Variant Two-Stage Ileal Pouch-Anal Anastomosis: An Innovative and Effective Alternative to Standard Resection in Ulcerative Colitis

Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis

BACKGROUND

Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state.

METHODS

We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery.

RESULTS

During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%).

CONCLUSION

In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.

Three-stage versus modified two-stage surgery for ulcerative colitis: a patient-centred treatment trade-off study

AIM

There is ongoing debate about whether ileal pouch-anal anastomosis needs temporary diversion at the time of construction. Stomas may reduce risk for anastomotic leak (AL) but are also associated with complications, emergency department visits and readmissions. This treatment trade-off study aims to measure patients' preferences by assessing the absolute risk of AL and pouch failure (PF) they are willing to accept to avoid a diverting ileostomy.

METHODS

Fifty-two patients with ulcerative colitis, with or without previous pouch surgery, from Mount Sinai Hospital, Toronto, participated in this study. Standardized interviews were conducted using the treatment trade-off threshold technique. An online anonymous survey was used to collect patient demographics. We measured the absolute increased risk in AL and PF that patients would accept to undergo modified two-stage surgery as opposed to traditional three-stage surgery.

RESULTS

Thirty-two patients (mean age 38.7 ± 15.3) with previous surgery and 20 patients (mean age 39.5 ± 11.9) with no previous surgery participated. Patients were willing to accept an absolute increased leak rate of 5% (interquartile range 4.5%-15%) to avoid a diverting ileostomy. Similarly, patients were willing to accept an absolute increased PF rate of 5% (interquartile range 2.5%-10%). Younger patients, aged 21-29, had lower tolerance for PF, accepting an absolute increase of only 2% versus 5% for patients older than 30 (P = 0.01).

CONCLUSION

Patients were willing to accept a 5% increased AL rate or PF rate to avoid a temporary diverting ileostomy. This should be taken into consideration when deciding between modified two- and three-stage pouch procedures.

Current Management of Acute Severe Ulcerative Colitis: New Insights on the Surgical Approaches

Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity. Despite recent advances in medical IBD therapy, colectomy rates for ASUC remain high. A scoping review of published articles on ASUC was performed. We collected data, such as general information of the disease, diagnosis and initial assessment, and available medical and surgical treatments focusing on technical aspects of surgical approaches. The most relevant articles were considered in this scoping review. The management of ASUC is challenging; currently, personalized treatment for it is unavailable. Sequential medical therapy should be administrated, preferably in high-volume IBD centers with close patient monitoring and indication for surgery in those cases with persistent symptoms despite medical treatment, complications, and clinical worsening. A total colectomy with end ileostomy is typically performed in the acute setting. Managing rectal stump is challenging, and all individual and technical aspects should be considered. Conversely, when performing elective colectomy for ASUC, a staged surgical procedure is usually preferred, thus optimizing the patients' status preoperatively and minimizing postoperative complications. The minimally invasive approach should be selected whenever technically feasible. Robotic versus laparoscopic ileal pouch-anal anastomosis (IPAA) has shown similar outcomes in terms of safety and postoperative morbidity. The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) is a recent technique for creating an ileal pouch-anal anastomosis via a transanal route. Early experiences suggest comparable short- and medium-term functional results of the transanal technique to those of traditional approaches. However, there is a need for additional comparative outcomes data and a better understanding of the ideal training and implementation pathways for this procedure. This manuscript predominantly explores the surgical treatment of ASUC. Additionally, it provides an overview of currently available medical treatment options that the surgeon should reasonably consider in a multidisciplinary setting.

Surgery for ulcerative colitis

Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.

Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis

AIM

The aim of this study was to compare modified 2-stage and 3-stage IPAA construction techniques to evaluate the effect of diverting loop ileostomy following completion proctectomy and IPAA for ulcerative colitis. In addition, our overall institutional experience was reviewed to describe long-term outcomes and changes in staging trends over time.

METHODS

Our institutional database was searched to identify all cases of IPAA for ulcerative colitis between 1981 and 2018. Patient, pouch and outcome characteristics were abstracted. Primary study outcomes were the incidence of primary pouch failure and pouch-related sepsis. Failure was evaluated by Kaplan-Meier estimates of survival over time. The adjusted effect of pouch stage was evaluated using multivariable Cox and logistic regression models. Exploratory analysis evaluated the effect of stage on failure in the pouch related sepsis subgroup.

