How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis?

Persistent perineal sinus following proctocolectomy in the inflammatory bowel disease patient

Prolonged perineal wound healing following proctocolectomy in patients with inflammatory bowel disease (IBD) is a frustrating result for the medical team and patients who were hoping for improved quality of life. Prolonged healing, which lasts more than 6 months following proctocolectomy, is termed persistent perineal sinus (PPS) and typically necessitates further surgical management. Healing of the PPS is difficult due to the resulting "dead space" following proctocolectomy, necessitating the need to fill the void with viable tissue in an area with anatomic constraints. Here we provide a narrative review and comprehensively address the incidence, pathogenesis, and clinical and operative management of a PPS in patients with IBD following proctocolectomy. Operative methods discussed include surgical debridement, flap closure of the perineum, omental flap closure, and gracilis muscle transposition. It is necessary to further investigate and establish a gold standard of care for these patients.

Long-term Outcomes and Factors Predicting Outcome of IPAA When Used Intentionally for Well-Defined Crohn's Disease

BACKGROUND

Crohn's disease is considered a contraindication for IPAA. In our prior study, when IPAA was used intentionally for well-defined Crohn's disease, we found a high incidence of recurrent disease with a low incidence of pouch failure.

OBJECTIVE

This study aimed to replicate these findings in a larger cohort over a longer period.

DESIGN

Retrospective review of a prospective IBD registry.

SETTINGS

Large IBD referral center.

PATIENTS

Patients with preoperative colorectal Crohn's disease requiring surgery were included in the study.

INTERVENTION

IPAA.

MAIN OUTCOME MEASURES

Long-term Crohn's disease recurrence, pouch failure, and pouch function.

RESULTS

Forty-six patients were identified. Crohn's disease was diagnosed on the basis of perianal disease (n = 18; 39%), small-bowel disease (n = 16; 35%), noncaseating granuloma (n = 10; 22%), and discontinuous inflammation (colorectal skip lesions) (n = 11; 24%). After a median follow-up of 93 (7-291) months, 22 patients (48%) developed recurrent Crohn's disease based on afferent limb disease (n = 14; 30%) or pouch fistulizing disease (n = 8; 18%). Only 4 patients (9%) developed pouch failure. No clinical factor was associated with Crohn's disease recurrence. Young age at the time of surgery and short duration of disease before IPAA were associated with pouch fistula recurrence ( p = 0.003 and p = 0.03, respectively). Most patients (86%) reported excellent continence, with no urgency (67%) and median stool frequency of 6 (range, 3-9) per day.

LIMITATION

Retrospective nature and relatively small sample size.

CONCLUSION

This largest reported series examining the intentional use of IPAA in Crohn's disease showed a high (48%) incidence of postoperative Crohn's disease with a low (9%) incidence of pouch failure. Young age and short disease course before surgery were risk factors for poor outcomes. Highly motivated patients with colorectal Crohn's disease may consider IPAA and avoid a definitive ileostomy. See Video Abstract at http://links.lww.com/DCR/C171 .

RESULTADOS A LARGO PLAZO Y FACTORES PREDICTORES DE RESULTADOS DE LA ANASTOMOSIS ILEOANAL CON RESERVORIO CUANDO SE USA INTENCIONALMENTE PARA LA ENFERMEDAD DE CROHN BIEN DEFINIDA

