One- or two-stage procedure for restorative proctocolectomy: rationale for a surgical strategy in ulcerative colitis

State of the Art: Pouch Surgery in the 21st Century

BACKGROUND

An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations.

OBJECTIVE

To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration.

RESULTS

The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications.

CONCLUSIONS

Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.

Surgery for ulcerative colitis

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

Restorative pouch surgery following proctocolectomy for inflammatory bowel disease: past experience and future direction

Major advancements in surgery for patients suffering proctocolitis from ulcerative colitis (UC) or selected patients with Crohn's disease (CD) have emerged in a relatively short time. Historically, patients underwent a proctocolectomy with end ileostomy, however, a restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was introduced in the late 1970s in the United Kingdom and gave patients the opportunity to avoid a permanent stoma. Initially designed as a hand-sewn "S" shaped pouch, with the invention of the linear stapler, a "J" shaped pouch was described in Japan, and subsequent advances in the United States largely contributed to the pelvic pouch's evolution to the standard of care in the management of patients with inflammatory bowel disease (IBD). The procedure was then divided into different stages depending on the medical condition of the patient and minimally invasive techniques (laparoscopic & robotic surgery) have continued to advance the success of the operation. Unfortunately, pouch complications occur, and seem to be occurring at an increasing frequency with the adoption of minimally invasive surgery. The field of reoperative pouch surgery has emerged to offer patients the opportunity to restore their quality of life (QOL) without the need for a permanent ostomy. Many patients with signs of pouch failure such as pouchitis, fistulae, pain and obstruction are diagnosed with Crohn's of the pouch, but many have mechanical complications that can be corrected with surgery, rather than offering pouch excision with a permanent ostomy (continent or traditional). Patients with Crohn's may be offered an IPAA but they will not have success if they, like patients with UC, have mechanical complications leading to their pouch failure. Patients who undergo reoperative pouch surgery do well with an acceptable QOL.

Staging Pouch Surgery in Ulcerative Colitis in the Biological Era

Restorative proctocolectomy, or ileal pouch anal anastomosis, is considered the standard treatment for intractable ulcerative colitis. When the pelvic pouch was first introduced in 1978, a two-stage procedure with proctocolectomy, construction of the pelvic pouch, and a diverting loop with subsequent closure were suggested. Over the decades that the pelvic pouch has been around, some principal technical issues have been addressed to improve the method. In more recent days the laparoscopic approach has been additionally introduced. During the same time-period the medical arsenal has developed far more with the increasing use of immune modulators and the introduction of biologicals. Staging of restorative proctocolectomy with a pelvic pouch refers to how many sessions, or stages, the procedure should be divided into. The main goal with restorative proctocolectomy is a safe operation with optimal short- and long-term function. In this paper we aim to review the present knowledge and views on staging of the pouch procedure in ulcerative colitis, especially with consideration to the treatment with biologicals.

Anastomotic Leak after Ileal Pouch-Anal Anastomosis

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

Determinants of Pouch-Related Symptoms, a Common Outcome of Patients With Adenomatous Polyposis Undergoing Ileoanal Pouch Surgery

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is performed in patients with adenomatous polyposis syndromes (APSs). Data regarding pouch outcomes in APS are scarce. The purposes of this study were to determine the prevalence of pouch-related symptoms in patients with APS and to identify the contributing factors.

Staged Approaches to Restorative Proctocolectomy with Ileoanal Pouch-When and Why?

Restorative proctocolectomy (RPC) with ileal pouch anal-anastomosis (IPAA) is commonly performed for patients with ulcerative colitis, familial adenomatous polyposis, and selected phenotypes of Crohn's disease (CD). Due to concerns about the effects of surgical complications on pouch functional outcomes, debate remains surrounding when and whether RPC with IPAA should be performed in a staged manner. Particularly debated are the timings of the IPAA, whether it is constructed at time of the proctocolectomy and whether to utilize temporary fecal diversion with a loop ileostomy. RPC with IPAA can be performed in one, two, or three stages, with each stage typically separated by 3-6 months. Proponents of a staged approach argue that poor pouch function, which is often a result of IPAA complications, including leak and infection, can be difficult to overcome and mandate additional, major surgeries, and that staging pouch creation and pairing with a protective ileostomy reduce those complications. However, subjecting patients to multiple surgeries and prolonging their time with an ileostomy present unique risks as well. Surgeons' experience and preference and patient characteristics need to be considered when determining operative planning. Highly selected patients with CD can be considered for RPC with IPAA, although with an acknowledgment of inherently higher pouch failure rates. Understanding the short- and long-term consequences of RPC with IPAA construction can help surgeons determine the appropriate approach.

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

INTRODUCTION

Children with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the "modified 2-stage" approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.

METHODS

This is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.

RESULTS

N = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.

CONCLUSION

Delaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.

