Does technique of anastomosis play any role in developing late perianal abscess or fistula?

Stapled Anastomosis Versus Hand-Sewn Anastomosis With Mucosectomy for Ileal Pouch-Anal Anastomosis: A Systematic Review and Meta-analysis of Postoperative Outcomes, Functional Outcomes, and Oncological Safety

PURPOSE

This systematic review and meta-analysis aimed to compare outcomes between stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA with mucosectomy in cases of ulcerative colitis and familial adenomatous polyposis.

METHODS

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines 2020 and AMSTAR 2 (Assessing the methodological quality of systematic reviews) guidelines. We included randomized clinical trials (RCTs) and controlled clinical trials (CCTs). Subgroup analysis was performed according to the indication for surgery.

RESULTS

The bibliographic research yielded 31 trials: 3 RCTs, 5 prospective clinical trials, and 24 CCTs including 8872 patients: 4871 patients in the stapled group and 4038 in the hand-sewn group. Regarding postoperative outcomes, the stapled group had a lower rate of anastomotic stricture, small bowel obstruction, and ileal pouch failure. There were no differences between the 2 groups in terms of operative time, anastomotic leak, pelvic sepsis, pouchitis, or hospital stay. For functional outcomes, the stapled group was associated with greater outcomes in terms of seepage per day and by night, pad use, night incontinence, resting pressure, and squeeze pressure. There were no differences in stool Frequency per 24h, stool frequency at night, antidiarrheal medication, sexual impotence, or length of the high-pressure zone. There was no difference between the 2 groups in terms of dysplasia and neoplasia.

CONCLUSIONS

Compared to hand-sewn anastomosis, stapled ileoanal anastomosis leads to a large reduction in anastomotic stricture, small bowel obstruction, ileal pouch failure, seepage by day and night, pad use, and night incontinence. This may ensure a higher resting pressure and squeeze pressure in manometry evaluation.

PROTOCOL REGISTRATION

The protocol was registered at PROSPERO under CRD 42022379880.

Predictors of outcome for treatment of enterovaginal fistula : Therapeutical strategies for treatment

BACKGROUND

Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary.

METHODS

The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure.

RESULTS

Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031).

CONCLUSION

Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.

A systematic review and meta-analysis of the outcome of ileal pouch-anal anastomosis in patients with ulcerative colitis versus patients with familial adenomatous polyposis

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is commonly used to restore gastrointestinal continuity after surgical treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). The aim of the present systematic review was to compare the outcomes of patients with MUC and patients with FAP who underwent IPAA.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review was performed. PubMed, Scopus, and Web of Science were searched through December 2021. Cohort and randomized studies were eligible for inclusion if they directly compared patients with MUC and FAP who underwent IPAA. The main outcome measures were pouch failure, complications, and need for pouch excision or revision. ROBINS-I tool was used to assess the risk of bias across the studies. A random-effect meta-analysis was conducted.

RESULTS

Twenty-three studies (9200 patients) were included in this meta-analysis. Seven thousand nine hundred fifty (86.4%) had MUC and 1250 (13.6%) had FAP. The median age of patients was 33.1 years. The male to female ratio was 1.4:1. MUC had higher odds of pouchitis (OR 3.9, 95% CI 2.8-5.4, p < 0.001), stricture (OR 1.82, 95% CI 1.25-2.65, p = 0.002), fistula (OR 1.74, 95% CI 1.18-2.54, p = 0.004), and total complications (OR 1.89, 95% CI 1.3-2.77, p < 0.001) as compared to FAP. Both groups had similar odds of pelvic sepsis, leakage, pouch failure, excision, revision, and fecal incontinence.

CONCLUSIONS

Although patients with MUC undergoing IPAA may be at a higher risk of developing complications, particularly pouchitis, stricture, and fistula; the ultimate and functional outcome of the pouch is similar to patients with FAP. Pouch failure, excision and revision were similar in the two groups.

Updates in diagnosis and management of inflammatory bowel disease

Worldwide incidence of inflammatory bowel disease (IBD) is stable in developed countries, but rising in developing countries. Presenting symptoms of IBD can be highly variable. New imaging modalities, a greater armamentarium of therapeutic options, and a greater understanding of complication risks have changed the diagnosis and management of pediatric inflammatory bowel diseases. Effective teamwork among those who care for pediatric patients with IBD minimizes complications and maximizes desired outcomes.

