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Clement E, Lin W, Shojaei D, Au-Yeung P, Motamedi A, Phang PT. Modified 2-stage IPAA has similar postoperative complication rates and functional outcomes compared to 3-stage IPAA. Am J Surg 2024; 231:96-99. [PMID: 38423807 DOI: 10.1016/j.amjsurg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/22/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Reconstructive ileal-pouch anal anastomosis (IPAA) for ulcerative colitis (UC) is often created in 3-stages: colectomy + ileostomy, proctectomy + pouch creation with diverting loop ileostomy, then subsequent ileostomy closure. Modified 2-stage IPAA is without pouch diversion, thus avoiding a third operation. This study compares perioperative complications, quality of life (QOL) and functional outcomes of 3- versus modified 2-stage IPAA. METHODS Charts were reviewed for adult UC patients undergoing IPAA between 2010 and 2020. QOL and function were assessed with EQ-5D-3L Quality of Life and Pouch Functional Score questionnaires. RESULTS 152 patients were identified. 43 modified 2-stage and 109 3-stage IPAA were similar for anastomotic leak (9.3% vs. 1.8%, p = 0.06), SSI (34.9% vs. 29.7%, p = 0.51) and ileus (32.6% vs. 33%, p = 0.96). Modified 2-stage had less bowel obstruction than 3-stage IPAA (7.0% vs. 30.1%, p = 0.006). 92 patients returned questionnaires with similar QOL and pouch function. CONCLUSIONS Perioperative complications, QOL and function are similar for 3-stage IPAA and modified 2-stage IPAA. Modified 2-stage IPAA in select patients is safe and has less postoperative bowel obstruction than 3-stage IPAA.
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Affiliation(s)
- E Clement
- University of British Columbia, Canada.
| | - W Lin
- University of British Columbia, Canada
| | - D Shojaei
- University of British Columbia, Canada
| | | | | | - P T Phang
- University of British Columbia, Canada
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2
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Maspero M, Hull TL. Clinical approach to patients with an ileal pouch. Abdom Radiol (NY) 2023; 48:2918-2929. [PMID: 37005915 DOI: 10.1007/s00261-023-03888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.
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Affiliation(s)
- Marianna Maspero
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Plietz MC, Coste M, Miller J, Kayal M, Chuquin KEP, Rizvi A, Bangla VG, Dubinsky MC, Khaitov S, Sylla PA, Greenstein AJ. Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages. J Gastrointest Surg 2023; 27:760-765. [PMID: 36913174 DOI: 10.1007/s11605-023-05631-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/09/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE The most common surgery for ulcerative colitis (UC) is the staged restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). On occasion, an emergent first-stage subtotal colectomy must be performed. The purpose of this study was to compare rates of postoperative complications in three-stage IPAA patients who underwent emergent vs non-emergent first-stage subtotal colectomies in the subsequent staged procedures. METHODS This was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All UC or IBD-Unspecified patients who underwent a three-stage IPAA between 2008 and 2017 were identified. Emergent surgery was defined as that performed on an inpatient who had perforation, toxic megacolon, uncontrolled hemorrhage, or septic shock. The primary outcomes were the presence of anastomotic leak, obstruction, bleeding, and the need for reoperation for each within a 6-month postoperative period of the second (RPC with IPAA and DLI) and third surgical stages (ileostomy reversal). RESULTS A total of 342 patients underwent a three-stage IPAA, of which 30 (9.4%) had emergent first-stage operations. Patients who underwent an emergent STC were more likely to have a post-operative anastomotic leak and need an additional procedure following the subsequent second and third-staged operations on both univariate and multivariate analysis (p < 0.05). No difference was found for obstruction, wound infection, intra-abdominal abscess, or bleeding (p > 0.05). CONCLUSION Three-stage IPAA patients with emergent first-stage subtotal colectomies were more likely to have a post-operative anastomotic leak and need an additional procedure for a leak following the subsequent second- and third-stage operations.
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Affiliation(s)
- Michael C Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marine Coste
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jeremy Miller
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kathryn Ely Pierce Chuquin
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anam Rizvi
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Venu Gopal Bangla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla C Dubinsky
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricia A Sylla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Huang AL, Plietz M, Greenstein AJ, Khaitov S. Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis. Clin Colon Rectal Surg 2022; 35:469-474. [PMID: 36591405 PMCID: PMC9797281 DOI: 10.1055/s-0042-1758138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.
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Affiliation(s)
- Alex Liu Huang
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Michael Plietz
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Alexander J. Greenstein
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Sergey Khaitov
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
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Olortegui KS, Graham A, Hyman N. Staging Considerations for the Ileal Pouch-Anal Anastomosis. J Gastrointest Surg 2022; 26:1531-1536. [PMID: 35469035 DOI: 10.1007/s11605-022-05317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Affiliation(s)
| | - Ada Graham
- University of Chicago Medical Center, Chicago, IL, USA
| | - Neil Hyman
- University of Chicago Medical Center, Chicago, IL, USA
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Harsløf S, Pachler FR, Thaysen HV, Drejer M, Brandsborg S, Nørager CB, Tøttrup A. Functional outcome and quality of life after transanal minimal invasive pouch surgery. Int J Colorectal Dis 2022; 37:1141-1150. [PMID: 35467122 DOI: 10.1007/s00384-022-04158-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate functional outcomes and quality of life (QoL) after restorative proctocolectomy (RPC) using transanal minimal invasive surgery (TAMIS). METHOD The study consists of two sub-studies. A cohort study comprised 98 consecutive patients, who underwent TAMIS RPC. These patients were the first at our department to undergo TAMIS RPC. We collected information about surgery, complications, postoperative morbidity and mortality ≤ 30 days, and pouch problems. Patients were also invited to participate in a case-control study in which the patients would respond to three different questionnaires, the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short Form-36 General Health Questionnaire (SF-36), and questions from the Pouch Dysfunction Score. We compared the responding TAMIS RPC patients to a Danish national cohort (0-10 years from RPC, n = 514) of patients having RPC between 1980 and 2010. We compared functional outcomes and QoL. RESULTS Four (4%) of the TAMIS patients had an anastomotic leak; none of these required re-operation with removal of the pouch. Anastomotic leak was treated with antibiotics and drain. Out of the four leaks, only one ended up with a permanent stoma; all others had their stoma reversed successfully. The TAMIS patients had the same number of bowel movements as the patients in the Danish national cohort study. The same was seen with regard to incontinence. We had no conversions in our series of TAMIS procedures. CONCLUSION The TAMIS technique shows acceptable outcomes, both in regard to postoperative complications and also functional outcome and QoL.
