1
|
MacDonald S, Au S, Thornton M, Macdonald A. Complications and functional outcomes after ileo-anal pouch excision-a systematic review of 14 retrospective observational studies. Int J Colorectal Dis 2021; 36:677-687. [PMID: 33471205 DOI: 10.1007/s00384-021-03838-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The ileo-anal pouch (IAP) has been the gold standard procedure for maintenance of bowel continuity after panproctocolectomy for ulcerative colitis, familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. However, the IAP has an estimated failure rate of 13% at 10 years post-procedure (Tulchinsky et al., Ann Surg 238(2):229-34, 2003), which can result in pouch excision (P.E.). This systematic review aims to synthesise all the available studies reporting post-operative outcomes of P.E. and its impact on patient quality of life (QoL), when available, which have not previously been summarised. METHODS PubMed, Embase, Medline and the Cochrane library databases were searched with terms 'Pouch AND excision' OR 'Pouch AND removal' OR 'Pouch AND remove' OR 'IAP AND excision'. All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. were included. Studies with < 5 patients, non-English studies and conference abstracts were excluded. RESULTS 14 studies comprising 1601 patients were included. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9-40%) or surgical site infection (wound-2 to 30%; intra-abdominal collection-3 to 24%). The mortality rate was between 0.58 and 1.4%. QoL is generally lower in P.E. patients compared to the normal population across various QoL measures and P.E. patients often had urinary and sexual dysfunction post-operatively. CONCLUSIONS There is a substantial incidence of complications after P.E.; however, there is no evidence describing QoL pre- and post-P.E. Further longitudinal research comparing QoL in patients undergoing P.E. and other treatment options such as indefinite diversion is required to definitively assess QoL post-procedure.
Collapse
Affiliation(s)
- S MacDonald
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK.
| | - S Au
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK
| | - M Thornton
- Department of Surgery, Wishaw General Hospital, 50 Netherton St., Wishaw, Scotland, ML2 0DP, UK
| | - A Macdonald
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK
| |
Collapse
|
2
|
Ng KS, Gonsalves SJ, Sagar PM. Ileal-anal pouches: A review of its history, indications, and complications. World J Gastroenterol 2019; 25:4320-4342. [PMID: 31496616 PMCID: PMC6710180 DOI: 10.3748/wjg.v25.i31.4320] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/12/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.
Collapse
Affiliation(s)
- Kheng-Seong Ng
- John Goligher Colorectal Unit, St. James’s University Hospital, Leeds LS9 7TF, United Kingdom
- Institute of Academic Surgery, University of Sydney, Camperdown, New South Wales 2050, Australia
| | - Simon Joseph Gonsalves
- Department of Colorectal Surgery, Huddersfield Royal Infirmary, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HD3 3EA, United Kingdom
| | - Peter Michael Sagar
- John Goligher Colorectal Unit, St. James’s University Hospital, Leeds LS9 7TF, United Kingdom
| |
Collapse
|
3
|
|
4
|
Abstract
This article describes a novel qualitative study exploring the lived experience of participants having undergone ileoanal pouch failure, on a background of ulcerative colitis (UC). It focuses on the impact of living with indefinite diversion of the pouch and a permanent end ileostomy. Six participants were interviewed with an aim to establish their experience of pouch failure and the support they required. Five pertinent themes emerged that suggested participants did not expect pouch failure and were unprepared for the regression towards UC. Some participants recommenced drug therapy, wore pads to manage leakage from the diverted pouch, avoided certain social settings or manipulated diet and lifestyle in order to gain an acceptable quality of life with a permanent ileostomy. Pouch failure potentially presents adverse effects on patients' quality of life, but currently there is a deficit in support and resources available in order to provide acceptable outcomes for patients experiencing pouch failure.
Collapse
|
5
|
Abstract
The ability to appropriately construct and care for an ostomy is crucial to good colorectal surgical practice. Enterostomal therapy is critical to the successful management of ostomies and their complications. Although associated with morbidity, a well-constructed ostomy can provide our patients with a good, durable QoL.
