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

A retrospective cohort study on renal morbidity related to stoma type in inflammatory bowel disease patients following colectomy and ileal pouch-anal anastomosis surgery

BACKGROUND AND OBJECTIVE

Defunctioning loop ileostomy (DLI) is frequently used to decrease the consequences of anastomotic leak after ileal pouch-anal anastomosis (IPAA) surgery but is controversial because of stoma-associated morbidity. The aim of this study was to describe stoma-associated morbidity in IPAA-DLI patients compared with terminal ileostomy patients.

METHODS

Patients treated with colectomy for inflammatory bowel disease at Skåne University Hospital, Sweden, between 2005 and 2021 were eligible for inclusion. Terminal stoma-related morbidity was measured until 12 months after colectomy, IPAA surgery, or conversion to ileorectal anastomosis, whichever occurred first. DLI-related morbidity was measured until 12 months after IPAA surgery or stoma closure, whichever occurred first. Laboratory data were reviewed up to 18 months after surgery since patients without complications were rarely subjected to blood sampling. Data on patient characteristics, renal function, surgical complications, and readmissions were collected retrospectively. Primary outcomes were DLI- and terminal ileostomy-related renal morbidity, whereas secondary outcomes focused on stoma-related complications.

RESULTS

The study cohort consisted of 165 patients with terminal ileostomy after colectomy (median (interquartile range (IQR)): stoma time 30 (15-74) months) and 42 patients with IPAA-DLI (median (IQR): stoma time 4 (3-5) months). One case of anastomotic IPAA leakage was observed. IPAA-DLI patients more often required hospital care due to high-volume stoma output immediately after surgery (0-30 days, 29%) compared with terminal ileostomy patients (4%, p < 0.001). There were no significant differences in acute renal injury (p = 0.073) or chronic renal failure (p = 0.936) incidences between the groups. DLI closure was achieved in 95% of IPAA-DLI patients, with 5% suffering Clavien-Dindo complications > 2.

CONCLUSIONS

IPAA-DLI patients exhibited higher incidence of short-term high-volume stoma output without higher rates of acute renal injury or chronic renal failure compared with terminal ileostomy patients in this small single-center retrospective study suggesting that the risk of renal morbidity in IPAA-DLI patients may have been overestimated.

Modified 2-stage IPAA has similar postoperative complication rates and functional outcomes compared to 3-stage IPAA

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.

High Complication Rate After Early Ileostomy Closure: Early Termination of the Short Versus Long Interval to Loop Ileostomy Reversal After Pouch Surgery Randomized Trial

BACKGROUND

In patients with ulcerative colitis who undergo IPAA, a diverting ileostomy is used to diminish the severity of anastomotic complications. Typically, the ileostomy is closed after an interval of 2 to 4 months. The safety of earlier closure of the ileostomy after pouch surgery is unknown.

OBJECTIVE

This study aimed to compare postoperative outcomes in patients randomly assigned to early (7-12 days) or late (≥8 weeks) ileostomy closure after ileal pouch construction.

DESIGN

This was a multicenter, prospective randomized trial.

SETTING

The study was conducted at colorectal surgical units at select United States hospitals.

PATIENTS

Adults with ulcerative colitis who underwent 2- or 3-stage proctocolectomy with IPAA were included.

MAIN OUTCOME MEASURES

The primary outcomes included Comprehensive Complication Index at 30 days after ileostomy closure. The secondary outcomes included complications, severe complications, reoperations, and readmissions within 30 days of ileostomy closure.