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Affiliation(s)
- Sanne Harsløf
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Frederik Rønne Pachler
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Henriette Vind Thaysen
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marie Drejer
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Søren Brandsborg
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Charlotte Buchard Nørager
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Anders Tøttrup
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Tzatzarakis E, Herrle F, Reindl W, Altmayer N, Minas D, Kienle P, Reissfelder C, Şandra-Petrescu F. Association of ileocolic pedicle division with postoperative complications after restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. BMC Surg 2021; 21:426. [PMID: 34922520 PMCID: PMC8684109 DOI: 10.1186/s12893-021-01428-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/06/2021] [Indexed: 12/04/2022] Open
Abstract
Background When performing a restorative proctocolectomy (RPC) with an ileal pouch-anal anastomosis (IPAA), it is common practice to divide the ileocolic artery (ICA) if the patient has a tumor or dysplasia, or in order to gain sufficient length to secure a tension-free anastomosis. However, it is unclear whether there is an association between division of the ICA and the rate of postoperative complications. Methods We retrospectively analysed all patients with ulcerative colitis who underwent RPC and IPAA in our department between January 2010 and December 2016. These were divided in two groups, with regard to the ICA being preserved (PRE group) or divided (DIV group). Complications such as stenosis or leakage of the IPAA, perianal fistulas, abscess formation within the lesser pelvis and pouchitis were analysed and compared between both groups. Results We identified 130 patients meeting the study inclusion criteria, 49 patients in the PRE and 81 patients in the DIV group. No statistical significance was observed in IPAA leakages (p = 0.71), anastomotic strictures (p = 0.33), fistulas (p = 0.19) and pouchitis (p = 0.72). Abscess formation frequency was similar in both groups (p > 0.99). Moreover, short-term (p = 0.53) and long-term complications (p = 0.11) were similar in both groups. A higher conversion rate was observed in obese (p = 0.006) and male (p = 0.02) patients. Within the entire study population, fistulas and IPAA leakages were associated with a higher rate of anastomotic strictures (p = 0.008 and p = 0.02 respectively). Conclusion Our data suggest similar IPAA related complications after either division or preservation of the ICA. Further trials are required in order to examine the trends observed in this study.
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Affiliation(s)
- Emmanouil Tzatzarakis
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Florian Herrle
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Wolfgang Reindl
- Department of Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nora Altmayer
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Dominik Minas
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Peter Kienle
- Department of Surgery, Theresienkrankenhaus, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Flavius Şandra-Petrescu
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Plietz MC, Kayal M, Rizvi A, Bangla VG, Khetan P, LaChapelle CR, Whitney SL, Huber HM, Hwa Walter Wang Y, Radcliffe M, Khaitov S, Sylla PA, Dubinsky MC, Greenstein AJ. Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis. Dis Colon Rectum 2021; 64:1511-1520. [PMID: 34561342 DOI: 10.1097/dcr.0000000000002113] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA. OBJECTIVE The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a single tertiary care IBD center. PATIENTS All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified. MAIN OUTCOME MEASURES The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks. RESULTS The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05). LIMITATIONS This study was limited by its retrospective design and evolving electronic medical charts system. CONCLUSIONS The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693. LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.
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Affiliation(s)
- Michael C Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anam Rizvi
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Venu G Bangla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Prerna Khetan
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Stewart L Whitney
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hans M Huber
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yun Hwa Walter Wang
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marlana Radcliffe
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patricia A Sylla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marla C Dubinsky
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Heuthorst L, Wasmann KATGM, Reijntjes MA, Hompes R, Buskens CJ, Bemelman WA. Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis. ANNALS OF SURGERY OPEN 2021; 2:e074. [PMID: 37636549 PMCID: PMC10455305 DOI: 10.1097/as9.0000000000000074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Objective This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure. Background Previous studies demonstrated wide variation in postoperative complication rates following IPAA. Methods A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman's correlations. Results Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56-10.59) and 10.3% (95% confidence intervals: 7.24-14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1-17%), pelvic sepsis (2-18%), fistula (1-30%), stricture (1-34%), pouchitis (11-61%), and Crohn's disease of the pouch (0-18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01). Conclusions The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak. Mini abstract This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure.
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Affiliation(s)
- Lianne Heuthorst
- From the Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Maud A. Reijntjes
- From the Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Roel Hompes
- From the Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Christianne J. Buskens
- From the Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Willem A. Bemelman
- From the Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
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10
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Yu J, Clark DA, Sidhom D, Edmundson A, Solomon M. Anastomotic leak does not affect long-term and longitudinal functional outcomes after ileal pouch surgery for ulcerative colitis when managed aggressively. Tech Coloproctol 2020; 24:1285-1292. [PMID: 32856185 DOI: 10.1007/s10151-020-02331-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is an effective surgical alternative to a permanent ileostomy following proctocolectomy in patients with ulcerative colitis (UC). Anastomotic leakage (AL) is a serious postoperative complication of an intestinal anastomosis that is associated with increased morbidity and mortality. The aim of this study was to evaluate the longitudinal long-term functional outcomes of patients who had IPAA that was complicated by AL. METHODS A retrospective longitudinal cohort study was performed of patients who had an IPAA procedure at a tertiary referral centre and a metropolitan private centre in Australia, over a 14-year period (October 2003-October 2017). The long-term functional outcome was assessed using objective clinical measures such as the number of bowel motions during the day and overnight, ability to defer defaecation and the presence of faecal incontinence, and repeated at annual intervals. RESULTS A total of 138 patients [mean age 38.5 (± 16.9) years, 72 males] satisfied the inclusion criteria. AL was diagnosed in 14 (10%) patients [mean age 38.8 (± 17) years, 10 males], 11 (79%) of which were managed with surgery. The median bowel motion frequency during the day and overnight remained stable over a median of 62 (28-91) months follow-up, with no significant difference between those who had AL or not (p = 0.6, p = 0.1 respectively). The incidence of faecal incontinence remained low, and the majority of patients in both groups were able to defer defaecation for more than 60 min. Six patients (4.3%) had their pouch excised. CONCLUSIONS There is no statistical difference in longitudinal function between patients who experienced AL after IPAA surgery for UC compared with those who did not. Therefore, an acute AL does not negatively impact long-term functional outcomes in IPAA patients.