RESULTS

A total of 2105 patients underwent primary IPAA over the study period. The 5, 10 and 20-year pouch survival probabilities were 95.2%, 92.7% and 86.6%. The incidence of pouch related sepsis was 12.3%. Adjusted analysis demonstrated no difference in pouch failure (HR = 0.64: 95% 0.39-1.07, p = 0.09) or post-operative sepsis (aOR = 0.79: 95% CI 0.53-1.17, p = 0.24) by stage of construction. Among patients experiencing pouch sepsis, there was no difference in Kaplan-Meier estimates of pouch survival by stage (p = 0.90).

CONCLUSIONS

Pouch related sepsis and IPAA failure did not differ between modified 2-stage and 3-stage construction techniques. Among the sub-group of patients experiencing pouch related sepsis, there was no difference in failure between groups. The results suggest diverting ileostomy may be safely avoided following delayed pouch reconstruction in appropriately selected patients.

The Role of Diversion During Ileal Pouch Anal Anastomosis (IPAA) Creation in Pediatric Ulcerative Colitis

INTRODUCTION

In pediatric ulcerative colitis (UC), surgery is often postponed until disease is life-threatening or refractory to immune suppression. In these settings, diverting ileostomy (DI) is theorized to have a protective effect on the new anastomosis. However, analyses have been performed only in single-institution series and the true impact of performing DI at the time of IPAA on postoperative outcomes is unclear.

METHODS

We performed a retrospective cohort study using claims data from the International Business Machines (IBM) MarketScan® database. Patients were sorted to the DI group if they carried a CPT code for ostomy closure within 6 months of index procedure. We examined demographics, preoperative risk factors, and performed regression analysis to compare 30-day postoperative outcomes between groups.

RESULTS

We identified 317 patients ≤18yo that underwent IPAA procedure and met inclusion criteria from 2000 to 2019. Of these, 238 patients were assigned to the IPAA + DI cohort and 79 patients were assigned to the IPAA cohort. Adverse outcomes were comparable between cohorts. Surgical site infection (SSI) rates between IPAA and IPAA + DI were 10.1 vs. 11.3% (p = 0.67). Rates of intra-abdominal drainage procedures were 3.8 vs. 2.1% (p = 0.39). The rates of 30-day readmissions were 16.5 vs. 19.3% (p = 0.39). Creation of a DI was not associated with higher odds of 30-day readmission (OR = 1.4, p = 0.31).

CONCLUSION

Creating a DI necessitates an additional surgery for closure and is not associated with decreased adverse outcomes. There is still a role for multicenter studies to define which patient populations may benefit from diversion.

LEVEL OF EVIDENCE

Retrospective comparative study.

TYPE OF STUDY

Level III.

Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages

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.

Relationship Between Stages of Ileal Pouch-Anal Anastomosis, Timing of Restoration of Fecal Continuity, and Pouchitis

BACKGROUND

The most common complication following ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC) is pouchitis.

AIMS

We aimed to investigate whether a shorter period between pouch creation and restoration of fecal flow through an IPAA was associated with an increased risk of development of pouchitis within the first 2 years after IPAA.

METHODS

We performed a retrospective cohort study evaluating patients undergoing colectomy with IPAA for UC between January 1, 2004 and December 31, 2016. We used Kaplan-Meier testing and Cox Proportional Hazards Modeling to evaluate the relationship between the time between restoration of fecal continuity and time to subsequent development of pouchitis, adjusting for other clinical and demographic factors.

RESULTS

We identified 624 patients who underwent proctocolectomy with IPAA for UC, of whom 246 (39%) developed pouchitis within the first 2 years after IPAA. There was no difference when comparing the median time to restoration of continuity among those patients who developed pouchitis and those who did not (49 days vs. 49 days, p = 0.85) or in multivariable analysis. Primary sclerosing cholangitis (Hazard Ratio [HR] 2.14, 95% CI 1.12-4.08), family history of inflammatory bowel disease (HR 1.49, 95% CI 1.08-2.06), and delayed pouch creation (HR 0.75, 95% CI 0.57-1.00) were significantly associated with time to development of pouchitis.

CONCLUSION

Although a staged approach to IPAA may have benefits in the surgical management of UC, the timing interval between pouch creation and restoration of continuity did not impact the subsequent development of early pouchitis in this cohort.