ANTECEDENTES: La enfermedad de Crohn (EC) se considera una contraindicación para la anastomosis ileoanal con reservorio (IPAA). Nuestro estudio previo de IPAA cuando fue usada intencionalmente para EC bien definida mostró una alta incidencia de enfermedad recurrente con una baja incidencia de falla del reservorio.OBJETIVO: Replicar estos hallazgos en una cohorte más grande durante un período más largo.DISEÑO: Revisión retrospectiva de una base de datos prospectiva de enfermedad inflamatoria intestinal.ESCENARIO: Un centro grande de referencia de EII.PACIENTES: EC colorrectal preoperatoria con necesidad de tratamiento quirúrgico.INTERVENCIÓN: Anastomosis ileoanal con reservorio.RESULTADOS PRINCIPALES: Recurrencia de EC a largo plazo, falla del reservorio y función del reservorio.RESULTADOS: Cuarenta y seis pacientes fueron identificados. El diagnóstico de EC se basó en enfermedad perianal (n = 18; 39%), enfermedad del intestino delgado (n = 16; 35%), granuloma no caseificante (n = 10; 22%) e inflamación discontinua (lesiones salteadas colorrectales) (n = 11; 24%). Después de una mediana de seguimiento de 93 (7-291) meses, 22 (48 %) pacientes desarrollaron EC recurrente debido a enfermedad del asa aferente (n = 14; 30%) o enfermedad fistulizante del reservorio (n = 8; 18%). Solo 4 (9%) pacientes desarrollaron falla del reservorio. Ningún factor clínico se asoció con la recurrencia de EC. La edad joven en el momento de la cirugía y la corta duración de la enfermedad antes de IPAA se asociaron con la recurrencia de la fístula del reservorio ( p = 0.003 y p = 0.03, respectivamente). El recuento de plaquetas preoperatorio más alto fue la única característica clínica significativamente asociada con el fracaso del reservorio ( p = 0.02). La mayoría de los pacientes (86%) reportaron una continencia excelente, sin urgencia (67%) y una mediana de frecuencia evacuatoria de 6 (rango, 3-9) por día.LIMITACIONES: Naturaleza retrospectiva y tamaño de muestra relativamente pequeño.CONCLUSIÓN: Esta serie, la más grande reportada que examina el uso intencional de IPAA en la EC mostró una incidencia alta (48Rectal Cancer: Clinical and Molecular Predictors of a Complete Response to Total Neoadjuvant Therapy%) de EC posoperatoria con una incidencia baja (9%) de falla del reservorio. La edad joven y el curso corto de la enfermedad antes de la cirugía fueron factores de riesgo para pobres resultados. Pacientes altamente motivados con EC colorrectal pueden considerar una IPAA y evitar una ileostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/C171 . (Traducción-Dr. Jorge Silva Velazco ).

Crohn's of the Pouch: Now What?

Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the gold standard surgical treatment for the majority (∼90%) of ulcerative colitis (UC) patients. In cases of carefully selected Crohn's colitis patients without small bowel or perianal involvement an "intentional IPAA" may be a viable option for disease resection and restoration of intestinal continuity. More commonly, Crohn's is incidentally found either in the resection specimen or, more commonly, when inflammatory complications subsequently arise after pouch construction for UC or indeterminate colitis. These incidental Crohn's pouches may be diagnosed early or late period post-IPAA. Crohn's may manifest within the pouch, in the proximal small bowel, and/or distally in the rectal cuff or anus. Like intestinal Crohn's, Crohn's disease of the pouch may be of an inflammatory, fibrostenosing, or fistulizing phenotype. Treatment depends on the phenotype and includes medical treatment, most commonly in the form of tumor necrosis factor inhibitor medications; however, the newer small molecules offer a potential treatment for these patients. Surgery first entails treating the sequelae of Crohn's and is typically staged. In up to 60% of Crohn's pouches, particularly in fistulizing disease and/or recalcitrant perianal disease, the pouch fails and must be defunctioned or excised. In patients with Crohn's pouches in situ long term, outcomes including quality of life are comparable to patients who underwent IPAA for UC.

Validation of the Padova Prognostic Score for Colitis in Predicting Long-Term Outcome After Restorative Proctocolectomy

Background

In 10%–20% of cases it is impossible to make a differential diagnosis between ulcerative colitis and Crohn's colitis. A 50% failure rate of J pouch ilea-anal anastomosis is observed in Crohn's colitis. In 2009, we created the Padua Prognostic Score for Colitis (PPSC) to predict the long-term clinical and functional outcome and quality of life of patients undergoing restorative proctocolectomy with J pouch. The aim of the present study is to establish and validate the accuracy of a prognostic score for chronic inflammatory bowel diseases (IBD).

Patient population and methods

The PPSC was created in 2009 by integrating clinical and histological information of patients undergoing RPC. It included preoperative perianal abscess or fistula, rectal sparing, terminal ileum involvement, skip lesions and histological diagnosis of indeterminate colitis or Crohn's colitis on the operative specimen. The validity of this score was tested in predicting postoperative abscess or fistula, anal canal disease, pouchitis, pouch failure and new diagnosis of Crohn's disease. Correlation analysis, ROC curve analysis and survival analysis were used to validate the PPSC in a different cohort from the previous one.

Results

We retrospectively enrolled in this study 138 consecutive patients undergoing CPR for ulcerative colitis (n = 127) or indeterminate colitis (n = 11) in our institution since 2005 to 2020. In this period, we observed 11 patients with postoperative abscess or fistula, 3 with anal canal disease, 40 with pouchitis, 6 with pouch failure and 6 with new diagnosis of Crohn's disease. In the new validation cohort, the PPSC confirmed to have a good accuracy in predicting the onset of postoperative CD (AUC = 74.5%, p = 0.018). Kaplan Meier curves demonstrate how a PPSC over 1 can reliably predicts the long-term onset of, pouchitis (p = 0.002) and anal abscess or fistulae (p = 0.04).

