Does the level of stapled ileoanal anastomosis influence physiologic and functional outcome?

Dynamic ileal pouch emptying studies

Although much radiologic literature has focused on the short-term post-operative complications associated with ileal pouches, as the number of patients with long-term pouches has grown, there is increasing realization of the functional deficits that may occur long after pouch creation. Dynamic pouch imaging using fluoroscopy and MRI can provide assessment of the underlying causes of symptomatic pouch dysfunction and can provide critical insight to the management of this complex patient population. In this paper, we provide an overview of the unique problems encountered in patients with long-term ileal pouches, and provide an overview of the techniques, interpretation, and reporting for fluoroscopic and MR pouch defecography.

Ulcerative colitis (K51), adults

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MRI defecography of the ileal pouch-anal anastomosis-contributes little to the understanding of functional outcome

PURPOSE

Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients.

METHODS

From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy.

RESULTS

Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores.

CONCLUSION

It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

Determinants of optimal bowel function in ileal pouch-anal anastomosis - physiological differences contributing to pouch function

BACKGROUND

Variability in functional outcome after ileal-pouch anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to perform multiple physiological and biochemical tests including an endoscopic examination with histology on IPAA patients with well and poorly functioning pouches to determine factors, or combinations thereof, contributing to functional outcome.

METHODS

All patients with ulcerative colitis undergoing restorative proctocolectomy between 2000 and 2013 (N = 108) were interviewed using a pouch functioning score. The best and worst functioning quartiles were invited to undergo examination with a barostat measuring pouch volume at preset variable distension pressures, and a pouch endoscopy.

RESULTS

Forty five of 58 eligible patients agreed to participate. The most significant physiological parameter differing between the well and poorly functioning pouches was pouch volume at first sensation, urge and discomfort (p value <.001). Urge volumes were 213 (CI 171-256) ml for poorly and 352 (CI 305-401) ml for well functioning pouches. Pouchitis episodes were negatively correlated to function. The poorly functioning patients had a higher prevalence of histological signs of inflammation and hand-sewn anastomosis, and a longer remaining rectal cuff, however, nonsignificant. The pouch pressure at sensation thresholds did not differ between the groups.

CONCLUSIONS

Pouch volume is the most dominant predictor of pouch function in this study. The present comprehensive study of a multitude of different factors that possibly could be contributing to functional outcome, failed to shed much further light on the functional variability among pouch patients. The pouch physiology remains to a large extent unexplained.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgery in the age of biological treatment

Surgery for IBD is in constant evolution; it does not appear that the introduction of biologicals has had a major effect on the chance of a patient being operated on or not. Pouch surgery had its heydays in the 80s and 90s and has since then become less frequent, but the number of patients undergoing surgery still seem about the same from one year to the other. Likewise, there is no substantial evidence that surgery for Crohn's disease is diminishing. There have been fears that patients on biological treatment have an increased risk of postoperative complications. The issue is not completely settled but it is likely that patients on biological treatment who come to surgery are those who do not benefit from biologicals. Thus, they are compromised in that they have an ongoing inflammation, are in bad nutritional state, and might have several other known risk factors for a complicated postoperative course. These factors and perhaps not the biologicals per se is what surgeons should consider. During the recent years, we have seen several new developments in IBD surgery; the ileorectal anastomosis is being used for ulcerative colitis and laparoscopic surgery usually resulting in a shorter hospital stay, less pain, and better cosmetics. We have also seen the introduction of robotic surgery, single incision minimal invasive surgery, transanal minimal invasive surgery, and other approaches to minimize surgical trauma. Time will show which of these innovations patients will benefit from.

Human tissue-engineered colon forms from postnatal progenitor cells: an in vivo murine model

AIM

Loss of colon reservoir function after colectomy can adversely affect patient outcomes. In previous work, human fetal intestinal cells developed epithelium without mesenchyme following implantation in mice. However, for humans, postnatal tissue would be the preferred donor source. We generated tissue-engineered colon (TEC) from postnatal human organoid units.

MATERIALS & METHODS

Organoid units were prepared from human colon waste specimens, loaded onto biodegradable scaffolds and implanted into immunocompromised mice. After 4 weeks, human TEC was harvested. Immunofluorescence staining confirmed human origin, identified differentiated epithelial cell types and verified the presence of supporting mesenchyme.

RESULTS

Human TEC demonstrated a simple columnar epithelium. Immunofluorescence staining demonstrated human origin and the three differentiated cell types of mature colon epithelium. Key mesenchymal components (smooth muscle, intestinal subepithelial myofibroblasts and ganglion cells) were seen.