Collapse
|
6
|
Abstract
BACKGROUND The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized. OBJECTIVE This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure. DESIGN This study is a retrospective review of prospectively gathered data. SETTINGS This investigation was conducted at a tertiary center. PATIENTS Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study. MAIN OUTCOME MEASURES The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires. RESULTS One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer. LIMITATIONS This study was limited by its retrospective nature. CONCLUSIONS Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.
Collapse
|
7
|
Umanskiy K, Fichera A. Health related quality of life in inflammatory bowel disease: The impact of surgical therapy. World J Gastroenterol 2010; 16:5024-34. [PMID: 20976838 PMCID: PMC2965278 DOI: 10.3748/wjg.v16.i40.5024] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Over the past 30 years, health related quality of life (HRQOL) has developed into a scientific index of subjective health status. Measurement of HRQOL is now clearly a mandatory component in evaluating interventions and management of medical and surgical diseases. In designing comprehensive and meaningful clinical studies particular attention ought to be made of measures of HRQOL. This is clearly very important in inflammatory bowel disease. Both ulcerative colitis (UC) and Crohn’s disease (CD) have a major impact on HRQOL. The chronic and unrelenting nature of these diseases, the often early age of onset, and the impact on social and sexual aspects of life significantly change patient’s perception, body image and quality of life. This manuscript is an overview of the available published data on HRQOL in UC and CD patients focusing on the impact of surgical therapy. While these two diseases may have some similarities in their management, clearly their impact on quality of life and the effects of are significantly different. Hence we are presenting the data separately.
Collapse
|
8
|
Das P, Smith JJ, Tekkis PP, Heriot AG, Antropoli M, John Nicholls R. Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients. Colorectal Dis 2007; 9:718-24. [PMID: 17764535 DOI: 10.1111/j.1463-1318.2007.01216.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Pouch failure occurs in up to 10% of patients over a 10-year period for a variety of reasons. One surgical option is pouch excision (PE) and form a permanent ileostomy. This is a major procedure with potential serious complications. An alternative is indefinite diversion (ID) of the pouch without excision. The aim of this study was to examine the quality of life and functional outcome in these two groups of patients. METHOD Ninety-seven patients were identified from the database to have either PE or ID. Fifty-three patients (17 men) responded; comprising 31 patients after PE and 22 patients with ID in a case-control study and completed the SF-36 general health survey and the Cleveland Clinic Foundation (CCF) functional outcomes questionnaire. RESULTS There was no significant difference in the domains of SF-36 between the two groups (P > 0.18). All patients with PE had an end ileostomy whereas most patients with ID had a loop ileostomy (18 loop vs 4 end). There was no difference in stoma related complications except for stoma retraction in ID (7%vs 47%; P = 0.003). There was no significant difference in urinary symptoms between PE and ID groups (weak stream 26%vs 14%; P = 0.49, nocturia 22%vs 4%; P = 0.12, urgency 22%vs 9%; P = 0.28, urinary incontinence 22%vs 14%; P = 0.72 respectively). There was no difference in sexually active patients (73%vs 94%; P = 0.11). Of the seven male PE patients, five (71%) could achieve an erection and four (57%) could maintain an erection, compared with all 10 male patients in the ID group (P = 0.151 and 0.05 respectively). Thirty-three per cent of patients with PE and 62% of patients with ID reported that they would have pouch surgery again if indicated (P = 0.052) and 58% of patients with PE and 81% of patients with ID reported that they would recommend pouch surgery to others (P = 0.129). No case of dysplasia was seen in 18 of 22 ID patients in whom histology was available. CONCLUSION Quality of life after PE or ID was no different and male sexual function was significantly better after ID. Retraction of the stoma was more common in this group.