Conclusions

In this validation study we confirmed the accuracy of the PPSC in predicting postoperative fistulas or abscesses and pouchitis. Therefore, we believe that in clinical practice patients with a PPSC score greater than 1 should be warned of this risk of possible Crohn’s disease diagnosis and pouch failure.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review

BACKGROUND

Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure.

OBJECTIVE

This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease.

DATA SOURCES

A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews.

STUDY SELECTION

The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected.

INTERVENTION

Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology.

MAIN OUTCOMES MEASURES

The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate.

RESULTS

Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified.

LIMITATIONS

This investigation was limited by the small number of studies with significant study heterogeneity.

CONCLUSION

In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

Long-Term Bowel Function and Fate of the Ileal Pouch After Restorative Proctocolectomy in Patients With Crohn's Disease: A Systematic Review With Meta-Analysis and Metaregression

BACKGROUND AND AIMS

Debate exists on whether ileal pouch anal anastomosis [IPAA] can be safely offered to patients diagnosed with Crohn's disease [CD]. Our aim was to assess the outcome of IPAA for CD vs ulcerative colitis [UC].

METHODS

We used a PRISMA/MOOSE-compliant meta-analysis. Studies published between 1993 and 2018 were retrieved. Primary end points included complications. Secondary endpoints included functional outcome. The time of CD diagnosis was considered [intentional vs incidental IPAA].

RESULTS

Eleven studies comprising 6770 patients [CD = 352, UC = 6418] were included, with 44-120 months of follow-up. Pouch fistulae were more common in CD (CD vs UC; odds ratio (OR) 6.08; p = 0.0003, GRADE+++), as were strictures [OR 1.82; p = 0.02, GRADE+++] and failure [OR 5.27; p < 0.0001, GRADE++++]. Compared with UC, postoperative CD diagnosis was associated with a much higher risk of fistulae [OR 6.23; p = 0.006, GRADE+++] and failure [OR 8.53; p < 0.0001, GRADE++++] than intentional IPAA in CD [fistula: OR 4.17; p = 0.04, GRADE+++; failure: OR 2.48; p = 0.009, GRADE++++]. Age at surgery was positively associated with failure in CD [p = 0.007]. Obstruction was more common after intentional IPAA for CD. The risk of pouchitis did not differ between CD and UC [OR 1.07, p = 0.76, GRADE+++]. CD patients were at a higher risk of seepage [OR 2.27; p = 0.010, GRADE++].

CONCLUSIONS

Patients with CD have 5-fold higher risk of failure, and a 2-fold risk of strictures after IPAA compared with UC. The risk is much higher if diagnosis is performed after IPAA. Function in those who retain the pouch seemed similar to that of patients with UC. CD does not increase the risk of pouchitis. IPAA could be offered to a selected population of CD patients after proper preoperative counselling.[PROSPERO registry 116811].

Is There a Role for Ileal Pouch Anal Anastomosis in Crohn's Disease?

Traditionally, surgical interventions for colonic Crohn's disease (CD) have been limited to total abdominal colectomy and ileorectal anastomosis, or total proctocolectomy with end ileostomy if there is rectal involvement. However, improved understandings of the biology of CD, as well as the development of biologic therapies, have enabled more limited resections. Here, we review the indications for, and limitations of, specific procedures aiming to preserve intestinal continuity in colonic CD.

Vedolizumab in the treatment of Crohn's disease of the pouch

Background

Our recent study showed the efficacy and safety of vedolizumab in the treatment of chronic antibiotic-refractory pouchitis. However, there are no published studies on its efficacy and safety in Crohn’s disease (CD) of the pouch. The aim of this study was to assess the efficacy and safety of vedolizumab in those patients.

Methods

This case series included all eligible patients with CD of the pouch from our prospectively maintained, IRB-approved Pouchitis Registry from 2015 to 2017. Disease activity in pouch patients can be monitored using the modified Pouchitis Disease Activity Index (mPDAI). mPDAI is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom (range, 0–6 points), endoscopy, (range 0–6 points), and histology (range, 2–6 points). Pre- and post- treatment (minimum 6 months) pouchoscopy and clinical visits were used to calculate mPDAI.