The pouch behaving badly: management of morbidity after ileal pouch-anal anastomosis

AIM

Ileal pouch-anal anastomosis (IPAA), or a 'pouch', allows restoration of intestinal continuity after proctocolectomy for ulcerative colitis or familial adenomatous polyposis. Most patients have a good long-term outcome after IPAA, but in a significant proportion the functional outcome and quality of life are unsatisfactory. We term this outcome 'the pouch behaving badly'. Managing this, especially one is when unfamiliar with the possible underlying pathologies, is a challenge for both patient and clinician. We aim to outline the clinical approach to the pouch behaving badly, highlighting key aspects of investigation and management.

METHOD

This is a narrative review of the literature covering the investigation and management of postoperative complications and morbidity after IPAA.

RESULTS

Management of the pouch behaving badly requires a careful clinical assessment. The patient may present with multiple symptoms and a clear picture of the symptomatology and past history should be constructed before thorough examination and specialist investigation. We divide the pathology that underlies this clinical scenario into surgical, inflammatory, mechanical, functional and dysplastic causes and outline the investigation and management of each one.

CONCLUSION

The pouch behaving badly is a challenging problem for both patient and clinician. A detailed clinical assessment with careful specialist investigation is key to diagnosing the underlying pathology. We stress the importance of patient-centred care - the aim is to improve quality of life.

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

PURPOSE

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors for postoperative stoma outlet obstruction in ulcerative colitis

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Results of One-stage Restorative Proctocolectomy with J-pouch Anal Anastomosis in 300 Ulcerative Colitis Patients

Objectives:

Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA), with diverting ileostomy, are established ulcerative colitis (UC) treatments. The routine use of diverting ileostomy is controversial because of the risk of stoma closure and stoma related complications. In our institution, proctocolectomy and IPAA, with mucosectomy and handsewn anastomosis without diversion (one-stage IPAA), were performed for select patients with UC. The present study aimed to evaluate the clinical and functional outcomes of patients undergoing one-stage IPAA.

Methods:

Between April 1999 and July 2017, 300 patients underwent one-stage IPAA in our institution. The clinical notes and prognosis were reviewed retrospectively.

Results:

Postoperative complications (Clavien-Dindo classification grade ≥III) occurred in 18 patients (6.0%). The most common complication was anastomotic leakage (n = 9, 3%). There were 15 patients (5.0%) who required a defunctioning ileostomy. However, 13 patients successfully underwent ileostomy closure and achieved acceptable pouch function. Finally, two patients (0.6%) required pouch excision in this series. The cumulative pouch functional rate was 99.6% / 5 years and 99.2% / 10 years.

Conclusions:

One-stage IPAA is a good strategy for carefully selected patients with UC.

Up-to-date surgery for ulcerative colitis in the era of biologics

Introduction: In recent decades, biologics have resulted in significantly improved medical management of ulcerative colitis (UC). Rates of surgery for UC are declining. However, there is still a controversial question of the relation of biologics to postoperative adverse outcomes and the most appropriate timing for operative intervention.Areas covered: In this review, we explore the updated treatment algorithm of acute severe colitis, describe postoperative outcomes in patients exposed to biologics preoperatively, and discuss the primary indications for staging surgery in chronic refractory cases, largely with prolonged medical therapy.Expert opinion: Delaying pouch construction to when patients are in better health is suggested as a safer strategy over the long term. The surgical management of UC patients in the biologic era needs to be individualized, and a case-based multidisciplinary decision is critical for improved outcomes and a reduction of morbidity and mortality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Morbidity associated with closure of ileostomy after a three-stage ileal pouch-anal anastomosis

The aim of the study was to compare the perioperative outcomes of patients undergoing ileostomy closure after a three-stage ileal pouch-anal anastomosis to a control group of patients who had elective colorectal resections and stoma, and to analyse the differences based on the technique of closure. The cases were retrospectively compared for demographic characteristics and postoperative outcomes. Chi-square, Fisher's exact and Wilcoxon rank sum tests were used as appropriate. Between 2011 and 2016, 338 patients having their stoma reversed after three-stage IPAA were compared to 158 patients in the control group. A younger age (43.2 vs 60.6 years, p < 0.0001), a lower body mass index (22 vs 24.4 kg/m², p < 0.0001), a higher rate of hand-sewn anastomosis (84.3 vs 15.7%, p < 0.0001), a lower rate of intraoperative complications (0 vs 1.2%, p = 0.038), a shorter operative time (91.5 vs 99.4 min, p = 0.0046) and length of hospital stay (6.6 vs 7.6 days, p = 0.045) were seen in the IPAA group. The 30-day rate of wound infection, anastomotic leak (0.6 vs 0.6%), small bowel obstruction (SBO, 8 vs 11.4%) and reoperation (1.8 vs 1.3%) was similar. Among IPAA patients, the hand-sewn anastomosis was correlated with a higher chance of developing SBO (9.1 vs 1.9%, p = 0.03). Closure of ileostomy after three-stage IPAA is associated with low rate of serious complications, despite the higher number of previous abdominal surgeries. This supports the construction of routine ileostomy during IPAA to reduce the risk of pelvic sepsis.