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Affiliation(s)
- J Yu
- Royal Brisbane and Women's Hospital, Herston Road, Brisbane, QLD, 4066, Australia.,University of Qld, St Lucia, Brisbane, QLD, 4072, Australia
| | - D A Clark
- Royal Brisbane and Women's Hospital, Herston Road, Brisbane, QLD, 4066, Australia. .,Faculty of Medicine and Health, Surgical Outcomes Research Centre (SOuRCe), University of Sydney, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia. .,University of Qld, St Lucia, Brisbane, QLD, 4072, Australia. .,St Vincent's Private Hospital Northside, 627 Rode Road, Chermside, Brisbane, QLD, 4032, Australia.
| | - D Sidhom
- Royal Brisbane and Women's Hospital, Herston Road, Brisbane, QLD, 4066, Australia
| | - A Edmundson
- Royal Brisbane and Women's Hospital, Herston Road, Brisbane, QLD, 4066, Australia.,University of Qld, St Lucia, Brisbane, QLD, 4072, Australia
| | - M Solomon
- Faculty of Medicine and Health, Surgical Outcomes Research Centre (SOuRCe), University of Sydney, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
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11
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Updates in diagnosis and management of inflammatory bowel disease. Curr Probl Pediatr Adolesc Health Care 2020; 50:100785. [PMID: 32402535 DOI: 10.1016/j.cppeds.2020.100785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 12/18/2022]
Abstract
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.
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12
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Lightner AL, Alsughayer A, Wang Z, McKenna NP, Seisa MO, Moir C. Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review. Inflamm Bowel Dis 2019; 25:1152-1168. [PMID: 30668719 DOI: 10.1093/ibd/izy375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/18/2018] [Accepted: 11/17/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the procedures of choice for restoration of intestinal continuity in ulcerative colitis or familial adenomatous polyposis. This systematic review aims to assess short-term postoperative and long-term functional outcomes in pediatric patients undergoing IPAA. METHODS A literature search was performed for all publications of pediatric IPAA in which short- and long-term outcomes were reported. Papers were excluded based on title, abstract, and full-length review. Data collection included patient demographics, medication use preoperatively, operative approach, 30-day postoperative outcomes, long-term functional outcomes (to maximal date of follow-up), and pouch failure rate. Outcomes were compared in those patients with and without perioperative corticosteroid exposure. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale as all studies were cohort studies. RESULTS Of 710 records reviewed, 42 full papers were included in the analysis. Rates of superficial surgical site infection, pelvic sepsis, ileus, and small bowel obstruction at <30 days were 10%, 11%, 10%, and 14%, respectively. Rates of pouchitis, stricture, chronic fistula tract, incontinence, and pouch failure were 30%, 17%, 12%, 20%, and 8%, respectively, at 37-109 months of follow-up; incontinence was significantly higher in those exposed to corticosteroids preoperatively (52% vs 20%; P < 0.001). The median daytime, nighttime, and 24-hour stool frequency were 5.3, 1.4, and 5 bowel movements, respectively. CONCLUSIONS IPAA is safe with good long-term functional outcomes in pediatric patients.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Ahmad Alsughayer
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Zhen Wang
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Nicholas P McKenna
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Mohamed O Seisa
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Christopher Moir
- Division ofPediatric Surgery, Mayo Clinic, Rochester Minnesota, USA
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13
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Kiely JM, Kiran RP. Leak, fistula, sepsis, sinus, portal vein thrombosis. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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14
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Quinn KP, Lightner AL, Faubion WA, Raffals LE. A Comprehensive Approach to Pouch Disorders. Inflamm Bowel Dis 2019; 25:460-471. [PMID: 30124882 DOI: 10.1093/ibd/izy267] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Indexed: 12/18/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or indeterminate colitis, UC with colonic dysplasia or neoplasia, and familial adenomatous polyposis. In general, patients experience good function outcomes and quality of life with an IPAA. Although pouchitis is the most well-recognized and frequent complication after IPAA, a number of additional inflammatory, postsurgical, structural, neoplastic, and functional complications may occur, resulting in pouch dysfunction. We herein provide a comprehensive review of pouch function and an approach to diagnosis and management of pouch complications.
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Affiliation(s)
- Kevin P Quinn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - William A Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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15
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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16
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Bemelman WA, Baron TH. Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae. Gastroenterology 2018; 154:1938-1946.e1. [PMID: 29454791 DOI: 10.1053/j.gastro.2018.01.067] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 02/06/2023]
Abstract
Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.
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Affiliation(s)
- Willem A Bemelman
- Department of Surgery, The Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill North Carolina. todd_baron.@med.unc.edu
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17
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Endoluminal vacuum-assisted therapy as treatment for anastomotic leak after ileal pouch-anal anastomosis: a pilot study. Tech Coloproctol 2018; 22:223-229. [PMID: 29502228 DOI: 10.1007/s10151-018-1762-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/20/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Anastomotic leak after ileal pouch-anal anastomosis (IPAA) could lead to poor functional results and failure of the pouch. The aim of the present study was to analyze the outcomes of the vacuum-assisted closure therapy as the unique treatment for anastomotic leaks following IPAA without any additional surgical operations. METHODS Consecutive patients with anastomotic leak after IPAA treated at our institution between March 2016 and March 2017 were prospectively enrolled. After diagnosis, the Endosponge® device was positioned in the gap and replaced until the cavity was reduced in size and covered by granulating tissue. A pouchoscopy was performed every week for the first month and monthly subsequently. No additional procedures were performed. RESULTS Eight patients were included in the study. The leak was diagnosed at a median of 14 (6-35) days after surgery. At the time of diagnosis, seven patients had a defunctioning ileostomy performed as routine at the time of pouch formation, while one patient was diagnosed after ileostomy closure and underwent emergency diversion ileostomy. The Endosponge® treatment started after a median of 6.5 (1-158) days after the diagnosis of the leakage and was carried on for a median of 12 (3-42) days. The device was replaced a median of 3 (1-10) times. The median length of hospital stay after the first application of the treatment was 15.5 (6-48) days. The complete healing of the leak was documented in all patients, after a median of 60 (24-90) days from the first treatment. All patients but one had their ileostomy reversed at a median of 2.5 (1-6) months from the confirmation of the complete closure. CONCLUSIONS Endosponge® is effective as the only treatment after IPAA leak. Based on the results of our prospective pilot study, application of Endosponge® should be the treatment of choice in selected pouch anastomotic leaks not requiring immediate surgery. These results will have to be confirmed by future prospective studies including a larger number of patients.
