Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)--a multivariate analysis

NSQIP 5-factor modified frailty index and complications after ileal anal pouch anastomosis for ulcerative colitis

Background

Frailty has been associated with worse postoperative outcomes. The 5-factor modified frailty index (mFI-5) is an objective measure although its validity in measuring frailty in patients undergoing ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) has not been reported.

Methods

This study used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy database. The mFI-5 was calculated by five preoperative diagnoses: insulin-dependent or noninsulin-dependent diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent or partially dependent functional status. The impact of mFI-5 on minor and major postoperative morbidity in CUC patients undergoing IPAA was analyzed.

Results

The cohort included 1454 patients (median age 38 years, median body mass index [BMI] 26 kg/m2) of which 87 % had a mFI-5 = 0, 11 % had a mFI-5 = 1, and 2.5 % a mFI-5 ≥ 2. In multivariable logistic regression, mFI-5 ≥ 2 was significantly associated with minor complications (OR = 2.29, 95 % CI [1.00-5.22], p = 0.049), but not with major complications (p = 0.860).

Conclusion

IPAA for CUC is associated with high postoperative morbidity, however, the mFI-5 alone has limited utility in determining which patients are at a higher risk of complications due to frailty. These observations suggest there is a need for more relevant instruments to measure frailty in this patient cohort.

Classification and Management of Disorders of the J Pouch

Total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.

Redo ileal pouch-anal anastomosis for early versus late sepsis-related pouch failure

BACKGROUND

Pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis occurs in 5% to 15% of cases, mostly due to septic complications. We aimed to determine if the timing of pouch failure impacted long-term outcomes for redo ileal pouch-anal anastomosis after sepsis-related complications.

METHOD

We retrospectively analyzed our prospectively collected institutional pouch database. Patients who underwent redo ileal pouch-anal anastomosis for septic complications between 1988 and 2020 were divided into an early (pouch failure within 6 months of stoma closure after index operation, or stoma never closed) and a late failure group (pouch failure after 6 months of stoma closure). The primary endpoint was pouch survival.

RESULTS

In total, 335 patients were included: 241 (72%) in the early and 94 (28%) in the late failure group. The most common indication for failure was an anastomotic leak in the early failure group (163, 68%) and fistula in the late failure group (59, 63%), P < .001. Pouch survival at 3, 5, and 10 years was 77%, 75%, and 72% for the early and 79%, 75%, and 68% for the late failure group (P = .94). The most common reason for redo pouch failure was fistula in both groups. Quality of life was similar in both groups. In multivariate analysis, the only factor associated with pouch failure was the final diagnosis of Crohn's disease.

CONCLUSION

Outcomes after redo ileal pouch-anal anastomosis were comparable between patients with early and late sepsis-related index pouch failure, with acceptable rates of long-term pouch survival and good quality of life.

Endoscopic Therapy for Pouch Leaks and Strictures: A Systematic Review

BACKGROUND

Patients with ulcerative colitis refractory to medication or familial adenomatous polyposis may require ileal pouch-anal anastomosis after a colectomy. IPAA is generally well tolerated. However, patients can experience posttreatment complications, including pouch strictures and leaks. Medical therapy has a limited role in mechanical fibrotic strictures, whereas surgery is invasive and costly. In the past few decades, endoscopic therapies have provided a less invasive and less costly intervention for pouch strictures and leaks.

OBJECTIVE

This systematic literature review aimed to describe the status of advancements in endoscopic therapy for pouch leaks and strictures.

DATA SOURCES

The sources used were PubMed and Cochrane databases.

STUDY SELECTION

Studies between January 1990 and January 2022, in any language, were included. Articles regarding surgical management or pouches other than adult ileal pouch-anal anastomosis were excluded.

INTERVENTIONS

Endoscopic management of acute and chronic leaks and strictures ileal pouch-anal anastomosis was included.

MAIN OUTCOME MEASURES

Successful management (including persistent leak or stricture, pouch failure, subsequent endoscopy, or surgery) was measured.

RESULTS

Sixty-one studies were included in this review, including 4 meta-analyses or systematic reviews, 11 reviews, 17 cohort studies, and 18 case series.

LIMITATIONS

The limitations include qualitative review of all study types, with no randomized controlled studies available.

CONCLUSION

Ileal pouch-anal anastomosis leaks are various in configuration, and endoscopic therapies have included clipping leaks at the tip of the "J" as well as endoscopic sinusotomy. Endoscopic therapies for pouch strictures have included endoscopic balloon dilation, endoscopic stricturotomy, and endoscopic stricturoplasty, which are now considered first-line therapies for pouch strictures. Endoscopic balloon dilation has shown safety and efficacy in single, short, and straight strictures and endoscopic stricturotomy for refractory long, fibrotic, anastomotic strictures. Endoscopic therapies can delay or prevent invasive surgeries. Key tenets of successful endoscopic therapy include patient and lesion candidacy, an experienced endoscopist, and adequate rescue surgery plans.

Short- and Long-term Outcomes of Ileal Pouch Anal Anastomosis Construction in Obese Patients With Ulcerative Colitis

BACKGROUND

Obese patients are traditionally considered difficult pouch candidates because of the potential for intraoperative technical difficulty and increased postoperative complications.

OBJECTIVE

The purpose of this study was to compare the outcomes of obese versus nonobese patients with ulcerative colitis undergoing an IPAA.

DESIGN

This is a retrospectively, propensity score-matched, prospectively collected cohort study.

SETTING

This study was conducted at an IBD quaternary referral center.

PATIENTS

Patients with ulcerative colitis undergoing IPAA (1990-2018) were included. Obesity was defined as a BMI ≥30 kg/m 2 .

MAIN OUTCOME MEASURES

The primary measures included 30-day complications, long-term anastomotic leak, and pouch failure rate (excision, permanent diversion, revision).