The Role of Temporary Fecal Diversion

The use of temporary fecal diversion is of great importance to tenuous anastomosis, immunosuppressed patient, or actively infected patient. Its use protects newly constructed intestinal anastomoses from being the culprit of pelvic sepsis or systemic illness. Thus, potential morbidity and mortality can be averted. However, its appropriate or optimal use is often debated. We herein discuss the evidence for when to best use a diverting stoma for colorectal, coloanal, and ileoanal anastomoses. We also discuss the importance of considering a temporary diverting stoma in the setting of high-dose immunosuppression (e.g., transplant patients or inflammatory bowel disease), active infection, or upon creation of ileal pouch-anal anastomosis. Lastly, we discuss the advantages and disadvantages of a loop ileostomy versus colostomy for temporary diversion of fecal contents.

Complications and Morbidity associated with Loop Ileostomies in Patients with Ulcerative Colitis

Background and Aims:

Loop ileostomies are frequently used as diversion of the fecal stream to protect a distal anastomosis. The aim of this study was to identify complications and morbidity related to loop ileostomies in patients with ulcerative colitis at a nonemergent setting.

Material and Methods:

Consecutive patients with ulcerative colitis who received a loop ileostomy at a tertiary referral center in Sweden from January 2006 until December 2012 were included and studied retrospectively.

Results:

In total, 71 patients were identified, and the median age was 39 years. A majority (94%) of the patients underwent proctectomy or proctocolectomy with primary construction of an ileal pouch–anal anastomosis. In total, 38 patients (54%) had one or more postoperative complications at index surgery. Stoma-related complications were seen in 49% where parastomal skin irritation was most common. In total, 18% of the patients were re-admitted due to morbidity related to the ileostomy, and the leading cause was high volume output. Complications related to closure were seen in 29% of the patients, and of these, 30% required surgical intervention. In total, five patients (7%) developed a symptomatic leakage in the ileo-ileal anastomosis. There was no mortality.

Conclusion:

Loop ileostomies in this young patient cohort resulted in considerable morbidity. Closure of the ileostomy was also associated with complications. Although the diverting loop ileostomy is constructed to decrease the clinical consequences of an anastomotic leakage, the inherent morbidity should be considered. Preventive measures for parastomal skin problems could improve results.

Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis

BACKGROUND AND AIMS

There is a paucity of evidence in ulcerative colitis [UC] comparing the traditional two-stage [total proctocolectomy with ileal pouch-anal anastomosis [IPAA] and diverting ileostomy, followed by ileostomy closure] vs the modified two-stage restorative proctocolectomy [subtotal colectomy with end ileostomy, followed by completion proctectomy and IPAA, without diverting ileostomy]. This study examines the risk of anastomotic leak following IPAA in traditional vs modified two-stage IPAA for UC patients.

METHODS

This was a single-institution, retrospective study of all UC patients who underwent a traditional or modified two-stage IPAA between 2002 and 2013. The primary outcome was anastomotic leak following IPAA.

RESULTS

In all, 460 patients had a two-stage IPAA procedure; 223 [48.5%] patients underwent traditional two-stage IPAA and 237 [51.5%] patients received the modified two-stage procedure. There was more preoperative enteral corticosteroid use [44.7% vs 33.2%, p = 0.04] before the first surgery in the modified two-stage group compared with the traditional two-stage group. The modified two-stage group had higher UC disease severity at presentation [86.9% patients with moderate/severe UC vs 73.1%, p < 0.01]. However, the modified two-stage group had a lower rate of anastomotic leak following IPAA [4.6% vs 15.7%, p < 0.01] and was associated with a lower risk of anastomotic leak on univariate (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.13, 0.52] and multivariate analysis [OR 0.27, 95% CI 0.12, 0.57].

CONCLUSIONS

Patients with ulcerative colitis who received the modified two-stage IPAA had a significantly lower rate of anastomotic leak following pouch creation, compared with the traditional two-stage procedure.

Restorative Proctocolectomy for Ulcerative Colitis in 1985-2009

BACKGROUND AND AIMS

Restorative proctocolectomy is the most common operation in patients with ulcerative colitis. The aim was to evaluate long-term changes in our operative treatment and early and late complications related to restorative proctocolectomy.

MATERIAL AND METHODS

The study comprised 352 (149 females) patients over 18 years of age with ulcerative colitis who underwent restorative proctocolectomy in 1985-2009 median follow-up time of 5 years.

RESULTS

The indication for surgery was active chronic colitis in 168 (47.7%), acute colitis in 159 (45.2%), and cancer or dysplasia in 25 (7.1%) patients. Ileal pouch-anal anastomosis was performed using hand-sewn anastomosis with mucosectomy in 283 patients and stapled anastomosis in 69. A shift from hand-sewn to stapler ileal pouch-anal anastomosis took place in 2005. Covering ileostomy was carried out in 133 (37.8%) patients. There were 82 (23.3%) J-pouch-related complications. The operative mortality was 0.3%. There were significantly fewer leakages and early re-operations when covering ileostomy was used than when it was omitted: 6.0% versus 16.4% (p = 0.004), 4.5% versus 11.9% (p = 0.02), respectively. There were more strictures in hand-sewn than in stapled ileal pouch-anal anastomoses (17.6% vs. 0%, p = 0.001). Pouchitis occurred at least once in 134 (38.1%) patients.

