pouch function, 235 IPAA patients with 15 to 155 months of follow-up (mean 70 months) were interviewed by telephone concerning pouch function and quality of life. Categorical responses were then evaluated by contingency table analysis to detect differences between mucosectomy (n = 157) and nonmucosectomy (n = 80) groups, and between J pouch (n = 50), S pouch with mucosectomy (n = 137), and S pouch nonmucosectomy (n = 30) subgroups. An index encompassing nine functional measures was used to quantify the overall impact of technique changes (optimal score 100). RESULTS Stool frequency for mucosectomy patients was 7.2 movements/24 hours, compared to 7.1 for nonmucosectomy patients. Elimination of a mucosectomy dramatically reduced nocturnal major incontinence (P < 0.001), nocturnal minor incontinence (P < 0.001), daytime minor incontinence (P = 0.03), and day-time pad use (P = 0.002). Nonmucosectomy patients had a better functional index score than had patients with an S pouch, even when only data from nonmucosectomy patients were analyzed (J = 95.5, S = 91.8, P = 0.009). CONCLUSIONS Avoidance of a mucosectomy in the performance of an ileal pouch-anal anastomosis does not influence stool frequency but does significantly improve fecal continence and introduces no detectable morbidity associated with the retained rectal mucosa.
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Affiliation(s)
- B T Gemlo
- Department of Surgery, University of Minnesota, Minneapolis
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Lewis WG, Sagar PM, Holdsworth PJ, Axon AT, Johnston D. Restorative proctocolectomy with end to end pouch-anal anastomosis in patients over the age of fifty. Gut 1993; 34:948-52. [PMID: 8344583 PMCID: PMC1374232 DOI: 10.1136/gut.34.7.948] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This study was to examine whether 'fit' patients over the age of 50 who require elective surgery for ulcerative colitis are suitable candidates for restorative proctocolectomy, providing that they are continent before operation and that the anal sphincter is preserved in its entirety without stripping of the mucosa or endoanal anastomosis. Between 1986 and 1991, 18 patients 50 to 66 years old (median 55 years: nine men) underwent restorative proctocolectomy with end to end ileoanal anastomosis without mucosal stripping (12 quadruplicated (W), four duplicated (J), two no reservoir). The results were compared 12 (range three to 24) months later with those of 18 matched patients who were less than 50 years of age (median 34 years). In patients over 50, median resting anal pressure was 88 (range 44-131) cm water before and 80 (47-138) cm water after the operation (NS). In patients under 50, median resting anal pressure was 76 (51-128) cm water before and 77 (36-137) cm water after operation (NS). Resting anal pressure in older patients did not differ significantly from that in younger patients either before or after the operation. Both sensory and reflex anal functions were preserved as well after operation in the older patients as in the younger ones. The clinical results in patients over 50 were slightly inferior to the results for the younger patients, but the difference was small and not significant. Hence age alone is not a contraindication to restorative surgery provided that the anal sphincter is preserved in its entirety.
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Affiliation(s)
- W G Lewis
- Department of Surgery and Gastroenterology, General Infirmary, Leeds
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Pescatori M. The results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease: the manometric assessment of pouch continence and its reservoir function. World J Surg 1992; 16:872-9. [PMID: 1462622 DOI: 10.1007/bf02066984] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Anal sphincter function after restorative proctocolectomy has mainly been investigated by anal manometry. A significant decrease of basal pressure up to 45%, has been recorded postoperatively, possibly due to sphincter stretch during endoanal mucosectomy. Both abdominal mucosectomy and anastomosis at the level of the anorectal ring have been reported to prevent anal sphincter damage and lead to better continence. The striated sphincter is not significantly affected by the surgical procedure. Pouch-anal inhibitory reflex is partly maintained in the presence of a rectal cuff which leaves the ganglionic plexus unaltered; a satisfactory continence is also retained in the absence of the reflex when the rectum is totally excised. Pouch capacity, compliance and motility have been investigated by endoluminal balloon and probes. Pouch emptying has been studied by a "porridge" test, by a semi-solid medium labelled with technetium-99, and by other methods. A more effective storage function is achieved by large capacity reservoirs which lower the bowel frequency. The motor response to pouch distension, to a meal, and to pharmacological stimuli is usually counteracted by sphincter contraction. Ileal hypermotility may lead to fecal leakage mainly in the presence of weak sphincters. Poor pouch emptying may be related to an anal stricture.
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Affiliation(s)
- M Pescatori
- Istituto di Clinica Chirurgica, Università Cattolica, Roma, Italy
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Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon Rectum 1992; 35:482-7. [PMID: 1568401 DOI: 10.1007/bf02049407] [Citation(s) in RCA: 219] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A grading system of anal incontinence (AI) is described that takes into account both degree and frequency of symptoms. A, B, and C indicate AI for flatus/mucus, liquid stool, and solid stool, respectively; 1, 2, and 3 indicate occasional, weekly, and daily AI. A scoring system, ranging from 0 (continence) to 6 (severe AI, i.e., daily AI for solid stool or C3) also is reported. Three hundred thirty-five patients have been evaluated by this method in our institution: 30 percent had severe AI, graded as C3; only 9 percent had mild symptoms graded as A. Both males and females could not control diarrhea (Grade B) in 44 percent of cases. Nearly half of the 110 patients who underwent surgery had a C3 incontinence before treatment. Positive results were achieved in 75 percent of cases after surgery: e.g., AI score significantly improved from 4.2 +/- 1.6 to 1.5 +/- 1.9 (P less than 0.001) in those with AI and rectal prolapse. Most of the failures were the patients with idiopathic C3 incontinence. In conclusion, this grading and scoring system allowed a satisfactory assessment of patients' AI before and after treatment. It may also be used to achieve an objective comparison between different series.
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Affiliation(s)
- M Pescatori
- Instituto di Clinica Chirurgica, Università Cattolica, Rome, Italy
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