Collapse
Affiliation(s)
- P Das
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK
| | | | | | | | | | | |
Collapse
|
9
|
Berndtsson I, Lindholm E, Oresland T, Börjesson L. Long-term outcome after ileal pouch-anal anastomosis: function and health-related quality of life. Dis Colon Rectum 2007; 50:1545-52. [PMID: 17762968 DOI: 10.1007/s10350-007-0278-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to investigate long-term pouch function and health-related quality of life in a single, large cohort of patients with ileal pouch-anal anastomosis for ulcerative colitis. METHODS Data from 370 patients were included in the study. Thirty-nine patients (11 percent) did not have a functioning pouch (failures) but were included in the health-related quality of life analyses. Pouch function (Oresland score) and health-related quality of life (Short Form-36) were evaluated by postal questionnaires. A total of 88 percent of the patients with a functioning ileal pouch-anal anastomosis returned the questionnaires vs. 76 percent of the failures. Median follow-up time after ileal pouch-anal anastomosis was 15 years vs. 11 years after failure. An age-matched and gender-matched reference sample (n = 286) was randomly drawn from the Swedish Short Form-36 database. RESULTS Median bowel frequency was six per 24 hours: 76 percent emptied the reservoir at night, 23 percent had urgency, 12 percent had evacuation difficulties, and 17 percent experienced soiling during the day. Fifty-two percent of the males and 32 percent of the females suffered from soiling at night. More than one-half of the patients had occasional perianal soreness, 6 percent considered the pouch to be a social handicap, and 94 percent were satisfied with their pouch. Patients with a functioning ileal pouch-anal anastomosis did not differ from the reference sample on any Short Form-36 domain, except for a reduced score in General Health (P = 0.02). Pouch function was positively correlated to health-related quality of life. Patients with pouch failure had reduced health-related quality of life in most domains. CONCLUSIONS Patients' satisfaction is high and functional outcome is good after ileal pouch-anal anastomosis. Poor pouch function affects health-related quality of life negatively. Patients with failure after ileal pouch-anal anastomosis are substantially limited in a variety of health-related quality of life domains.
Collapse
Affiliation(s)
- Ina Berndtsson
- The Colorectal Unit, Sahlgrenska University Hospital/Ostra, S-416 85, Göteborg, Sweden.
| | | | | | | |
Collapse
|
10
|
Abstract
OBJECTIVE Failure after ileal pouch-anal anastomosis (IPAA) is reported with a frequency of 10-20%. The failed IPAA can be excised or defunctioned. Indications for excision and further management of an indefinitely diverted pouch are poorly described. The aim of the present investigation was to investigate pouch-related problems and the histopathological pattern of the pouch mucosa in this group of patients. METHOD In a cohort of 620 patients having IPAA with a median follow-up of 14 years, 56 patients with failure were identified. The patients with defunctioned pouches were assessed with regard to pouch-related problems and endoscopy with biopsies was performed. Biopsies were stained with haematoxylin-eosin, PAS for neutral mucins and Alcian blue/high iron diamine for sialomucins/sulphomucins. Morphological changes were grouped into three types modified according to Veress and assessed for dysplasia. RESULTS Twenty-two patients with an indefinitely diverted pouch were found. The follow-up time after surgery for failure was 10 years. Thirteen patients completed the follow-up. Except for two patients with pelvic/perineal pain, there were no clinical problems. The majority of patients displayed mild to moderate macroscopic signs of inflammation. Morphologically, findings ranged from a preserved mucosal pattern to intense inflammatory reaction. No case of dysplasia or carcinoma was found. CONCLUSION Most patients with an indefinitely diverted pouch had no complaints regarding the pouch. There was no case of dysplasia. Indefinite diversion may be preferable to pouch excision, especially given the associated morbidity.