CONCLUSION

The ileal pouch-anal anastomosis technique used in restorative proctocolectomy had changed over the past years from hand-sewn to stapled anastomosis. Covering ileostomy seemed to protect against major complications. Pouchitis was the most common late complication.

Review of our ileal pouch experience in the light of literature

OBJECTIVE

Retrospective proctocolectomy is a distinguished, sphincter saving treatment used for the treatment of ulcerative colitis and FAP disease. We aimed to evaluate ileal pouch interventions performed at our clinic and their results in the light of literature.

MATERIAL AND METHODS

Medical records of 35 restorative proctocolectomy and J pouch ileo-anal anastomosis surgeries performed at Necmettin Erbakan University, Meram School of Medicine between the years 2006-2013 were retrospectively examined. The patients were assessed according to their age, gender, length of hospital stay, diagnosis, follow-up duration and pouch-related complications. All patients were contacted by phone and they were scheduled for controls at the outpatient clinic.

RESULTS

Nineteen patients were male (54%) and 16 were female (46%). Their mean age was 45 years (21-74). The mean length of hospital stay was 11 (5-20) days. Twenty two (63%) patients were operated on due to FAP, 12 (34%) due to synchronous rectum cancer and colon tumor or polyp, and one (3%) due to ulcerative colitis. All patients received J pouch and protective ileostomy. After the closure of ileostomy, two cases were identified to have J pouch fistulas. The patients were followed up for 6 months to 7 years. They were contacted by phone and they were questioned about their active complaints, number of defecations, urinary and sexual dysfunctions. It was identified that they had 5 (3-8) defecations per day on average and that 4 (11%) cases had one nocturnal defecation. No pouchitis was identified in the follow-up endoscopic examinations.

CONCLUSION

Restorative proctocolectomy and ileo-anal anastomosis technique is a surgical procedure that can be performed with low rates of morbidity and mortality, including the elderly.

Characterizing readmission in ulcerative colitis patients undergoing restorative proctocolectomy

BACKGROUND

Postoperative readmissions increase costs and affect patient quality of life. Ulcerative colitis (UC) patients are at a high risk for hospital readmission following restorative proctocolectomy (RP).

OBJECTIVE

The objective of this study is to characterize UC patients undergoing RP and identify causes and risk factors for readmission.

DESIGN

A retrospective review of a prospectively maintained institutional database was performed. Postoperative readmission rates and reasons for readmission were examined following RP. Univariate and multivariate analyses were performed to evaluate for risk factors associated with readmission.

RESULTS

Of 533 patients who met our inclusion criteria, 18.2 % (n = 97) were readmitted within 30 days while 22.7 % (n = 121) were readmitted within 90 days of stage I of RP. Younger patient age (OR 1.825, 95 % CI 1.139-2.957), laparoscopic approach (OR 1.943, 95 % CI 1.217-3.104), and increased length of initial stay (OR 1.155, 95 % CI 1.090-1.225) were all associated with 30-day readmission. The most common reason for readmission was dehydration/ileus/partial bowel obstruction, with 10 % of patients readmitted for this reason within 30 days.

CONCLUSIONS

Patients undergoing restorative proctocolectomy are at high risk for readmission, particularly following the first stage of the operation. Novel treatment pathways to prevent ileus and dehydration as an outpatient may decrease the rates of readmission following RP.

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.

Outcomes and cost of diverted versus undiverted restorative proctocolectomy

BACKGROUND

Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy.

METHODS

This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected.

RESULTS

There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients.

CONCLUSION

Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.

Predictive value of the Pediatric Ulcerative Colitis Activity Index in the surgical management of ulcerative colitis

PURPOSE

The primary purpose of this study was to investigate the relationship between Pediatric Ulcerative Colitis Activity Index (PUCAI) and operative management. We also specifically evaluated those patients receiving tacrolimus for their disease.

METHODS

A retrospective review (1/06-1/11) identified ulcerative colitis patients (≤21 years old) undergoing restorative proctocolectomy with rectal mucosectomy and ileal pouch-anal anastomosis. Main outcomes included pre-operative PUCAI, combined versus staged procedure, and postoperative complications. Patients receiving tacrolimus within 3 months of surgical intervention were identified. PUCAI at tacrolimus induction and medication side effects were also noted.

RESULTS

Sixty patients were identified. Forty-two (70%) underwent combined and 18 (30%) had staged procedures. Pre-operative PUCAI was lower for combined versus staged patients (p = < 0.001). Furthermore, a higher pre-operative PUCAI strongly correlated with the likelihood of undergoing a staged procedure (p < 0.001). Forty-four patients (73%) received tacrolimus. Significant improvement in their PUCAI was noted from induction to pre-operative evaluation (p < 0.001). Minor and reversible side effects occurred in 46% of patients receiving tacrolimus, but complication rates were not significantly different.

CONCLUSIONS

There is a very strong correlation between the PUCAI and the likelihood of undergoing a staged procedure. A significant improvement in PUCAI occurs following preoperative tacrolimus therapy.

Surgical management of IBD--from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Ileal J-pouch construction

INTRODUCTION

Several configurations and techniques have been described to fashion an ileal pouch during the performance of a restorative proctectomy or proctocolectomy with ileo-anal anastomosis.

