Restorative proctocolectomy without diverting ileostomy

Stoma-less IPAA Is Not Associated With Increased Anastomotic Leak Rate or Long-term Pouch Failure in Patients With Ulcerative Colitis

BACKGROUND

There is debate regarding the utility of diverting loop ileostomy with IPAA construction in patients requiring colectomy for ulcerative colitis.

OBJECTIVE

This study aimed to determine whether the omission of diverting loop ileostomy at the time of IPAA construction increases the risk of complications.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted in a high-volume, quaternary referral center with an IBD program.

PATIENTS

The patients, who underwent IPAA with or without ileostomy, were diagnosed for ulcerative colitis.

MAIN OUTCOME MEASURES

Anastomotic leak rate and pouch failure rates were determined between patients who either had a diverting ileostomy at the time of IPAA creation or had stoma-less IPAA.

RESULTS

Of the 414 patients included in this study, 91 had stoma-less IPAA. When compared to IPAA with diverting loop ileostomy, patients with stoma-less IPAA were less likely to be taking prednisone and had decreased blood loss. Short- and long-term outcomes were similar when comparing stoma-less IPAA and IPAA with diverting loop ileostomy, with no significant difference in anastomotic leak rate and long-term pouch failure rates. Diverting loop ileostomy was associated with a 14.6% risk of complication at the time of stoma reversal.

LIMITATIONS

The study is limited by its retrospective nature.

CONCLUSIONS

The results of this study suggest that the omission of a diverting ileostomy is feasible in select patients undergoing IPAA. Stoma-less IPAA does not have a statistically significant higher risk of anastomotic leak or pouch failure when compared to IPAA with diverting loop ileostomy in properly selected patients. Diverting loop ileostomies have their own risks, which partially offset their perceived safety. See Video Abstract at http://links.lww.com/DCR/B891 .LA ANASTOMÓSIS DE RESERVORIO ILEAL AL ANO SIN ESTOMA NO ESTÁ ASOCIADO CON UN AUMENTO EN LA TASA DE FUGA ANASTOMÓTICA O DISFUNCIÓN DE LA BOLSA A LARGO PLAZO EN PACIENTES CON COLITIS ULCERATIVA.

ANTECEDENTES

Existe debate en lo que respecta a la utilidad de efectuar una ileostomía en asa en la construcción de una anastomosis de reservorio ileal al ano en pacientes que requieren colectomía para colitis ulcerativa.

OBJETIVO

Determinar si el evitar una ileostomía de derivación en el momento de efectuar una anstomósis de reservorio ileal al ano aumenta el riesgo de complicaciones.

DISEO

Estudio retrospectivo.

REFERENCIA

Centro de referencia de cuarto nivel de grandes volúmenes con programa de enfermedad inflamatoria intestinal.

PACIENTES

Con diagnóstico de colitis ulcerativa sometidos a anastomosis de reservorio ileal al ano con o sin ileostomía derivative.

PRINCIPALES MEDIDAS DE RESULTADOS

Tasa de fuga anastomótica y disfunción del reservorio en pacientes sometidos a anastomosis de reservorio ileal al ano con ileostomía derivativa en el mismo evento y aquellos sin derivación de protección.

RESULTADOS

De los 414 pacientes incluídos en el estudio, 91 no contaban con ileostomía de protección de la anastomosis del reservorio ileal al ano. Al comprarse con aquellos con ileostomía derivativa, aquellos sin estoma requirieron menor dosis de prednisona y presentaron menor pérdida sanguínea. Los resultados a corto y largo plazo fueron similares al comprar ambos grupos sin haber evidencia significativa de fuga anastomótica o falla del reservorio a largo plazo. La derivación con ileostomía en asa se asoció en un 14.6% de riesgo de complicaciones al efectuar el cierre de la misma.

LIMITACIONES

Es una revision retrospectiva.

CONCLUSIONES

: Los resultados de este estudio sugieren que la omisión de una ileostomía de protección es posible en pacientes seleccionados sometidos a una anastomosis de reservorio ileoanal. La anastomosis sin derivación de protección no confiere un riesgo estadísticamente significativo de fuga anastomótica o disfunción de la misma al compararse con el procedimiento con estoma derivativo en pacientes seleccionados. Las ileostomías de derivación en asa tienen su propia morbilidad que cuestiona la perfección de su seguridad. Consulte Video Resumen at http://links.lww.com/DCR/B891 . (Traducción- Dr. Miguel Esquivel-Herrera ).

Laparoscopic restorative proctocolectomy with ileal-J-pouch anal canal anastomosis without diverting ileostomy for total colonic and extensive aganglionosis is safe and feasible with combined Lugol's iodine staining technique and indocyanine green fluorescence angiography

BACKGROUND

We present the surgical technique and outcomes of reduced-port laparoscopic restorative proctocolectomy with ileal-J-pouch anal canal anastomosis (IPACA) without diverting ileostomy for total colonic and extensive aganglionosis (TCA+).

METHODS

We retrospectively reviewed TCA+ cases between 2014 and 2022. Preoperative ileostomy was performed when transanal bowel irrigation was ineffective. Radical surgery for TCA+ was performed at approximately 6 kg. The surgery was performed using laparoscopy through a multi-channel trocar with or without an additional 3-mm trocar and IPACA reconstruction with indocyanine green fluorescence angiography (ICG) to assess anastomotic perfusion and Lugol's iodine staining to visualize the surgical anal canal.

RESULTS

Ten patients with TCA+ were included. Ileostomy was performed in seven cases. The median operation time and blood loss were 274.5 min and 20 ml, respectively. No significant postoperative complications were found. All patients experienced frequent liquid stools and perianal excoriation in the early postoperative period, requiring anti-flatulence or codeine. The median follow-up period was 3.5 years. Three patients required irrigation management 1 year postoperatively, and the others defecated a median of 3.5 times per day. The median Kelly's clinical score was 5 in 5 patients aged >4 years.

CONCLUSION

Reduced-port surgery, combined with Lugol's iodine staining and ICG, was safe, feasible, and had cosmetically and clinically acceptable mid-term outcomes.

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.