Postoperative complications after stapled and hand-sewn ileal pouch-anal anastomosis for familial adenomatous polyposis: A multicenter study

Ileal pouch‐anal anastomosis (IPAA) after total proctocolectomy (TPC) can be conducted with either hand‐sewn or stapled anastomosis for patients with familial adenomatous polyposis (FAP). Although stapled IPAA without mucosectomy has a higher risk for developing adenomas in the remnant mucosa, it is the simpler procedure with potential benefit in short‐term outcomes. However, it remains controversial as to whether stapled IPAA has any advantages in reducing postoperative complications. The aim of the present study was to compare the postoperative complications and short‐term outcomes of stapled and hand‐sewn IPAA for patients with FAP, using a multicenter cohort sample in Japan. Data of 143 patients with FAP who underwent TPC with stapled IPAA (n=37) and hand‐sewn IPAA (n=106) at 23 institutions between 2000 and 2012 were collected. Postoperative complications, proportion of ostomy, fecal continence and overall survival were compared. Overall rates of the Clavien‐Dindo grade II‐IV complications were not different between the two groups (19% in stapled vs 25% in hand‐sewn, P=.42), with significantly fewer pouch‐related complications including leakage, pelvic abscess, vaginal fistula and anastomotic stricture in stapled IPAA (none in stapled vs 11% in hand‐sewn, P=.036). There was no mortality. Proportion of ostomy at 12 months was similar (2.7% in stapled vs 4.3% in hand‐sewn, P=.26). Mean Wexner score was similar. (0.47 in stapled vs 2.0 in hand‐sewn, P=.12). Five‐year overall survival excluding Stage IV patients was 96% in both groups. Stapled IPAA is a safe option in patients with FAP with a potential benefit in reducing pouch‐related complications.

Prophylactic surgery in familial adenomatous polyposis (FAP)--a single surgeon's short- and long-term experience with hand-assisted proctocolectomy and smaller J-pouches

PURPOSE

Prophylactic proctocolectomy with an ileoanal neo-reservoir is the established procedure in non-attenuated familial adenomatous polyposis (FAP). Traditionally, the ileal J-pouch is created by doubling 15 cm of the terminal ileum. Pouch inlet problems are not infrequently encountered in longer pouches. On this rationale, this series reports on the functional outcome and quality of life (QoL) following standardized construction of a shorter J-pouch with a limb of 8-9 cm length.

METHODS

All patients of a single-surgeon series with FAP who underwent hand-assisted laparoscopic proctocolectomy and small ileal pouch-anal anastomosis as the primary procedure between 10/2005 and 04/2010 and responded to the questionnaire were included and retrospectively analyzed.

RESULTS

A total of 46 patients (78 %) out of the consecutive series who underwent operation in this period were included in the study. After a mean follow-up of 38 months, 40/46 patients (87 %) did not report any incontinence and 3 patients (6.5 %) complained about occasional nocturnal incontinence (3 failed to answer this question). The mean stool frequency per 24 h was 6.25. No significant difference was encountered between the QoL outcome of our patients versus the German normative population. Comparable results were achieved in a study analyzing the long-term results in FAP patients with a 15-cm pouch.

CONCLUSIONS

Smaller, 8-9 cm J-pouches show excellent functional results both in short- and in long-term results. The hand-assisted procedure was safe and no conversions were required. QoL is equal to a normative population, as it is in a series of patients with larger J-pouches.

Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)--a critical issue

INTRODUCTION

Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis.

PATIENTS AND METHODS

One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed.

RESULTS

Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02).

CONCLUSION

Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.

Ileal pouch-anal anastomosis surgery: anatomy, postoperative complications, and image-guided intervention

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) surgery has become the surgical procedure of choice for chronic ulcerative colitis and familial adenomatous polyposis. Since its introduction in 1978, the technique of ileal pouch-anal anastomosis has improved and is commonly performed. Although associated with low mortality, postsurgical complications are frequent with which the radiologist should be familiar. An understanding of surgical technique and postsurgical anatomy facilitates the diagnosis of these frequently encountered complications and governs their potential image-guided intervention.