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18
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Sunde ML, Ricanek P, Øresland T, Jahnsen J, Naimy N, Færden AE. Determinants of optimal bowel function in ileal pouch-anal anastomosis - physiological differences contributing to pouch function. Scand J Gastroenterol 2018; 53:8-14. [PMID: 29043868 DOI: 10.1080/00365521.2017.1390601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Marie Louise Sunde
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway.,b Division of Surgical Sciences, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Petr Ricanek
- c Department of Gastroenterology , Akershus University Hospital , Lørenskog , Norway
| | - Tom Øresland
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway.,b Division of Surgical Sciences, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Jørgen Jahnsen
- c Department of Gastroenterology , Akershus University Hospital , Lørenskog , Norway.,d Division of Medicine and Laboratory Sciences, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Nazir Naimy
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway
| | - Arne Engebreth Færden
- a Department of Colorectal Surgery , Akershus University Hospital , Lørenskog , Norway
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19
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van der Ploeg VA, Maeda Y, Faiz OD, Hart AL, Clark SK. The prevalence of chronic peri-pouch sepsis in patients treated for antibiotic-dependent or refractory primary idiopathic pouchitis. Colorectal Dis 2017; 19:827-831. [PMID: 27688067 DOI: 10.1111/codi.13536] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/05/2016] [Indexed: 02/08/2023]
Abstract
AIM Chronic peri-pouch sepsis (CPPS) may be mistaken for antibiotic-dependent or refractory primary idiopathic pouchitis (ADRP), but requires different treatment such as drainage. The study aimed to identify the prevalence of CPPS in patients thought to have ADRP. The secondary aims were to identify any specific features on pouchoscopy suggesting CPPS and to determine the results of treatment for CPPS. METHOD The records of patients who had been treated for ADRP between March 2006 and June 2015 were reviewed retrospectively. Only those with endoscopic evidence of pouch inflammation who had also undergone MRI of the pelvis were included. The findings on pouchoscopy and the outcome of treatment were determined. RESULTS Sixty-eight patients (43 men, 63%) were identified with apparent ADRP between March 2006 and June 2015. MRI of the pelvis showed CPPS in 26 (38%). In those with CPPS, the inflammation was more often located in the upper pouch alone (15%) compared with patients without CPPS (0%) (P = 0.0184). Examination under anaesthesia was performed in 13 of those with CPPS. In five a collection was identified and drained; symptoms improved in only one (4%). Eighteen patients (69%) remained on antibiotics and seven (27%) had a defunctioning stoma or underwent pouch excision. CONCLUSION In patients thought to have ADRP, 38% had CPPS on MRI. There was no clinically relevant specific feature on pouchoscopy suggestive of CPPS. The possibility of CPPS should be considered early in patients with apparent ADRP and pelvic MRI performed. This might lead to earlier detection of CPPS and appropriate treatment.
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Affiliation(s)
| | - Y Maeda
- Department of Surgery, St Mark's Hospital, Harrow, London, UK
| | - O D Faiz
- Department of Surgery, St Mark's Hospital, Harrow, London, UK
| | - A L Hart
- IBD Unit, St Mark's Hospital, Harrow, London, UK
| | - S K Clark
- Department of Surgery, St Mark's Hospital, Harrow, London, UK
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20
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Colombo F, Sahami S, de Buck Van Overstraeten A, Tulchinsky H, Mege D, Dotan I, Foschi D, Leo CA, Warusavitarne J, D'Hoore A, Panis Y, Bemelman W, Sampietro GM. Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy. J Crohns Colitis 2017; 11:671-679. [PMID: 27927720 DOI: 10.1093/ecco-jcc/jjw209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 11/16/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres. METHODS The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate. RESULTS In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery. CONCLUSIONS Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.
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Affiliation(s)
- Francesco Colombo
- Luigi Sacco University Hospital, Department of Surgery, Milan, Italy
| | - Saloomeh Sahami
- Academisch Medisch Centrum, Department of Colorectal Surgery, Amsterdam, The Netherlands
| | | | - Hagit Tulchinsky
- Sourasky Medical Centre, Division of Surgery Colorectal Unit, Tel Aviv, Israel
| | - Diane Mege
- Hopital Beaujon, Pole des Maladies de l'Appareil Digestif, Clichy, France
| | - Iris Dotan
- Sourasky Medical Centre, Department of Gastroenterology and Liver Diseases, Tel Aviv, Israel
| | - Diego Foschi
- Luigi Sacco University Hospital, Department of Surgery, Milan, Italy
| | | | | | - André D'Hoore
- Universitaire Ziekenhuizen, Department of Abdominal Surgery, Leuven, Belgium
| | - Yves Panis
- Hopital Beaujon, Pole des Maladies de l'Appareil Digestif, Clichy, France
| | - Willem Bemelman
- Academisch Medisch Centrum, Department of Colorectal Surgery, Amsterdam, The Netherlands
| | - Gianluca M Sampietro
- Luigi Sacco University Hospital, Department of Surgery - IBD Surgical Unit, Milan, Italy
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21
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Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with chronic ulcerative colitis. No study to date has examined functional and quality-of-life outcomes 30 years after pouch construction. METHODS Using data from a prospectively maintained database with annually distributed questionnaires, functional outcomes, pouch complications, and quality of life after IPAA were determined. RESULTS Overall, 93.3% of patients had a functioning pouch at 30 years. Stool frequency during the day increased slightly from a mean of 5.7 (SD, 2.3) at 1 year to 6.2 (SD, 2.9) at 30 years (P < 0.001); nighttime frequency also increased slightly from 1.5 (SD, 1.2) to 2.1 (SD, 1.2) (P < 0.001). Pouch outcomes and stool frequency were significantly associated with diagnosis, being worse in patients with Crohn's disease, but were minimally associated with age greater than 65 years. After IPAA, the 30-year cumulative probability of pouchitis, stricture, obstruction, and fistula were 80.2%, 56.7%, 44.0%, and 15.8%, respectively. Quality of life scores remained stable over the 30 years. CONCLUSIONS IPAA is a durable operation for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The functional outcomes and quality of life remained relatively unchanged over the 30 years after IPAA underscoring the longevity of pouches.
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22
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Sunde ML, Øresland T, Faerden AE. Restorative proctocolectomy with two different pouch designs: few complications with good function. Colorectal Dis 2017; 19:363-371. [PMID: 27496246 DOI: 10.1111/codi.13478] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023]
Abstract
AIM The object of this study was to compare function and quality of life after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) surgery having two different pouch designs. METHOD Patients having RPC in an academic unit from 2000 who had had the loop-ileostomy closed by June 2013 were identified from the hospital medical records. They were sent a questionnaire regarding quality of life and interviewed using a pouch function score (PFS) described by Oresland (score 0-16, higher scores denote worse function). RESULTS One hundred and three patients underwent surgery, of whom 56 had a J-pouch design and 47 a K-pouch design, this being a double-folded Kock pouch without the nipple valve. No patients have had the pouch removed or defunctioned due to failure at a mean of 8 years. The reoperation rate was 11.6%. The mean PFS was 5.43 and 5.27 for J- and K-pouches, respectively (P = 0.766). More patients with a J-pouch reported a social handicap due to poor bowel function (P = 0.041). Patients with a PFS ≥ 8 had a poorer quality of life. A score of ≥ 8 was reported by 16% of K-pouch and 25% of J-pouch patients (P = 0.29). CONCLUSION RPC is a safe procedure with a low complication rate and good functional outcome. Small improvements in function have an impact on a patient's quality of life. Although the J-pouch is the most commonly used, the K-pouch has some advantages. Other pouch designs deserve further evaluation.