Current trends regarding protective ileostomy after restorative proctocolectomy

The decision to perform a protective ileostomy after ileoanal-pouch anastomosis is con- troversial, and most of the discussion is based on its advantages and disadvantages. Al- though a temporary intestinal diversion has been routinely indicated in most patients, this choice is also associated with complications. The present work aims to review the outcomes after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes. Most papers emphasize that di- version protects against anastomosis leaks; consequently, it may prevent pelvic sepsis and pouch failure. Otherwise, a defunctioning ileostomy may cause morbidity such as dehydra- tion, electrolyte imbalance, psychological problems, skin irritation, anastomosis strictures and intestinal obstruction, among others. There are those who believe that the omission of an ileostomy after the confection of ileal pouches should be reserved for selected patients, with quite acceptable results. The selection criteria should include surgeon, patient and procedure features to ensure a good outcome.

Up-to-date surgery for ulcerative colitis in the era of biologics

Introduction: In recent decades, biologics have resulted in significantly improved medical management of ulcerative colitis (UC). Rates of surgery for UC are declining. However, there is still a controversial question of the relation of biologics to postoperative adverse outcomes and the most appropriate timing for operative intervention.Areas covered: In this review, we explore the updated treatment algorithm of acute severe colitis, describe postoperative outcomes in patients exposed to biologics preoperatively, and discuss the primary indications for staging surgery in chronic refractory cases, largely with prolonged medical therapy.Expert opinion: Delaying pouch construction to when patients are in better health is suggested as a safer strategy over the long term. The surgical management of UC patients in the biologic era needs to be individualized, and a case-based multidisciplinary decision is critical for improved outcomes and a reduction of morbidity and mortality.

Is fecal diversion necessary during ileal pouch creation after initial subtotal colectomy in pediatric ulcerative colitis?

BACKGROUND

Pediatric patients with medically refractory ulcerative colitis (UC) often undergo an initial subtotal colectomy end ileostomy (STC-I). The role of fecal diversion in the subsequent completion proctectomy/ileal-pouch anal anastomosis (CP-IPAA) remains controversial.

METHODS

A multi-institutional retrospective review was performed of pediatric UC patients who underwent an STC-I followed by CP-IPAA from 2008 to 2016. 37 patients were included [diverted (n = 20), undiverted (n = 17)].

RESULTS

Children who underwent undiverted CP-IPAA had a longer length of stay (days) compared to the diverted group (9, 6.5-13 vs. 6, 5-6, p = 0.002). The 30-day complication rate was significantly higher in the undiverted group (p = 0.003) although the difference in anastomotic leak, readmission rate, unplanned computer tomography use, and reoperation was not statistically significant. Three patients with undiverted CP-IPAA required additional surgery in the perioperative period for fecal diversion. The mean long-term follow-up was 25.68 ± 21.56 months. There were no significant differences in functional pouch outcomes.

CONCLUSIONS

Patients who underwent an undiverted CP-IPAA after initial STC-I had significantly more complications in the immediate postoperative period compared to diverted patients, although this did not translate into long-term differences in functional outcomes. Questions remain regarding careful patient selection and counseling for undiverted pouches in the pediatric UC population.

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.

Risk Factors for Small Bowel Obstruction After Laparoscopic Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: A Multivariate Analysis in Four Expert Centres in Europe

BACKGROUND AND AIMS

Although laparoscopy is associated with a reduction in adhesions, no data are available about the risk factors for small bowel obstruction [SBO] after laparoscopic ileal pouch-anal anastomosis [IPAA]. Our aims here were to identify the risk factors for SBO after laparoscopic IPAA for inflammatory bowel disease [IBD].

METHODS

All consecutive patients undergoing laparoscopic IPAA for IBD in four European expert centres were included and divided into Groups A [SBO during follow-up] and B [no SBO].

RESULTS

From 2005 to 2015, SBO occurred in 41/521 patients [Group A; 8%]. Two-stage IPAA was more frequently complicated by SBO than 3- and modified 2-stage IPAA [12% vs 7% and 4%, p = 0.04]. After multivariate analysis, postoperative morbidity (odds ratio [OR] = 3, 95% confidence interval [CI] = 1.5-7, p = 0.002), stoma-related complications [OR = 3, 95% CI = 1-6, p = 0.03] and long-term incisional hernia [OR = 6, 95% CI = 2-18, p = 0.003] were predictive factors for SBO, while subtotal colectomy as first surgery was an independent protective factor [OR = 0.4, 95% CI = 0.2-0.8, p = 0.002]. In the subgroup of patients receiving restorative proctocolectomy as first operation, stoma-related or other surgical complications and long-term incisional hernia were predictive of SBO. In the patient subgroup of subtotal colectomy as first operation, postoperative morbidity and long-term incisional hernia were predictive of SBO, whereas ulcerative colitis and a laparoscopic approach during the second surgical stage were protective factors.

CONCLUSIONS

We found that SBO occurred in less than 10% of patients after laparoscopic IPAA. The study also suggested that modified 2-stage IPAA could potentially be safer than procedures with temporary ileostomy [2- and 3-stage IPAA] in terms of SBO occurrence.

Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. 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.

Pouch failures following ileal pouch-anal anastomosis for ulcerative colitis

AIM

Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure.

METHOD

The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis.

RESULTS

Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy.

CONCLUSION

In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.

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.

The Role of Temporary Fecal Diversion

The use of temporary fecal diversion is of great importance to tenuous anastomosis, immunosuppressed patient, or actively infected patient. Its use protects newly constructed intestinal anastomoses from being the culprit of pelvic sepsis or systemic illness. Thus, potential morbidity and mortality can be averted. However, its appropriate or optimal use is often debated. We herein discuss the evidence for when to best use a diverting stoma for colorectal, coloanal, and ileoanal anastomoses. We also discuss the importance of considering a temporary diverting stoma in the setting of high-dose immunosuppression (e.g., transplant patients or inflammatory bowel disease), active infection, or upon creation of ileal pouch-anal anastomosis. Lastly, we discuss the advantages and disadvantages of a loop ileostomy versus colostomy for temporary diversion of fecal contents.

Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients

BACKGROUND

There are very few studies and no consensus concerning the choice between two- and three-stage ileal pouch-anal anastomosis [IPAA] in inflammatory bowel diseases [IBD]. This study aimed to compare operative results between both surgical procedures.

