Septic complications after restorative proctocolectomy do not impair functional outcome: long-term follow-up from a specialty center

Management, Functional Outcomes, and Quality of Life After Development of Pelvic Sepsis in Patients Undergoing Re-Do Ileal Pouch Anal Anastomosis

BACKGROUND

The data on management and outcomes of pelvic sepsis after re-do IPAA are scarce.

OBJECTIVE

The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do IPAA and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no sepsis control group.

DESIGN

This is a retrospective cohort study.

SETTINGS

This investigation is based on a single academic practice group experience on re-do IPAA.

PATIENTS

Patients who underwent re-do IPAA for ileal pouch failure between September 2016 and September 2020 were included in the study.

MAIN OUTCOME MEASURES

Management of pelvic sepsis was reported. Functional outcomes, restrictions, and quality-of-life scores were compared between the sepsis and no sepsis groups.

RESULTS

One-hundred ten patients were included in our study, of whom 25 (22.7%) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure, and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included interventional radiology abscess drainage (n = 7), IV antibiotics alone (n = 5), interventional radiology drainage and mushroom catheter placement (n = 1), mushroom catheter placement (n = 1), and endoluminal vacuum-assisted closure (n = 1). Average number of bowel movements, urgency, incontinence, pad use, and seepage were comparable between the pelvic sepsis and no pelvic sepsis groups ( p > 0.05). Lifestyle alterations, Cleveland Global Quality of Life scores, and happiness with the results of the surgery were similar ( p > 0.05).

LIMITATIONS

This study is limited by its low study power and limited follow-up time.

CONCLUSIONS

Pelvic sepsis is common after re-do IPAA, and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823 .

MANEJO, RESULTADOS FUNCIONALES Y CALIDAD DE VIDA DESPUS DEL DESARROLLO DE SEPSIS PLVICA EN PACIENTES SOMETIDAS A RECONFECCIN DE ANASTOMOSIS ANAL CON BOLSA ILEAL

ANTECEDENTES:Los datos sobre el tratamiento y los resultados de la sepsis pélvica después de reconfección de anastomosis anal, de la bolsa ileal son escasos.OBJETIVO:El objetivo de este estudio es informar nuestro algoritmo de manejo de la sepsis pélvica en el contexto de reconfección de anastomosis anal de la bolsa ileal y comparar los resultados funcionales y la calidad de vida después del manejo exitoso de la sepsis pélvica con un grupo de control sin sepsis.DISEÑO:Este es un estudio de cohorte retrospectivo.AJUSTES:Esta investigación se basa en una experiencia de un solo grupo de práctica académica sobre reconfección de IPAA.PACIENTES:Se incluyeron en el estudio pacientes que se sometieron a una nueva anastomosis anal, del reservorio ileal por falla del reservorio ileal entre el 09/2016 y el 09/2020.PRINCIPALES MEDIDAS DE RESULTADO:Se informó el manejo de la sepsis pélvica. Los resultados funcionales, las restricciones y las puntuaciones de calidad de vida, se compararon entre los grupos con sepsis y sin sepsis.RESULTADOS:Se incluyeron 110 pacientes en nuestro estudio, de los cuales 25 (22,7) desarrollaron sepsis pélvica. Veintitrés pacientes presentaron sepsis pélvica antes del cierre de la ileostomía y 2 pacientes presentaron sepsis pélvica después del cierre de la ileostomía. Hubo 6 fallas de la bolsa en el período de estudio debido a sepsis pélvica. Nuestro manejo fue exitoso en el 79% de los pacientes con una mediana de seguimiento de 26 meses. Los tratamientos incluyeron drenaje de abscesos IR (n = 7), antibióticos intravenosos solos (n = 5), drenaje IR y colocación de catéter en forma de hongo (n = 1), colocación de catéter en forma de hongo (n = 1) y cierre endoluminal asistido por vacío (n = 1). El número promedio de evacuaciones intestinales, urgencia, incontinencia, uso de almohadillas y filtraciones fueron comparables entre los grupos con sepsis pélvica y sin sepsis pélvica ( p > 0,05). Las alteraciones del estilo de vida, las puntuaciones de la Calidad de vida global de Cleveland y la felicidad con los resultados de la cirugía fueron similares ( p > 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:La sepsis pélvica es común después de la reconfección de anastomosis anal de la bolsa ileal y el manejo varía según la ubicación y el tamaño del absceso / seno. Si se detecta temprano, nuestra estrategia de manejo se asoció con altas tasas de recuperación de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/B823 . (Traducción-Dr. Mauricio Santamaria ).