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Affiliation(s)
- M L Sunde
- Department of Colorectal Surgery, Akershus University Hospital, Lørenskog, Norway.,Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - T Øresland
- Department of Colorectal Surgery, Akershus University Hospital, Lørenskog, Norway.,Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - A E Faerden
- Department of Colorectal Surgery, Akershus University Hospital, Lørenskog, Norway
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23
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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24
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Abstract
Colorectal pediatric surgery is a diverse field that encompasses many different procedures. The pullthrough for Hirschsprung disease, the posterior sagittal anorectoplasty for anorectal malformations including complex cloaca reconstructions and the ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis present some of the most technically challenging procedures pediatric surgeons undertake. Many children prevail successfully following these surgical interventions, however, a small number of patients suffer from complications following these procedures. Anticipated postoperative problems are discussed along with medical and surgical strategies for managing these complications.
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Affiliation(s)
- Jason S Frischer
- Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Ave, MLC-2023, Cincinnati, Ohio 45229.
| | - Beth Rymeski
- Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Ave, MLC-2023, Cincinnati, Ohio 45229
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Outcome and functional prognosis of pelvic sepsis after ileal pouch-anal anastomosis in patients with ulcerative colitis. Surg Today 2016; 47:301-306. [DOI: 10.1007/s00595-016-1430-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/06/2016] [Indexed: 10/20/2022]
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Controversies in J Pouch Surgery for Ulcerative Colitis: A Focus on Handsewn Versus Stapled Anastomosis. Inflamm Bowel Dis 2016; 22:2302-9. [PMID: 27542137 DOI: 10.1097/mib.0000000000000876] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The accepted current standard for treatment of medically refractory ulcerative colitis is total proctocolectomy with an ileal pouch-anal anastomosis for restoration of continence. There are 2 techniques by which the anastomosis can be performed, including handsewn and stapled. Handsewn anastomosis with mucosectomy was the first method described; however, it has been associated with significant incontinence. The double-stapled anastomosis was developed in response to improve postoperative function. Controversy remains as to which technique is superior as both have disadvantages. This review article addresses differences between the 2 methodologies in relation to postoperative complications, anorectal physiology, functional outcomes, and oncological safety.
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Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the standard surgical option for patients with ulcerative colitis. Although ileal pouches have been shown to have acceptable functional outcomes, some patients experience fecal incontinence. OBJECTIVE The purpose of this study was to evaluate the incidence of fecal leakage and the way it may change over time in patients with an ileoanal pouch. DESIGN This study used a retrospective design. SETTINGS The study was conducted at a tertiary care center. PATIENTS Patients who received an IPAA for ulcerative colitis between 1983 and 2008 were accessed from a prospectively maintained database. We excluded patients with cancer, colonic dysplasia, and missing record of ileostomy closure and without long-term functional data. MAIN OUTCOME MEASURES We defined fecal leakage as leakage of stool more than once per day. Univariate and multivariate analyses were performed to identify associations with and possible risk factors for fecal leakage. RESULTS A total of 1228 patients were included in this study. There were 656 men, with a mean age of 38.7 years. The median follow-up time was 158 months. The fecal leakage rates at 5, 10, and >15 years were 24.6%, 25.7%, and 27.4% (p = 0.66). Patients with fecal leakage were significantly older at the time of surgery (p < 0.001), had longer disease duration before surgery (p = 0.04), underwent more 2-stage surgery (p = 0.04), included more women (p < 0.01), and showed lower preoperative maximum anal squeeze pressure (p = 0.008). On multivariate analysis, the only significant factor predisposing to fecal leakage was older age at the time of pouch surgery (OR = 1.07 (95% CI, 1.02-1.12); p = 0.005). LIMITATIONS The study was limited by its retrospective and non-randomized nature. CONCLUSIONS The occurrence of fecal leakage in patients with IPAA does not change with time. However, increased age at the time of surgery may increase the chances of patients with IPAA having fecal leakage.
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Affiliation(s)
- HyungJin Kim
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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28
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Gardenbroek TJ, Musters GD, Buskens CJ, Ponsioen CY, D'Haens GRAM, Dijkgraaf MGW, Tanis PJ, Bemelman WA. Early reconstruction of the leaking ileal pouch-anal anastomosis: a novel solution to an old problem. Colorectal Dis 2015; 17:426-32. [PMID: 25512241 DOI: 10.1111/codi.12867] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 10/08/2014] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to determine the effectiveness and direct medical costs of early surgical closure of the anastomotic defect after a short course of Endo-sponge® therapy of the presacral cavity, compared with conventional treatment in patients with anastomotic leakage after ileal pouch-anal anastomosis (IPAA). METHOD Patients with anastomotic leakage after IPAA undergoing early surgical closure of the anastomotic defect after a short Endo-sponge® treatment were prospectively followed and compared with a consecutive cohort of patients with an anastomotic leak treated by creation of a loop ileostomy and occasional drainage of the presacral cavity. RESULTS A total of 15 patients were treated with early surgical closure and 29 were treated conventionally. In the early surgical closure group, the Endo-sponge® treatment was continued for a median of 12 days [interquartile range (IQR) 7-15 days] with a median of 3 (IQR 2-4) Endo-sponge® changes. Secondary anastomotic healing was achieved in all patients (n = 15) in the early surgical closure group compared with 52% (n = 16) in the conventional treatment group (P = 0.003). Closure of the anastomotic defect was achieved after a median of 48 (25-103) days in the early surgical closure group compared with 70 (IQR 49-175) days in the conventional treatment group (P = 0.013). A functional pouch was seen in 93% and 86% of the patients in each group. There was no significant difference in direct medical cost. CONCLUSION Early surgical closure after a short period of Endo-sponge® treatment is highly effective in treating anastomotic leakage after IPAA without increasing cost.