RESULTS

Of 3300 patients, 631 (19.1%) were obese (median BMI = 32.4 kg/m 2 ). On univariate analysis, obese patients were more likely to be >50 years old (32.5% versus 22.7%, p < 0.001), ASA class 3 (41.7% versus 27.7%, p < 0.001), have diabetes (8.1% versus 3.3%, p < 0.001), and have had surgery in the biologic era (72.4% versus 66.2%, p = 0.003); they were less likely to have received preoperative steroids (31.2% versus 37.4%, p = 0.004). After a median follow-up of 7 years, 66.7% had completed at least 1 quality-of-life survey. Pouch survival in the matched sample was 99.2% (99.8% nonobese versus 95.4% obese, p = 0.002). After matching and controlling for confounding variables, worse clinical outcomes associated with obesity included global quality of life (relative risk, -0.71; p = 0.002) and long-term pouch failure (HR, 4.24; p = 0.007). Obesity was also independently associated with an additional 27 minutes of operating time ( p < 0.001). There was no association of obesity with the likelihood of developing a postoperative complication, length of stay, or pouch leak.

CONCLUSION

Restorative ileoanal pouch surgery in obese patients with ulcerative colitis is associated with a relatively decreased quality of life and increased risk of long-term pouch failure compared with nonobese patients. Obese patients may benefit from focused counseling about these risks before undergoing restorative pouch surgery. See Video Abstract at http://links.lww.com/DCR/B873 .

RESULTADOS A CORTO Y LARGO PLAZO EN LA REALIZACIN DEL RESERVORIO ILEAL EN PACIENTES OBESOS CON COLITIS ULCEROSA

ANTECEDENTES:Habitualmente se considera a los obesos como pacientes difíciles para la realización de un reservorio ileal, debido a su alta probabilidad de presentar dificultades técnicas intraoperatoria y aumento de las complicaciones posoperatorias.OBJETIVO:El propósito de este estudio fue comparar los resultados de pacientes con colitis ulcerosa obesos versus no obesos sometidos a un reservorio ileal y anastomosis anal (IPAA).DISEÑO:Este es un estudio de cohorte recopilado prospectivamente, retrospectivo, emparejado por puntajes de propensión.AJUSTE:Este estudio se llevó a cabo en un centro de referencia de cuarto nivel para enfermedades inflamatorias del intestino.PACIENTES:Se incluyeron pacientes con colitis ulcerosa sometidos a un reservorio ileal y anastomosis anal (1990-2018). Obesidad definida como un IMC ≥ 30 kg/m2.PRINCIPALES RESULTADO MEDIDOS:Los principales resultados medidos incluyeron complicaciones a los 30 días, fuga anastomótica a largo plazo y tasa de falla del reservorio ileal (escisión, derivación permanente, revisión).RESULTADOS:De 3.300 pacientes, 631 (19,1%) eran obesos (mediana de IMC = 32,4 kg/m2). En el análisis univariado, los pacientes obesos tenían más probabilidades de ser > 50 años (32,5% frente a 22,7%, p < 0,001), clase ASA 3 (41,7% frente a 27,7%, p < 0,001), tener diabetes (8,1% frente a 3,3%, p < 0,001), haberse sometido a cirugía en la era biológica (72,4% frente a 66,2%, p = 0,003), y tenían menos probabilidades de haber recibido esteroides preoperatorios (31,2% frente a 37,4%, p = 0,004). Después de una mediana de seguimiento de 7 años, el 66,7% había completado al menos una encuesta de calidad de vida. La supervivencia de la bolsa en la muestra emparejada fue del 99,2% (99,8% no obesos versus 95,4% obesos, p = 0,002). Después de emparejar y controlar las variables de confusión, los peores resultados clínicos asociados con la obesidad incluyeron la calidad de vida global (RR = -0,71, p = 0,002) y el fracaso de la bolsa a largo plazo (HR = 4,24, p = 0,007). La obesidad también se asoció de forma independiente con 27 minutos adicionales de tiempo quirúrgico ( p < 0,001). No hubo asociación de la obesidad con la probabilidad de desarrollar una complicación posoperatoria, la duración de la estadía o la fuga de la bolsa.CONCLUSIÓNES:La cirugía restauradora del reservorio ileoanal en pacientes obesos con colitis ulcerosa se asocia a una disminución relativa de la calidad de vida y un mayor riesgo de falla del reservorio a largo plazo en comparación con los pacientes no obesos. Los pacientes obesos pueden beneficiarse de un asesoramiento centrado en estos riesgos antes de someterse a una cirugía restauradoracon reservorio ileal y anastomosis anal. Consulte Video Resumen en http://links.lww.com/DCR/B873 . (Traducción-Dr. Rodrigo Azolas ).

Ileal pouch-anal anastomosis in the elderly: A systematic review and meta-analysis

AIM

Despite good overall outcomes in most patients undergoing ileal pouch-anal anastomosis (IPAA), there is still hesitation about performing an IPAA in older patients due to the comorbidity burden and concern about incontinence. The aim of this work was to identify short- and long-term outcomes in older patinets undergoing IPAA to determine the perioperative safety and long-term functional success of IPAA in older patients.

METHOD

A literature search was performed for all publications on IPAA in adults aged ≥50 years that reported short- and long-term outcomes. Data extraction included demographics, 30-day outcomes, long-term functional outcomes and pouch failure. Data were further separated by age group (50-65 and ≥65 years). Outcomes were compared between age groups. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1053 publications reviewed, 13 full papers were included in the analysis. The overall 30-day morbidity and mortality rates were 47.3% and 1.3%, respectively. Thirty-day postoperative rates of small bowel obstruction and pelvic sepsis were 7.6% and 9.9%, respectively. After a median follow-up time of 62 months, rates of pouchitis, incontinence and pouch failure were 13.9%, 17.5% and 7.5%, respectively. There was no statically significant difference in rates of short- or long-term functional outcomes based on age 50-65 versus ≥65 years.

CONCLUSION

Increasing age did not increase the rate of short- or long-term outcomes, including pouch failure. These data suggest that the decision for IPAA construction should not be based on age alone.

Anti-TNF and Pouch Surgery for Ulcerative Colitis: The Ones who Blame for More Complications?