Early postoperative complications after stapled vs handsewn restorative proctocolectomy with ileal pouch-anal anastomosis in 148 patients with familial adenomatous polyposis coli: a matched-pair analysis

AIM

Restorative proctocolectomy with ileal pouch-anal anastomosis for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) has been modified from a transanal hand-suture after mucosectomy to a stapled ileal pouch-anal anastomosis (IPAA) without mucosectomy. Better functional results favour stapled anastomosis; however, stapled anastomosis results in higher rates of adenomas in persisting anorectal mucosa. The purpose of this study was to compare the two techniques of pouch-anal anastomosis with respect to early postoperative complications in a collective of FAP patients.

METHOD

The study was performed as a matched-pair analysis. Data were obtained from a prospectively collected database.

RESULTS

The overall rate of postoperative complications was higher after stapled IPAA (31% stapled vs 23% handsewn), with anastomotic stricture occurring in 24.3% (stapled) and 16.2% (handsewn) (P = 0.22). Any leakage or pelvic abscess formation after stapled anastomosis occurred within 30 days in almost all patients, whereas these were mainly diagnosed between 30 days and 6 months after handsewn IPAA. A laparoscopic approach was used in 56.7% of patients in the stapled group but in only two patients in the handsewn group. Intra-operative blood loss was significantly higher in the handsewn group (mean ± SD: 699 ± 511 ml vs 369 ± 343 ml; P < 0.0001), as was the volume of blood transfused (mean ± SD: 205 ± 365 ml vs 8 ± 49 ml; P < 0.0001). Function did not differ between the groups.

CONCLUSION

There was a nonstatistically significant tendency towards a higher rate of early postoperative complications after stapled IPAA. The timing of anastomotic leakage and abscess formation differed between the groups.

German S3-Guideline: rectovaginal fistula

Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease.

Methods: A systematic review of the literature was undertaken.

Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction).

Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well.

Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient.

Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.

Clinical and microbiological analysis of adult perianal abscess

BACKGROUND

In Taiwan, Klebsiella pneumoniae is the predominant pathogen causing pyogenic liver abscess in patients with diabetes mellitus (DM). The purpose of our hospital-based study was to determine the predominant bacterial species causing perianal abscess in hospitalized patients with and without DM in Taiwan.

METHODS

Data on patients admitted and then operated on for perianal abscess during the period of March 2001 to December 2008 were reviewed. Information extracted from medical records included clinical information and laboratory data as well as culture and antibiotic sensitivity results.

RESULTS

A total of 183 patients underwent surgery for perianal abscess. The most common pathogen causing perianal abscess in non-DM patients was Escherichia coli (67.1%), and the most common pathogen isolated in DM patients was K pneumoniae (60%; p=0.009). Among the 25 patients with DM, incident DM was diagnosed in 24.0% (6 of 25). In addition, five patients had transient hyperglycemia.

CONCLUSIONS

Escherichia coli was the predominant pathogen isolated from perianal abscesses in patients without DM. Klebsiella pneumoniae, however, was the predominant pathogen isolated in DM patients. In both DM and non-DM patients, more than 90% of K pneumoniae isolates showed in vitro sensitivity to first-generation cephalosporins.

Quality of life ten and more years after restorative proctocolectomy for patients with familial adenomatous polyposis coli

PURPOSE

Few studies on long-term quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis have been published. Most of them survey a mixed patient population of familial adenomatous polyposis and ulcerative colitis. The present study analyzes long-term results more than 10 years after ileal pouch-anal anastomosis for patients with familial adenomatous polyposis, exclusively.

METHODS

One hundred thirty-five patients who underwent ileal pouch-anal anastomosis more than 10 years ago were identified from the prospective familial adenomatous polyposis registry at Heidelberg University hospital. They received the German version of the health-specific Short Form 36 Health Survey and the disease-specific Gastrointestinal Quality of Life Index by mail. To assess the impact of disease-specific factors, 10 questions asking for ability to work, current medication, pouchitis, and extracolonic manifestations of familial adenomatous polyposis were added to the Gastrointestinal Quality of Life Index questionnaire.

RESULTS

Among 84 patients who answered the questionnaires the median follow-up was 13.4 years (range, 10.3-23.8 y).The results of the Short Form 36 Health Survey were comparable to a German normative population in all dimensions, whereas the overall score for the Gastrointestinal Quality of Life Index was significantly reduced compared with healthy individuals (111.8 vs 120.8, P = .0014). Carcinoma at the time of ileal pouch-anal anastomosis, desmoid tumors, or duodenal adenomas had no significant influence on quality of life. More than 7 bowel movements during the daytime were found to reduce quality of life significantly (103.5 vs 115, P = .0127). More than 2 defecations per night diminished the score further (101 vs 125, P < .0001). Patients younger than 40 years at the time of ileal pouch-anal anastomosis had significantly better results than older patients (120 vs 109.5, P = .0076).