Results

A total of 12 patients were included in this study, who had restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis (UC). The mean age at the time of pre-colectomy diagnosis of UC was 25.0 ± 11.5 years. The mean current age was 41.0 ± 12.1 years, nine (75.0%) were female, three (25.0%) had smoked and eight (66.7%) had used anti-tumor necrosis factor agents prior to vedolizumab use. The mean duration of vedolizumab use was 1.0 ± 6.4 years. There was a significant reduction in mPDAI symptom subscores after vedolizumab therapy (3.50 ± 1.93 vs 5.08 ± 0.79, P = 0.015). The pre- and post-treatment mean endoscopy subscores were 1.25 ± 1.36 and 0.91 ± 1.50 in the afferent limb (P = 0.583); 2.58 ± 1.68 and 2.27 ± 2.05 (P = 0.701) in the pouch body; and 2.67 ± 1.93 and 2.09 ± 2.12 (P = 0.511) in the cuff, respectively. None of the patients experienced side effects throughout the vedolizumab therapy.

Conclusion

The findings of our study suggests that vedolizumab appears to be effective and safe in reducing the symptoms in patients with CD of the pouch.

A systematic review of segmental vs subtotal colectomy and subtotal colectomy vs total proctocolectomy for colonic Crohn's disease

AIM

Surgical management of colonic Crohn's disease (CD) is still unclear because different procedures can be adopted. The choice of operation is dependent on the involvement of colonic disease but the advantages and disadvantages of the extent of resection are still debated.

METHOD

The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileorectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). Studies published between 1984 and 2012 including comparisons of STC vs SC and of STC vs TPC were selected. The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma. Fixed effect models were used to evaluate the study outcomes.

RESULTS

Eleven studies, consisting of a total of 1436 patients (510 STC, 500 SC and 426 TPC), were included. Analysis of the data showed no significant difference between STC and SC in terms of overall and surgical recurrence of CD. In contrast, STC showed a higher risk of overall and surgical recurrence of CD than TPC (OR 3.53, 95% CI 2.45-5.10, P < 0.0001; OR 3.52, 95% CI 2.27-5.44, P < 0.0001, respectively). SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC (OR 2.84, 95% CI 1.16-6.96, P < 0.02; OR 0.19, 95% CI 0.09-0.38, P < 0.0001, respectively). SC resulted in a lower risk of permanent stoma than STC (OR 0.52, 95% CI 0.35-0.77).

CONCLUSION

All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. However, patients in the TPC group showed a lower recurrence risk than those in the STC group. Moreover, SC had a higher risk of postoperative complications but a lower risk of permanent stoma. These data should be taken into account when deciding surgical strategies and when informing patients about postoperative risks.

Long-term Outcomes of Sphincter-Saving Procedures for Diffuse Crohn's Disease of the Large Bowel

BACKGROUND

Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease.

OBJECTIVE

The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease.

DESIGN

Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included.

SETTINGS

The study was conducted at a tertiary care research center.

PATIENTS

Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA.

MAIN OUTCOME MEASURES

Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy.

RESULTS

Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis.

LIMITATIONS

The study was limited by its retrospective nature and small sample size.

CONCLUSIONS

Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

Crohn's Disease of the Colon, Rectum, and Anus

There is no cure for Crohn disease. Newer treatments, such as biological therapy, have led to an improved quality of life. This article focuses on the surgical management of Crohn disease of the colon, rectum, and anus. Restorative and nonrestorative surgical options for colonic Crohn disease are discussed. Treatment options for perianal Crohn disease are also reviewed.

Gastrointestinal endoscopy biopsy derived proteomic patterns predict indeterminate colitis into ulcerative colitis and Crohn’s colitis

Patients with indeterminate colitis (IC) are significantly younger at diagnosis with onset of symptoms before the age of 18 years with significant morbidity in the interim. The successful care of IC is based on microscopic visual predict precision of eventual ulcerative colitis (UC) or Crohn’s colitis (CC) which is not offered in 15%-30% of inflammatory bowel disease (IBD) patients even after a combined state-of-the-art classification system of clinical, visual endoscopic, radiologic and histologic examination. These figures have not changed over the past 3 decades despite the introduction of newer diagnostic modalities. The patient outcomes after restorative proctocolectomy and ileal pouch-anal anastomosis may be painstaking if IC turns into CC. Our approach is aiming at developing a single sensitive and absolute accurate diagnostic test tool during the first clinic visit through endoscopic biopsy derived proteomic patterns. Matrix-assisted-laser desorption/ionization mass spectrometry (MS) and/or imaging MS technologies permit a histology-directed cellular test of endoscopy biopsy which identifies phenotype specific proteins, as biomarker that would assist clinicians more accurately delineate IC as being either a UC or CC or a non-IBD condition. These novel studies are underway on larger cohorts and are highly innovative with significances in differentiating a UC from CC in patients with IC and could lend mechanistic insights into IBD pathogenesis.