RESULTS

The trial was stopped after interim analysis because of a high rate of complications after early ileostomy closure. Among 36 patients analyzed, 1 patient (3%) had unplanned proctectomy with end-ileostomy. Of the remaining 35 patients, 28 patients (80%) were clinically eligible for early closure and underwent radiologic assessment. There were 3 radiologic failures. Of the 25 remaining patients, 22 patients (88%) were randomly assigned to early closure (n = 10) or late closure (n = 12), and 3 patients were excluded. Median Comprehensive Complication Index was 14.8 (0-54) and 0 (0-23) after early and late closure (p = 0.02). One or more complications occurred in 7 patients (70%) after early closure and in 2 patients (17%) after late closure (p = 0.01)' and complications were severe in 3 patients (30%) after early closure and 0 patients after late closure (p = 0.04). Reoperation was required in 1 patient (10%) and 0 patients (p = 0.26) after early closure and readmission was required in 7 patients (70%) and 1 patient (8%) after late closure (p = 0.003).

LIMITATIONS

This study was limited by early study closure and selection bias.

CONCLUSIONS

Early closure of a diverting ileostomy in patients with ulcerative colitis who underwent IPAA is associated with an unacceptably high rate of complications. See Video Abstract at http://links.lww.com/DCR/C68.

ALTA TASA DE COMPLICACIONES DESPUS DEL CIERRE PRECOZ DE LA ILEOSTOMA TERMINACIN TEMPRANA DEL ENSAYO ALEATORIZADO DE INTERVALO CORTO VERSUS LARGO PARA LA REVERSIN DE LA ILEOSTOMA EN ASA DESPUS DE LA CIRUGA DE RESERVORIO ILEAL

ANTECEDENTES:En los pacientes con colitis ulcerosa que se someten a una anastomosis del reservorio ileoanal, se utiliza una ileostomía de derivación para disminuir la gravedad de las complicaciones de la anastomosis. Por lo general, la ileostomía se cierra después de un intervalo de 2 a 4 meses. Se desconoce la seguridad del cierre más temprano de la ileostomía después de la cirugía de reservorio.OBJETIVO:Comparar los resultados posoperatorios en pacientes asignados al azar al cierre temprano (7-12 días) o tardío (≥ 8 semanas) de la ileostomía después de la construcción de un reservorio ileal.DISEÑO:Este fue un ensayo aleatorizado prospectivo multicéntrico.ESCENARIO:El estudio se realizó en unidades quirúrgicas colorrectales en hospitales seleccionados de los Estados Unidos.PACIENTES:Se incluyeron adultos con colitis ulcerosa que se sometieron a proctocolectomía en 2 o 3 tiempos con anastomosis ileoanal con reservorio.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron el Índice Integral de Complicaciones a los 30 días después del cierre de la ileostomía. Los resultados secundarios incluyeron complicaciones, complicaciones graves, reoperaciones y readmisiones dentro de los 30 días posteriores al cierre de la ileostomía.RESULTADOS:El ensayo se detuvo después del análisis interino debido a una alta tasa de complicaciones después del cierre temprano de la ileostomía. Entre los 36 pacientes analizados, 1 (3%) tuvo una proctectomía no planificada con ileostomía terminal. De los 35 pacientes restantes, 28 (80%) fueron clínicamente elegibles para el cierre temprano y se sometieron a una evaluación radiológica. Hubo 3 fracasos radiológicos. De los 25 pacientes restantes, 22 (88 %) se asignaron al azar a cierre temprano (n = 10) o tardío (n = 12) y 3 fueron excluidos. La mediana del Índice Integral de Complicaciones fue de 14,8 (0-54) y 0 (0-23) después del cierre temprano y tardío (p = 0,02). Una o más complicaciones ocurrieron en 7 pacientes (70%) después del cierre temprano y 2 (17%) pacientes después del cierre tardío (p = 0,01) y fueron graves en 3 (30%) y 0 pacientes, respectivamente (p = 0,04). Requirieron reintervención en 1 (10%) y 0 (p = 0,26) y reingreso en 7 (70%) y 1 (8%) pacientes (p = 0,003).LIMITACIONES:Este estudio estuvo limitado por el cierre temprano del estudio; sesgo de selección.CONCLUSIONES:El cierre temprano de una ileostomía de derivación en pacientes con colitis ulcerosa con anastomosis de reservorio ileoanal se asocia con una tasa inaceptablemente alta de complicaciones. Consulte Video Resumen en http://links.lww.com/DCR/C68. (Traducción-Dr. Felipe Bellolio).