CONCLUSION

Ileal pouch-anal anastomosis is a safe surgical procedure with a high quality of life comparable to that of a normative population after long-term follow-up of patients with familial adenomatous polyposis.

Complications of ileoanal pouches

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical therapy of choice for patients with chronic ulcerative colitis and the majority of patients with familial adenomatous polyposis. It restores gastrointestinal continuity, re-establishes transanal defecation, and avoids a permanent stoma. Although this technically demanding procedure is associated with low mortality rates, it is frequently accompanied by early and late complications. This article will review these complications and discuss the interventions that are needed to provide appropriate treatment.

Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients

BACKGROUND

The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA).

METHODS

Patients undergoing a primary IPAA (1983-2007) were identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated.

RESULTS

Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1-24). Mean age was 37.9 +/- 13.2 years. Overall, 1,741 patients (56%) were male. Group A (n = 474) and group B (n = 2635) had similar age (P = .28), sex (P = .8), albumin level (P = .74), prior colectomy (P = .98), and use of steroids (P = .1). Group A had a greater use of ileostomy (P = .001) and a longer duration of stay (P < .001). Group B had a greater body mass index (P < .001) and J-pouch (P < or = .001). Wound infection (P = .42) and pouchitis (P = .59) were similar. Anastomotic stricture (P = .002), septic complications (P = .019), bowel obstruction (P = .027), and pouch failure (P < .001) were greater in group A. At most recent follow-up, bowel frequency (P = .74) and rate of urgency were similar (P = .71). A greater proportion of patients in group A described incontinence (P < .001), seepage (P < .001), pad usage (P < .001), dietary (P < .001), social (P < .001), and work restrictions (P = .025). The Cleveland Global QOL score (P = .018) was greater in group B.

CONCLUSION

Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.

Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy?

BACKGROUND AND AIMS

The technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum.

PATIENTS AND METHODS

One hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14-169) months after surgery.

RESULTS

Only one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature.

CONCLUSION

The low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.

Complicações imediatas e tardias após cirurgia de reservatório ileal na polipose adenomatosa familiar

RACIONAL: A retocolectomia total com confecção de reservatório ileal é cirurgia ideal para o tratamento do cólon e reto dos doentes com polipose adenomatosa familiar, no entanto pode estar associada a complicações no pós-operatório imediato e tardio. OBJETIVO: Estudar as complicações pós-operatórias da cirurgia do reservatório ileal na polipose adenomatosa familiar. MÉTODOS: Estudo retrospectivo de 69 doentes com polipose adenomatosa familiar submetidos a cirurgia de reservatório ileal no período de 1984 a 2006, pelo Grupo de Coloproctologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, SP. O seguimento médio pós-operatório foi de 82 (2-280) meses. Dados de interesse: ocorrência de complicações no pós-operatório. RESULTADOS: A morbidade e mortalidade foram de 63,8% e 2,9%, respectivamente. As complicações mais freqüentes foram obstrução intestinal (17,4%), estenose da anastomose (15,9%) e sepse pélvica (10,1%). Outras complicações foram isquemia aguda do reservatório ileal (4,3%), ileíte do reservatório (" pouchitis" ) (2,9%) e fístulas relacionadas ao reservatório (2,9%). CONCLUSÕES: A morbimortalidade foi semelhante à da literatura e aceitável para uma cirurgia complexa como é a do reservatório ileal, realizada em dois tempos operatórios. A obstrução intestinal foi a complicação mais freqüente. Entretanto, isquemia do reservatório, " pouchitis" e sepse pélvica constituíram importantes complicações relacionadas à perda do reservatório ileal.

Should ileal pouch-anal anastomosis include mucosectomy?

OBJECTIVE

Debate exists as to the benefits of performing mucosectomy as part of pouch surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Whilst mucosectomy results in a more complete removal of diseased mucosa, this benefit may be at the price of poorer function. We examined these issues.

METHOD

Using Medline, Embase, Ovid and Cochrane database searches papers were identified relating to the outcome following pouch surgery with and without mucosectomy. Potential reasons for functional problems were investigated, as were rates of 'cuffitis', dysplasia, polyposis and cancer in the ileal pouch and anal canal.