Diagnosis of inflammatory bowel disease: Potential role of molecular biometrics

Accurate diagnosis of predominantly colonic inflammatory bowel disease (IBD) is not possible in 30% of patients. For decades, scientists have worked to find a solution to improve diagnostic accuracy for IBD, encompassing Crohn's colitis and ulcerative colitis. Evaluating protein patterns in surgical pathology colectomy specimens of colonic mucosal and submucosal compartments, individually, has potential for diagnostic medicine by identifying integrally independent, phenotype-specific cellular and molecular characteristics. Mass spectrometry (MS) and imaging (I) MS are analytical technologies that directly measure molecular species in clinical specimens, contributing to the in-depth understanding of biological molecules. The biometric-system complexity and functional diversity is well suited to proteomic and diagnostic studies. The direct analysis of cells and tissues by Matrix-Assisted-Laser Desorption/Ionization (MALDI) MS/IMS has relevant medical diagnostic potential. MALDI-MS/IMS detection generates molecular signatures obtained from specific cell types within tissue sections. Herein discussed is a perspective on the use of MALDI-MS/IMS and bioinformatics technologies for detection of molecular-biometric patterns and identification of differentiating proteins. I also discuss a perspective on the global challenge of transferring technologies to clinical laboratories dealing with IBD issues. The significance of serologic-immunometric advances is also discussed.

Diagnosis of inflammatory bowel disease: Potential role of molecular biometrics

Accurate diagnosis of predominantly colonic inflammatory bowel disease (IBD) is not possible in 30% of patients. For decades, scientists have worked to find a solution to improve diagnostic accuracy for IBD, encompassing Crohn’s colitis and ulcerative colitis. Evaluating protein patterns in surgical pathology colectomy specimens of colonic mucosal and submucosal compartments, individually, has potential for diagnostic medicine by identifying integrally independent, phenotype-specific cellular and molecular characteristics. Mass spectrometry (MS) and imaging (I) MS are analytical technologies that directly measure molecular species in clinical specimens, contributing to the in-depth understanding of biological molecules. The biometric-system complexity and functional diversity is well suited to proteomic and diagnostic studies. The direct analysis of cells and tissues by Matrix-Assisted-Laser Desorption/Ionization (MALDI) MS/IMS has relevant medical diagnostic potential. MALDI-MS/IMS detection generates molecular signatures obtained from specific cell types within tissue sections. Herein discussed is a perspective on the use of MALDI-MS/IMS and bioinformatics technologies for detection of molecular-biometric patterns and identification of differentiating proteins. I also discuss a perspective on the global challenge of transferring technologies to clinical laboratories dealing with IBD issues. The significance of serologic-immunometric advances is also discussed.

Ileal pouch-anal anastomosis: Points of controversy

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current "hot topics" for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn's disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues.

Factors affecting the healing of the perineum following surgery

INTRODUCTION

The aim of this study was to establish patient and procedural factors associated with the development of an unhealed perineum in patients undergoing a proctectomy or excision of an ileoanal pouch.

METHODS

A review of 194 case notes for procedures performed between 1997 and 2009 was carried out. All patients had at least 12 months' follow-up. Univariate and multivariate analyses were performed in 16 parameters. For those patients who developed an unhealed perineum, Cox regression analysis was performed to establish healing over a 12-month period.

RESULTS

Two hundred patients were included in the study, of which six had unknown wound status and were subsequently excluded. This left 194 study patients. Of these, 86 (44%) achieved primary wound healing with a fully healed perineum and 108 (56%) experienced primary wound failure. With reference to the latter, 63 (58%) healed by 12 months. Comparing patients with an initially intact perineum with those with initial wound failure showed pre-existing sepsis was highly relevant (odds ratio: 4.32, 95% confidence interval [CI]: 2.16-8.62, p<0.001). In patients who had an unhealed perineum initially, perineal sepsis and surgical treatment were both significantly associated with time to healing (hazard ratio [HR]: 0.54, 95% CI: 0.31-0.93, p=0.03; and HR: 0.42, 95% CI: 0.21-0.84, p=0.01).

CONCLUSIONS

The presence of pre-existing perineal sepsis is associated with an unhealed perineum following proctectomy in inflammatory bowel disease (IBD) and non-IBD surgery. Further studies are indicated to establish perineal sepsis as a causative factor.

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.