METHODS

Only patients who underwent a laparoscopic IPAA for IBD were included. They were divided into two groups: two-stage [IPAA and stoma closure] [Group A] and three-stage IPAA [subtotal colectomy, IPAA, stoma closure] [Group B].

RESULTS

From 2000 to 2015, 185 patients (107 men, median age of 42 [range, 15-78] years) were divided into Groups A [n = 82] and B [n = 103]. Patients in Group B were younger than in Group A (39 [15-78] vs 43 [16-74] years; p = 0.019), presented more frequently with Crohn's disease [16% vs 5%; p < 0.04], and were more frequently operated in emergency for acute colitis [37% vs 1%; p < 0.0001]. Cumulative operative time and length of stay were significantly longer in Group B (580 [300-900] min, and 19 [13-60] days) than in Group A (290 [145-490] min and 10 [7-47] days; p < 0.0001). Cumulative postoperative morbidity, delay for stoma closure, and function were similar between the two groups. Long-term morbidity was similar between Group A [13%] and Group B [21%; p = 0.18].

CONCLUSIONS

Our study suggested that postoperative morbidity was similar between two- and three-stage laparoscopic IPAA. It suggested that the three-stage procedure is probably safer for high-risk patients [ie in acute colitis].

Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis

BACKGROUND AND AIMS

There is a paucity of evidence in ulcerative colitis [UC] comparing the traditional two-stage [total proctocolectomy with ileal pouch-anal anastomosis [IPAA] and diverting ileostomy, followed by ileostomy closure] vs the modified two-stage restorative proctocolectomy [subtotal colectomy with end ileostomy, followed by completion proctectomy and IPAA, without diverting ileostomy]. This study examines the risk of anastomotic leak following IPAA in traditional vs modified two-stage IPAA for UC patients.

METHODS

This was a single-institution, retrospective study of all UC patients who underwent a traditional or modified two-stage IPAA between 2002 and 2013. The primary outcome was anastomotic leak following IPAA.

RESULTS

In all, 460 patients had a two-stage IPAA procedure; 223 [48.5%] patients underwent traditional two-stage IPAA and 237 [51.5%] patients received the modified two-stage procedure. There was more preoperative enteral corticosteroid use [44.7% vs 33.2%, p = 0.04] before the first surgery in the modified two-stage group compared with the traditional two-stage group. The modified two-stage group had higher UC disease severity at presentation [86.9% patients with moderate/severe UC vs 73.1%, p < 0.01]. However, the modified two-stage group had a lower rate of anastomotic leak following IPAA [4.6% vs 15.7%, p < 0.01] and was associated with a lower risk of anastomotic leak on univariate (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.13, 0.52] and multivariate analysis [OR 0.27, 95% CI 0.12, 0.57].

CONCLUSIONS

Patients with ulcerative colitis who received the modified two-stage IPAA had a significantly lower rate of anastomotic leak following pouch creation, compared with the traditional two-stage procedure.

Anti-Tumor Necrosis Factor-α Antibody Therapy Management Before and After Intestinal Surgery for Inflammatory Bowel Disease: A CCFA Position Paper

Biologic therapy with anti-tumor necrosis factor (TNF)-α antibody medications has become part of the standard of care for medical therapy for patients with inflammatory bowel disease and may help to avoid surgery in some. However, many of these patients will still require surgical intervention in the form of bowel resection and anastomosis or ostomy formation for the treatment of their disease. Postsurgical studies suggest up to 30% of patients with inflammatory bowel disease may be on or have used anti-TNF-α antibody medications for disease management preoperatively. Significant controversy exists regarding the potential deleterious impact of these medications on the outcomes of surgery, specifically overall and/or infectious complications. In this position statement, we systematically reviewed the literature regarding the potential risk of anti-TNF-α antibody use in the perioperative period, offer recommendations based both on the best-available evidence and expert opinion on the use and timing of anti-TNF-α antibody therapy in the perioperative period, and discuss whether or not the presence of these medications should lead to an alteration in surgical technique such as temporary stoma formation.

Reduced-port laparoscopic restorative proctocolectomy without diverting ileostomy

INTRODUCTION

We introduced a reduced-port procedure for laparoscopic restorative proctocolectomy without diverting ileostomy for patients with familial adenomatous polyposis and ulcerative colitis.

MATERIALS AND SURGICAL TECHNIQUE

A multichannel port was inserted through a 2.5-cm umbilical incision. A 12-mm port in the right lower abdomen and a 3- or 5-mm port were also employed. A proctocolectomy was performed intracorporeally, and the entire colon and rectum were delivered through the umbilical incision. An ileal J-pouch was made extracorporeally following division of the mesenteric vessels. Ileal j-pouch-anal anastomosis was performed intracorporeally or transanally after rectal mucosectomy. A drain was inserted through the 12-mm port incision, and a transanal decompression tube was placed in the pouch. Two women and one man underwent this surgery, and their postoperative recovery was uneventful.

DISCUSSION

Laparoscopic restorative proctocolectomy without a diverting stoma by a reduced-port technique is feasible and provides excellent cosmetic outcomes in selected patients.

Severity of inflammation as a risk factor for ileo-anal anastomotic leak after a pouch procedure in ulcerative colitis

PURPOSE

The pelvic pouch procedure (PPP) carries significant post-operative complication risks including a 4-14 % risk of ileo-anal anastomotic (IAA) leak [1-4]. The aim of this study is to evaluate the severity of disease at the distal resection margin as an independent risk factor for an IAA leak following the PPP for patients with ulcerative colitis (UC).

METHODS

A retrospective matched case-control study was undertaken. The distal margin of each subject's specimen was reviewed by a blinded pathologist and the degree of inflammation was scored using a modified histological activity index (mHAI)--a 0 to 5 graded scale with HAI of 5 representing ulcerations >25 % the depth of bowel wall.

RESULTS

Forty-nine patients with perioperative IAA leaks (mean 11 days ±0.92) were identified and matched for gender, age and year of surgery. The case cohort had 33 males (67 %) of mean age at time of surgery of 36.3 years (±1.42). The severity of distal inflammation did not increase the risk of IAA leak. The presence of a diverting ileostomy was associated with a decreased incidence of an IAA leak (p = 0.01).