Since the approval in 2005 of anti-TNF drugs for the treatment of ulcerative colitis, concerns have been raised about the potential detrimental effect of these agents on postoperative infectious complications related to pouch surgery. Data on this topic are controversial and mostly derived from retrospective underpowered cohort studies largely affected by relevant bias. Three meta-analyses have been published with contradictory results. Moreover, the correlation between serum levels of infliximab at the time of surgery and the occurrence of septic postoperative complication is far to be proven and remains an answered research question. The construction of an ileal pouch-anal anastomosis (IPAA) as first surgical step in patients with ulcerative colitis (UC) refractory to medical treatment seems to be associated with an increased risk of septic complications. Population-based data from the United States show a shift towards stage surgery for patients with refractory UC as a consequence of the widespread use of biological agents and the increased tendency to consider surgery as ultimate resort (step-up approach). In this setting, the classic 3-stage procedure (ileoanal pouch and diversion ileostomy after initial total colectomy) together with the modified 2-stage approach (ileoanal pouch without diversion ileostomy after initial total colectomy) are both effective options. Whether or not a diversion ileostomy could prevent pouch complications at the time of the pouch construction during the second stage of surgery is still a matter of debate. Emerging data seem to claim for increased risk of small bowel obstructions related to the presence of a stoma without proven effect on the prevention of anastomotic leak.

Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time?

BACKGROUND

Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points.

OBJECTIVE

The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss.

DESIGN

This was a retrospective study from an institutional database.

SETTINGS

The study was conducted at the Cleveland Clinic Foundation.

PATIENTS

Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included.

MAIN OUTCOME MEASURES

Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years.

RESULTS

A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula.

LIMITATIONS

This was a retrospective, single-institution study.

CONCLUSIONS

Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUÉS DE ANASTOMOSIS CON BOLSA ÍLEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ¿LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relación lineal con la pérdida de la bolsa y con el tiempo. La supervivencia condicional es un método para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en función de aparición de factores de riesgo para la pérdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa íleo anal, de 1986 a 2016.Los pacientes fueron estratificados en función de la fuga anastomótica postoperatoria, absceso o aparición de fístula. El método de Kaplan Meier con supervivencia condicional, se utilizó para estimar la supervivencia general y la causa específica a los 10 años.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el período de estudio. La tasa de supervivencia global de la bolsa a 10 años, fue de 0,94 (0,93 a 0,95), y después de 1 año, la supervivencia condicional de la bolsa aumentó a 0,95 (0,94 a 0,96), después de 3 años a 0,97 (0,96 a 0,98) y después de 5 años a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomótica, y la supervivencia de la anastomosis de bolsa íleo anal a 10 años en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, después de 1 año de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumentó a 0,89 (IC del 95%: 0,82 a 0,96), y después de 3 años a 0,98 (IC del 95%: 0,94 a 1). Se observó un patrón similar para la anastomosis de bolsa íleo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fístula.Estudio retrospectivo, de una sola institución.La supervivencia condicional global de la bolsa, mejoró con el tiempo para pacientes con fuga anastomótica postoperatoria y absceso. Estos nuevos hallazgos pueden ser útiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traducción-Dr Fidel Ruiz Healy).

Restorative Proctocolectomy in Ulcerative Colitis: Effect of Preoperative Immunomodulatory Therapy on Postoperative Complications and Pouch Failure

BACKGROUND AND AIMS

Patients with ulcerative colitis are often treated with multiple immunomodulative agents to achieve remission. In refractory disease, the next option is frequently proctocolectomy with ileal pouch-anal anastomosis. No consensus exists as to whether immunomodulatory therapy at the time of ileal pouch surgery leads to any increase in postoperative complications. Our aim was to assess, in ulcerative colitis patients with restorative proctocolectomy, the effect of preoperative anti-tumor necrosis factor therapy and corticosteroids on postoperative complications and pouch failure.

MATERIALS AND METHODS

A retrospective medical record review of 445 patients with ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis in Helsinki University Hospital between January 2005 and June 2016.

RESULTS

Anti-tumor necrosis factor agents were not associated with postoperative complications. Only high-dose corticosteroids (prednisolone ⩾20 mg or equivalent) were associated with higher incidence of anastomotic leak (12.6% vs 2.5%, P = 0.002) and wound dehiscence (4.2% vs 0%, P = 0.019), but pouch failure rate was no higher (2.1% vs 0%, P = 0.141) than in patients without corticosteroid treatment. A lower dosage of corticosteroids had no effect on early postoperative complications, but pouch failure rate was increased (4.4% vs 0%, P = 0.015).

CONCLUSION

Corticosteroids, but not anti-tumor necrosis factor therapy, were associated with postoperative complications. Preoperative use of corticosteroids may increase pouch failure rate, but the risk is still minor in high-volume centers performing ileal pouch surgery.

Endo-sponge Assisted Early Surgical Closure of Ileal Pouch-anal Anastomotic Leakage Preserves Long-term Function: A Cohort Study

BACKGROUND AND AIMS

Endo-sponge [Braun Medical] assisted early surgical closure [ESC] is an effective treatment to control pelvic sepsis after ileal pouch-anal anastomosis [IPAA] leakage, and became standard treatment in our centre from 2010 onwards. The aim of this cohort study was to assess the long-term pouch function of ulcerative colitis [UC] patients treated with ESC or conventional management [CM] for anastomotic leakage after IPAA.

METHODS

Consecutive patients who underwent an IPAA for UC between 2002 and 2017 were included. Patients treated with ESC [2010-2017] or CM [2002-2009] for anastomotic leakage were compared with control patients without anastomotic leakage of the corresponding time period. Main endpoints were long-term pouch function on a 3-point scale and pouch failure, as measured with the validated pouch dysfunction score questionnaire.

RESULTS

Some 280 of 334 patients [84%] returned the pouch dysfunction questionnaire, of whom 18 were treated with ESC and 22 with CM for anastomotic leakage. Control cohorts included 133 [2010-2017] and 107 patients [2002-2009]. Between ESC-treated patients and control patients, pouch function [p = 0.647] and pouch failure rates [0/18 versus 5/133, p >0.99] were similar. CM resulted in worse pouch function [p = 0.016] and a higher pouch failure rate [5/22 versus 5/107, p = 0.013] compared with control patients.

CONCLUSIONS

ESC, in contrast to CM, for IPAA leakage in UC patients is associated with preservation of pouch function and preclusion of pouch failure, probably due to early and effective treatment of pelvic sepsis.

Indications and outcomes of home parenteral nutrition in patients with an ileoanal pouch

INTRODUCTION

Restorative proctocolectomy is a surgical treatment for patients with medically refractory ulcerative colitis and some cases of familial adenomatous polyposis. Intestinal failure, defined as an inability to maintain adequate hydration and micronutrient balances when on a conventionally accepted normal diet, is a rare complication of restorative proctocolectomy. We describe our experience of patients with restorative proctocolectomy who have developed intestinal failure requiring parenteral support.