Restorative operations for Crohn's disease

Restoration of the continuity of the intestinal tract is one of the key concepts for maintaining the quality of life in patients with Crohn's disease. Restorative procedures have an important role in the scope of operative modalities for these patients. The authors review operative options aimed at fulfilling these goals including restorative partial small bowel resection; segmental, subtotal, and total colectomies; and ileal pouch anal anastomosis in patients with Crohn's disease.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

Restorative proctocolectomy for inflammatory bowel disease: the Padova prognostic score for colitis in predicting long-term outcome and quality of life

BACKGROUND

In 10-20% of cases, it is impossible to distinguish between ulcerative colitis and Crohn's colitis, affecting the possibility to predict the long-term outcome after restorative proctocolectomy (RPC). The study aimed to assess the accuracy of a new prognostic score for inflammatory bowel diseases (IBD) colitis [the Padova Prognostic Score for Colitis (PPSC)] in predicting long-term clinical/functional outcome and quality of life after RPC.

MATERIALS AND METHODS

The PPSC was created by the integration of histological and clinical information. The accuracy of the PPSC was tested in predicting long-term clinical outcome (i.e. pouch complications/survival) and quality of life of 58 consecutive patients who had undergone RPC in our institute from 1984 to 2004. Clinical outcome was assessed with an ad hoc functional questionnaire and the revision of the hospital and outpatients clinic notes. Quality of life surveys were carried out with the Padova IBD Quality of Life (PIBDQL) and with Cleveland Global Quality of Life (CGQL) scores.

RESULTS

The PPSC predicted pouch fistulae (accuracy = 84.5%; sensitivity = 50%; specificity = 90%) and changes in sexual life (accuracy = 71%; sensitivity = 23%; specificity = 87%). The PPSC also predicted the PIBDQL score with an accuracy of 62%, a sensitivity of 28% and a specificity of 97%, whilst it predicted the CGQL score with an accuracy of 29%, a sensitivity of 12% and a specificity of 80%. The PPSC failed to predict pouchitis or pouch failure.

CONCLUSIONS

The Padova Prognostic Score for Colitis proved effective in predicting pouch fistulae or abscesses, but not pouchitis and pouch failure. The PPSC was accurate in predicting disease-specific quality of life.

[Long-term outcomes of ileal pouch after secondary diagnosis of Crohn's disease]

BACKGROUND

Total rectocolectomy and ileal pouch-anal anastomosis is the choice surgical procedure for patients with ulcerative colitis. In cases of Crohn's disease post-operative diagnosis, it can be followed by pouch failure.

AIM

To evaluate ileal pouch-anal anastomosis long-term outcome in patients with Crohn's disease.

METHODS

Between February 1983 and March 2007, 151 patients were submitted to ileal pouch-anal anastomosis by Campinas State University Colorectal Unit, Campinas, SP, Brazil, 76 had pre-operative ulcerative colitis diagnosis and 11 had post-operative Crohn's disease diagnosis. Crohn's disease diagnosis was made by histopathological biopsies in nine cases, being one in surgical specimen, two cases in rectal stump, small bowel in two cases, ileal pouch in three and in perianal abscess in one of them. The median age was 30.6 years and eight (72.7%) were female.

RESULTS

All patients had previous ulcerative colitis diagnosis and in five cases emergency colectomy was done by toxic megacolon. The mean time until of Crohn's disease diagnosis was 30.6 (6-80) months after ileal pouch-anal anastomosis. Ileostomy closure was possible in 10 cases except in one that had ileal pouch fistula, perianal disease and small bowel involvement. In the long-term follow-up, three patients had perineal fistulas and one had also a pouch-vaginal fistula. All of them were submitted to a new ileostomy and one had the pouch excised. Another patient presented pouch-vaginal fistula which was successfully treated by mucosal flap. Three patients had small bowel involvement and three others, pouch involvement. All improved with medical treatment. Presently, the mean follow-up is 76.5 months and all patients are in clinical remission, and four have fecal diversion. The remaining patients have good functional results with 6-10 bowel movements/day.

CONCLUSION

Crohn's disease diagnosis after ileal pouch-anal anastomosis for ulcerative colitis may be usual and later complications such fistulas and stenosis are common. However, when left in situ ileal pouch is associated with good function.

Family history and serology predict Crohn's disease after ileal pouch-anal anastomosis for ulcerative colitis

PURPOSE

Approximately 5 to 10 percent of patients undergoing ileal pouch-anal anastomosis with a diagnosis of ulcerative colitis are subsequently diagnosed with Crohn's disease. Preoperative predictors for Crohn's disease post-ileal pouch-anal anastomosis have not been prospectively defined.