CONCLUSION

Studies with greater power will be required to evaluate the association (if any) between histological severity of UC at the distal margin of a PPP procedure and IAA leak rate. This risk factor could influence preoperative management and post-operative outcome in patients requiring the PPP.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Review of our ileal pouch experience in the light of literature

OBJECTIVE

Retrospective proctocolectomy is a distinguished, sphincter saving treatment used for the treatment of ulcerative colitis and FAP disease. We aimed to evaluate ileal pouch interventions performed at our clinic and their results in the light of literature.

MATERIAL AND METHODS

Medical records of 35 restorative proctocolectomy and J pouch ileo-anal anastomosis surgeries performed at Necmettin Erbakan University, Meram School of Medicine between the years 2006-2013 were retrospectively examined. The patients were assessed according to their age, gender, length of hospital stay, diagnosis, follow-up duration and pouch-related complications. All patients were contacted by phone and they were scheduled for controls at the outpatient clinic.

RESULTS

Nineteen patients were male (54%) and 16 were female (46%). Their mean age was 45 years (21-74). The mean length of hospital stay was 11 (5-20) days. Twenty two (63%) patients were operated on due to FAP, 12 (34%) due to synchronous rectum cancer and colon tumor or polyp, and one (3%) due to ulcerative colitis. All patients received J pouch and protective ileostomy. After the closure of ileostomy, two cases were identified to have J pouch fistulas. The patients were followed up for 6 months to 7 years. They were contacted by phone and they were questioned about their active complaints, number of defecations, urinary and sexual dysfunctions. It was identified that they had 5 (3-8) defecations per day on average and that 4 (11%) cases had one nocturnal defecation. No pouchitis was identified in the follow-up endoscopic examinations.

CONCLUSION

Restorative proctocolectomy and ileo-anal anastomosis technique is a surgical procedure that can be performed with low rates of morbidity and mortality, including the elderly.

Outcomes and cost of diverted versus undiverted restorative proctocolectomy

BACKGROUND

Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy.

METHODS

This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected.

RESULTS

There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients.

CONCLUSION

Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.

Predictive value of the Pediatric Ulcerative Colitis Activity Index in the surgical management of ulcerative colitis

PURPOSE

The primary purpose of this study was to investigate the relationship between Pediatric Ulcerative Colitis Activity Index (PUCAI) and operative management. We also specifically evaluated those patients receiving tacrolimus for their disease.

METHODS

A retrospective review (1/06-1/11) identified ulcerative colitis patients (≤21 years old) undergoing restorative proctocolectomy with rectal mucosectomy and ileal pouch-anal anastomosis. Main outcomes included pre-operative PUCAI, combined versus staged procedure, and postoperative complications. Patients receiving tacrolimus within 3 months of surgical intervention were identified. PUCAI at tacrolimus induction and medication side effects were also noted.

RESULTS

Sixty patients were identified. Forty-two (70%) underwent combined and 18 (30%) had staged procedures. Pre-operative PUCAI was lower for combined versus staged patients (p = < 0.001). Furthermore, a higher pre-operative PUCAI strongly correlated with the likelihood of undergoing a staged procedure (p < 0.001). Forty-four patients (73%) received tacrolimus. Significant improvement in their PUCAI was noted from induction to pre-operative evaluation (p < 0.001). Minor and reversible side effects occurred in 46% of patients receiving tacrolimus, but complication rates were not significantly different.

CONCLUSIONS

There is a very strong correlation between the PUCAI and the likelihood of undergoing a staged procedure. A significant improvement in PUCAI occurs following preoperative tacrolimus therapy.

The surgical treatment of inflammatory bowel disease-associated dysplasia

Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is controversial. Total proctocolectomy (TPC) is the most definitive treatment for the eradication of undiagnosed synchronous dysplasias and/or carcinomas and the prevention of subsequent metachronous lesions in both Crohn's disease (CD) and ulcerative colitis (UC). However, TPC is not always an attractive option owing to patient comorbidities and patient preference. Historically, dysplasia has been most studied in patients with UC, where the option of reconstruction without a stoma makes TPC more acceptable. Due to a relative lack of research on CD-related dysplasia, surveillance and treatment of CD dysplasia has followed paradigms based on UC data. However, due to pathophysiological differences in CD versus UC, options for surgical management in CD may be more varied than simple TPC, particularly in the less healthy surgical candidate and those who refuse end ileostomy.

Role of ileostomy in restorative proctocolectomy

Restorative proctocolectomy (RP) is the treatment of choice in patients affected with refractory ulcerative colitis or familial adenomatous polyposis. Surgery in elective settings is often performed in 2 stages, fashioning an ileostomy which is closed 2-3-mo later. It is still debated whether omitting ileostomy could offer advantages in the management of patients undergoing RP.

Long-term followup with evaluation of the surgical and functional results of the ileal pouch reservoir in restorative proctocolectomy for ulcerative colitis

Aims. Evaluate the early and long term surgical and functional results of the ileal pouch-reservoir (IPAA) in patients with intractable ulcerative colitis. Material and Methods. Followup of 134 consecutive patients with W-or J-ileal pouch by diseases-specific and general health (SF-36) questionnaire. In the first 44 patients, early and late followup was performed. Results. Followup was performed 7.4 years (0.5-17 years) after construction of W (n = 9) and J (n = 125) ileal pouch, which had similar results. There were 14.9% early and 43.6% late complications with 12.7% early and 19.5% late reoperations. Protecting loop-ileostomy used in 54 patients (43.9%), did not protect against complications. Thirteen reservoirs (9.8%) were resected (n = 8) or deactivated (n = 5) due to functional failure. Operation time, postoperative complications and pouchitis were determinators for reservoir failure and reduced quality of life. The functional results at followup of 44 patients at 2.5 years (0.8-6.7 years) and 11.5 years (8.2-19.2 years) were remarkably similar. Conclusions. IPAA is a good option for most patients when medication fails. 10% experience failure with inferior quality of life. Protective stoma will not reduce failure rates. After an initial time period, reservoir function will not change over time.