METHODS

In this article, we describe a simplified J-pouch construction technique which is designed to avoid unnecessary enterotomies, facilitate the subsequent ileo-anal anastomosis and reduce potential contamination to the pelvis.

[Current status of elective surgical treatment of ulcerative colitis. A systematic review]

Despite recent advances in the medical treatment of ulcerative colitis (UC), approximately 25-40% of patients will need surgery during their disease. The aim of elective surgical treatment of UC is to remove the colon/and rectum with minimal postoperative morbidity, and to offer a good long-term quality of life. There are several technical options for the surgical treatment of UC; at present, the most frequently offered is restorative proctocolectomy and ileal pouch-anal anastomosis. Both the surgeon and patient should be aware of the risks associated with a technically demanding procedure and possible postoperative complications, including the possibility of infertility, permanent stoma, or several surgical procedures for pouch-related complications. A precise knowledge of each surgical technique, and its indications, complications, long-term risks and benefits is useful to offer the best surgical option tailored to each patient. We searched in PubMed, MEDLINE, and EMBASE for all kinds of articles (all the publications until April 2012). Papers on Crohn's disease, indeterminate colitis, or other forms of colitis were excluded from the review. We reviewed the abstracts and identified potentially relevant articles. MeSH words were used as search, "ulcerative colitis", "surgery", "indications", "elective surgery", "colectomy," "proctocolectomy," "laparoscopy", "Complications," "outcome", "results" "quality of life". One hundred and four articles were included in this review.

Role of ileostomy in restorative proctocolectomy

Restorative proctocolectomy (RP) is the treatment of choice in patients affected with refractory ulcerative colitis or familial adenomatous polyposis. Surgery in elective settings is often performed in 2 stages, fashioning an ileostomy which is closed 2-3-mo later. It is still debated whether omitting ileostomy could offer advantages in the management of patients undergoing RP.

Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

OBJECTIVE

The objective of this study is to provide a comprehensive update of the outcome of the ileo-pouch anal anastomosis (IPAA).

DATA SOURCES

An extensive search in PubMed, EMBASE, and The Cochrane Library was conducted.

STUDY SELECTION AND DATA EXTRACTION

All studies published after 2000 reporting on complications or functional outcome after a primary open IPAA procedure for UC or FAP were selected. Study characteristics, functional outcome, and complications were extracted.

DATA SYNTHESIS

A review with similar methodology conducted 10 years earlier was used to evaluate developments in outcome over time. Pooled estimates were compared using a random-effects logistic meta-analyzing technique. Analyses focusing on the effect of time of study conductance, centralization, and variation in surgical techniques were performed.

RESULTS

Fifty-three studies including 14,966 patients were included. Pooled rates of pouch failure and pelvic sepsis were 4.3% (95% CI, 3.5-6.3) and 7.5% (95% CI 6.1-9.1), respectively. Compared to studies published before 2000, a reduction of 2.5% was observed in the pouch failure rate (p = 0.0038). Analysis on the effect of the time of study conductance confirmed a decline in pouch failure. Functional outcome remained stable over time, with a 24-h defecation frequency of 5.9 (95% CI, 5.0-6.9). Technical surgery aspects did not have an important effect on outcome.

CONCLUSION

This review provides up to date outcome estimates of the IPAA procedure that can be useful as reference values for practice and research. It is also shows a reduction in pouch failure over time.

Surgical management of ulcerative colitis: a comparison of Canadian and American colorectal surgeons

BACKGROUND

Ileal pouch anal anastomosis (IPAA) to surgically manage ulcerative colitis may involve multiple separate surgical procedures, impacting treatment costs, length of stay in hospital, complication rates and patient outcomes, and there is currently no accepted standard of care regarding the number of stages that should be performed. The purpose of this study was to compare the practice patterns of Canadian and American colorectal surgeons regarding the surgical management of ulcerative colitis.

METHODS

A questionnaire was mailed to all practisng fellows of the American Society of Colon and Rectal Surgeons (ASCRS) in Canada and the United States. Surgeons were asked to describe their typical practices for 3 clinical scenarios.

RESULTS

Questionnaires were mailed to 40 Canadian and 873 American ASCRS fellows with response rates of 86% and 62%, respectively. In the case of a patient who has had a prior colectomy, who is not taking steroids and in whom a tension-free IPAA is possible, 44% of Canadian surgeons would perform IPAA alone and 56% would perform IPAA with a loop ileostomy. In contrast, only 26% of American surgeons would perform IPAA alone and 74% would perform IPAA with a loop ileostomy (p = 0.002). In the case of a patient who has not had previous surgery, who is taking 10 mg/day of prednisone and in whom a tension-free IPAA is possible, the majority of both Canadian and American surgeons would perform an IPAA with a loop ileostomy (93% and 89%, respectively, p = 0.06). In the case of a patient who has not had previous surgery, who is taking 40 mg/day of prednisone and in whom a tension-free IPAA is possible, 45% of Canadian surgeons would perform a subtotal colectomy with an end ileostomy compared with 14% of American surgeons (p < 0.001).