Structural Characteristics of Inulin and Microcrystalline Cellulose and Their Effect on Ameliorating Colitis and Altering Colonic Microbiota in Dextran Sodium Sulfate-Induced Colitic Mice

Several studies have reported that dietary fibers (DFs) from plants may exert beneficial effects on inflammatory bowel disease. In the present study, we investigated the structural differences of soluble DF (inulin) and insoluble DF (microcrystalline cellulose, MCC) and their effects on the intestinal barrier integrity, gut microbiota community, and inflammation response in mice with dextran sodium sulfate (DSS)-induced colitis. Mice were fed for 21 days with diets containing inulin or MCC (2.5 g/kg body weight), and colitis was induced by administration of DSS (4% w/v) in drinking water during the last 8 days of experimentation. The results showed that inulin and MCC differ in morphology and structure. MCC exhibited a smaller particle size, a larger specific surface area, and higher thermal stability than inulin. In addition, both inulin and MCC restored various physical signs (body weight, colon weight and length, disease activity index score, and infiltration of inflammatory cells), gut barrier function (as evidenced by the increased expression of claudin-3, claudin-7, ZO-2, occludin, JAM-2, and MUC-3 and the decreased activity of myeloperoxidase activity), downregulation of mRNA expression of proinflammatory cytokines (caspase-1, NLPR3, TLR4, TNF-α, and IL-1β), and modulation of colon microbiota community. Taken together, the present study demonstrates that DFs differ in morphology and structure and ameliorate DSS-induced colitis in mice by blocking proinflammatory cytokines, reinforcing gut barrier integrity, and modulating gut microbiota. Therefore, DFs, especially inulin, are promising dietary supplements to alleviate intestinal inflammation.

Postoperative complications, bowel function, and prognosis in restorative proctocolectomy for ulcerative colitis-a single-center observational study of 320 patients

PURPOSE

To determine the selection criteria, postoperative complications, bowel function, and prognosis of stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA for ulcerative colitis (UC).

METHODS

We defined our surgical indications and strategy, and compared the postoperative complications, bowel function, and prognoses between patients who underwent stapled and hand-sewn IPAA for UC at the Yokohama City University Medical Center between 2004 and 2017.

RESULTS

Among 320 patients enrolled, 298 patients underwent stapled IPAA while 22 underwent hand-sewn IPAA. There was no significant difference in the postoperative complications between the two groups. Regarding postoperative bowel function, stapled IPAA caused significantly less soiling (stapled vs hand-sewn: 9.1% vs 41.0%, odds ratio (OR) = 0.14, p < 0.0002), spotting (stapled vs hand-sewn: 23.2% vs 63.6%, OR = 0.17, p < 0.0001), and difficulty in distinguishing feces from flatus (stapled vs hand-sewn: 39.9% vs 63.6%, OR = 0.36, p < 0.026). No postoperative neoplasia was observed at the final follow-up in all patients.

CONCLUSION

In this study, there was no clear difference in the postoperative complications between stapled and hand-sewn IPAA, but stapled IPAA resulted in better postoperative bowel function. Postoperative oncogenesis from the residual mucosa is rare. However, future cancer risk remains; thus, careful follow-up is required.

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment

This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.

Transmural Inflammation, Ileitis, and Granulomas at the Time of Proctocolectomy in Patients with Ulcerative Colitis Do Not Predict Future Development of Pouchitis

Background

The most common complication following ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC) is pouchitis. Our study aimed to investigate the relationship between histopathologic findings of ileitis, granuloma, or transmural inflammation on the colectomy specimen of patients with clinically and endoscopically diagnosed UC and the development of pouchitis within the first 2 years after IPAA.

Methods

We performed a retrospective cohort study evaluating patients undergoing colectomy with IPAA for UC between January 1, 2004 and December 31, 2016. Bivariate analyses were conducted to evaluate the relationship between clinical factors and the development of pouchitis. We performed multivariate logistic regression to evaluate the relationship between histologic, clinical, and demographic factors at the time of colectomy and subsequent development of pouchitis.

Results

Among 626 patients, pouchitis occurred in 246 (39%). Patients with primary sclerosing cholangitis were more likely to develop pouchitis (adjusted odds ratio [aOR] 2.81, 95% confidence interval [CI] 1.02-7.72), as were patients with a family history of inflammatory bowel disease (aOR 1.75, 95% CI 1.11-2.77). Histologic findings of ileitis, granuloma, or transmural inflammation were not associated with an increased odds of developing pouchitis (aOR 0.70, 95% CI 0.45-1.08).