Postoperative complications of colectomy and J-pouch with ileostomy versus without ileostomy in children with inflammatory bowel diseases: a systematic review and meta-analysis

Background

The efficacy of performing a restorative proctocolectomy and J-pouch ileoanal anastomosis without diverting ileostomy in children with inflammatory bowel disease has been a longstanding debate. A systematic review and meta-analysis is presented comparing the occurrence of postoperative complications in children who underwent either the pouch-anal anastomosis (IPAA) with ileostomy (diverted) versus the undiverted procedure.

Methods

Records were sourced from CINAHL, CENTRAL, EMBASE and MEDLINE databases. Studies followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and compared postoperative complications in pediatric patients diagnosed with inflammatory diseases aged less than 18 years who underwent J-pouch with ileostomy versus without ileostomy. The primary outcome was the occurrence of postoperative leaks, and the secondary outcomes were presence of postoperative small bowel obstruction (SBO), pouchitis, stricture and fistula complications. A random-effects meta-analysis was used.

Results

Twenty-three observational studies in the systematic review were included with 658 patients (83% diverted, 17% undiverted). Pooled estimates showed no difference in occurrence of leaks in children who underwent J-pouch/IPAA with ileostomy versus without (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.17 to 1.64, I2=16%). There was no difference in the occurrence of SBO, pouchitis or strictures in children who underwent J-pouch/IPAA with ileostomy versus without (SBO: OR 2.27, 95% CI 0.52 to 9.92, I2=0%, pouchitis: OR 1.76, 95% CI 0.95 to 3.24, I2=0%, strictures: OR 2.72, 95% CI 0.44 to 16.69, I2=66%).

Conclusion

The meta-analysis did not find differences in the occurrence of complications in pediatric patients who underwent the IPAA with ileostomy procedure versus without ileostomy.

Long-term cost and complications of surgery in patients with ulcerative colitis: a claims data analysis

OBJECTIVES

Use claims data to assess healthcare resource utilization (HCRU) and cost for patients with ulcerative colitis (UC) who had surgery and patients who did not.

METHODS

UC patients from a German health insurance were included between 01/01/2010-31/12/2017. Patients with proctocolectomy or colectomy between 01/07/2010 and 31/12/2014 were identified, and surgery date was set as index. For patients with IPAA, the last surgery in the 6 months was taken as index. Non-surgery patients received random index. After propensity score matching, UC-related HCRU and cost were observed for three years post-index.

RESULTS

Of 21,392 UC patients, 85 underwent surgery and 2655 did not. After matching, 76 were included in the surgery group and 114 in the non-surgery group. Matched cohorts did not differ in baseline characteristics and mortality rates where high in both groups (21.1% and 29.0%, respectively). The percentage of patients with at least one hospitalization in the follow-up period was higher in the surgery (53.9%) compared to the non-surgery group (25.4%, p<0.001). In contrast, the number of outpatient prescriptions of UC-related drugs in the non-surgery group (11.2) was almost twice as large as in the surgery group (5.8, p<0.001). Hospitalization cost was 4.6 times higher in the surgery (1955.5€) than in the non-surgery group (419.6€, p<0.001). Medication cost was three times higher in the non-surgery group (6519€) compared to the surgery group (2151.7€, p<0.001).

CONCLUSIONS

Based on hospitalizations, outpatient visits, and medical treatment, results show a considerable patient burden in UC from surgery complications or disease exacerbation in case of colectomy.

Current trends regarding protective ileostomy after restorative proctocolectomy

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

Unexplained systemic inflammatory response following ileostomy closure after ileal pouch-anal anastomosis: a deeper dive into a rare entity

AIM

The purpose of this study is to shed light on a rare complication following ileostomy closure after 3-stage IPAA for further study and discussion.