CONCLUSION

Colon can form from human progenitor cells on a scaffold in a mouse host. This proof-of-concept experiment is an important step in transitioning TEC to human therapy.

[Current status of elective surgical treatment of ulcerative colitis. A systematic review]

Despite recent advances in the medical treatment of ulcerative colitis (UC), approximately 25-40% of patients will need surgery during their disease. The aim of elective surgical treatment of UC is to remove the colon/and rectum with minimal postoperative morbidity, and to offer a good long-term quality of life. There are several technical options for the surgical treatment of UC; at present, the most frequently offered is restorative proctocolectomy and ileal pouch-anal anastomosis. Both the surgeon and patient should be aware of the risks associated with a technically demanding procedure and possible postoperative complications, including the possibility of infertility, permanent stoma, or several surgical procedures for pouch-related complications. A precise knowledge of each surgical technique, and its indications, complications, long-term risks and benefits is useful to offer the best surgical option tailored to each patient. We searched in PubMed, MEDLINE, and EMBASE for all kinds of articles (all the publications until April 2012). Papers on Crohn's disease, indeterminate colitis, or other forms of colitis were excluded from the review. We reviewed the abstracts and identified potentially relevant articles. MeSH words were used as search, "ulcerative colitis", "surgery", "indications", "elective surgery", "colectomy," "proctocolectomy," "laparoscopy", "Complications," "outcome", "results" "quality of life". One hundred and four articles were included in this review.

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients

OBJECTIVE

Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.

BACKGROUND

The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes.

METHODS

Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone.

RESULTS

Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080).

CONCLUSIONS

Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

A new operative technique for restorative proctocolectomy: the endorectal pull-through combined with a double-stapled ileo-anal anastomosis

BACKGROUND

In children, restorative proctocolectomy is usually accomplished by a rectal mucosectomy followed by a hand-sewn ileo-anal anastomosis+/-ileal pouch. In certain patients, a hand-sewn anastomosis can be technically difficult. This led us to develop a new technique that combines endorectal mucosectomy with a double-stapled ileo-anal anastomosis.

METHODS

After colectomy, an ileal J-pouch is constructed. The head of the circular stapler is placed in the apex of the pouch and secured. An endorectal mucosectomy is completed from the abdomen to approximately 1.5 cm above the dentate line. The rectal mucosal/submucosal tube is everted onto the perineum. A transverse stapler is positioned 1.5 cm above the dentate line on the perineum and fired. The circular stapler is inserted transanally and the trocar advanced through the transverse staple line until the head and anvil are mated and then fired. A loop ileostomy is constructed.

RESULTS

Thirteen patients, with a mean age of 12.3 years, have undergone endorectal mucosectomy with a double-stapled anastomosis without major complication. The operative time averaged 280+/-70 minutes. The mean 24-hour stool frequency, with 9 months' follow-up, was 6.8+/-3.2, of which 1+/-0.7 were at night.

CONCLUSIONS

The combination of endorectal mucosectomy with a double-stapled anastomosis is a new approach for patients requiring restorative proctocolectomy. In our early experience, this technique was completed with a low complication rate and excellent functional results.

Randomized, controlled trial of topical phenylephrine for fecal incontinence in patients after ileoanal pouch construction

INTRODUCTION

Fecal incontinence is experienced by some patients with an ileoanal reservoir pouch. The alpha1-adrenergic agonist phenylephrine raises resting anal sphincter pressure in healthy volunteers and may be of value in these patients.

METHODS

Twelve patients (7 female), median age 44 (range, 29-67) years were studied. All had fecal incontinence despite a noninflamed pouch of normal size and ultrasonographically structurally normal anal sphincter muscles. Patients were treated with topical 10 percent phenylephrine and placebo gels, allocated in random order in a double-blind, crossover study for two four-week periods. Before and during treatment, maximum resting anal sphincter pressure and anodermal blood flow were measured, a symptom questionnaire was completed, and incontinence score was determined using a validated scale.

RESULTS

Six of 12 (50 percent) patients improved subjectively after phenylephrine compared with one on placebo (P = 0.07). Four patients had complete cessation of incontinence with active treatment. Phenylephrine significantly reduced the incontinence score (P = 0.015). It also resulted in a significant rise in mean maximum resting anal sphincter pressure when compared with placebo (P = 0.012). For all 12 patients, mean percent subjective improvement was higher after phenylephrine compared with placebo (P = 0.04). There were no side effects.