MATERIAL AND METHODS

This was a retrospective analysis using a database of patients referred to our intestinal failure unit from January 1998 to January 2016. We analysed the records of all those patients who had restorative proctocolectomy who developed intestinal failure.

RESULTS

807 patient records analysed, 35 patients were found to have had a restorative proctocolectomy (13 male and 22 female). Ninety-one percent (n = 32) of patients developed IF as a consequence of unpredictable complications which occurred after RPC formation. Potentially predictable complications were noted in 9% (n = 3) of patients.

DISCUSSION AND CONCLUSIONS

Most cases of intestinal failure in restorative proctocolectomy were unpredictable. In a small number of patients, accurate assessment and measurement of the small intestine may have better predicted the adverse outcome of intestinal failure allowing improved pre-operative counseling of patients.

Management of early pouch-related septic complications in ulcerative colitis: a systematic review

AIM

It is well established that ileo-anal pouch-related septic complications (PRSC) increase the risk of pouch failure. There are a number of publications that describe the management of early PRSC in ulcerative colitis (UC) in small series. This article aims to systematically review and summarize the relevant current data on this subject and provide an algorithm for the management of early PRSC.

METHOD

A systematic review was undertaken in accordance with PRISMA guidelines. Studies published between 2000 and 2017 describing the clinical management of PRSC in patients with UC within 30 days of primary ileo-anal pouch surgery were included. A qualitative analysis was undertaken due to the heterogeneity and quality of studies included.

RESULTS

A total of 1157 abstracts and 266 full text articles were screened. Twelve studies were included for analysis involving a total of 207 patients. The studies described a range of techniques including image-guided, endoscopic, surgical and endocavitational vacuum methods. Based on the evidence from these studies, an algorithm was created to guide the management of early PRSC.

CONCLUSION

The results of this review suggest that although successful salvage of early PRSC is improving there is little information available relating to methods of salvage and outcomes. Novel techniques may offer an increased chance of salvage but comparative studies with longer follow-up are required.

Predictors of quality-of-life after ileal pouch-anal anastomosis in patients with ulcerative colitis

OBJECTIVES

Predictors of the postoperative quality of life (QoL) following ileal pouch anal anastomosis (IPAA) have not been thoroughly investigated. This study was planned to assess the postoperative QoL following IPAA and to identify its predictors using the 15D instrument.

MATERIALS AND METHODS

A retrospective cohort study was conducted on IPAA-operated patients with ulcerative colitis in two Finnish tertiary hospitals during the period 1985-2014 (n = 485). Medical records were examined to collect data on baseline, operative and postoperative characteristics. Patients were surveyed using the 15D-instrument to assess their postoperative QoL. Linear regression analyses and receiver operating characteristic curve were applied to identify the predictors of postoperative QoL.

RESULTS AND CONCLUSIONS

Of all patients, 61.5% experienced worse postoperative QoL, with significantly lower QoL level than that of an age and sex-standardized general population in 12 dimensions of the 15D-instrument, with the highest mean difference QoL scores calculated for excretion, sexual activity and sleeping dimensions. Older age and preoperative hypertension were the only significant predictors of lower overall QoL (p = .003 and p = .03, respectively). A preoperative age of ≥35 years was the most valid predictor of lower postoperative QoL (Sensitivity = 62.4% and Specificity = 49.6%, p = .04). In conclusion, postoperative QoL is generally low using the 15D-instrument after IPAA. Worse postoperative QoL is predicted after the age of 35.

Cost of Ulcerative Colitis in Quebec, Canada: A Retrospective Cohort Study

BACKGROUND

Ulcerative colitis (UC) is associated with significant health care utilization and costs. We assessed UC direct medical costs in Quebec, Canada, in 2 time periods (1998-2004 and 2005-2011) and determined changes over time.

METHODS

Because the introduction of anti-tumor necrosis factor α may have influenced the UC cost, we used the Quebec health services administrative databases and the same inclusion criteria to create 2 separate UC cohorts, before (1998-2004) and after (2005-2011) anti-tumor necrosis factor α introduction.

RESULTS

The postcohort included 801 patients and the precohort 716 patients. Overall, cohorts were predominately women and were comparable in terms of patient's demographics and comorbidities. Corticosteroid use, emergency department visits and hospitalizations for colectomies, and other gastrointestinal disorders were fewer in the postcohort versus precohort. The median daily cost (interquartile range) was $16.96 ($6.80-$48.16) for the postcohort and $18.65 ($7.82-$53.31) for the precohort. In generalized linear models with log link and gamma distribution, the adjusted daily cost ratios (95% confidence interval) in the postcohort versus precohort was 0.75 (0.67-0.85). Older age at inclusion, low income, lower socioeconomic status, and previous use of gastroprotective agents, antidepressants, and sulfasalazine, methotrexate, or cyclosporine were associated with increased costs. Women and those who visited a gastroenterologist in the previous year incurred lower costs.

CONCLUSIONS

The mean UC daily cost decreased from 2005 to 2011 as compared to 1998 to 2004 because of a decrease in rates of colectomy and other gastrointestinal hospitalizations and emergency department visits. Further investigation is required to determine the reasons for these changes.

External validation of a prognostic model of preoperative risk factors for failure of restorative proctocolectomy

AIM

The Cleveland Clinic has proposed a prognostic model of preoperative risk factors for failure of restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis. The model incorporates four predictive variables: completion proctectomy, handsewn anastomosis, diabetes mellitus and Crohn's disease. The aim of the present study was to perform an external validation of this model in a new cohort of patients who had RPC.

METHOD

Validation was performed in a multicentre cohort of 747 consecutive patients who had an RPC between 1990 and 2015 in three tertiary-care facilities, using a Kaplan-Meier survival analysis and Cox regression analysis. The performance of the model was expressed using the Harrell concordance error rate. The primary outcome measure was pouch survival with maintenance of anal function.

RESULTS

During the study period, 45 (6.0%) patients experienced failure at a median interval of 31 months (interquartile range 9-82 months) from the original RPC. Multivariable analysis showed handsewn anastomosis to be the only significant independent predictor. The Harrell concordance error rate was 0.42, indicating poor performance. Anastomotic leakage and Crohn's disease of the pouch were strong postoperative predictors for pouch failure and showed a significant difference in pouch survival after 10 years (P < 0.001).