CONCLUSION

There are significant differences in the surgical management of ulcerative colitis between Canadian and American colorectal surgeons.

Long-term followup with evaluation of the surgical and functional results of the ileal pouch reservoir in restorative proctocolectomy for ulcerative colitis

Aims. Evaluate the early and long term surgical and functional results of the ileal pouch-reservoir (IPAA) in patients with intractable ulcerative colitis. Material and Methods. Followup of 134 consecutive patients with W-or J-ileal pouch by diseases-specific and general health (SF-36) questionnaire. In the first 44 patients, early and late followup was performed. Results. Followup was performed 7.4 years (0.5-17 years) after construction of W (n = 9) and J (n = 125) ileal pouch, which had similar results. There were 14.9% early and 43.6% late complications with 12.7% early and 19.5% late reoperations. Protecting loop-ileostomy used in 54 patients (43.9%), did not protect against complications. Thirteen reservoirs (9.8%) were resected (n = 8) or deactivated (n = 5) due to functional failure. Operation time, postoperative complications and pouchitis were determinators for reservoir failure and reduced quality of life. The functional results at followup of 44 patients at 2.5 years (0.8-6.7 years) and 11.5 years (8.2-19.2 years) were remarkably similar. Conclusions. IPAA is a good option for most patients when medication fails. 10% experience failure with inferior quality of life. Protective stoma will not reduce failure rates. After an initial time period, reservoir function will not change over time.

Impact of defunctioning loop ileostomy on outcome after restorative proctocolectomy for ulcerative colitis

PURPOSE

This study analyzes the impact of a temporary loop ileostomy on postoperative outcome after restorative proctocolectomy for ulcerative colitis in terms of complications and reoperations including ileostomy closure.

METHODS

The records of 122 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis during a 12-year period were reviewed. In 89 patients, a defunctioning ileostomy was created, while 33 patients had no ileostomy. Statistics were done with Chi-square test and Mann-Whitney U test, p < 0.05 considered significant.

RESULTS

Both study groups were comparable concerning age, colitis activity, previous diseases, previous surgery, use of steroids, and immunosuppressives. Pouch-related septic complications (anastomotic dehiscence, pouch leakage, pelvic abscess) were significantly lower in the ileostomy group (5.6% vs. 18.2%, p = 0.031), resulting in a lower rate of emergency laparotomies following restorative proctocolectomy (4.5% vs. 30.3%, p < 0.001). Including all complications associated with scheduled closure of ileostomy, the cumulative frequency of emergency laparotomies was significantly lower in the ileostomy group (13.5% vs. 30.3%, p = 0.032). The cumulative duration of hospitalization, including all hospital stays for complications or closure of the ileostomy, was significantly longer in the ileostomy group [median 22 days (11-92) vs. 14 days (9-109), p < 0.001]. During long-term follow-up, a stricture at the pouch-anal anastomosis was more common in the ileostomy group (24.7% vs. 6.1%, p = 0.021), whereas only one stricture necessitated surgical therapy.

CONCLUSIONS

Creation of a defunctioning loop ileostomy reduces pouch-related septic complications and the frequency of emergency second laparotomies after restorative proctocolectomy for ulcerative colitis.

Ileal reservoir with ileo-anal anastomosis: long-term complications

Coloproctectomy with ileo-anal anastomosis (CP-IAA) has been in use for 30 years. This intervention is the standard technique when surgery is indicated for familial adenomatous polyposis (FAP) and for ulcerative colitis (UC). Although the surgery is safe with mortality of less than 1%, it is associated with a morbidity of 18-70%. We thought a literature review about long-term complications would be enlightening. Pouchitis is the most common complication; it occurs in 70% of patients over 20 years follow-up; small bowel obstruction affects 25% of patients and pelvic sepsis occurs in 20-30% within 10 years. CP-IAA can impact the patient's sexual life due to erectile and ejaculatory dysfunction, dyspareunia, and incontinence of stool during sexual intercourse. Nevertheless, patients with long-standing UC describe an overall improvement in their sexual function after surgery. The failure rate varies from 3.5 to 15%; major causes of failure are sepsis, unrecognized Crohn's disease, and poor functional results. Cases of dysplasia and cancer have been reported in the reservoir, but more particularly when there is retained colonic glandular mucosa. The transitional zone should be monitored whenever there are risk factors for colon neoplasia. The relatively high morbidity of CP-IAA should not overshadow the good functional results of this technique.

Current surgical management of ulcerative colitis

Inflammatory bowel disease is divided into 2 major disease entities: Crohn's disease and ulcerative colitis. Ulcerative colitis is characterized by contiguous inflammation of the colorectal mucosa, always beginning in and involving the rectum and progressing for variable distances proximally within the colon. In ulcerative colitis, medical therapy, which is not curative, is directed at controlling symptoms and reducing the underlying inflammatory process. However, emergent or elective removal of the colon and rectum does cure the disease and also eliminates the possibility of developing a malignancy. Here we present the current surgical treatment of ulcerative colitis and issues in the management of ulcerative colitis. We discuss indications for surgical treatment, elective and emergent operative management, early and late complications of surgery, and functional results.