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Affiliation(s)
- T J Gardenbroek
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands; Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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29
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Byrne CM, Rooney PS. Ileo-anal pouch excision: A review of indications and outcomes. World J Surg Proced 2015; 5:119-126. [DOI: 10.5412/wjsp.v5.i1.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 01/12/2015] [Accepted: 02/02/2015] [Indexed: 02/06/2023] Open
Abstract
Restorative proctocolectomy (RP) is the surgical treatment of choice for ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). A devastating complication for both patient and surgeon is failure of the pouch that requires excision. There is currently no single paper in the literature that consolidates the indications for ileo-anal pouch excision and the subsequent outcomes following this procedure. A literature search was carried out to identify articles on RP and ileal pouch-anal anastomosis. The main search terms used were “RP”; “ileal pouch-anal anastomosis” or “ileal reservoir” or “ileal pouch”; “failure of ileal pouch-anal anastomosis” and “excision of ileal pouch-anal anastomosis”. The search was completed using electronic databases MEDLINE, PubMed and EMBASE from 1975 to June 2014. Characteristics of patients with pouch failure differ between institutions. Reported overall excision rates of the pouches vary and in this review ranged from 0.93% to 12.8%. Age and lower institutional volume (less than 3.3 cases) were independent predictors of pouch failure; however surgeon case load was not. The main reasons identified for excision are sepsis (early cause), Crohn’s disease and poor functional outcomes (both late causes). Pouch cancers in UC and FAP are still rare but 135 cases exist in the literature. The most common complication following excision is persistent perineal sinus. The decision to excise a pouch should not be taken lightly and an awareness of the technical pitfalls and complications that can occur should be fully appreciated.
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Systematic review of the impact of surgical harm on quality of life after general and gastrointestinal surgery. Ann Surg 2015; 260:975-83. [PMID: 24854455 DOI: 10.1097/sla.0000000000000676] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the impact of surgical harm on quality of life (QoL) in general and gastrointestinal surgery. BACKGROUND Surgical adverse events (SAEs) are associated with poor outcome. Although SAEs are likely to affect QoL, this has not been demonstrated in surgery. METHODS Studies in general and gastrointestinal surgery measuring postoperative QoL in patients who suffered SAEs were identified. The overall impact of SAEs on QoL scores was determined by combining results from different studies. Component scores, adjustment for confounders, and time trends were evaluated. RESULTS Data from 57,058 patients in 31 studies were analyzed. Most studies assessed the combined effect of different SAEs. High-quality studies adjusted for preoperative QoL. When different QoL instruments were scaled down to a common 0 to 1 score, the mean difference in QoL between SAE and no-SAE patients was 0.140 in esophagectomy, 0.110 in the Crohn resection, 0.089 in colorectal resection, 0.085 in gastric bypass, 0.072 in cholecystectomy, and 0.060 in inguinal hernia repair. Studies evaluating ileal pouch formation and antireflux surgery showed conflicting results. SAEs did not significantly affect QoL in emergency laparotomy and pancreatectomy. The frequency of SAEs was 5% to 48%. Physical QoL was affected more than emotional QoL. CONCLUSIONS Significantly negative effects of SAEs on QoL were demonstrated in a range of procedures. Postoperative QoL seems to be a surrogate for the severity of impact of SAEs on patients. QoL may be an important utility to evaluate the economic and societal impact of SAEs thereby defining the threshold for safe practice.
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31
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Øresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, Marteau P, Zmora O, Kotze PG, Espin-Basany E, Tiret E, Sica G, Panis Y, Faerden AE, Biancone L, Angriman I, Serclova Z, de Buck van Overstraeten A, Gionchetti P, Stassen L, Warusavitarne J, Adamina M, Dignass A, Eliakim R, Magro F, D'Hoore A. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis 2015; 9:4-25. [PMID: 25304060 DOI: 10.1016/j.crohns.2014.08.012] [Citation(s) in RCA: 232] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mennigen R, Sewald W, Senninger N, Rijcken E. Morbidity of loop ileostomy closure after restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis: a systematic review. J Gastrointest Surg 2014; 18:2192-200. [PMID: 25231081 DOI: 10.1007/s11605-014-2660-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 09/03/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Temporary loop ileostomy is a routine procedure to reduce the morbidity of restorative proctocolectomy. However, morbidity of ileostomy closure could reduce the benefit of this concept. The objective of this systematic review was to assess the risks of ileostomy closure after restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis. MATERIALS AND METHODS Publications in English or German language reporting morbidity of ileostomy closure after restorative proctocolectomy were identified by Medline search. Two hundred thirty-two publications were screened, 143 were assessed in full-text, and finally 26 studies (reporting 2146 ileostomy closures) fulfilled the eligibility criteria. Weighted means for overall morbidity and mortality of ileostomy closure, rate of redo operations, anastomotic dehiscence, bowel obstruction, wound infection, and late complications were calculated. RESULTS Overall morbidity of ileostomy closure was 16.5 %, there was no mortality. Redo operations for complications were necessary in 3.0 %. Anastomotic dehiscence occurred in 2.0 %. Postoperative bowel obstruction developed in 7.6 %, with 2.9 % of patients requiring laparotomy for this complication. Wound infection rate was 4.0 %. Hernia or bowel obstruction as late complications developed in 1.9 and 9.4 %, respectively. CONCLUSION The considerable morbidity of ileostomy reversal reduces the overall benefit of temporary fecal diversion. However, ileostomy creation is still recommended, as it effectively reduces the risk of pouch-related septic complications.
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Affiliation(s)
- Rudolf Mennigen
- Department of General and Visceral Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Geb. W1, 48149, Muenster, Germany,
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33
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Theodoropoulos GE, Choman EN, Wexner SD. Salvage procedures after restorative proctocolectomy: a systematic review and meta-analysis. J Am Coll Surg 2014; 220:225-42.e1. [PMID: 25535169 DOI: 10.1016/j.jamcollsurg.2014.10.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 10/12/2014] [Accepted: 10/13/2014] [Indexed: 02/06/2023]
Affiliation(s)
| | - Eran N Choman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL.
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34
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Abstract
Ileal pouch-anal anastomosis is currently accepted as the standard method to restore continence after total proctocolectomy for medically refractory ulcerative colitis and familial adenomatous polyposis. Ileal pouches offer improved quality of life and high patient satisfaction; however, there are many pouch-related complications due to the original disease process and change in anatomy. This is a review article of the common and some rare surgical complications after J pouches, which can be subdivided into the septic and nonseptic categories. Septic-related complications include anastomotic leak, abscess, and fistulas, whereas common nonseptic-related complications include small bowel obstruction, strictures, Crohn's disease, pouchitis, and cuffitis. Rare nonseptic complications to be discussed are prolapse, volvulus, and neoplasia.