CONCLUSION

The poor performance of the Cleveland Clinic prognostic model makes it unsuitable for daily clinical practice. Handsewn anastomosis was associated with pouch failure in our cohort with relatively few events. A prediction model for anastomotic leakage or Crohn's disease of the pouch may be a better solution since these variables are strongly associated with pouch failure.

A Multicentre Evaluation of Risk Factors for Anastomotic Leakage After Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease

BACKGROUND

Anastomotic leakage is a major complication after restorative proctocolectomy with ileal pouch-anal anastomosis [IPAA]. Identification of patients at high risk of leakage may influence surgical decision making. The aim of this study was to identify risk factors associated with anastomotic leakage after restorative proctocolectomy with IPAA.

METHODS

Between September 1990 and January 2015, patients who underwent IPAA for inflammatory bowel disease [IBD] were identified from prospectively maintained databases of three tertiary referral centres. Retrospective chart review identified additional data on demographic and surgical variables. Multivariable regression models were developed to identify risk factors for anastomotic leakage. Separate analyses were performed for type of procedure.

RESULTS

A total of 640 patients [56.9% male] were included, with a median age of 38 years [interquartile range 29-48]; 96 [15.0%] patients developed anastomotic leakage. Multivariable regression analysis demonstrated that being overweight (body mass index [BMI] > 25], (odds ratio [OR] 1.92; 95% confidence interval [CI] 1.15 - 3.18), and American Society of Anesthesiologists classification [ASA score > 2] [OR 1.91; 95% CI 1.03 - 3.54] were independent risk factors for anastomotic leakage in patients who underwent a completion proctectomy. A disease course of > 5 years [OR 2.34; 95% CI 1.42 - 3.87] and concurrent combination of anti-tumour necrosis factor [TNF] and steroids [OR 6.40; 95% CI 1.76 - 23.20] were independent risk factors for anastomotic leakage in patients who underwent a proctocolectomy and IPAA.

CONCLUSIONS

Independent risk factors for anastomotic leakage in IBD patients undergoing IPAA are BMI >25, ASA score >2, disease course > 5 years, and concurrent steroid and anti-TNF treatment, with a different risk profile for one-stage proctocolectomy and completion proctectomy procedures.

Endoscopy-assisted transanal repair of afferent limb obstruction and long efferent limb with ileopexy after ileal J-pouch-anal anastomosis

Afferent limb obstruction can be a persistent complication after restorative proctocolectomy with ileal pouch-anal anastomosis. We present a case of afferent limb obstruction complicated by a long efferent limb of the ileal pouch that we successfully treated with side-to-side anastomosis of the afferent and efferent limbs. The procedure involved using a transanal endoscopic stapling device assisted by transanal endoscopy with a thin intestinal video endoscope. This allowed reliable, safe visualization of the lesion from the tight pouch-anal anastomosis and facilitated repair with an endoscopic stapling device. Because the technique was performed without enterotomy, it reduced the risks of contamination and leakage from transabdominal small bowel anastomosis. Laparotomy view also prevented of injury to the pouch itself and entrapment of the mesentery of the afferent and efferent limbs of the pouch between the stapler anvils.

Increased Incidence of Surgical Site Infection in IBD Patients

BACKGROUND

Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for.

OBJECTIVE

This study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection.

DESIGN

The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012.

OUTCOME MEASURES

The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection.

RESULTS

The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity.

LIMITATIONS

This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents.

CONCLUSIONS

Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.

Frequency, Clinical Features and Factors Associated with Pouchitis after Proctocolectomy with Ileo-Pouch-Anal Anastomosis in Patients with Ulcerative Colitis: A Latin-American Country Retrospective-Cohort Study

BACKGROUND

Pouchitis is the most common complication of proctocolectomy with ileo-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). No previous study in Mexico has evaluated this issue; our aim was to evaluate its frequency, clinical characteristics and factors associated with its presence in Mexican patients with UC and IPAA.

METHODS

Retrospective-cohort study including 70 patients with histopathological diagnosis of UC and IPAA between 1983 and 2014 from inflammatory bowel disease clinic of a tertiary care center. The statistical analysis used descriptive statistics, chi-square and Fisher's exact test for categorical variables and Student's t test for numeric variables. Univariate analysis was performed to identify the factors associated.

RESULTS

Patients presenting with pouchitis accounted for 48.6%. From the 34 cases, 12 (35.3%) had inactive pouchitis; 7 (20.6%) active acute pouchitis; 15 (44.1%) chronic active pouchitis. On average, pouchitis occurred 5.37 years after IPPA. Factors probably associated with its occurrence were the presence of autoimmune concomitant diseases (ACDs; p = 0.06, OR 4.40, 95% CI 0.84-22.9) and extra-intestinal manifestations (EIMs; p = 0.05, OR 2.53, 95% CI 0.96-6.64), which was also probably associated with chronic active pouchitis (p = 0.06, OR 0.31, 95% CI 0.07-1.31).

CONCLUSIONS

The frequency of pouchitis is high in Mexican UC patients after IPAA. ACDs and EIMs were probably associated with its development.

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.

Surgical treatment of ulcerative colitis: Ileorectal vs ileal pouch-anal anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the current gold standard in the surgical treatment of ulcerative colitis (UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis (IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.

Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center

BACKGROUND

There are no published studies comparing pouch configurations and long-term adverse outcomes.

AIM

To evaluate outcomes of ulcerative colitis (UC) patients undergoing restorative proctocolectomy with S-, J- pouches or continent ileostomy (CI).

METHODS

We conducted a historical cohort study from the prospectively maintained Pouch Registry. Demographic and clinical variables were evaluated with univariate and multivariable analyses.