Restorative proctocolectomy and ileal pouch-anal anastomosis in children

PURPOSE

This study was designed to evaluate the results of restorative proctocolectomy with distal rectal mucosectomy and ileal pouch-anal anastomosis in children.

METHODS

This study is a retrospective review of 100 consecutively referred children (<18 years old) who underwent reconstruction with a J-pouch of ileum and preservation of the transitional anorectal epithelium by the same two-surgeon team. Temporary diverting ileostomy was used. The main outcome measures were daytime and nocturnal fecal continence, bowel movements per day, and complications including pouchitis, ileoanal stricture, or postoperative small-bowel obstruction.

RESULTS

Average age of the 100 children (48 males/52 females) was 13.2 years (range, 2.95-17.99). All 25 children with familial adenomatous polyposis had proctocolectomy and reconstruction performed simultaneously. Of 75 children with ulcerative colitis, 50 (67%) had their colectomy followed by reconstruction after an interval ranging from 2 months to 4.4 years. Median postoperative follow-up was 2.6 years. Daytime fecal continence was achieved in 98 children, although 4 reported rare accidents. Nighttime continence was achieved in 93 children, of whom 14 reported rare accidents. The average frequency of bowel movements was 5.43/day (+/-2.22). Only one child with polyposis had pouchitis. Of 75 children with ulcerative colitis, 35 had symptoms consistent with pouchitis; of these 35 children, 10 required prolonged treatment. The most frequent postoperative complication was ileoanal stricture requiring operative dilatation and/or anoplasty (18 children). Bowel obstruction requiring surgery occurred in 18 children. One child eventually required pouchectomy for probable Crohn's disease.

CONCLUSIONS

Excellent results can be achieved with restorative proctocolectomy in children with respect to fecal continence and stool frequency. However, with ulcerative colitis, a substantial risk of pouchitis remains.

Clinical guidelines for the management of pouchitis

When surgery is necessary in patients with ulcerative colitis, total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice. Several inflammatory and noninflammatory complications can occur after IPAA. Pouchitis is the most common, occurring in approximately 50% of patients. Whereas "acute" pouchitis can be treated rapidly and successfully in the majority of patients, "refractory" and "chronic pouchitis" remain therapeutic challenges to patients and physicians. This article reviews the literature and offers consensus guidelines on issues related to the epidemiology, diagnosis, pathogenesis, risk factors, and treatment of pouchitis.

Laparoscopic versus open proctocolectomy with ileal pouch‐anal anastomosis

In recent years laparoscopic proctocolectomy with ileal pouch-anal anastomosis has been used as an alternative to conventional open techniques. Since many published series on proctectomy and ileal pouch-anal anastomosis are based on open experience, in this paper we compare our laparoscopic experience on 21 patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) to 25 patients who had undergone open proctocolectomy with ileal pouch-anal anastomosis. The median operative time in the laparoscopic group was significantly longer than that in the open group (325 min vs. 220 min). However, blood loss was less (115 ml vs.240 ml), bowel function returned earlier (2 days vs.4 days), and hospitalization time was shorter (9 days vs.11 days) in the laparoscopic group (all p<0.05). Early postoperative complications were encountered in five patients of the laparoscopic group and in seven patients of the open group. The median follow-up time was 15 months (range 6-34) in both groups. Late postoperative complications were encountered in three patients of the laparoscopic group and in three patients of the open group. In conclusion, laparoscopic proctocolectomy with ileal pouch-anal anastomosis is technically feasible. The technique described in this study provides the advantages of less blood loss, shorter hospitalization, quicker return of bowel function and more favorable cosmetic results when compared to the open technique.

Proximal diversion at the time of ileal pouch-anal anastomosis for ulcerative colitis: current practices of North American colorectal surgeons

PURPOSE

Pelvic sepsis is a serious complication after ileal pouch-anal anastomosis for ulcerative colitis that may lead to pouch failure or poor function. Although a temporary loop ileostomy may be created at the time of ileal pouch-anal anastomosis to prevent or minimize the consequences of an anastomotic leak, research has suggested that an ileostomy can be safely omitted in selected patients. The purpose of this study was to examine the use of proximal diversion by colorectal surgeons at the time of ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

A questionnaire was mailed to all practicing fellows of The American Society of Colon and Rectal Surgeons in North America. Surgeons were asked to describe their typical practice for a number of clinical scenarios.

RESULTS

Questionnaires were mailed to 913 American Society of Colon and Rectal Surgeons fellows, and 63 percent responded. For a patient who has had a prior colectomy and is not taking steroids, 27 percent of surgeons would perform ileal pouch-anal anastomosis alone, and 73 percent would perform ileal pouch-anal anastomosis with a loop ileostomy. For a patient who has not had previous surgery and is taking prednisone 40 mg/day, 16 percent of surgeons would perform a subtotal colectomy with an end ileostomy, 82 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis with a loop ileostomy, and 2 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis without an ileostomy. There was no relationship between practice setting, annual ileal pouch-anal anastomosis volume, or years in practice and surgeon response for either scenario.