METHODS

A total of 238 consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis were prospectively enrolled into a longitudinal database. Clinical factors were assessed perioperatively. Serum drawn preoperatively was assayed for anti-Saccharomyces cerevisiae, antiouter membrane porin-C, anti-CBir1, and perinuclear antineutrophil cytoplasmic antibody using enzyme-linked immunosorbent assay. Crohn's disease was defined by small bowel inflammation proximal to the ileal pouch or a perianal fistula identified at least three months after ileostomy closure. Predictors were assessed in a multivariate Cox proportional hazards model to predict the rate of Crohn's disease after ileostomy closure.

RESULTS

Sixteen patients (7 percent) were diagnosed with Crohn's disease; median time to Crohn's disease was 19 (range, 1-41) months. Significant factors for postoperative Crohn's disease after ileal pouch-anal anastomosis included family history of Crohn's disease (hazard ratio, 8.4; 95 percent confidence interval, 2.96-24.1; P < 0.0001) and anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity (hazard ratio, 3.14; 95 percent confidence interval, 1.1-9.81; P = 0.04). Crohn's disease developed in only 8 of 198 patients (4 percent) without these predictors vs. 8 of 40 patients (20 percent) in those with at least one of these factors (P = 0.002). The cumulative risk of Crohn's disease among patients with two risk factors (67 percent) was higher than in patients with either risk factor (18 percent) or neither risk factor (4 percent, P < 0.001).

CONCLUSIONS

Patients with ulcerative colitis and indeterminate colitis with a family history of Crohn's disease or preoperative anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity are more likely to be diagnosed with Crohn's disease after ileal pouch-anal anastomosis.

Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure

PURPOSE

This study was designed to determine the outcome of patients with Crohn's disease and indeterminate colitis who have an ileal pouch-anal anastomosis.

METHODS

Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn's disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35-question survey mailed to all patients with a functioning pouch of at least six months duration.

RESULTS

Pouch complications were significantly more common in patients with Crohn's disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn's disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn's disease, multivariate analysis revealed that the pathologist's initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn's disease were independently associated with pouch failure. The functional results in patients with Crohn's disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis.

CONCLUSIONS

Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one-half of patients with Crohn's disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn's disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn's disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.

Crohn's disease in the ileal pouch after total colectomy for ulcerative colitis: findings on pouch enemas in six patients

OBJECTIVE

The purpose of this study was to describe our experience with six patients who developed Crohn's disease in the ileal pouch or distal ileum after a total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis.

CONCLUSION

Pouch enemas showed characteristic findings of Crohn's disease, including nodularity, thickened folds, ulceration, cobblestoning, strictures, sinus tracks, and fistulas to the perianal region and vagina. It is important for radiologists to be aware of the findings of Crohn's disease in the ileal pouch and distal ileum on radiographic studies of the pouch after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis because of the implications for patient management.

Long-term outcomes of restorative proctocolectomy for Crohn's disease and indeterminate colitis

INTRODUCTION

The present study aims to evaluate the short-term and long-term outcomes of patients undergoing restorative proctocolectomy (RPC) for Crohn's disease (CD) and Indeterminate colitis (IC) and to identify factors associated with adverse outcomes.

METHODS

A descriptive study of 52 patients with CD or IC from a total of 1652 patients undergoing primary or salvage RPC in a single tertiary referral centre between 1978 and 2003. Primary outcomes were ileal pouch failure (excision or indefinite diversion), adverse events and functional outcomes (bowel frequency, urgency and continence).

RESULTS

Patients with IC or IC favouring ulcerative colitis (Group 1, n = 26) had a pouch failure rate of 11.5%vs 57.5% for patients with CD or IC favouring CD (Group 2, n = 26). Pouch salvage surgery was undertaken in 15 patients with a 13.3% failure rate. Patients in Group 2 were 2.6 times more likely (95% CI: 0.96-7. No significant differences were evident between CD and IC patients with regards to pelvic sepsis (19.2%vs 15.4%), anastomotic stricture (23.1%vs 21.7%), small bowel obstruction (26.9%vs 26.9%) or pouchitis (15.4%vs 11.5%). The 24-h bowel frequency (7.5 vs 8), faecal urgency, daytime or night time incontinence were similar between patients with CD or IC..17) to develop a pouch-related fistula than patients in Group 1.