RESULTS

Fourty-five patients with S pouches and 36 with CI (33 K pouches and 3 Barnett continent ileal reservoirs) were compared with 215 J pouches serving as controls (ratio 1:2.5). In multivariable analysis, patients with S pouches were 93% less likely to develop chronic antibiotic-refractory pouchitis (CARP) than subjects with J pouches (odds ratio [OR]=0.07; 95% confidence interval: <0.001, 0.54; p<0.001). However, no significant difference in the frequency of CARP was found between the CI and J pouch groups (OR=0.68; 95% confidence interval: 0.17, 2.00, p=0.40). Patients with S pouches were 8 times more likely (95% confidence interval: 3.7, 17.5; p<0.001) and patients with CI 5.6 had times more likely (95% confidence interval: 2.4, 13.3; p<0.001) to have pouch surgery-related complications than those with J pouches. There was no difference in the rate of CD of the pouch, pouch-associated hospitalization and pouch failure between the S- pouch, CI and J- pouch groups.

CONCLUSIONS

Patients with J pouches appeared to have a greater risk for chronic pouchitis than those with S-pouches and but had a lower risk for developing pouch surgery-related complications than those with S pouches or CI.

Ileal j pouch complications and surgical solutions: a review

Ileal pouch-anal anastomosis is currently accepted as the standard method to restore continence after total proctocolectomy for medically refractory ulcerative colitis and familial adenomatous polyposis. Ileal pouches offer improved quality of life and high patient satisfaction; however, there are many pouch-related complications due to the original disease process and change in anatomy. This is a review article of the common and some rare surgical complications after J pouches, which can be subdivided into the septic and nonseptic categories. Septic-related complications include anastomotic leak, abscess, and fistulas, whereas common nonseptic-related complications include small bowel obstruction, strictures, Crohn's disease, pouchitis, and cuffitis. Rare nonseptic complications to be discussed are prolapse, volvulus, and neoplasia.

Colectomy for patients with ulcerative colitis and primary sclerosing cholangitis - what next?

BACKGROUND AND AIMS

Primary sclerosing cholangitis (PSC) occurs in 2%-8% of patients who suffer from ulcerative colitis (UC). For patients who require colectomy, ileal pouch-anal anastomosis (IPAA) or ileorectal anastomosis (IRA) is employed to preserve continence.We evaluated the outcomes after IPAA and IRA for patients with UC-PSC, using patients with UC but without PSC as controls (UC-only group).

PATIENTS

In a case-control study conducted at Sahlgrenska University Hospital, Sweden, patients with UC-PSC (N=48; 31 IPAA and 17 IRA) were compared to patients with UC only (N=113; 62 IPAA and 51 IRA). Functional outcomes (Öresland score), pouchitis, surgical complications, and failure were evaluated.

RESULTS

For patients with IPAA, the median Öresland scores were similar for the two groups: 5 (range, 0-13) for the UC-PSC group and 5 for the UC-only group (range, 0-12; p>0.05). However, the IRA scores were significantly different at 7 (range, 2-11) and 3 (range, 0-11) for the respective groups (p=0.005). Pouchitis was more frequent in patients with UC-PSC. Complication rates did not differ. For patients with IPAA, the failure rate was 16% for those in the UC-PSC group versus 6% for those in the UC-only group (p>0.05); the corresponding results for IRA were 53% versus 22% (p=0.03).

CONCLUSIONS

For cases of IPAA, pouchitis seems to be more common in patients with UC-PSC. However, the functional outcomes and failure rates are unaffected by concurrent PSC. For patients with UC-PSC, functional outcome is poor and the failure rate is high after IRA.

The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist

Pediatric severe ulcerative colitis that is resistant to current medical treatment can successfully be managed surgically with a colectomy, ileal pouch creation and pouch-anal anastomosis. Key issues that should be considered and discussed before the pouch option can be offered include alternative surgical procedures, pouch function expectations, risk of surgical leak, pelvic sepsis, anastomotic strictures, acute and chronic pouch inflammation, Crohn's disease of the pouch and risk of reduced fertility for females. A long-term risk is malignancy of the residual colonic tissue. The decision to proceed with a pouch or not poses a substantial emotional burden to the child and family. Despite the risk of surgical complications and pouch inflammatory and functional challenges, the overwhelming majority of children and their families are satisfied with their pouch surgery outcomes. Further study is needed to assess preoperative risk predictors, prevention and treatment of complications.

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

Bacteriology in the etiopathogenesis of pouchitis

BACKGROUND

Pouchitis is the most common long-term complication in ulcerative colitis that follows restorative proctocolectomy. Clinical evidence suggests that dysbiosis plays a key role in its pathogenesis.

METHODS

Current literature on the topic was reviewed. A therapeutic approach was proposed based on the literature along with personal experience from the subspecialty Pouchitis Clinic.

RESULTS

Pouchitis represents a disease spectrum in the reservoir, with ranging etiopathogenesis, clinical phenotypes, disease courses and prognoses. Dysbiosis plays a critical role in disease initiation and progress, with antibiotic therapy as the mainstay for treatment. On the other hand, superimposed infection from pathogens contributes to flare-up of the disease. Pouchitis can progress into an 'IBD-like' condition, requiring anti-inflammatory, immunomodulator or even biological therapy.

CONCLUSION

Pouchitis represents a unique form of IBD. Investigation on the evolution from an antibiotic-responsive phenotype to chronic antibiotic-refractory pouchitis may shed some light on the pathogenesis and therapeutic targets of IBD.

Evaluating pouch problems

IPAA is a technically demanding procedure that requires appropriate skills and expertise. Adverse sequelae of IPAA are common. Accurate diagnosis and classification of pouch disorders and associated complications are important for proper management and prognosis. Based on presenting symptoms, appropriate and combined diagnostic modalities should apply. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and gastrointestinal radiologists is advocated for diagnosis and treatment of pouch disorders.

Diagnosis and management of postoperative ileal pouch disorders

Although restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with refractory ulcerative colitis (UC) or UC with dysplasia, surgical, inflammatory, and noninflammatory adverse sequelae are common. Pouchitis, representing a spectrum of disease phenotypes, is the most common long-term complication of IPAA. De novo Crohn disease (CD) of the pouch can occur in patients with a preoperative diagnosis of UC. Differential diagnosis between fibrostenotic or fistulizing CD and surgery-associated strictures, sinuses, and fistulas often requires a combined assessment of symptom, endoscopy, histology, radiography, and examination under anesthesia. There is a role for endoscopic therapy for stricturing complications of IPAA. Chronic antibiotic-refractory pouchitis, refractory cuffitis, as well as fibrostenotic or fistulizing CD of the pouch are the leading late-onset causes for pouch failure.