Discussion/Conclusion

Patients with ileitis, granulomas, or transmural inflammation at the time of colectomy were not at greater risk for development of pouchitis in the 2 years after IPAA. These pathological findings should not preclude IPAA for UC.

Anastomotic Leak after Ileal Pouch-Anal Anastomosis

There are special considerations when treating anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis. The epidemiology, risk factors, anatomic considerations, diagnosis and management, as well as the short- and long-term consequences to the patient are unique to this patent population. Additionally, there are specific concerns such as "tip of the J" leaks, transanal management of anastomotic leak/presacral sinus, functional outcomes after leak, and considerations of redo pouch procedures.

Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis

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.

Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis

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.

Is diversion free ileal pouch-anal anastomosis a safe procedure? A meta-analysis of 4973 cases

PURPOSE

Ileal pouch-anal anastomosis (IPAA) has been established as the procedure of choice for patients who require excision of the colon and rectum for familial adenomatous polyposis and ulcerative colitis. The requirement for proximal stomal diversion in IPAA is controversial.

OBJECTIVES

To compare post-operative outcomes following IPAA with and without proximal diversion.

METHODS

Computerised literature search, of Ovid MEDLINE and EMBASE. Full-text comparative studies published between 1992 and 2019, in English language and on adult patients. Ileal pouch-anal anastomosis with or without proximal stomal diversion following proctocolectomy. Outcome measures were anastomotic leak, anastomosis strictures, re-operations, pouch failure, intra-abdominal sepsis, small bowel obstruction/ileus and mortality.

RESULTS

Five hundred and forty-six studies were screened. Fourteen relevant studies included 4973 cases (1832 patients with no stomas vs 3141 with stomas). Anastomotic strictures (p ≤ 0.0001 OR 0.40; 95% CI (0.26-0.62)) and pouch failures (p = 0.003 OR 0.54; 95% CI (0.36-0.82)) were higher in diverted than non-diverted patients. Re-operation was more frequently required in non-diverted patients (p = 0.02 OR 2.51; 95% CI (1.12-5.59)). Heterogeneity was low in 5 out of 7 variables.

CONCLUSION

In selected patients, diversion-free IPAA is a safe procedure associated with lower anastomotic stricture and pouch failure rates than diverted IPAA. This appears to occur at the expense of a higher re-operation rate. An RCT is required to help define the selection criteria.

A systematic review and meta-analysis of outcomes after elective surgery for ulcerative colitis

AIM

Approximately 20%-30% of patients with ulcerative colitis (UC) will undergo surgery during their disease course, the vast majority being elective due to chronic refractory disease. The risks of elective surgery are reported variably. The aim of this systematic review and meta-analysis is to summarize the outcomes after elective surgery for UC.

METHODS

A systematic review was conducted that analysed studies reporting outcomes for elective surgery in the modern era (>2002). It was prospectively registered on the PROSPERO database (ref: CRD42018115513). Searches were performed of Embase and MEDLINE on 15 January 2019. Outcomes were split by operation performed. Primary outcome was quality of life; secondary outcomes were early, late and functional outcomes after surgery. Outcomes reported in five or more studies underwent a meta-analysis of incidence using random effects. Heterogeneity is reported with I² , and publication bias was assessed using Doi plots and the Luis Furuya-Kanamori index.

RESULTS

A total of 34 studies were included (11 774 patients). Quality of life was reported in 12 studies, with variable and contrasting results. Thirteen outcomes (eight early surgical complications, five functional outcomes) were included in the formal meta-analysis, all of which were outcomes for ileal pouch-anal anastomosis (IPAA). A further 71 outcomes were reported (50 IPAA, 21 end ileostomy). Only 14 of 84 outcomes received formal definitions, with high inter-study variation of definitions.

CONCLUSION

Outcomes after elective surgery for UC are variably defined. This systematic review and meta-analysis highlights the range of reported incidences and provides practical information that facilitates shared decision making in clinical practice.