Surgical results and quality of life of patients submitted to restorative proctocolectomy and ileal pouch-anal anastomosis

PURPOSE

restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice in some cases of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). IPAA allows complete removal of the diseased colon and rectum, however, it is associated with substantial morbidity and potential consequences to patients' quality of life (QoL).

AIMS

to evaluate the surgical results, functional outcomes and QoL after IPAA; and to examine the impact of surgical complications upon QoL.

METHODS

we reviewed the records of 55 patients after IPAA, with emphasis on surgical outcomes. Forty patients answered the questionnaires. The Cleveland Global Quality of Life (CGQL), Inflammatory Bowel Disease Questionnaire (IBDQ), and Short Form 36 Health Survey Questionnaire (SF36).

RESULTS

the average age was 42.1±14.1 years. 63.6% of the patients were male, and 69.1% had FAP. Operative mortality was 1.8% and overall morbidity was 76.4%. Anastomotic leakage was the most frequent early complication (34.5%). Pouchitis (10.8%) and small bowel obstruction (9.1%) were the most common late complications. Patients with UC had the most severe complications (p=0.014). Pelvic complications did not have a negative effect on functional outcomes or QoL scores. Female patients had decreased pouch evacuation frequency, fewer nocturnal bowel movements, decreased bowel symptom impact on QoL (p=0.012), and better CGQL (p=0.04). Patients with better education had better QoL scores, and patients who had their pouches for more than five years scored lower.

CONCLUSION

the high morbidity has no impact on function or QoL. Bowel function is generally acceptable. QoL is good and affected by sex, education and time interval since IPAA.

Ileal pouch-anal anastomosis in ulcerative colitis: outcomes, functional results, and quality of life in patients with more than 10-year follow-up

PURPOSE

Ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with ulcerative colitis (UC). IPAA was incorporated into our institution in 1984, and thereafter, more than 200 procedures have been performed. The functional results and morbidity of this surgery have been reported previously. However, long-term functional outcomes and quality of life have not been evaluated.

METHODS

As a cohort study, we identified all consecutive patients who underwent IPAA for UC between 1984 and 2017 and selected those with more than 10-year follow-up. Demographic data, morbidity, and pouch survival information were obtained. Long-term functional results and quality of life were evaluated through an e-mail survey using the Öresland score and the Cleveland Global Quality of Life scales, respectively.

RESULTS

Of 201 patients, 116 met the inclusion criteria. Median follow-up was 20 (10-34) years. Early post-operative complications (30 days) were observed in 19 (16.4%) patients and 66 (56.9%) presented adverse events. The IPAA preservation rate at 10 and 20 years was 96.5% and 93.1%, respectively. Long-term functional scores presented a median of 6 (1-15) points. IPAA function was satisfactory in 11 (20.0%) patients, acceptable in 18 (32.7%), and deficient in 26 (47.3%). The median score for global quality of life was 0.8 (0.23-1.0) points.

CONCLUSION

IPAA as treatment for UC meets the expectations of cure of the disease, maintaining adequate long-term intestinal functionality associated with a good quality of life in most patients.

Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak

BACKGROUND

The safety of undiverted restorative proctocolectomy (RPC) is debated. This study compares long-term outcomes after pouch leak in diverted and undiverted RPC patients.

METHODS

Data were obtained from a prospectively maintained registry from a single surgical practice. One-stage and staged procedures with an undiverted pouch were considered undiverted pouches; all others were considered diverted pouches. The outcomes measured were pouch excision and long-term diversion defined as the need for loop ileostomy at 200 weeks after pouch creation. Regression models were used to compare outcomes.

RESULTS

There were 317 diverted and 670 undiverted pouches, of which 378 were one-stage procedures. Pouch leaks occurred in 135 patients, 92 (13.7%) after undiverted, and 43 (13.6%) after diverted pouches. Eighty-six (64%) leaks were diagnosed within 6 months of pouch creation. Undiverted patients underwent more emergent procedures within 30 days of pouch creation (p < 0.01). Pouch excision occurred in 14 (33%) diverted patients and 13 (14%) undiverted patients (p = 0.01). Thirteen (32%) diverted patients and 18 (21%) undiverted patients (p = 0.17) had ileostomies at 200 weeks after surgery. In multivariable analyses, diverted patients had a higher risk of pouch excision (HR 3.67 p < 0.01), but similar rates of ileostomy at 200 weeks (HR 1.8, p = 0.19) compared to undiverted patients.