Outcome and long-term function of restorative proctocolectomy for Crohn's disease: comparison to patients with ulcerative colitis

AIM

Restorative proctocolectomy (RPC) is the most common operation for chronic ulcerative colitis (CUC), as it provides excellent functional outcome. However, among patients with Crohn's disease (CD), RPC is generally not recommended, as outcome and long-term function may be poor. Our purpose was to compare matched cohorts of CD and CUC patients to determine whether there are differences in outcome or function.

METHOD

We queried our prospectively maintained database of patients who underwent RPC from 1991 to 2008. We identified patients who underwent RPC for CD and compared them with a matched cohort of patients who underwent RPC for CUC.

RESULTS

We identified 13 patients with CD (seven women, median age 34 years) and 39 patients with CUC (21 women, median age 35 years). The patients were well matched for gender, clinical and demographic variables. Seven patients (54%) with CD had proctitis, but none had perianal or ileal disease. There were four (30.8%) postoperative complications and no anastomotic leaks. The CD group experienced significantly fewer median daily bowel movements (P = 0.02), incontinence for liquids (P < 0.01) and pouchitis (P < 0.01). With a median follow up of 44 months, pouch excision rate was significantly higher in the Crohn's group (2 vs 0%, P < 0.01).

CONCLUSION

In patients with CD, RPC may result in fewer daily bowel movements, less liquid incontinence and a lower incidence of pouchitis compared with CUC patients who undergo RPC. However, risk of pouch loss is higher in patients with CD. Therefore, in properly selected patients with CD, RPC provides an acceptable long-term functional outcome.

Minimally invasive pouch surgery for ulcerative colitis: is there a benefit in staging?

BACKGROUND

With the introduction of biologic agents, medical and surgical management of ulcerative colitis has been associated with significant morbidity. A staged surgical approach is advocated to obviate the risks of infectious complication and consequent poor pouch function.

OBJECTIVE

The aim of this study was to analyze the outcomes of our selective staged approaches in patients with ulcerative colitis who were undergoing laparoscopic pouch surgery.

DESIGN

Consecutive patients with ulcerative colitis referred for laparoscopic surgical treatment between 2002 and 2008 were included in the study. Data were prospectively collected. Patients were divided into 2 groups: a 3-stage group, initial laparoscopic abdominal colectomy followed by pouch surgery with a diverting loop ileostomy, and a 2-stage group, laparoscopic pouch surgery with a diverting loop ileostomy at the initial operation.

RESULTS

Of the 118 patients eligible for the study, 68 were in the 2-stage group and 50 were in the 3-stage group. Patients were more likely to have been receiving aggressive medical therapy in the 3-stage group than in the 2-stage group: 43% vs 16% (P = .01) receiving anti-tumor necrosis factor therapy and 96% vs 67% (P = .04) receiving systemic corticosteroids. Although overall complication rates were similar between groups (P = .4), infectious complications were higher in the 2-stage group (38.2% vs 21%, P < .05).

CONCLUSIONS

In our practice, we have selectively applied a 3-stage laparoscopic surgical approach to restorative proctocolectomy in patients with ulcerative colitis who are receiving aggressive medical therapy in an attempt to minimize perioperative complications. This strategy appears efficacious, and short-term outcomes compare favorably with those following a 2-stage approach.

Diverting loop ileostomy after restorative proctocolectomy: predictors of poor outcome and poor quality of life

AIM

Diverting loop ileostomy is used to minimize the impact of anastomotic complication after restorative proctocolectomy (RPC). However, the ileostomy itself may have complications and therefore affect quality of life (QOL). The aim of this study was to analyse the predictors of complications of the ileostomy formation and closure and of the QOL of these patients.

METHOD

Forty-four consecutive patients who underwent RPC were enrolled. Records of the ileostomy follow-up were retrieved from a prospectively collected database and QOL was assessed with the Stoma-QOL questionnaire. Ileostomy site coordinates were measured. Univariate and multivariate analysis were performed.

RESULTS

In this series, three patients experienced peristomal herniae, two ileostomy stenosis, seven ileostomy retraction and fourteen peristomal dermatitis. Emergency surgery was the only predictor of parastomal hernia (P = 0.017). Stenosis correlated with the distance from the umbilicus (tau = 0.24, P = 0.021). Use of standard rod and retraction were independent predictors of peristomal dermatitis (P = 0.049 and P = 0.001). Stoma-QOL was directly correlated to the age of the patients and to the occurrence of parastomal hernia (P = 0.001 and P = 0.021, respectively). After stoma closure, two patients reported wound sepsis and seven suffered obstructive episodes.

CONCLUSION

The predictors of negative outcome after construction of a diverting loop ileostomy after RPC were urgent surgery, use of standard rod, the distance of the stoma site from the umbilicus, parastomal herniae and the older age of patients.

Restorative proctocolectomy and ileal pouch-anal anastomosis in children

PURPOSE

This study was designed to evaluate the results of restorative proctocolectomy with distal rectal mucosectomy and ileal pouch-anal anastomosis in children.

METHODS

This study is a retrospective review of 100 consecutively referred children (<18 years old) who underwent reconstruction with a J-pouch of ileum and preservation of the transitional anorectal epithelium by the same two-surgeon team. Temporary diverting ileostomy was used. The main outcome measures were daytime and nocturnal fecal continence, bowel movements per day, and complications including pouchitis, ileoanal stricture, or postoperative small-bowel obstruction.

RESULTS

Average age of the 100 children (48 males/52 females) was 13.2 years (range, 2.95-17.99). All 25 children with familial adenomatous polyposis had proctocolectomy and reconstruction performed simultaneously. Of 75 children with ulcerative colitis, 50 (67%) had their colectomy followed by reconstruction after an interval ranging from 2 months to 4.4 years. Median postoperative follow-up was 2.6 years. Daytime fecal continence was achieved in 98 children, although 4 reported rare accidents. Nighttime continence was achieved in 93 children, of whom 14 reported rare accidents. The average frequency of bowel movements was 5.43/day (+/-2.22). Only one child with polyposis had pouchitis. Of 75 children with ulcerative colitis, 35 had symptoms consistent with pouchitis; of these 35 children, 10 required prolonged treatment. The most frequent postoperative complication was ileoanal stricture requiring operative dilatation and/or anoplasty (18 children). Bowel obstruction requiring surgery occurred in 18 children. One child eventually required pouchectomy for probable Crohn's disease.