CONCLUSIONS

Topical phenylephrine significantly improves fecal continence in patients with an ileoanal pouch. In some patients it totally eliminates nocturnal episodes. The mechanism of benefit is likely to be one of altered neural sphincter control. This is the first study of the use of a topical pharmacologic agent to treat fecal incontinence and may have a wider application.

Gradient of pressure and time between proximal anal canal and high-pressure zone during internal anal sphincter relaxation. Its role in the fecal continence mechanism

PURPOSE

The normal response to rectal distention is a relaxation of the proximal anal canal (PAC). We hypothesized that this mechanism would require a gradient of pressure and time to preserve continence.

METHODS

Sixteen volunteers (10 male), mean age, 41.5 (range, 24-60) years, were studied using an eight port axial catheter with a compliant balloon at its tip. Relaxation was induced by a small volume of rectal distention (15-30 ml of air) and was recorded until recovery of resting anal pressure (RAP). Duration of relaxation was measured until recovery of RAP. Amplitude of relaxation was determined between RAP before rectal distention (RAP-BR) and pressure at the point of maximum relaxation (RAP-PMR). Gradient of pressure was determined by comparing RAP-PMR in the high-pressure zone (HPZ) and PAC. Contraction in the distal anal canal was interpreted as external anal sphincter contraction (EASC) and was compared with RAP-PMR in the HPZ.

RESULTS

Relaxation was significantly greater in PAC than in HPZ (50 vs. 36 percent; P = 0.001). RAP-PMR was significantly higher in HPZ than in PAC (30.7 vs. 12.6 mmHg; P = 0.001). EASC was observed in six patients and did not show significant difference with RAP-PMR in HPZ (39.7 vs. 36.3 mmHg; not significant). Relaxation began at the same time in all levels but lasted significantly longer in PAC compared with HPZ (13.5 vs. 9.4 sec; P = 0.003).

CONCLUSION

Anal relaxation induced by small volume rectal distention involves a gradient in the pressure and time of relaxation between PAC and the HPZ.

Physiology of ileal pouch-anal anastomosis. Current concepts

PURPOSE

Increasing experience with ileal pouch-anal anastomosis (IPAA) associated with increasing knowledge about anorectal physiology has lead to a large number of publications. The purpose of this review is to evaluate the current understanding of fecal continence as revealed by the evolution of the ileoanal procedure.

METHODS

Review of the literature covering the most important physiologic parameters involved in fecal continence was undertaken.

RESULTS

Rectoanal inhibitory reflex is probably absent after IPAA but is preserved when distal anorectal mucosa is spared. Anal resting pressure decreases but is less affected when the internal anal sphincter is less traumatized. Squeeze pressure is not importantly affected, and the importance of reservoir function as a determinant of stool frequency is emphasized. IPAA does not affect the coordination between pouch and anal canal motility in the majority of cases. Normal continence is preserved, even during the night, by preserving a gradient of pressure between the pouch and anal canal.

CONCLUSIONS

Physiologic concepts are well established, but controversies about the continence mechanism related to IPAA remain. The IPAA procedure has allowed discrimination of details about the function of multiple structures involved in fecal continence.

Stapled ileal pouch-anal anastomosis with resection of the anal transition zone

We assessed the outcome of stapled ileal J-pouch-anal anastomosis with intersphincteric resection of the anal transition zone in 83 consecutive patients with ulcerative colitis (n = 71) or familial adenomatous polyposis (n = 12). There was no postoperative mortality. Two patients (2.4%) required permanent ileostomy for manifestation of unsuspected Crohn's disease. Major postoperative complications consisted of pelvic sepsis, anastomotic leakage, and pancreatitis with 3.6% each. Both, frequency of bowel movements and degree of continence improved with time. Two years after takedown of the diverting ileostomy 45 patients with ulcerative colitis and 12 with familial adenomatous polyposis were assessed with a frequency of bowel movements of 5.6 +/- 2 and 3.2 +/- 1 per 24 h, respectively (P < 0.05). At this time none of them had major daytime or nighttime incontinence. Minor incontinence was reported by 9% and 14% of the patients with ulcerative colitis during day-time and night-time, respectively. The patients with familial adenomatous polyposis demonstrated better results, without day-time seepage and intermittent nocturnal seepage in only 9%. It is concluded that direct ileal J-pouch-anal anastomosis is a safe procedure with excellent functional results for patients with ulcerative colitis and familial adenomatous polyposis.