CONCLUSIONS

Despite a likely selection bias in which "healthier" patients undergo an undiverted pouch, our data suggest that diversion does not prevent pouch excision and the need for long-term diversion after pouch leak. These findings suggest that undiverted RPC is a safe procedure in appropriately selected patients.

Factors Associated with Long-Term Quality of Life After Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

THE AIM

The aim of this study was to analyze factors associated with quality of life (QoL) after ileal pouch anal anastomosis (IPAA).

METHODS

Patients who underwent IPAA (1983-2015) and replied to QoL questionnaire were identified from an IRB-approved prospectively maintained IPAA-database. QoL was assessed using Cleveland Global Quality of Life (CGQL) questionnaire at 1, 3, 5, and 10 years postoperatively. Patient cohort was divided in two groups: overall QoL score ≤ 0.7 (low) and > 0.7 (high). Demographics, perioperative morbidity, and functional results were analyzed.

RESULTS

A total of 4059 patients replied to the questionnaire at the most recent follow-up and were included. A total of 2889 (71%) had overall QoL > 0.7 (group 1) and 1170 (29%) patients had overall QoL ≤ 0.7 (group 2). Patients in group 1 had lower rates of early (44.6 vs. 50.4%, p = 0.003) and late (55.7 vs. 64.5%, p < 0.003) postoperative complications. Kaplan-Meier survival analysis demonstrated significantly higher rates of pouch failure among patients with lower QoL. Pouchitis, obstruction, fistulas, higher number of stools, and IPAA performed during the most recent decade (2005-2015) were significantly associated with lower QoL (≤ 0.7), while S-pouch configuration was associated with higher QoL (> 0.7).

CONCLUSION

Patient's characteristics and minimal perioperative complications impact patient's QoL following IPAA not only in the short term, but also in the long term.

Impact of sex on 30-day complications and long-term functional outcomes following ileal pouch-anal anastomosis for chronic ulcerative colitis

PURPOSE

To determine the impact of patient sex on operative characteristics, short-term complications, and long-term functional outcomes following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC).

METHODS

A retrospective review was performed on all patients undergoing two- or three-stage IPAA for CUC at our institution between January 2002 and August 2013. Patient demographics, operative characteristics, 30-day postoperative complications, and long-term functional outcomes from annual survey data were analyzed comparing men and women patients.

RESULTS

During the study period, 911 IPAAs (542 men, 369 women) were performed. Men were older and were more often obese (both p < 0.01). Use of a three-stage approach and laparoscopic approach were similar between men and women, but operation length, intraoperative blood loss, and hospital length of stay were all higher in men (all p < 0.05). At 30 days, women had increased rates of superficial surgical site infections and urinary tract infections (both p < 0.05), while men had increased rates of urinary retention (p = 0.03). Five hundred forty-six patients (60%; 307 men, 239 women) responded to the annual post IPAA survey with a median follow-up of 5.1 and 5.0 years in men and women, respectively. Women reported increased frequency of daytime stools in the early follow-up period, but this difference resolved with time. Other functional outcomes were similar.

CONCLUSION

Patient sex impacts intraoperative complexity, postoperative length of stay, 30-day postoperative outcomes, and initial long-term function. These findings underscore the need to adjust preoperative counseling regarding IPAA outcomes based on sex.

Systematic review of the impact of surgical harm on quality of life after general and gastrointestinal surgery

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.

Pelvic sepsis after IPAA adversely affects function of the pouch and quality of life

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.

Long-term function after ileal pouch-anal anastomosis - function does not deteriorate with time

AIM

There are conflicting reports regarding long term function after ileal pouch-anal anastomosis (IPAA). The aim of the present prospective study was to investigate the influence of duration as an independent factor on long-term function results.

METHOD

Between 1984 and 2007, 315 patients underwent IPAA and were followed by a standardised interview and endoscopy protocol. There were 1802 interviews. Two hundred and thirty-five patients had three or more visits and these data were analysed by Time-Series-Cross-Section multivariate regression analysis. The mean time follow up was 12 years and the mean interval between visits was 34.5 months.

RESULTS

Mean frequency of defecation was 5.2 in the day and 0.55 at night. This did not change with time. Daytime and night incontinence occurred in 13% and 21%. There was no change in incontinence, urgency, soiling or perineal excoriation with time. After 24 years the cumulative incidence of pouchitis was 43.5%. Twenty patients had chronic pouchitis (6.3%).

CONCLUSION

The interval from IPAA did not influence the long-term functional outcome.