CONCLUSIONS

Excellent results can be achieved with restorative proctocolectomy in children with respect to fecal continence and stool frequency. However, with ulcerative colitis, a substantial risk of pouchitis remains.

Surgical site infection following surgery for inflammatory bowel disease in patients with clean-contaminated wounds

BACKGROUND

It is generally believed that the accompanying conditions in patients with inflammatory bowel disease (IBD) are associated with a high incidence of surgical site infection (SSI), and sometimes these patients are classified as compromised hosts without definitive clinical evidence. The aim of this study was to clarify the impact of IBD on the occurrence and features of SSI in patients with clean-contaminated wounds.

METHODS

We conducted prospective SSI surveillance of 580 patients with clean-contaminated wounds who underwent surgery between March 2006 and December 2007 using the National Nosocomial Infection Surveillance system. Multivariate analyses using stepwise logistic regression were performed to determine risk factors for SSI.

RESULTS

A total of 562 patients with clean-contaminated wounds who underwent surgery for IBD [ulcerative colitis (UC), n = 173; Crohn's disease (CD), n = 122] or colorectal cancer [(CA), n = 267] were identified for evaluation. SSI was observed in 12.6% of all patients and there was no significant difference in infection rate by type of disease (UC, 14.5%; CD, 13.9%; CA, 10.9%). Multivariate logistic regression analysis yielded an ASA score > or =3 [odds ratio (OR) = 2.04; 95% confidence interval (CI) = 1.06-3.93] and rectal surgery (OR = 2.35; 95% CI = 1.28-4.31) as independent risk factors for SSI. IBD surgery was not an independent risk factor for overall SSI (OR = 1.62; 95% CI = 0.94-2.80). However, there was a significant difference in the incidence of incisional SSI [IBD, 11.9% (UC, 12.7%; CD, 10.7%); CA, 4.9%, p = 0.003]. In the analysis of rectal surgery, the incidence of incisional SSI was 5.3% in CA patients, 12.0% in UC patients, and 26.3% in CD patients. In contrast to overall SSI data, IBD surgery was found to be an independent risk factor for incisional SSI (OR = 2.59; 95% CI = 1.34-5.03).

CONCLUSIONS

In patients of surgery restricted to clean-contaminated wounds, IBD was shown to be an independent risk factor for incisional SSI. With the use of proper operative procedures and techniques, the incidence of organ/space SSI should not be high in patients who undergo an uncomplicated IBD surgical procedure.

Proximal diversion at the time of ileal pouch-anal anastomosis for ulcerative colitis: current practices of North American colorectal surgeons

PURPOSE

Pelvic sepsis is a serious complication after ileal pouch-anal anastomosis for ulcerative colitis that may lead to pouch failure or poor function. Although a temporary loop ileostomy may be created at the time of ileal pouch-anal anastomosis to prevent or minimize the consequences of an anastomotic leak, research has suggested that an ileostomy can be safely omitted in selected patients. The purpose of this study was to examine the use of proximal diversion by colorectal surgeons at the time of ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

A questionnaire was mailed to all practicing fellows of The American Society of Colon and Rectal Surgeons in North America. Surgeons were asked to describe their typical practice for a number of clinical scenarios.

RESULTS

Questionnaires were mailed to 913 American Society of Colon and Rectal Surgeons fellows, and 63 percent responded. For a patient who has had a prior colectomy and is not taking steroids, 27 percent of surgeons would perform ileal pouch-anal anastomosis alone, and 73 percent would perform ileal pouch-anal anastomosis with a loop ileostomy. For a patient who has not had previous surgery and is taking prednisone 40 mg/day, 16 percent of surgeons would perform a subtotal colectomy with an end ileostomy, 82 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis with a loop ileostomy, and 2 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis without an ileostomy. There was no relationship between practice setting, annual ileal pouch-anal anastomosis volume, or years in practice and surgeon response for either scenario.

CONCLUSIONS

The majority of surgeons create a temporary loop ileostomy at the time of ileal pouch-anal anastomosis for ulcerative colitis.

Evaluation of one-stage laparoscopic-assisted restorative proctocolectomy at a specialty center: comparison with the open approach

PURPOSE

This study compared outcomes after laparoscopically assisted and open restorative proctocolectomy performed as a one-stage procedure, including anorectal mucosectomy and omission of ileal diversion.

METHODS

We reviewed our prospectively maintained database of patients who underwent restorative proctocolectomy between 1998 and 2006. Demographic data, surgical indications, and intraoperative and postoperative complications were evaluated. Anastomotic leaks were identified by radiologic, endoscopic, or intraoperative evidence. The primary outcome variables were complications, duration of operation, blood loss, intraoperative spillage of enteric contents, and the ability to complete the procedure in one stage.

RESULTS

One-stage laparoscopically assisted restorative proctocolectomy was performed in 50 patients and open restorative proctocolectomy was performed in 155 patients. The mean operative time was longer for the laparoscopically assisted group (198.7 vs. 159.1 minutes; P = 0.006). The mean estimated blood loss was less among the patients in the laparoscopically assisted group (287.5 vs. 386.4 ml; P = 0.006). There were no significant differences in intraoperative or postoperative complications between the two groups.

CONCLUSIONS

Laparoscopically assisted one stage restorative proctocolectomy is a safe and technically feasible procedure. There seems to be no increase in the rate of postoperative complications compared with the open approach. Laparoscopically assisted restorative proctocolectomy should be considered in the surgical management of patients who require this procedure.

Chronic inflammatory changes in the anal transition zone after stapled ileal pouch-anal anastomosis: is mucosectomy a superior alternative?

BACKGROUND

Chronic inflammation (CI) is commonly found in the anal transition zone (ATZ) after stapled ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Yet, its impact on defecatory function and the need for a complete mucosectomy has not been completely elucidated. This study aims to evaluate the long-term functional outcomes of patients with CI of the ATZ after stapled IPAA in comparison with mucosectomy patients.

METHODS

Between June 1987 and November 2007, 66 UC patients were found to have CI of the ATZ after stapled IPAA and were compared with 228 UC patients who underwent mucosectomy with hand-sewn (HS) IPAA. Patients were mailed a questionnaire to assess defecatory function and quality of life. Data were analyzed prospectively.