CONCLUSIONS

The majority of surgeons create a temporary loop ileostomy at the time of ileal pouch-anal anastomosis for ulcerative colitis.

Evaluation of one-stage laparoscopic-assisted restorative proctocolectomy at a specialty center: comparison with the open approach

PURPOSE

This study compared outcomes after laparoscopically assisted and open restorative proctocolectomy performed as a one-stage procedure, including anorectal mucosectomy and omission of ileal diversion.

METHODS

We reviewed our prospectively maintained database of patients who underwent restorative proctocolectomy between 1998 and 2006. Demographic data, surgical indications, and intraoperative and postoperative complications were evaluated. Anastomotic leaks were identified by radiologic, endoscopic, or intraoperative evidence. The primary outcome variables were complications, duration of operation, blood loss, intraoperative spillage of enteric contents, and the ability to complete the procedure in one stage.

RESULTS

One-stage laparoscopically assisted restorative proctocolectomy was performed in 50 patients and open restorative proctocolectomy was performed in 155 patients. The mean operative time was longer for the laparoscopically assisted group (198.7 vs. 159.1 minutes; P = 0.006). The mean estimated blood loss was less among the patients in the laparoscopically assisted group (287.5 vs. 386.4 ml; P = 0.006). There were no significant differences in intraoperative or postoperative complications between the two groups.

CONCLUSIONS

Laparoscopically assisted one stage restorative proctocolectomy is a safe and technically feasible procedure. There seems to be no increase in the rate of postoperative complications compared with the open approach. Laparoscopically assisted restorative proctocolectomy should be considered in the surgical management of patients who require this procedure.

Functional outcome after restorative proctocolectomy in pigs: comparing a novel transverse ileal pouch to the J-pouch and straight ileoanal anastomosis

BACKGROUND

Restorative proctocolectomy followed by an ileoanal J-pouch procedure is the therapy of choice for patients with familial adenomatous polyposis and ulcerative colitis. After low anterior rectal resection, the authors have reported on a novel, less complex pouch configuration, a transverse coloplasty pouch. The aim of the present work was to apply this new design to the ileal pouch construction, to evaluate feasibility, and to measure functional results in comparison with the J-pouch and the straight ileoanal anastomosis using the pig as an animal model.

METHODS

Twenty-three pigs underwent restorative proctocolectomy followed by reconstruction with straight ileoanal anastomosis (IAA; n = 5), J-pouch (n = 7), and a transverse ileal pouch (TIP; n = 11). Pigs were followed for 6 days postoperatively. Peristaltic function was assessed by manometry proximal to the pouch, in the reservoir, and at the level of the ileoanal anastomosis. Functional outcome was monitored by semiquantitative assessment of the general condition of the animals, postoperative feeding habits, and stool frequency and consistency. A Fourier analysis was performed in order to compare peristalsis in the ileal reservoirs. The reservoir volume was measured in situ by triple contrast computed tomography scan with 3D reconstruction.

RESULTS

Seventeen animals survived for 1 week. There was no difference in the general condition or the feeding habits of the groups. A significant number of pigs with the TIP pouch (7/10) had semisolid or formed stools as opposed to liquid stools after J-pouch (6/6) and IAA (4/5; p = 0.01). TIP animals had a lower stool frequency (3.2 +/- 1.14 per day) on day 6 after the operation than pigs with J-pouch, 5.33 +/- 1,03, and IAA, 4.6 +/- 1.82 (p = 0.0036). The in situ volume of the pouches did not differ significantly. The Fourier analysis demonstrated a disruption of peristalsis by the J-pouch and the TIP reconstruction but not after IAA.

CONCLUSION

The function of ileoanal reservoirs after proctocolectomy may result from the disruption of properistaltic waves after pouch formation. The mechanism of peristalsis disruption is independent of the in situ volume of the pouch.

Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy?

BACKGROUND AND AIMS

The technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum.

PATIENTS AND METHODS

One hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14-169) months after surgery.

RESULTS

Only one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature.

CONCLUSION

The low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.

Parking the pouch: pouch salvage after anastomotic leak following restorative proctocolectomy. Report of a case

Anastomotic leak is a feared complication after restorative proctocolectomy with formation of an ileal pouch. We describe the use of a technique that is appropriate for profound anastomotic failure in the immediate postoperative period, which will aid in controlling sepsis and may allow salvage of the pouch. A 59-year-old man who failed medical treatment underwent restorative proctocolectomy and ileal pouch-anal anastomosis as a single-stage procedure. The patient developed an anastomotic leak that was not controlled by defunctioning stoma formation. Further surgery was undertaken and the pouch was exteriorized as a mucous fistula. A redo pouch-anal anastomosis was performed 12 months after the original procedure. The patient has good functional outcome with complete continence. Anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis often can be managed by conservative or local procedures. Laparotomy may be required rarely, but this subgroup is associated with pouch failure in up to half of the patients. Awareness that the ileal pouch-anal anastomosis can be taken down and the pouch temporarily parked in the abdominal cavity may persuade surgeons to retain a pouch with the knowledge that the acute pelvic sepsis after an anastomotic leak can be safely treated.