METHODS

Our department IPAA database was queried for all patients who underwent 3-stage IPAA creation from 2011 through 2018. Data was reviewed and analyzed using the SPSS application. Chi-square test and Fisher's exact test were used for categorical variables. t test or ANOVA was used for continuous variables. Significance was set at p < 0.05.

RESULTS

Three hundred seventy-eight charts were queried. Sixty-eight complications (18.0%) were identified after ileostomy closure. Thirty-seven were small bowel obstruction or partial small bowel obstruction (SBO or pSBO, 9.79%), 5 cases of leak from ileoileostomy anastomosis (7.4%), and 4 cases of leak from pouch (5.9%). There was no significant difference in time between restorative proctocolectomy with IPAA and loop ileostomy closure with cases where a complication occurred and where one did not (p = 0.28). Eight patients developed a SIRS response in the first 5 days after surgery without an identified intraabdominal source after extensive work-up. Of these patients, 87.5% also had negative re-explorations (both open and laparoscopic). None required re-diversion, and all recovered well.

CONCLUSIONS

While SBO remains the most common complication following ileostomy closure, a surprisingly large number of presents present with a SIRS response with no identifiable source. All of these patients recovered with supportive care, and none required further intervention or diversion. This is a poorly understood phenomenon which is unique to ileostomy closure after IPAA, and further study is required.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. A prospective study on safety, efficacy and long-term results

BACKGROUND

Laparoscopic ileo-pouch-anal anastomosis (IPAA) has been reported as having low morbidity and several advantages.

AIMS

To evaluate safety, efficacy and long-term results of laparoscopic IPAA, performed in elective or emergency settings, in consecutive unselected IBD patients.

METHODS

All the patients received totally laparoscopic 2-stage (proctocolectomy and IPAA - stoma closure) or 3-stage (colectomy - proctectomy and IPAA - stoma closure) procedure according to their presentation.

RESULTS

From July 2007 to July 2016, 160 patients entered the study. 50.6% underwent a 3-stage procedure and 49.4% a 2-stage procedure. Mortality and morbidity were 0.6% and 24.6%. Conversion rate was 3.75%. 8.7% septic complications were associated with steroids and Infliximab treatment (p = 0.0001). 3-stage patients were younger (p = 0.0001), with shorter disease duration (p = 0.0001), minor ASA scores of 2 and 3 (p = 0.0007), lower inflammatory index and better nutritional status (p = 0.003 and 0.0001), fewer Clavien-Dindo's grade II complications (p = .0001), reduced rates of readmission and reoperation at 90 days (p = 0.03), and shorter hospitalization (p = .0001), but with similar pouch and IPAA leakage, compared to 2-stage patients. 8 years pouch failure and definitive ileostomy were 5.1% and 3.7%.

CONCLUSION

A totally laparoscopic approach is safe and feasible, with very low mortality and morbidity rates and very low conversion rate, even in multi-stage procedures and high-risk patients.

Surgery in ulcerative colitis: When? How?

Ulcerative Colitis (UC) is an idiopathic chronically-remitting inflammatory bowel disorder characterized by a contiguous inflammation of the colonic mucosa affecting the rectum that generally extends proximally in a continuous manner through the entire colon. Patients typically experience intermittent exacerbations, with symptoms characterized by bloody diarrhea associated with urgency and tenesmus. The anatomical extent of mucosal involvement is the most important factor determining disease course and is an important predictor of colectomy. The precise etiology of UC is unknown. However, a combination of genetic predisposition and environmental factors seems to have a key role in the development of the disease. UC usually is mildly active but it can be a life-threatening condition because of colonic and systemic complications, and later in the disease course due to the development of colorectal cancer. Interestingly, even if pathogenetic features detected in patients with sporadic CRC can be also found in UC-related colorectal cancer (UC-CRC), this latter is, usually, driven by an inflammation-driven pathway rising from a non-neoplastic inflammatory epithelium to dysplasia to cancer. Thus, a long-term follow-up with colonoscopy surveillance has been recommended. Approximately 15% of UC patients develop an acute attack of severe colitis, and 30% of these patients require colectomy. The initial treatment strategy in UC typically follows the traditional step-up approach. One third of the patients will not respond to steroid therapy and cyclosporine and infliximab are the most common salvage agents employed in these cases in order to avoid emergent surgery. Unfortunately, although a significant short-term benefit have been observed after infliximab treatment, the colectomy rate have remained stable. Surgery in UC depends on the stage of the disease as well as patient's status and is divided into the following settings: urgent, emergent and elective. Despite many efforts the surgical management of UC remains a significant challenge. A multidisciplinary management of UC is key in order to define the best timing and the best procedure for each patient in an individualized basis.