Laparoscopic rectal dissection preserves erectile function after ileal pouch-anal anastomosis: a two-centre study

AIM

Few studies have been published on erectile function after ileal pouch-anal anastomosis (IPAA) and, unlike in women, male fertility after IPAA has never been assessed. The primary objective was to assess the impact of IPAA on erectile function. The secondary objective was to assess the impact of IPAA on male fertility.

METHODS

All of the male patients who underwent IPAA in two university care centres between 2003 and 2017, aged 70 years or less at the time of operation, were included. Forty-eight per cent of the patients responded to the international index of erectile function, the Jorge-Wexner score and a fertility questionnaire. All demographic and perioperative data were prospectively collected. Fertility results were compared with those of a control group undergoing appendectomy, matched for age at the time of operation, desire for paternity and length of follow-up.

RESULTS

One hundred and thirty-nine patients were included, among which 46 (33%) presented with erectile dysfunction and 14 (10%) with severe erectile dysfunction. Age older than 50 years (OR 0.27, 95% CI 0.12-0.62, P = 0.002) and rectal dissection performed by open surgery (OR 4.16, 95% CI 1.62-10.65, P = 0.003) were independent risk factors for erectile dysfunction. There was no infertility after IPAA compared with controls: indeed, 23 (16%) IPAA patients presented with pregnancy in their couple versus 27 (22%) controls (P = 0.29), whereas 36 (26%) IPAA patients and 34 (28%) controls (P = 0.80) expressed paternity desire.

CONCLUSION

A total laparoscopic approach, including rectal dissection, should be preferred to preserve erectile function. Male fertility is not impaired after IPAA.

Risk factors for postoperative stoma outlet obstruction in ulcerative colitis

BACKGROUND

Current medical treatments can achieve remission of ulcerative colitis (UC). Surgery is required when potent drug treatment is ineffective or when colon cancer or high-grade dysplasia develops. The standard procedure is restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, commonly performed as two- or three-stage RPC with diverting ileostomy. Postoperative stoma outlet obstruction (SOO) is frequent, but the causes are not well known.

AIM

To identify the risk factors for SOO after stoma surgery in patients with UC.

METHODS

We retrospectively reviewed the files of 148 consecutive UC patients who underwent surgery with stoma construction. SOO was defined as small bowel obstruction symptoms and intestinal dilatation just below the penetrating part of the stoma on computed tomography. Patients were divided into two groups: Those who developed SOO within 30 d after surgery and those who did not. Patient characteristics, intraoperative parameters, the stoma site, and rectus abdominis muscle thickness were collected. Moreover, we identified the patients who repeatedly developed SOO. Univariate and multivariate analyses were performed to identify risk factors for SOO and recurring SOO.

RESULTS

Eighty-nine patients who underwent two-stage RPC were included between January 2008 and March 2020. Postoperatively, SOO occurred in 25 (16.9%) patients after a median time of 9 d (range 2-26). Compared to patients without SOO, patients with SOO had a significantly higher rate of malignant tumors or dysplasia (36.0% vs 17.1%, P = 0.032), lower total glucocorticoid dose one month before surgery (0 mg vs 0 mg, P = 0.026), higher preoperative total protein level (6.8 g/dL vs 6.3 g/dL, P = 0.048), higher rate of loop ileostomy (88.0% vs 55.3%, P = 0.002), and higher maximum stoma drainage volume (2300 mL vs 1690 mL, P = 0.004). Loop ileostomy (OR = 6.361; 95%CI 1.322–30.611; P = 0.021) and maximum stoma drainage volume (OR = 1.000; 95%CI 1.000–1.001; P = 0.015) were confirmed as independent risk factors for SOO. Eighteen patients with SOO were treated conservatively without recurrence (sSOO group). Seven (28.0%) patients repeatedly developed SOO (rSOO group) during the observation period. A significant difference was observed in the rectus abdominis muscle thickness between the two groups (sSOO 9.3 mm, rSOO 12.7 mm, P = 0.006). Muscle thickness was confirmed as an independent risk factor for recurring SOO (OR = 2.676; 95%CI 1.176-4.300; P = 0.008).

CONCLUSION

In this study, high maximum stoma drainage volume and loop ileostomy are independent risk factors for SOO. Additionally, among patients with a thick rectus abdominis muscle, the risk of SOO recurrence is high.

Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research

PURPOSE

Restorative proctocolectomy (RPC) is performed for patients with refractory ulcerative colitis (UC). This operation is performed in 2 or 3 stages and involves forming a diverting loop ileostomy thought to protect patients from complications related to anastomotic leak. However, some advocate for a modified 2-stage approach, consisting of subtotal colectomy followed by completion proctectomy and ileal pouch anal anastomosis without diverting ileostomy. We present a systematic review and meta-analysis comparing postoperative complication rates between modified 2-stage and traditional RPC with ileal pouch anal anastomosis.

METHODS

Records were sourced from PubMed/Embase databases. Studies comparing postoperative complications following RPC for ulcerative colitis (UC) were selected according to PRISMA guidelines comparing modified 2-stage (exposure), classic 2-stage, and 3-stage approaches (comparators). The primary outcome measure was safety as measured by postoperative complication rates. We employed random effects meta-analysis.

RESULTS

We included ten observational studies including 1727 patients (38% modified 2-stage). Among pediatric patients, modified 2-stage approaches had higher rates of anastomotic leak than 3-stage approaches (p = 0.03). Among adult cohorts with lower preoperative biologic use rates, modified 2-stage approaches had lower leak rates than classic 2-stage approaches (p < 0.001).

CONCLUSIONS

The modified 2-stage approach may be safe for adult patients who otherwise require a 3-stage approach while reducing costs and length of stay. Pediatric patients may benefit from lower leak rates when receiving 3-stage compared with modified 2-stage approaches, especially when on biologics. The modified 2-stage approach may be safer than the classic 2-stage approach for adult patients with lower biologic exposure.

Management of Rectal Stump During Laparoscopic Subtotal Colectomy for Inflammatory Bowel Disease: A Comparative Cohort Study from Six Referral Centres

BACKGROUND AND AIMS

There is no consensus on the best management of the rectum after subtotal colectomy for refractory colitis complicating inflammatory bowel disease [IBD]. The objective was to evaluate the impact of rectal stump management during laparoscopic subtotal colectomy [LSTC] for IBD.

METHODS

Patients who underwent LSTC with double-end ileo-sigmoidostomy [Gr.A] or end ileostomy with closed rectal stump [Gr.B] for IBD were included from a retrospective database of six European referral centres.

RESULTS

In total, 314 patients underwent LSTC and were allocated to Gr.A [n = 102] and B [n = 212]. After LSTC, stoma-related complications occurred more frequently in Gr.A [12%] than in Gr.B [4%, p = 0.01]. Completion proctectomy with ileal pouch-anal anastomosis [IPAA] was performed as a three-stage procedure in all patients from Gr.A, and in 88 patients from Gr.B [42%; Gr.B1]. The other 124 patients from Gr.B underwent a modified two-stage procedure [58%; Gr.B2]. The second stage was performed laparoscopically in all patients from Gr.A compared with 73% of Gr.B1 [p < 0.0001] and 65% of Gr.B2 patients [p < 0.0001]. When laparoscopy was intended for 2nd stage IPAA, conversion to laparotomy occurred less frequently in Gr.A when compared with B1 [0 vs 5%, p = 0.06] or B2 [10%, p = 0.001]. When all surgical stages were included [LSCT and IPAA], cumulative stoma-related complications occurred more frequently in Gr.A [n = 19] than in Gr.B1 [n = 6, p = 0.02] and Gr.B2 [n = 6, p = 0.001].

CONCLUSION

This study suggests that both techniques of double-end ileosigmoidostomy and end ileostomy with closed rectal stump are safe and effective for rectal stump management after laparoscopic subtotal colectomy.

Outcomes of Initial Subtotal Colectomy for Pediatric Inflammatory Bowel Disease

BACKGROUND

Subtotal colectomy with end ileostomy (STC-I) has been well established in the adult literature as an initial surgical treatment for refractory inflammatory bowel disease (IBD)-related colitis. However, in the pediatric population, the efficacy of this approach has been less well characterized, likely because of concerns regarding the advisability of leaving a diseased rectum in situ. Our aim was to examine the outcomes after STC-I for refractory IBD at our pediatric tertiary care center.

METHODS

An institutional review board-approved retrospective review of patients aged 5-21 y who underwent operative treatment with initial STC-I for medically refractory IBD from January 2010 to August 2018. Only complications related to the STC-I were considered; complications subsequent to reconstruction are excluded from analysis. Early complications were defined as occurring within 60 d of STC-I. We performed descriptive statistics using the Fisher exact test and the Student t-test, as appropriate.