DISCUSSION

Crohn's disease and to a great extent indeterminate colitis favouring CD were both associated with high failure rates and postoperative pouch-related fistula rates. Despite these problems, functional outcomes for patients with CD or IC were similar. Patients with IC should remain candidates for RPC but careful pre-operative assessment is advised to exclude clinical signs favouring the diagnosis of CD. The complications associated with failure are extensive and the option of reconstructive surgery in patients with CD should be questioned.

Analysis of the outcome of ileal pouch-anal anastomosis in patients with Crohn's disease

PURPOSE

Ileal pouch-anal anastomosis has come to represent the procedure of choice for patients requiring surgery for mucosal ulcerative colitis. In contrast, a proven diagnosis of Crohn's disease is generally held to preclude ileal pouch-anal anastomosis. However, patients with ileal pouch-anal anastomosis for apparent mucosal ulcerative colitis who are subsequently found to have Crohn's disease have a variable course. We reviewed our experience in this scenario to determine whether selected patients with Crohn's disease may be candidates for ileal pouch-anal anastomosis.

METHODS

A retrospective review of the prospectively maintained ileal pouch-anal anastomosis database was undertaken to identify patients with a diagnosis of Crohn's disease after ileal pouch-anal anastomosis. Clinical outcome and quality-of-life data were obtained from the database and chart review. End points were the development of recrudescent Crohn's disease, pouch failure, and quality of life and functional outcome at the time of data collection. Differences between groups were calculated using the chi-squared test. Cumulative incidence of recrudescent Crohn's disease and pouch loss were calculated by the Kaplan-Meier method. Factors predictive of development of recrudescent Crohn's disease and pouch loss were examined by univariate analysis.

RESULTS

Sixty patients (32 females; median age, 33 (range, 15-74) years) who underwent ileal pouch-anal anastomosis for mucosal ulcerative colitis subsequently had that diagnosis revised to Crohn's disease. Median follow-up of all patients was 46 (range, 4-158) months at time of data collection by which time 21 patients (35 percent) had developed recrudescent Crohn's disease. No pre-ileal pouch-anal anastomosis factors examined were predictors of the development of recrudescent Crohn's disease on univariate analysis. Median follow-up of the latter group was 63 (range, 0-132) months from time of diagnosis, by which time six patients underwent pouch excision and another patient was permanently defunctioned. The overall pouch loss rate for the entire cohort was 12 percent and 33 percent for those with recrudescent Crohn's disease. Median daily bowel movements in those with ileal pouch-anal anastomosis in situ at the time of data collection was 7 (range, 3-20), with 50 percent of patients rarely or never experiencing urgency and 59 percent reporting perfect or near perfect continence. Median quality of life, health, and happiness scores were 9.9 and 10 of 10.

CONCLUSIONS

The secondary diagnosis of Crohn's disease after ileal pouch-anal anastomosis is associated with protracted freedom from clinically evident Crohn's disease, low pouch loss rate, and good functional outcome. Such results only can be improved by the continued development of medical strategies for the long-term suppression of Crohn's disease. These data support a prospective evaluation of ileal pouch-anal anastomosis in selected patients with Crohn's disease.

Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) for indeterminate colitis (IndC) may lead to an increased risk of perineal complications and pouch loss. This study evaluated pathological subgroups of IndC to identify a predictor of increased complication rates after IPAA for IndC.

PATIENTS AND METHODS

Of 171 IPAAs with a postoperative diagnosis of IndC, IndC was confirmed in 115 of the 140 specimens available for re-examination. These were divided into IndC favouring ulcerative colitis (Group I; n = 99), 'true' IndC (Group II; n = 8), and IndC favouring Crohn's (Group III; n = 8). 61 presented with fulminant colitis. Patients in Group I were subdivided into having (A) deep ulcers (B) transmural lymphoid aggregates (C) skip lesions (D) terminal ileal inflammation and/or (E) a caecal patch. Outcome was determined by chart analysis, and compared to 231 randomly selected patients with IPAA for ulcerative colitis (UC) matched for age, gender, and follow-up.

RESULTS

Only patients with evidence of deep ulceration (Group IA) had a significant increase in the incidence of Crohn's disease (4.3%vs. 0.43%, P = 0.04), complex perianal fistulae (4.3%vs. 0.43%, P = 0.04), and pelvic abscess (12.9%vs. 2.2%, P < 0.001). No pathological subgroup of IndC patients had a significantly different rate of pouch failure or pouch loss.

CONCLUSIONS

Pathological stratification may predict those more likely to develop Crohn's disease or other complications, but not pouch failure. On this basis, we feel that patients with IndC should not be precluded from having IPAA surgery.