Collapse
Affiliation(s)
- J Bengtsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | | | | | | | | |
Collapse
|
11
|
Berndtsson IEK, Lindholm E, Oresland T, Hultén L. Health-related quality of life and pouch function in continent ileostomy patients: a 30-year perspective. Dis Colon Rectum 2004; 47:2131-7. [PMID: 15657665 DOI: 10.1007/s10350-004-0719-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The principal aim of this study was to assess long-term pouch durability and health-related quality of life in an original series of patients operated on with a continent ileostomy. PATIENTS Data from 68 of 88 patients who had a continent ileostomy performed at Sahlgrenska University Hospital between 1967 and 1974 were analyzed. Median age at follow-up was 60 (range, 40-89) years and median follow-up was 31 (range, 29-36) years. METHODS Patients were sent a questionnaire on pouch function along with the Short Form-36 Health Survey 2.0. A random age-matched and gender-matched sample was drawn from the Swedish national Short Form-36 Health Survey norm database to compare with the patient group. RESULTS The majority of the patients reported good physical condition and satisfactory pouch function. Patients evacuated the pouch a median of four times every 24 hours. Twelve patients (18 percent) had leakages. Forty-four patients (65 percent) had had at least one postoperative revision to restore continence. Generally minor peristomal skin irritation occurred in seven patients (10 percent). Patients with concurrent complaints (mostly age related) reported poorer health-related quality of life. Nevertheless, 78 percent of the patients rated their overall health as good, very good, or excellent. The patients' Short Form-36 Health Survey scores were comparable to reference values. CONCLUSIONS Although revisional operations may be needed to restore continence, continent ileostomy has a good durability. Pouch function was satisfactory and patients' satisfaction was high. Health-related quality of life levels were similar to those of the general population.
Collapse
|
12
|
Lepistö A, Luukkonen P, Järvinen HJ. Cumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure. Dis Colon Rectum 2002; 45:1289-94. [PMID: 12394424 DOI: 10.1007/s10350-004-6412-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of the study was to calculate the cumulative occurrence of pouch failure among 486 patients who had undergone proctocolectomy and ileoanal anastomosis for ulcerative colitis or familial adenomatous polyposis. The other goal was to compare the quality of life in the failure group of 21 patients, the successful group, and the healthy population. METHODS Data were collected from patient histories, with the probability of pouch failure being calculated by the Kaplan-Meier method. Patients with pouch failure and controls were sent a Short-Form 36-item quality-of-life questionnaire, and data were analyzed with paired -test. RESULTS The overall failure rate was 5.3 percent (26), including 24 pouch excisions and 2 early deaths (0.4 percent). Cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively. Neither pouchitis, gender, nor diagnosis correlated with pouch failure, but fistula formation ( p< 0.001) did. Patients with failure had lower quality-of-life scores for physical function (p < 0.02), social function ( p< 0.04), energy ( p< 0.02), and physical role function ( < 0.03) than the healthy population. Scores for physical function ( p< 0.01), energy ( p< 0.01), and physical role function ( p< 0.05) were also lower than those of control patients. CONCLUSIONS The most common cause of pouch failure is fistula, whereas pouch excision is rarely caused by pouchitis. The impaired quality of life of patients in the failure group was caused by impairment of physical function and restrictions in social life.
Collapse
Affiliation(s)
- Anna Lepistö
- Helsinki University Central Hospital, Department of Surgery, Helsinki, Finland
| | | | | |
Collapse
|
13
|
Sánchez-Santos R, de Oca J, Parés D, Martí-Ragué J, Biondo S, Osorio A, del Río C, Jaurrieta E. Morbilidad y resultados funcionales a largo plazo de los reservorios ileoanales. Cir Esp 2002. [DOI: 10.1016/s0009-739x(02)72026-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
14
|
Abstract
Although laparotomy with resection remains the treatment of choice for most patients who require surgery for intestinal Crohn's disease, mounting evidence supports the safety and efficacy of less traditional approaches and procedures (ie, laparoscopy, stricture-plasty). In contrast to the approach to intestinal disease, many centers are advocating a more aggressive operative approach to perianal Crohn's disease. Over the past few years, restorative proctocolectomy with ileal pouch-anal anastomosis has emerged as the operation of choice for most patients requiring surgery for ulcerative colitis. As experience with the operation grows, patient selection, technical features, and management of postoperative complications are being more clearly defined and optimized.
Collapse
Affiliation(s)
- S A Strong
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | |
Collapse
|