RESULTS

Over the study period, 37 patients (aged 12.3 ± 4.2 y) underwent STC-I, with 73.0% performed laparoscopically. Patients were predominately male (51.4%) and Caucasian (48.6%). Thirty-one (83.8%) colectomies were performed for ulcerative colitis, two (5.4%) for Crohn disease, and four (10.8%) for indeterminate colitis. Nutritional status improved postcolectomy. Albumin levels of 3.3 ± 0.8 preoperatively increased to 4.3 ± 0.47 postoperatively (P < 0.001). Colonic bleeding was stopped by STC-I with increases in the hematocrit from 30.5 ± 6.8 preoperative to 38.9 ± 4.1 postoperatively (P < 0.001). Average time to discontinuation of IBD-related medications was 4 wk (n = 27). Forty-eight percent required outpatient rectal treatment for proctitis. Patients did well long term, with 67.5% reestablishing intestinal continuity at our institution. Average postoperative length of stay was shorter in the laparoscopic group compared with those undergoing open operations (5.1 ± 2.2 versus 6.9 ± 1.6 d, P = 0.03). Readmission rate at 30 d was 21.1%. Patients experiencing unplanned readmission or unplanned operations were similar between groups (30% versus 33.3%, P = 0.85 and 30% versus 18.5%, P = 0.45, respectively). Overall, 14 (37.8%) patients experienced a complication with many patients experiencing multiple complications. Early complications occurred in nine (24.3%) patients. Late complications also occurred in 24.3% of patients. There were four (10.8%) patients with five admissions for bowel obstruction, two of whom required operative intervention (5.4%).

CONCLUSIONS

Use of STC-I as an initial procedure in the treatment of refractory IBD-related colitis in children is a safe and reasonable surgical approach that allows weaning from immunosuppressing mediations and stops colonic bleeding. Implementing a laparoscopic approach to subtotal colectomy provides further benefit by reducing postoperative length of stay.

Is diverting loop ileostomy necessary for completion proctectomy with ileal pouch-anal anastomosis? A multicenter randomized trial of the GETAID Chirurgie group (IDEAL trial): rationale and design (NCT03872271)

BACKGROUND

There is no quality evidence of the benefit of defunctioning ileostomy (DI) in ileal pouch-anal anastomoses (IPAAs) performed for inflammatory bowel disease (IBD), but most surgical teams currently resort to DI. In the case of a staged procedure with subtotal colectomy first, completion proctectomy with IPAA is performed for healthy patients, namely, after nutritional support, inflammation reduction and immunosuppressive agent weaning. Therefore, the aim of this trial is to assess the need for systematic DI after completion proctectomy and IPAA for IBD.

METHODS/DESIGN

This is a multicenter randomized open trial comparing completion proctectomy and IPAA without (experimental) or with (control) DI in patients presenting with ulcerative colitis or indeterminate colitis. Crohn's disease patients will not be included. The design is a superiority trial. The main objective is to compare the 6-month global postoperative morbidity, encompassing both surgical and medical complications, between the two groups. The morbidity of DI closure will be included, as appropriate. The sample size calculation is based on the hypothesis that the overall 6-month morbidity rate is 30% in the case of no stoma creation (i.e., experimental group) vs. 55% otherwise (control group). With the alpha risk and power are fixed to 0.05 and 0.80, respectively, and considering a dropout rate of 10%, the objective is set to 194 patients. The secondary objectives are to compare both strategies in terms of morbi-mortality at 6 months and functional results as well as quality of life at 12 months, namely, the 6-month major morbidity and unplanned reoperation rates, 6-month anastomotic leakage rate, 6-month mortality, length of hospital stay, 6-month unplanned readmission rate, quality of life assessed 3 and 12 months from continuity restoration (i.e., either IPAA or stoma closure), functional results assessed 3 and 12 months from continuity restoration, 12-month pouch results, 12-month cost-utility analysis, and 12-month global morbidity.

DISCUSSION

The IDEAL trial is a nationwide multicenter study that will help choose the optimal strategy between DI and no ileostomy in completion proctectomy with IPAA for IBD.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT03872271, date of registration March 13th, 2019.