RESULTS

No differences were observed in age, sex, number, or consistency of bowel movements (BMs) between groups. Complete continence was reported by 90.3% of CI and 66.8% of HS patients (P < .001). The CI group also had a significantly lower rate of major incontinence (P < .001). Functional parameters in favor of the CI group included the ability to discriminate between gas and stool (P < .001), the use of protective pads during both the day and the night (P < .001), dietary modifications in the timing of meals (P < .001) and type of food (P = .005), and the presence of perianal rash (P = .019). In the CI group, more patients rated their quality of life as improved from before the operation (P < .001).

CONCLUSIONS

Preservation of the ATZ, even in presence of persistent inflammation, confers improved continence, better functional outcomes, and superior quality of life.

Septic complications after restorative proctocolectomy do not impair functional outcome: long-term follow-up from a specialty center

PURPOSE

After restorative proctocolectomy, 7 to 8 percent of patients may have a pouch leak. Concern exists that pouch leak may be associated with impaired functional outcome. We evaluated patients who underwent restorative proctocolectomy to determine whether pouch leak adversely affected long-term functional outcome and quality of life.

METHODS

We queried our prospectively maintained database of patients who underwent restorative proctocolectomy for demographic and clinical data. We sent a long-term outcome questionnaire to patients, including the validated Fecal Incontinence Severity Index and Cleveland Global Quality of Life scores. Pouch leak was identified by clinical or radiographic evidence of leak. Patients with leak were compared with those without to determine the impact on long-term functional outcome or quality of life.

RESULTS

A total of 817 patients were available for follow-up and 374 patients (46 percent) completed questionnaires. The group with (n = 60; 16 percent) and without (n = 314; 84 percent) leak had similar demographics. The median Fecal Incontinence Severity Index score (15.3 vs. 14.7, P = 0.77), Cleveland Global Quality of Life score (0.79 vs. 0.81, P = 0.48), and bowel movements per 24 hours (7.92 vs. 7.88, P = 0.92) were similar. The pouch loss/permanent ileostomy rate was higher in those who leaked (13.3 vs. 0.9 percent, P < 0.001).

CONCLUSIONS

Anastomotic leak after restorative proctocolectomy does not adversely affect long-term quality of life or functional outcome. However, pouch loss/permanent ileostomy is significantly more likely in patients who have had an anastomotic leak.

Review article: restorative proctocolectomy, indications, management of complications and follow-up--a guide for gastroenterologists

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for the majority of patients with ulcerative colitis who require surgery. Over 2500 patients in the UK have undergone restorative proctocolectomy. It is now increasingly being performed in district general hospitals as well as in specialist inflammatory bowel disease units. Gastroenterologists are increasingly involved in the management of patients following restorative proctocolectomy.

AIM

To provide gastroenterologists with a clear understanding of the investigation and evidence-based management of complications and the aftercare required in patients who have undergone restorative proctocolectomy.

RESULTS

Following restorative proctocolectomy, most patients have an excellent long-term functional outcome. Pouchitis, pelvic sepsis and poor function are the most common causes of failure. The development of cancer is rare; nevertheless, long-term follow-up is required.

CONCLUSIONS

The investigation and management of patients who develop complications require a multidisciplinary team approach to optimize the outcome. Protocols are suggested for investigation and management of patients with complications and for long-term cancer surveillance.

Sexual function, body image, and quality of life after laparoscopic and open ileal pouch-anal anastomosis

PURPOSE

This study was designed to compare self-reported sexual function, body image, and quality of life outcomes among ulcerative colitis patients undergoing laparoscopic or open ileal pouch-anal anastomosis.

METHODS

Between 1978 and 2004, 100 laparoscopic and 189 open operations were performed in patients who were identified from a previously published cohort. Patients were surveyed one year after operation to evaluate sexual function, body image, and quality of life.

RESULTS

A total of 125 of 289 patients (43 percent) returned completed surveys. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between those who completed the surveys and those who did not. There were no clinical differences in results between laparoscopic and open patients using the three survey instruments. Orgasmic function scores were lower in men who underwent laparoscopic ileal pouch-anal anastomosis (P < 0.05) compared with open ileal pouch-anal anastomosis. Overall, sexual function scores were equal to or better than normal values for men but were lower in women. Finally, overall body image and quality of life scores were above the means published for the United States.

CONCLUSIONS

After ileal pouch-anal anastomosis, men and women reported excellent body image and high cosmetic and quality of life scores regardless of operative approach. Female sexual function was more adversely affected after ileal pouch-anal anastomosis than was male sexual function.

Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis

BACKGROUND & AIMS

Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes.

METHODS

We analyzed the 1995-2005 Nationwide Inpatient Sample to identify 7108 discharges for UC patients who underwent a total abdominal colectomy. The effects of hospital volume on postoperative morbidity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors.

RESULTS

Postoperative mortality and morbidity rates were 2.3% and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95% confidence interval [CI]: 1.26-4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48-8.40), aged 60-80 years (aOR, 8.70; 95% CI: 3.30-22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13-8.66). Emergently admitted UC patients whose surgery was performed 6 days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13-3.97).

CONCLUSIONS

Postoperative mortality was lowest in hospitals that performed the highest volume of operations. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC.

A systematic stapling defect - a potential cause of 'anastomotic' leak after restorative proctocolectomy

OBJECTIVE

When constructing ileal-anal pouches with staples, a novel potential cause of anastomotic leak was recently identified at the apex of the pouch. This study was performed to assess this stapling defect.

METHOD

Careful inspection of the ileal pouch staple lines was made in eight consecutive pouch constructions. Pouch construction was further evaluated using pig small bowel.

RESULTS

When constructing ileal-anal pouches with staples, a novel potential cause of anastomotic leak was recently identified at the apex of the pouch. This defect was present in seven of eight consecutive ileo-anal J-pouches. It was repaired by direct suturing and no clinical or radiological leaks were identified in these patients. In the pig model, the same defect was found in five of five stapled constructions. It was avoiding in five of five cases by limiting the amount of bowel placed into the stapler on the initial firing.