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35
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36
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Yarur AJ, Abreu MT, Salem MS, Deshpande AR, Sussman DA. The impact of Hispanic ethnicity and race on post-surgical complications in patients with inflammatory bowel disease. Dig Dis Sci 2014; 59:126-34. [PMID: 23483313 DOI: 10.1007/s10620-013-2603-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 02/07/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Surgery for inflammatory bowel disease (IBD) is common and represents a large portion of the cost of IBD treatment. There are multiple risk factors for post-operative complications after IBD surgery, but the role of ethnicity remains unclear. The aim of our study was to compare the rate of post-operative complications in Hispanic and non-Hispanic patients with equal access to health care. METHODS We designed a case-control study including patients enrolled in a health plan available to uninsured patients at Jackson Memorial Hospital (Miami, FL, USA) who had access to health care for at least 24 consecutive months prior to surgery. Sixty-seven Hispanic patients (cases) and 75 non-Hispanic patients (controls) met criteria and were compared with respect to demographics, type of surgery, disease phenotype, and laboratory markers. Primary outcome was the development of a medical or surgical complication. RESULTS A slight numerical increase in post-operative complications was seen in Hispanic patients; this did not reach statistical significance [1.06 (95 % CI 0.48-2.36; p = 0.88)]. Factors independently associated with post-operative complications included diagnosis of ulcerative colitis [OR 5.4 (95 % CI 1.67-20.58; p = 0.004)], pre-operative albumin levels <3 mg/dL [OR: 8.2 (95 % CI 2.3-35.5; p < 0.001)], smoking [OR 15.7 (95 % CI 4.2-72.35; p < 0.001)], and use of ≥20 mg of prednisone [OR 6.7 (95 % CI 2.15-24.62; p < 0.001)]. CONCLUSIONS In a group of patients with equal access to medical care and follow-up, Hispanics and non-Hispanics with IBD that underwent surgery had no significant differences in types of IBD surgeries or post-surgical outcomes.
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Affiliation(s)
- Andres J Yarur
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, 1120 NW 14th Street, Clinical Research Building 350 (D-49), Miami, FL, 33136, USA,
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37
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Naumann DN, Abbott S, Hall D, Bowley DM. Pouch dysfunction: don't forget the surgeons! Frontline Gastroenterol 2013; 4:308-309. [PMID: 28839742 PMCID: PMC5369833 DOI: 10.1136/flgastro-2013-100360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/03/2013] [Indexed: 02/04/2023] Open
Affiliation(s)
- David N Naumann
- Department of General Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sian Abbott
- Department of General Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Diane Hall
- Department of Inflammatory Bowel Disease, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Douglas M Bowley
- Department of General Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
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38
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Hermann J, Szmeja J, Kościński T, Meissner W, Drews M. Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis. Arch Med Sci 2013; 9:283-7. [PMID: 23671439 PMCID: PMC3648821 DOI: 10.5114/aoms.2013.33175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Revised: 05/26/2011] [Accepted: 07/14/2011] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Proctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients. MATERIAL AND METHODS Medical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study. RESULTS All patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant. CONCLUSIONS The IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.
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Affiliation(s)
- Jacek Hermann
- Department of General, Gastrointestinal and Endocrinological Surgery, Poznan University of Medical Sciences, Poland
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39
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Risk factors for anastomotic leakage and favorable antimicrobial treatment as empirical therapy for intra-abdominal infection in patients undergoing colorectal surgery. Surg Today 2013; 44:487-93. [DOI: 10.1007/s00595-013-0575-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 01/16/2013] [Indexed: 11/25/2022]
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40
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Francone TD, Champagne B. Considerations and complications in patients undergoing ileal pouch anal anastomosis. Surg Clin North Am 2013. [PMID: 23177068 DOI: 10.1016/j.suc.2012.09.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.
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Affiliation(s)
- Todd D Francone
- Department of Colon and Rectal Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA.
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41
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Privitera A, Dozois EJ. A novel approach to management of a sacral defect in ileal pouch-sacral fistula. J Surg Case Rep 2012; 2012:rjs006. [PMID: 24968393 PMCID: PMC3853803 DOI: 10.1093/jscr/rjs006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Fistula formation after restorative proctocolectomy poses a challenge to the surgeon and sometimes can lead to the excision of the pouch. While pouch-vaginal fistulas are more common, pouch-sacral fistulas are a rare event and treatment is still controversial. The authors report a case of pouch-sacral fistula which was treated successfully with a novel approach comprising pouch revision, debridement of sacrum and placement of a human acellular dermal matrix (Alloderm) mesh to patch the residual large sacral defect. This is the first report of the use of Alloderm under this rare condition.
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Affiliation(s)
- Antonio Privitera
- Department of Surgery, University Hospital of North Staffordshire, Stoke-On-Trent, Staffordshire, UK
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, USA
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42
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Millán Scheiding M, Rodriguez Moranta F, Kreisler Moreno E, Golda T, Fraccalvieri D, Biondo S. [Current status of elective surgical treatment of ulcerative colitis. A systematic review]. Cir Esp 2012; 90:548-57. [PMID: 23063060 DOI: 10.1016/j.ciresp.2012.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 07/29/2012] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Monica Millán Scheiding
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Bellvitge, ĹHospitalet de LLobregat, Barcelona, España.
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43
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Cowan ML, Fichera A. Ileal Pouch–Anal Anastomosis—A Surgical Perspective. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2012.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Karlbom U, Lindfors A, Påhlman L. Long-term functional outcome after restorative proctocolectomy in patients with ulcerative colitis. Colorectal Dis 2012; 14:977-84. [PMID: 22053822 DOI: 10.1111/j.1463-1318.2011.02873.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to evaluate the long-term functional outcome of ileal pouch-anal anastomosis for ulcerative colitis and to compare symptoms over time. METHODS In all, 188 patients were operated with an ileal pouch-anal anastomosis. Short-term functional outcome has previously been evaluated with a symptom questionnaire. The same questionnaire was sent to the 162 patients who were alive and had an intact pouch. A symptom index was studied over time and in relation to early complications and pouchitis. RESULTS The response rate of the questionnaire was 139/162 at a median of 12.5 (9.5-21) years postoperatively. Overall, the symptom index remained unchanged over time but both the frequency of night-time defaecation and episodes of night-time incontinence increased. Patients' global assessment was unchanged with approximately 80% stating an excellent or a good result. Frequency of pouchitis doubled in 10 years. Symptom index for patients with episodic pouchitis [median 40 (8-89), P = 0.018] and recurrent/chronic pouchitis [71 (8-136), P < 0.001] was higher than in patients without pouchitis [29 (0-105)]. Early complications did not affect the symptom index. CONCLUSION The overall functional outcome of ileal pouch-anal surgery for ulcerative colitis is stable over time. Patients' satisfaction with outcome remains high. Pouchitis is a determinant of functional outcome.