RESULTS

The available evidence suggests that performing a mucosectomy leads to a worse functional outcome. Meta-analysis suggested that nighttime seepage of stool and resting and squeeze pressure were worse after mucosectomy. The most likely reason for functional impairment following pouch surgery was the degree of anal manipulation. Mucosectomy does seem to confer benefit in terms of disease control but this benefit does not reach statistical significance.

CONCLUSION

Stapled anastomosis avoiding mucosectomy is the approach of choice for ileal pouch anal anastomosis because this leads to superior functional outcome. Performing mucosectomy results in some clinical benefits in terms of lower rates of inflammation and dysplasia in the retained mucosa in UC patients and lower rates of cuff polyposis in FAP patients. However, on the basis of available evidence mucosectomy is only indicated in those cases where the patient is at a high risk of disease in the retained rectal cuff.

A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis

PURPOSE

Restorative proctocolectomy is the procedure of choice for patients undergoing proctocolectomy for familial adenomatous polyposis or ulcerative colitis. This meta-analysis was designed to identify differences in adverse events and functional outcomes between these two groups.

METHODS

Studies published between 1986 and 2003 that compared outcomes between patients with familial adenomatous polyposis and ulcerative colitis were included. Meta-analytical techniques using random effect models were used to compare short-term and long-term adverse events as well as functional outcomes between the groups.

RESULTS

Nineteen studies comprising 5,199 patients (familial adenomatous polyposis, 782; ulcerative colitis, 4,417) were analyzed. There were no significant differences in immediate postoperative adverse events between the two groups. Pouch-related fistulation was significantly increased in the ulcerative colitis group (10.5 percent vs. familial adenomatous polyposis 4.8 percent; odds ratio 2.31; P < 0.001). There was no significant difference in pouch failure between the two groups (ulcerative colitis 5.8 percent vs. familial adenomatous polyposis 4.5 percent; odds ratio 1.22; P = 0.43). The incidence of pouchitis was significantly greater in the ulcerative colitis group (30.1 vs. 5.5 percent; odds ratio 6.44; P < 0.001). Patients with familial adenomatous polyposis had a significant advantage in stool frequency with one less motion per 24 hours (95 percent confidence interval, 0.21-1.76; P = 0.01).

CONCLUSIONS

In contrast to studies reporting similar outcomes for patients undergoing restorative proctocolectomy for familial adenomatous polyposis or ulcerative colitis, the present meta-analysis suggested that patients with ulcerative colitis are at greater risk of pouch-related fistulation and pouchitis. Although there was an increase in the 24-hour stool frequency in the ulcerative colitis group, this may be accounted for by the younger age at surgery in the familial adenomatous polyposis group.

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.

Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy

Introduction

Pouch-related fistula occurs in 5–10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas.

Methods

Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch–perineal, pouch–abdominal wall and pouch–vaginal fistula during follow-up.

Results

Median patient follow-up was 4·1 (range 0–19) years. By 15 years' follow-up, pouch–vaginal fistulas had occurred in 44 women (5·2 per cent). The prevalence of ileal pouch–perineal and pouch–abdominal wall fistula was 3·6 per cent (70 patients) and 1·5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1·28 (95 per cent confidence interval (c.i.) 1·00 to 1·65) and 1·73 (95 per cent c.i. 1·07 to 3·48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3·43 (95 per cent c.i. 2·43 to 4·84) and 4·02 (95 per cent c.i. 1·27 to 12·77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4·29 (95 per cent c.i. 2·33 to 7·91)), patient sex (HR 0·74 (95 per cent c.i. 0·58 to 0·95) for men versus women) and pelvic sepsis (HR 3·79 (95 per cent c.i. 2·48 to 5·79)).

Conclusion

This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula.