CONCLUSION

This defect may be related to stapler design. It can be avoided by using less than the full staple line on the initial firing of the stapler or by using an alternative device. Surgeons creating ileal pouches using staplers, or indeed any use of this particular stapler, need to be aware of this potential for a defect in the staple line and should take steps to avoid the defect or repair it depending on the circumstances.

Surgery for ulcerative colitis

Ulcerative colitis is an inflammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are specific indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the final decision regarding choice of procedure.

Ileal pouch-anal anastomosis

BACKGROUND

Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application.

METHODS AND RESULTS

Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

CONCLUSION

The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

Ileal pouch-anal anastomosis for ulcerative colitis: technical considerations

Total colectomy with ileal pouch-anal anastomosis has emerged as the preferred surgical treatment for ulcerative colitis. The operation has evolved over the last few decades. Various technical issues are discussed, including types of reservoir, options for mesenteric lengthening, method and level of ileoanal anastomosis (hand-sewn versus stapled), and rationale for staging. Anticipated postoperative problems and strategies for management are discussed.

Clinical outcomes and cost analysis of a "fast track" postoperative care pathway for ileal pouch-anal anastomosis: a case control study

PURPOSE

Traditional length of hospital stay after ileal pouch-anal anastomosis is 8 to 15 days. Fast track rehabilitation programs reduce stay, but there are concerns that readmission and complication rates may be increased. This study evaluated a fast track pathway after ileoanal pouch surgery.

METHODS

One hundred three consecutive patients underwent ileal pouch-anal anastomosis on two colorectal services using a fast track protocol with early ambulation, diet, and defined discharge criteria. Direct hospital costs and 30-day and long-term complication data were collected. Patients were matched to controls managed with traditional care pathways by other colorectal staff.

RESULTS

Matching was established for 97 patients. Fast track patients had shorter hospital stay than controls (median 4 vs. 5 days; mean 5.0 vs. 5.9, P = 0.012). Readmission and recurrent operation rates were similar (24 vs. 20 percent, P = 0.49, and 9 vs. 10 percent, P = 0.8, fast track vs. control, respectively). Median direct costs per patient (US$) within 30 days were lower with fast track (5692 vs. 6672, P = 0.001), primarily because of reductions in postoperative management expenses. Complication rates, including pouch failure, bowel obstruction, pouchitis, and anastomotic stricture were comparable. Early discharge (< or = 5 days from surgery) occurred in 79 (77 percent) fast track patients. Failure with early discharge was associated with male gender, reoperations, and anastomotic complications.

CONCLUSIONS

Fast track protocol after ileoanal pouch surgery reduces length of stay and hospital costs without increasing complication rates. Successful early discharge usually signals a benign postoperative course.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.

Rod in loop ileostomy: just an insignificant detail for ileostomy-related complications?

BACKGROUND AND AIMS

The aim of this prospective study was to validate a variant in the loop ileostomy construction to reduce peristomal pressure ulcers and, subsequently, the need of stoma therapist assistance and the frequency of changing the stoma appliance.

PATIENTS AND METHODS

We have enrolled 33 consecutive patients who underwent two stage restorative proctocolectomies. The first consecutive 13 patients operated on had their ileostomies constructed with a standard rod. In the following 20 patients, we placed a 5.3-mm suction catheter tube closed with a stitch to form a "ring" and without any stitches fixing it to the skin.

RESULTS

In the "ring" rod group 40% of patients did not report any complication compared to the 8% of patients in the standard rod group (p = 0.046). Pressure ulcers were absent in this group, while it affected 61% of the patients in the standard rod group (p < 0.001). Patients in the "ring" rod group needed significantly less assistance time by the stoma therapist (p < 0.01) and required significantly fewer stoma appliance changes (p < 0.01). In our institution, the overall cost for the complete management of a standard rod ileostomy was 73.16 (29.83-130.49) euro compared to 46.65 (23.15-93.48) euro for a "ring" rod ileostomy (p = 0.002).

CONCLUSIONS

The adoption of a "ring" rod configuration led to an elimination of pressure ulcers due to the rigid rod, a shorter time requirement for stoma care and a decreased number of appliances required and was subsequently associated with lower costs of assistance. A tighter fitting around the ileostomy that avoided stool infiltration improved the practical management of the stoma with a "ring" rod.

Safety, feasibility, and short-term outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case-matched experience

OBJECTIVE

To compare safety and short-term outcomes of 100 laparoscopic ileal pouch-anal anastomosis (IPAA) versus 200 conventional open IPAA patients.

SUMMARY BACKGROUND DATA

Outcomes of laparoscopic IPAA (LAP-IPAA) have been incompletely characterized. Previous reports are characterized by small numbers of patients and rarely include case-matched or randomized trial methodology. This report describes 100 LAP-IPAA patients case matched to 200 open IPAA patients.

METHODS

Between 1998 and 2004, 100 consecutive LAP-IPAA patients (75 laparoscopic assisted, 25 hand assisted) were identified and case matched to 200 open IPAA control patients by age, operation, gender, date of operation, and body mass index. Operative and postoperative outcomes at 90 days were compared.

RESULTS

A total of 300 patients (180 female) with a median age of 32 years (range, 17-66 years), and a median body mass index of 23 kg/m (range, 16-34 kg/m) underwent IPAA (100 LAP-IPAA, 200 open IPAA). Diagnosis (chronic ulcerative colitis 97%, familial adenomatous polyposis 3%) and previous operative history were equivalent between groups. One intraoperative complication occurred in each group. Overall, the laparoscopic conversion rate was 6%. Median operative time was longer for the LAP-IPAA group (333 minutes versus 230 minutes, P < 0.0001). LAP-IPAA patients had shorter median time to regular diet (3 versus 5 days), time to ileostomy output (2 versus 3 days), length of stay (4 versus 7 days), and decreased IV narcotic use (all P < 0.05. Postoperative morbidity was equivalent (LAP-IPAA = 33%, open IPAA = 37%), mortality was nil, and readmission rates were equal (LAP-IPAA = 21%, open IPAA = 22%). Reoperation was required in 3% of LAP-IPAA and 6.5% of open IPAA patients (P < 0.2) during the first 3 months.

CONCLUSION

LAP-IPAA is equivalent to open IPAA in terms of safety and feasibility. In addition, LAP-IPAA provides significant improvements in short-term recovery outcomes.