Ileorectal anastomosis and proctocolectomy with end ileostomy for ulcerative colitis

Until the development of the ileal pouch-anal anastomosis in the early 1980s, proctocolectomy with end ileostomy was the only definitive surgery for ulcerative colitis and colectomy with ileorectal anastomosis was the procedure of choice for affected patients who were reluctant to have a permanent ileostomy. Currently, ileal pouch-anal anastomosis is the most common procedure for patients with ulcerative colitis requiring surgical treatment. However, there is still a role for ileorectal anastomosis and proctocolectomy with end ileostomy for a selected group of patients. In this review, the authors summarize the current indications for ileorectal anastomosis and proctocolectomy with end ileostomy in patients with ulcerative colitis.

Prognostic modeling of preoperative risk factors of pouch failure

BACKGROUND

The prospect of pouch failure needs to be considered when evaluating the management strategy for patients who may be candidates for an ileo anal pouch. An ability to predict the likelihood and timing of failure preoperatively may influence surgical decision making.

OBJECTIVE

The aim of this study was to define a preoperative prognostic model for ileoanal pouch failure.

DESIGN

A novel random forest methodology was used to evaluate the prognostic significance of 21 preoperative potential risk factors for pouch failure. A forest of 3000 random survival trees was grown to estimate pouch failure for each patient and to identify important risk factors that maximize survival prediction.

SETTINGS

This study took place at a tertiary referral department at a major academic medical center.

PATIENTS

Patients undergoing an ileoanal pouch at this institution between 1983 and 2008 were included.

MAIN OUTCOME MEASURES

The primary outcome measured was pouch survival.

RESULTS

Between 1983 and 2008, 3754 patients underwent ileoanal pouch. Type of resection (total proctocolectomy vs completion proctectomy), type of anastomosis (stapled vs mucosectomy), patient diagnosis (mucosal ulcerative colitis and others vs Crohn's disease) and diagnosis of diabetes had the strongest effect on pouch survival. Predicted survival was worse for completion proctectomy (HR, 1.44; 95% CI, 1.08-1.93), Crohn's disease (HR, 2.37; 95% CI, 1.48-3.79), handsewn anastomosis (HR, 1.72; 95% CI, 1.23-2.42), and diabetes (HR, 2.31; 95% CI, 1.25-4.24). Pouch survival was worse for the oldest group of patients.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSION

Random forest techniques applied to a large number of patients undergoing the ileoanal pouch identify factors associated with pouch failure. Attention directed at these factors may improve outcomes for these patients.

Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis

PURPOSE

Defunctioning ileostomies are widely performed in order to prevent or treat anastomotic leakage after colorectal surgery. The aim of the present study was to determine morbidity related to stoma closure and to identify predictive factors of a complicated postoperative course.

METHODS

A consecutive series of 138 patients were retrospectively analyzed after stoma reversal. Data collection included general demographics and surgery-related aspects. Morbidity related to stoma closure was retrieved from our prospectively collected registry of complications.

RESULTS

In 74 of 138 patients, defunctioning ileostomy was performed after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The remaining ileostomies (n = 64) were constructed after a low colorectal or coloanal anastomosis. A total of 46 complications were recorded in 28 patients resulting in an overall complication rate of 20.3%. Anastomotic leakage rate was 4.3%, and reoperation rate was 8.0%. The number of complications according to the Clavien-Dindo classification was 5 for grade I (10.9%), 26 for grade II (56.5%), 13 for grade III (28.3%), 1 for grade IV (2.2%), and 1 for grade V (2.2%). Multivariate analysis revealed a significantly higher ASA score in the complicated group (P = 0.015, odds ratio 2.6, 95% confidence interval 1.2-5.6).

CONCLUSIONS

Closure of a defunctioning ileostomy is associated with 20% morbidity and a reoperation rate of 8%. There is an urgent need for criteria on which a more selective use of a defunctioning ileostomy after low colonic anastomosis or IPAA can be based given its associated morbidity.

Pelvic abscess associated with anastomotic leak in patients with ileal pouch-anal anastomosis (IPAA): transanastomotic or CT-guided drainage?

AIM

Evidence is lacking whether an abscess associated with anastomotic leak after an ileal pouch-anal anastomosis (IPAA) should be drained by transanal or CT-guided drainage. Therefore, the aim of this study was to compare outcomes after the two techniques for drainage.

METHOD

Patients who underwent IPAA (1984-2009) and diagnosed with a pelvic abscess associated with an anastomotic leak were identified. The choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (group TA) and CT-guided drainage (group CT) were determined.

RESULTS

Groups TA (n = 53) and CT (n = 18) had similar age (p = 0.3), gender (p = 0.3), body mass index (p = 0.6), steroid use (p = 0.4), albumin level (p = 0.9), ileostomy (p = 0.6), and follow-up time (p = 0.5). The size of the abscess was greater in group CT (p = 0.012). Two patients developed fistula at the CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Thirteen patients in group TA and three patients in group CT (p = 0.6) had failure of drainage and underwent surgery. The success rates for the procedures in terms of long-term pouch retention were 75.5% and 83%, respectively, for TA and CT. Groups TA and CT had similar bowel frequency (p = 0.9), incontinence (p = 0.6), urgency (p = 0.9), seepage (p = 0.6), pad usage (p = 0.1), quality of life (p = 0.9), and happiness with surgery (p = 0.9).

CONCLUSIONS

There is a risk of fistula at drainage site after a CT-guided drainage of the pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage are equally effective and result in similar long-term pouch-related outcomes.

How I do it: the stapled ileal J pouch at restorative proctocolectomy

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) following proctocolectomy is the preferred option for patients with medically refractory ulcerative colitis, indeterminate colitis, and familial adenomatous polyposis. However, it remains a procedure associated with morbidity and mortality. Pelvic sepsis, pouch fistulae, and anastomotic dehiscence predispose to pouch failure. We report our experience with an adaptation for the formation of the stapled ileal J pouch using the GIA™ 100 stapling device (Covidien, Mansfield, Massachusetts, USA). When creating the J pouch, we remove the bevelled plastic protector from the thin fork of the stapling device, allowing the staple line to be completed to the tip of the stapled efferent limb of the pouch, thereby minimizing potential blind ending in the efferent limb and injury to the transverse staple line.