Risk Factors for Small Bowel Obstruction After Laparoscopic Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: A Multivariate Analysis in Four Expert Centres in Europe

BACKGROUND AND AIMS

Although laparoscopy is associated with a reduction in adhesions, no data are available about the risk factors for small bowel obstruction [SBO] after laparoscopic ileal pouch-anal anastomosis [IPAA]. Our aims here were to identify the risk factors for SBO after laparoscopic IPAA for inflammatory bowel disease [IBD].

METHODS

All consecutive patients undergoing laparoscopic IPAA for IBD in four European expert centres were included and divided into Groups A [SBO during follow-up] and B [no SBO].

RESULTS

From 2005 to 2015, SBO occurred in 41/521 patients [Group A; 8%]. Two-stage IPAA was more frequently complicated by SBO than 3- and modified 2-stage IPAA [12% vs 7% and 4%, p = 0.04]. After multivariate analysis, postoperative morbidity (odds ratio [OR] = 3, 95% confidence interval [CI] = 1.5-7, p = 0.002), stoma-related complications [OR = 3, 95% CI = 1-6, p = 0.03] and long-term incisional hernia [OR = 6, 95% CI = 2-18, p = 0.003] were predictive factors for SBO, while subtotal colectomy as first surgery was an independent protective factor [OR = 0.4, 95% CI = 0.2-0.8, p = 0.002]. In the subgroup of patients receiving restorative proctocolectomy as first operation, stoma-related or other surgical complications and long-term incisional hernia were predictive of SBO. In the patient subgroup of subtotal colectomy as first operation, postoperative morbidity and long-term incisional hernia were predictive of SBO, whereas ulcerative colitis and a laparoscopic approach during the second surgical stage were protective factors.

CONCLUSIONS

We found that SBO occurred in less than 10% of patients after laparoscopic IPAA. The study also suggested that modified 2-stage IPAA could potentially be safer than procedures with temporary ileostomy [2- and 3-stage IPAA] in terms of SBO occurrence.

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.

Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program

BACKGROUND

Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC).

METHODS

Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities.

RESULTS

Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC.

CONCLUSIONS

Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.

Recent trends (2016-2017) in the treatment of inflammatory bowel disease

Prevalence of inflammatory bowel disease (IBD), ulcerative colitis and Crohn's disease has dramatically increased in Asian countries in the last three decades. In this period, many new medical therapies were introduced for the treatment of IBD, such as immunosuppressants, anti-tumor necrosis factor agents, leukocyte apheresis, anti-integrin antibody, and so on, which have contributed to induce remission and to reduce complications in IBD. As for surgical techniques for Crohn's disease, a stapled functional end-to-end anastomosis and conventional end-to-end anastomosis have similar perianastomotic recurrence rate and reoperation rate. Prospective randomized controlled studies which compare Kono-S anastomosis and stapled side-to-side anastomosis are ongoing. Variant two-stage ileal pouch anal anastomosis (IPAA) and transanal IPAA are new concepts for surgical treatment of ulcerative colitis. Various endoscopic procedures, such as balloon dilation for stenosis or stricture, endoscopic fistulotomy, injection of filling agents, and clipping for fistulas or perforations will be new options in the treatment of Crohn's disease. Adverse effects of preoperative treatments on postoperative complications should also be taken into account to improve surgical outcomes in IBD patients.

Risk factors for organ space infection after ileal pouch anal anastomosis for chronic ulcerative colitis: An ACS NSQIP analysis

BACKGROUND

Organ space infection (OSI) after ileal pouch anal anastomosis (IPAA) is a devastating complication. The aim of this was study was to determine separately risk factors for OSI after total proctocolectomy (TPC) with IPAA and completion proctectomy (CP) with IPAA.

METHODS

4049 patients with a diagnosis of chronic ulcerative colitis undergoing TPC with IPAA or CP with IPAA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Primary outcome was an OSI within 30 days of surgery. Multivariable analyses were conducted for the development of OSI after each operation.

RESULTS

For TPC with IPAA, urgent surgery (OR: 2.0, p < 0.01) and obesity (OR: 1.6, p < 0.01) were independent risk factors for OSI. Operation length of 275 + minutes (versus <170 min; OR: 2.2, p = 0.02) was predictive of OSI after CP with IPAA.

CONCLUSION

Risk factors for OSI differed between the operations. This highlights the importance of the consideration of the physiologic status of the patient when deciding to perform TPC with IPAA or subtotal colectomy with ileostomy initially.