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Affiliation(s)
- U Karlbom
- Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
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Abstract
BACKGROUND Pelvic sepsis after IPAA predisposes to pouch failure. There are limited data on long-term pouch function for patients with pelvic sepsis. OBJECTIVE The aim of this study was to investigate functional outcomes and quality of life for patients undergoing IPAA who develop pelvic sepsis and preserve their pouch long-term. DESIGN This study is based on retrospective analysis of prospectively accrued data. SETTINGS This study was conducted at a single-center institution. PATIENTS All patients undergoing IPAA from 1983 to 2007 were included. MAIN OUTCOME MEASURES The primary outcomes measured were functional outcomes (urgency, incontinence, bowel movements) and quality-of-life (restrictions, energy, happiness) parameters. RESULTS Two hundred (6.2%) of 3234 patients developed pelvic septic complications within 3 months of IPAA. In the comparison of complications at the time of IPAA for the 2 groups, patients with pelvic sepsis had higher rates of postoperative hemorrhage (13.5% vs 3.7%, p < 0.001), anastomotic leak (35% vs 3.7%, p < 0.001), wound infection (14% vs 7.4%, p < 0.001), and fistula formation (37% vs 7.1%, p < 0.001). The overall median follow-up was 7 years. Pelvic sepsis was associated with greater pouch failure (19.5% vs 4%, p < 0.001). For patients with follow-up (pelvic sepsis = 144, nonpelvic sepsis = 2677) with a retained pouch, for whom we compared functional outcomes and quality of life, incontinence was worse (never/rare: 69.5% vs 77.8%, p = 0.03). Urgency scores were lower in pelvic sepsis but not statistically significant. The overall Cleveland Global Quality of Life score (and components) in the sepsis group were significantly worse than in the nonsepsis group (0.74 vs 0.79, p < 0.001). Patients who developed sepsis were also less likely to recommend IPAA to others than patients who did not develop pelvic sepsis. LIMITATIONS This study was limited by the retrospective analysis and the use of questionnaires. CONCLUSIONS Pelvic sepsis after IPAA leads to worse functional outcomes and quality of life even when it does not lead to pouch failure. This finding argues for careful attention to preoperative and intraoperative planning and strategies aimed at reducing this complication after IPAA.
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Pelvic abscess associated with anastomotic leak in patients with ileal pouch-anal anastomosis (IPAA): transanastomotic or CT-guided drainage? Int J Colorectal Dis 2011; 26:1469-74. [PMID: 21773700 DOI: 10.1007/s00384-011-1272-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2011] [Indexed: 02/07/2023]
Abstract
AIM Evidence is lacking whether an abscess associated with anastomotic leak after an ileal pouch-anal anastomosis (IPAA) should be drained by transanal or CT-guided drainage. Therefore, the aim of this study was to compare outcomes after the two techniques for drainage. METHOD Patients who underwent IPAA (1984-2009) and diagnosed with a pelvic abscess associated with an anastomotic leak were identified. The choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (group TA) and CT-guided drainage (group CT) were determined. RESULTS Groups TA (n = 53) and CT (n = 18) had similar age (p = 0.3), gender (p = 0.3), body mass index (p = 0.6), steroid use (p = 0.4), albumin level (p = 0.9), ileostomy (p = 0.6), and follow-up time (p = 0.5). The size of the abscess was greater in group CT (p = 0.012). Two patients developed fistula at the CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Thirteen patients in group TA and three patients in group CT (p = 0.6) had failure of drainage and underwent surgery. The success rates for the procedures in terms of long-term pouch retention were 75.5% and 83%, respectively, for TA and CT. Groups TA and CT had similar bowel frequency (p = 0.9), incontinence (p = 0.6), urgency (p = 0.9), seepage (p = 0.6), pad usage (p = 0.1), quality of life (p = 0.9), and happiness with surgery (p = 0.9). CONCLUSIONS There is a risk of fistula at drainage site after a CT-guided drainage of the pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage are equally effective and result in similar long-term pouch-related outcomes.
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Beddy D, Pemberton JH. Volume analysis of outcome following restorative proctocolectomy (Br J Surg 2011; 98: 408-417). Br J Surg 2011; 98:1031; author reply 1031-2. [PMID: 21618488 DOI: 10.1002/bjs.7606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (http://www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.
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Beddy D, Dozois EJ, Pemberton JH. Perioperative complications in inflammatory bowel disease. Inflamm Bowel Dis 2011; 17:1610-9. [PMID: 21674718 DOI: 10.1002/ibd.21504] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 08/25/2010] [Indexed: 12/27/2022]
Abstract
Almost 50% of patients with inflammatory bowel disease (IBD) will undergo surgery for their disease at some stage of its clinical course. Complications seen following surgery may occur early or late in the postoperative period. Patient factors, including active inflammatory disease, malnutrition, and use of immunosuppressant medications, make these patients a challenging surgical group and at increased risk for surgical complications. The purpose of this review is to characterize the complications that are commonly seen following surgery in patients with IBD and to discuss the surgical and patient factors that may influence their development.
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Affiliation(s)
- David Beddy
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Rochester, Minnesota, USA
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Pouch function and quality of life after successful management of pouch-related septic complications in patients with ulcerative colitis. Langenbecks Arch Surg 2011; 397:37-44. [DOI: 10.1007/s00423-011-0802-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 05/02/2011] [Indexed: 12/19/2022]
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Impact of defunctioning loop ileostomy on outcome after restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 2011; 26:627-33. [PMID: 21318298 DOI: 10.1007/s00384-011-1151-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE This study analyzes the impact of a temporary loop ileostomy on postoperative outcome after restorative proctocolectomy for ulcerative colitis in terms of complications and reoperations including ileostomy closure. METHODS The records of 122 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis during a 12-year period were reviewed. In 89 patients, a defunctioning ileostomy was created, while 33 patients had no ileostomy. Statistics were done with Chi-square test and Mann-Whitney U test, p < 0.05 considered significant. RESULTS Both study groups were comparable concerning age, colitis activity, previous diseases, previous surgery, use of steroids, and immunosuppressives. Pouch-related septic complications (anastomotic dehiscence, pouch leakage, pelvic abscess) were significantly lower in the ileostomy group (5.6% vs. 18.2%, p = 0.031), resulting in a lower rate of emergency laparotomies following restorative proctocolectomy (4.5% vs. 30.3%, p < 0.001). Including all complications associated with scheduled closure of ileostomy, the cumulative frequency of emergency laparotomies was significantly lower in the ileostomy group (13.5% vs. 30.3%, p = 0.032). The cumulative duration of hospitalization, including all hospital stays for complications or closure of the ileostomy, was significantly longer in the ileostomy group [median 22 days (11-92) vs. 14 days (9-109), p < 0.001]. During long-term follow-up, a stricture at the pouch-anal anastomosis was more common in the ileostomy group (24.7% vs. 6.1%, p = 0.021), whereas only one stricture necessitated surgical therapy. CONCLUSIONS Creation of a defunctioning loop ileostomy reduces pouch-related septic complications and the frequency of emergency second laparotomies after restorative proctocolectomy for ulcerative colitis.
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