[Diagnosis and treatment of chronic anastomotic fistulas]

Treatment of anastomotic fistulas generally implies an individualized concept. The origin of these complications is multifactorial and comprises such factors as primary operation, oncologic situation, comorbidity, and patient age as well as fistula-specific considerations such as anatomic localization, secretion volume, etc. In the case of high-output fistulas, it is of great importance to counteract fluid and electrolyte imbalances. Furthermore, skin maceration due to aggressive secretion needs to be averted. Therapeutic options include operative and endoscopic interventions. Octreotide plays a role in high-output and pancreatic fistulas. Any underlying ailment (e.g., Crohn's disease) requires an optimal disease-specific treatment which characterizes an interdisciplinary approach to such fistulas. The following article discusses general and site-specific considerations in the diagnosis and treatment of anastomotic fistulas.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Elimination of mucosectomy during restorative proctocolectomy in patients with ulcerative colitis may provide better results in low-volume centers

BACKGROUND

To compare the outcomes of hand-sewn and double-stapling techniques among ulcerative colitis patients undergoing restorative proctocolectomy at a center that has limited experience with restorative proctocolectomy.

METHODS

Forty-four patients with ulcerative colitis were divided into two groups according to the anastomosis techniques: hand sewing and double stapling. Postoperative early and late complications, postoperative hospital stay, and long-term functional results were compared.

RESULTS

Pelvic sepsis (9% versus 36%, P = 0.03), operation time (median 240 minutes versus 270 minutes, P = 0.01), postoperative hospital stay (median 9 days versus 12 days, P = 0.04), and night incontinence (42% versus 80%, P = 0.07) were less common in the double-stapling group.

CONCLUSIONS

We recommend the double-stapling technique to centers that do not have extensive experience with restorative proctocolectomy for ulcerative colitis. This technique provides a good postoperative course in most patients and provides satisfactory long-term results. The results of the double-stapling group were similar to the results of the high-volume centers.

Cumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure

PURPOSE

The aim of the study was to calculate the cumulative occurrence of pouch failure among 486 patients who had undergone proctocolectomy and ileoanal anastomosis for ulcerative colitis or familial adenomatous polyposis. The other goal was to compare the quality of life in the failure group of 21 patients, the successful group, and the healthy population.

METHODS

Data were collected from patient histories, with the probability of pouch failure being calculated by the Kaplan-Meier method. Patients with pouch failure and controls were sent a Short-Form 36-item quality-of-life questionnaire, and data were analyzed with paired -test.

RESULTS

The overall failure rate was 5.3 percent (26), including 24 pouch excisions and 2 early deaths (0.4 percent). Cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively. Neither pouchitis, gender, nor diagnosis correlated with pouch failure, but fistula formation ( p< 0.001) did. Patients with failure had lower quality-of-life scores for physical function (p < 0.02), social function ( p< 0.04), energy ( p< 0.02), and physical role function ( < 0.03) than the healthy population. Scores for physical function ( p< 0.01), energy ( p< 0.01), and physical role function ( p< 0.05) were also lower than those of control patients.

CONCLUSIONS

The most common cause of pouch failure is fistula, whereas pouch excision is rarely caused by pouchitis. The impaired quality of life of patients in the failure group was caused by impairment of physical function and restrictions in social life.

Azathioprine or 6-mercaptopurine before colectomy for ulcerative colitis is not associated with increased postoperative complications

AIM

To determine whether the use of azathioprine/6-mercaptopurine before colectomy is associated with an increased rate of postoperative complications.

METHODS

All patients who underwent colectomy with ileal pouch-anal anastomosis for ulcerative colitis between 1997 and 1999 were identified. Medical records were abstracted for demographics, extent and duration of disease, dose and duration of corticosteroids and azathioprine/6-mercaptopurine, albumin, and Truelove/Witts score. Early (30-day) and late (6-month) complications were identified. Noncorticosteroid immunosuppressive use was coded as none, azathioprine/6-mercaptopurine within 1 week of surgery, or therapy with other immunosuppressive agents within 1 month of surgery. A logistic regression analysis assessed the association between these variables and complications.

RESULTS

Early complications occurred in 49 of 151 (32%) patients not treated with immunosuppressive agents, 12 of 46 (26%) azathioprine/6-mercaptopurine-treated patients, and 4 of 12 (33%) patients treated with other immunosuppressive agents (p = 0.71). Late complications occurred in 72 of 148 (49%), 20 of 46 (43%), and 8 of 12 (67%) patients in these same groups, respectively. Intravenous or oral steroids at doses of 40 mg/d or greater (p < 0.01) and severe or fulminant disease (p = 0.0094) were associated with greater early complication rates.

CONCLUSION

Early complications after restorative proctocolectomy for ulcerative colitis are associated with high dose steroids and severe disease but not use of azathioprine/6-mercaptopurine.