METHODS

Patients undergoing elective IPAA at our institution over a 5-year period using this adapted stapling technique for creation of the ileal J pouch were reviewed. Data were collected from a prospectively maintained inflammatory bowel disease database, theater records, and patient chart review.

RESULTS

Forty-one patients underwent IPAA using this technique at our institution during the study period. Postoperative morbidity was encountered in 11 of 41 patients including pelvic sepsis, pouch fistulae, anastomotic stricture, or leak. There was no morbidity observed related to a blind efferent limb or transverse staple line disruption. No mortality was observed in this series.

CONCLUSION

Maximizing the length of the efferent fork of the GIA stapling device can reduce the length of redundant efferent J limb of the ileal J pouch. This may reduce the incidence of torsion, volvulus, distension, fistulae/sinuses, and pelvic sepsis/anastomotic leak following IPAA.

Factors associated with ileoanal pouch failure in patients developing early or late pouch-related fistula

BACKGROUND

The natural history of a pouch-related fistula in terms of timing of its development and its impact on pouch survival is poorly defined.

OBJECTIVE

This study aimed to evaluate factors associated with the time of onset of ileoanal pouch-related fistulas and predictors of pouch failure after the development of fistulas.

DESIGN

This study is an evaluation of prospectively collected data from a cohort of patients with pouch-related fistulas.

SETTING

Patients were identified from a prospective ileoanal pouch database, with data recorded from 1983 to 2009.

PARTICIPANTS

Patients who participated had developed a fistula after ileoanal pouch surgery. Patients were classified according to the time of onset, origin, and target of pouch fistulas into "early" and late" groups.

MAIN OUTCOME MEASURE

Ileoanal pouch failure was the main outcome measure.

RESULTS

Three hundred six patients (158 early-onset, 148 late-onset) with 373 pouch-related fistulas were identified. The early-onset group had a higher mean body mass index (P = .013) and more patients in this group developed a postoperative leak (P < .001), whereas diagnosis revision to Crohn's disease was more frequent in the late-onset group (P = .018). Overall, pouch failure occurred in 89 (29%) patients. Major abdominal procedures were more common in the early-onset group (18 vs 6%). There was no difference in pouch failure between the early- and late-onset groups (P = .24). On multivariate analysis, a current Crohn's diagnosis (P < .001), major fistula (P = .022), history of colectomy before ileoanal pouch (P = .005), handsewn anastomosis (P = .008), anastomotic leak (P = .012), and body mass index over 30 (P = .018) were independent risk factors for failure. No individual risk factor for failure was separately associated with either early or late fistula groups.

CONCLUSIONS

The timing and etiology of pouch fistula appear to be interrelated. There is a temporal association between procedure-related sepsis and early and delayed diagnosis of Crohn's disease and late fistula development. Cause of the fistula and associated factors rather than timing after IPAA is associated with long term pouch retention.

The Effect of Pelvic Septic Complications on Function and Quality of Life after Ileal Pouch-Anal Anastomosis: A Single Center Experience

Ileal pouch-anal anastomosis (IPAA) has become the procedure of choice for surgical treatment of intractable ulcerative colitis (UC). Surgical complications occurring in the short-term, like pelvic sepsis, are responsible for pouch dysfunction. We prospectively evaluated 118 patients with IPAA for UC operated on between 1987 and 2002. Follow-up intervals were at 3, 6, and 12 months in the first year, then every year for at least 5 years. Patients answered a questionnaire 1 and 5 years after ileostomy closure. One hundred and seventeen patients completed the early follow-up. Nine patients developed early pelvic sepsis (7.69%); six required pouch salvage procedure. In about 33.3 per cent of cases more than one procedure was necessary. Eighty-eight patients were available for 5-year functional evaluation. Patients developing early sepsis (n = 9) showed worse long-term functional results compared with the remaining study population (n = 79): stool frequency; night evacuation; perfect day/night continence; discrimination; antidiarrhoeals need; pad usage; and sexual restriction were significantly different ( P < 0.05). Quality of life and satisfaction after surgery were good in all patients. This observation did not correlate with function. Eighty-eight and 97 per cent would undergo IPAA again and would recommend it to others respectively, in septic group and controls. Functional outcome after IPAA may be influenced by early septic complications. Overall quality of life and satisfaction with surgery are comparable with those of controls.

Pouchitis and pouch dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require surgery. Although the surgical procedure offers a cure in some patients, postoperative inflammatory and noninflammatory complications are common. Pouchitis is the most common long-term complication of the procedure. Pouchitis represents a spectrum of disease processes with heterogeneous risk factors, clinical phenotypes, natural history, and prognosis. Accurate diagnosis and classification are important for proper treatment and prognosis.

Clinical outcomes of ileorectal anastomosis for ulcerative colitis

BACKGROUND

The aim of this study was to determine the fate of the rectum, functional results and quality of life after ileorectal anastomosis (IRA) in ulcerative colitis.

METHODS

Patients with ulcerative colitis and indeterminate colitis who underwent IRA from 1971 to 2006 were evaluated retrospectively. Twenty-two patients with an IRA were matched by age, sex and follow-up duration with 66 patients with an ileal pouch-anal anastomosis (IPAA) and compared for functional outcomes and quality of life.

RESULTS

Eighty-six patients with an IRA were included. Median follow-up was 9 (range 1-36) years. Rectal dysplasia and cancer rates were 17 and 8 per cent respectively. The rectum was resected in 46 patients (53 per cent) because of refractory proctitis in 24, rectal dysplasia in 15 and rectal cancer in seven. The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 per cent respectively. Patients with an IRA had fewer bowel movements (P = 0.020) and less night-time seepage (P = 0.020) but increased urgency (P < 0.001) compared with patients with an IPAA, whereas quality of life was similar.

CONCLUSION

In selected patients with ulcerative colitis IRA gives an acceptable quality of life and functional outcome that are comparable to those in patients with an IPAA. Owing to the risk of cancer, surveillance of the rectum is mandatory.

Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn's disease

INTRODUCTION

Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis.

METHODS

We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate.

RESULTS

Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8-4.9). Median follow-up was 1.7 years (interquartile range, 1.0-3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups.

CONCLUSION

Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

Sepsis is a major predictor of failure after ileal pouch-anal anastomosis

PURPOSE

This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications.

METHODS

Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications.

RESULTS

The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]).

CONCLUSION

Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.