Histologic inflammatory activity of the rectal margin as a predictor of postoperative complication in ileoanal anastomosis (J-pouch) procedure in children with refractory ulcerative colitis

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.

Inflammation of the rectal remnant endangers the outcome of ileal pouch-anal anastomosis: a case-control study

BACKGROUND

Inflammation of the rectal remnant may affect the postoperative outcome of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We aimed to determine the extent of inflammation in the anastomotic area during IPAA and to investigate the impact of proctitis on postoperative complications and long-term outcomes.

METHODS

Three hundred thirty-four UC patients with primary IPAA were included in this retrospective case-control study. The histopathologic degree of inflammation in the anastomotic area was graded into three stages of no proctitis ("NOP"), mild to medium proctitis ("MIP"), and severe proctitis ("SEP"). Preoperative risk factors, 30-day morbidity, and follow-up data were assessed. Kaplan-Meier analysis was performed in the event of pouch failure.

RESULTS

The prevalence of proctitis was high (MIP 40.4%, and SEP 42.8%). During follow-up, the incidence of complications was highest among SEP: resulting in re-intervention (n = 40; 28.2%, p = 0.017), pouchitis (n = 36; 25.2%, p < 0.01), and pouch failure (n = 32; 22.4%, p = 0.032). The time interval to pouch failure was 5.0 (4.0-6.9) years among NOP, and 1.2 (0.5-2.3) years in SEP (p = 0.036). ASA 3, pouchitis, and pouch fistula were independent risk factors for pouch failure.

CONCLUSION

Proctitis at the time of IPAA is common. A high degree of inflammation is associated with poor long-term outcomes, an effect that declines over time. In addition, a higher degree of proctitis leads to earlier pouch failure.

The Impact of Rectal Stump Inflammation After Subtotal Colectomy on Pouch Outcomes in Ulcerative Colitis Patients

BACKGROUND AND AIMS

Proctitis after subtotal colectomy with ileostomy for ulcerative colitis [UC] is common, but its impact on short- and long-term outcome after pouch surgery is unknown. The aim of this study was to determine the incidence of proctitis after subtotal colectomy and its impact on postoperative morbidity and pouchitis.

METHODS

The distal margin of the rectal stump of all consecutive patients undergoing completion proctectomy and pouch procedure for UC, between 1999 and 2017, was revised and scored for active inflammation according to the validated Geboes score, and for diversion proctitis. Pathological findings were correlated to complications after pouch surgery and pouchitis [including therapy-refractory] using multivariate analyses.

RESULTS

Out of 204 included patients, 167 [82%] had active inflammation in the rectal stump and diversion colitis was found in 170 specimens [83%]. Overall postoperative complications and anastomotic leakage rates were not significantly different between patients with and without active inflammation in the rectal stump [34.7% vs 32.4%, p = 0.79, and 10.2% vs 5.4%, p = 0.54, respectively]. Active inflammation of the rectal stump was significantly associated with the development of pouchitis [54.3% vs 25.5%, plog = 0.02], as well as with therapy refractory pouchitis [14% vs 0%, plog = 0.05]. Following multivariate analysis, active inflammation was an independent predictor for the development of pouchitis. Diversion proctitis showed no association with these outcome parameters.

CONCLUSIONS

Active inflammation in the rectal stump after subtotal colectomy occurs in 80% of UC patients and is a predictor for the development of pouchitis and therapy-refractory pouchitis.

Acute histologic inflammatory activity and postoperative outcomes in pediatric patients with ulcerative colitis

BACKGROUND

The aim of this study was to determine whether acute histologic inflammatory activity at the rectal margin predicts postoperative complications in children with ulcerative colitis following ileal pouch-anal anastomoses (IPAA).

METHODS

Patients who underwent IPAA following previous total abdominal colectomy for ulcerative colitis between 2006 and 2014 were included. Data collected included demographics, operative and postoperative data, histologic grading of the rectal margin at time of IPAA, and stooling outcomes at one, six and 12 months following ileostomy closure.

RESULTS

Twenty-seven patients were included. Acute inflammation scores ranged between 2 and 13. Unadjusted and adjusted models showed no statistically significant relationship between inflammation and presence of any postoperative complications, number of daily stools, nighttime stooling, soiling, or stool-altering medication usage.

CONCLUSION

Acute histologic inflammatory activity at the rectal margin is not associated with increased rates of postoperative complications following IPAA creation in children, nor with poorer continence outcomes following ileostomy closure.

Outcomes following two-stage surgical approaches in the treatment of pediatric ulcerative colitis

INTRODUCTION

Surgery for the treatment of ulcerative colitis (UC) can be performed in one-, two-, or three-stage procedures [1]. The more traditional approach is a total proctocolectomy and creation of an ileo pouch-anal anastomosis and diverting stoma at the initial operation, followed by ileostomy closure several weeks later (TIPPA) [1]. An alternative is an initial subtotal colectomy and end ileostomy [2]. In this alternative approach (NIPAA), a completion proctectomy and definitive ileo pouch-anal anastomosis can be performed without a diverting stoma. We hypothesize that functional outcomes following a NIPAA approach when performed in children, in our experience, are likely similar or improved when compared to those treated by TIPAA.

METHODS

After IRB approval, a review of patients who underwent a two-stage Laparoscopic IPAA from 2004 to 2017 occurred. Data included demographics, diagnosis, surgical intervention time to full diet, level of continence, use of antidiarrheals and complications.

RESULTS

N = 41 (NIPAA = 14, TIPAA = 27). After establishment of bowel continuity, no significant differences in appetite recovery, continence, or complications were noted. The number of antidiarrheals prescribed were significantly higher in the TIPAA group (p = 0.01). Thirteen patients (31.7%) had pouchitis: 4 NIPAA and 9 TIPAA (p = NS). Of the 41 patients, 11 required subsequent surgery; 2 patients (18.2%) received NIPAA and 9 (81.8%) received TIPAA (p = 0.20). Two TIPAA patients received a diverting ileostomy owing to chronic anal pain and failure to achieve continence.

CONCLUSION

This study suggests children with medically refractory UC treated by NIPAA or TIPAA have similar outcomes. Minimal differences in overall outcome were noted following either approach. However, NIPAA may reduce reliance on antidiarrheals to achieve satisfactory defecation outcomes.

LEVEL OF EVIDENCE

III Retrospective comparative study.