Current Approaches to Pediatric Polyposis Syndromes

Colorectal adenomatous polyposis syndromes encompass a diverse group of disorders with varying modes of inheritance and penetrance. Children may present with overt disease or within screening programs for families at high risk. We provide an overview of the array of pediatric polyposis syndromes, current screening recommendations, and surgical indications and technical considerations. Optimal disease management for these pediatric patients is still evolving and has implications for screening, surveillance, pediatric surgical management, and transition of care gastroenterologic neoplasia physicians and surgeons.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Systematic Review: Sequential Rescue Therapy in Severe Ulcerative Colitis: Do the Benefits Outweigh the Risks?

BACKGROUND

The options for medical management of acute severe steroid-refractory ulcerative colitis (UC) are limited. Recent guidelines recommend against use of sequential rescue therapy in the setting of failed medical management with initial salvage therapy. A systematic review was conducted to assess outcomes of sequential rescue therapy with infliximab (IFX) and calcineurin inhibitors like cyclosporine (CsA) or tacrolimus (Tac) in patients with steroid-refractory UC.

METHODS

A literature search identified studies that investigated treatment with IFX and CsA or Tac in acute severe UC. Outcomes of interest included short-term symptomatic response to treatment, rates of remission, adverse drug reactions, serious infections, mortality, and colectomy at 3 and 12 months.

RESULTS

Overall, ten studies with 314 participants were eligible for inclusion. After sequential treatment, patients achieved short-term treatment response in 62.4% (95% confidence interval [CI], 57.0%-67.8%) of cases and remission in 38.9% (95% CI, 33.5%-44.3%). Colectomy rates were 28.3% (95% CI, 21.7%-34.5%) at 3 months and 42.3% (95% CI, 36.0%-48.6%) at 12 months. Adverse events were encountered by 23.0% (95% CI, 17.7%-28.3%) of patients, including serious infections in 6.7% (95% CI, 3.6%-9.8%) and mortality in 1% (95% CI, 0%-2.1%).

CONCLUSIONS

The risk of sequential therapy in steroid-refractory UC seems lower than initially reported. Caution must be exercised however because of very low-quality evidence. In contrast to recent guidelines, the current analysis does not support a decision for or against use of sequential rescue therapy, which should only be performed at specialized referral centers familiar with the use of calcineurin inhibition.

Morbidity of loop ileostomy closure after restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis: a systematic review

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.

Impact of defunctioning loop ileostomy on outcome after restorative proctocolectomy for ulcerative colitis

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.

Consensus for managing acute severe ulcerative colitis in children: a systematic review and joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN

OBJECTIVES

Acute severe ulcerative colitis (ASC) is a potentially life-threatening disease. We aimed to formulate guidelines for managing ASC in children based on systematic review of the literature and robust consensus process. This manuscript is a product of a joint effort of the ECCO (European Crohn's and Colitis Organization), the Pediatric Porto Inflammatory Bowel Disease (IBD) Working group of ESPGHAN (European Society of Pediatric Gastroenterology, Hepatology, and Nutrition) and ESPGHAN.

METHODS

A group of 19 experts in pediatric IBD participated in an iterative consensus process including two face-to-face meetings. A total of 17 predefined questions were addressed by working subgroups based on a systematic review of the literature.

RESULTS

The recommendations and practice points were eventually endorsed with a consensus rate of at least 95% regarding: definitions, initial evaluation, standard therapy, timing of second-line therapy, the role of endoscopic evaluation and heparin prophylaxis, how to administer second-line medical therapy, how to assess response, surgical considerations, and discharge recommendations. A management flowchart is presented based on daily scoring of the Pediatric Ulcerative Colitis Activity Index (PUCAI), along with 28 formal recommendations and 34 practice points.

CONCLUSIONS

These guidelines provide clinically useful points to guide the management of ASC in children. Taken together, the recommendations offer a standardized protocol that allows effective monitoring of disease progress and timely treatment escalation when needed.

Restorative proctocolectomy with and without protective ileostomy in a pediatric population

PURPOSE

This study aim was to review outcomes of pediatric patients after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes.

METHODS

All patients who underwent rectal mucosectomy with ileal pouch reservoir and hand-sewn ileal pouch anal anastomosis (IPAA) during 19-year period were reviewed retrospectively.

RESULTS

Eighty-three patients with ulcerative colitis and 7 patients with polyposis syndromes (ages 2.0-21.8 years) were reviewed. Sixty-eight patients underwent IPAA without diverting ileostomy. Fifty-six patients underwent restorative proctocolectomy as single-stage procedures, and 12 had abdominal colectomy and subsequent definitive IPAA without diverting ileostomy. Nineteen patients had IPAA with diverting ileostomy and subsequent closure of ileostomy. Three-stage procedures were performed in 3 cases. An ileal pouch leak or pelvic abscess occurred in 2 patients. Surgical pouch revision for retraction, efferent limb syndrome, prolapse, pouchitis, or perirectal infections occurred in 19 (6/62 J-pouch, 13/28 S-pouch). Fourteen patients (5/22 with diversion, 9/68 without diversion) developed small bowel obstruction. Overall, daytime and nighttime continence was excellent with rare nocturnal evacuations.

CONCLUSIONS

Restorative proctocolectomy without protective ileostomy is not associated with an increased morbidity, even in patients with active colitis, and may be appropriate most patients.

Regenerated oxidized cellulose reinforcement of low rectal anastomosis: do we still need diversion?

PURPOSE

The leak rate after low anterior resection is in the region of 10% to 15%. The highest risks of anastomotic leak are in anastomoses less than 5 cm from the anal verge. We evaluated the outcome of oxidized regenerated cellulose reinforcement of low rectal anastomosis.

METHODS

The study group consisted of 108 patients with rectal cancer. Patients with low rectal cancer had low anterior resection with stapled straight low colorectal or coloanal anastomosis without proximal diversion. They were prospectively randomized to either oxidized regenerated cellulose reinforcement or no reinforcement. Data collected included age, sex, hemoglobin percentage, albumin level, histopathologic type of the tumor, anastomotic leak, and stricture.

RESULTS

The mean age of patients was 56 years, and sex was matched in both groups. Clinical leak occurred in 6 of 38 cases (15.7%) in the group that did not undergo reinforcement versus 2 of 33 (6.1%) in the oxidized regenerated cellulose reinforcement group (P < .01). In the case of a leak, diversion was needed in 3 of 6 patients in the group that did not undergo reinforcement vs no patients in the oxidized regenerated cellulose reinforcement group (P = .05). Generalized peritonitis occurred in 3 patients in the group that did not undergo reinforcement versus no patients in the oxidized regenerated cellulose reinforcement group (P < .01). Length of stay was 4.8 days in the oxidized regenerated cellulose reinforcement group versus 5.9 days in the group that did not undergo reinforcement (P = .047), with no mortalities in either group.

CONCLUSION

Oxidized regenerated cellulose reinforcement of low rectal anastomosis significantly decreases the risk of postoperative leak in low rectal anastomosis and may reduce the requirement for proximal diversion. Potential benefits include avoidance of a stoma, lower morbidity, shorter hospital stay, and a lower cost of care.