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Adamina M, Minozzi S, Warusavitarne J, Buskens C, Chaparro M, Verstockt B, Kopylov U, Agrawal M, Allocca M, Atreya R, Battat R, Bettenworth D, Bislenghi G, Brown SR, Burisch J, Casanova MJ, Czuber-Dochan W, de Groof J, El-Hussuna A, Ellul P, Fidalgo C, Fiorino G, Gisbert J, Sabino JG, Hanzel J, Holubar S, Iacucci M, Iqbal N, Kapizioni C, Karmiris K, Kobayashi T, Kotze PG, Luglio G, Maaser C, Moran G, Noor N, Papamichael K, Peros G, Reenaers C, Sica G, Sigall-Boneh R, Vavricka SR, Yanai H, Raine T, Gordon H, Myrelid P. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2024:jjae089. [PMID: 38878002 DOI: 10.1093/ecco-jcc/jjae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Indexed: 07/28/2024]
Abstract
This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital of Fribourg & Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Visceral and Thoracic Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Christianne Buskens
- Department of Surgery, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Maria Chaparro
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid; Spain
| | - Bram Verstockt
- Department Gastroenterology & Hepatology, University Hospitals Leuven, KU Leuven and Dpt. Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Manasi Agrawal
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva; Faculty of Medicine, Tel Aviv University, Tel Aviv; Israel
| | - Mariangela Allocca
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Raja Atreya
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert Battat
- Department of Surgery, Università Tor Vergata, Roma, Italy
| | | | - Gabriele Bislenghi
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Steven Ross Brown
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Johan Burisch
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - María José Casanova
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham
- Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham. NG7 2UH. United Kingdom
| | | | - Joline de Groof
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Alaa El-Hussuna
- Health Sciences Postgraduate Program, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Pierre Ellul
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Catarina Fidalgo
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - Gionata Fiorino
- Department of Gastroenterology, Attikon University Hospital, Athens, Greece
| | - Javier Gisbert
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - João Guedelha Sabino
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Jurij Hanzel
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana; Chair of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marietta Iacucci
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Nusrat Iqbal
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Konstantinos Karmiris
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal
| | | | | | - Gaetano Luglio
- Colorectal Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Christian Maaser
- Florence Nightingale Faculty of Nursing- Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Gordon Moran
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid. Spain
| | - Nurulamin Noor
- Gastrounit, Medical Division, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | | | - Georgios Peros
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
| | - Catherine Reenaers
- CED Schwerpunktpraxis, Münster and Medical Faculty of the University of Münster, Münster, NRW, Germany
| | - Giuseppe Sica
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Rotem Sigall-Boneh
- First Department of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan R Vavricka
- IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Gastroenterology and Endoscopy, Milan, Italy
| | - Henit Yanai
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Hannah Gordon
- Translational Gastroenterology and Liver Unit, University of Oxford, Oxford, UK
| | - Pär Myrelid
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Giddings HL, Yang PF, Steffens D, Solomon MJ, Ng KS. Influence of hospital-level and surgeon factors on the outcomes after ileo-anal pouch surgery for inflammatory bowel disease: systematic review. Br J Surg 2024; 111:znae088. [PMID: 38740552 DOI: 10.1093/bjs/znae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/19/2024] [Accepted: 03/05/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease. METHODS A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851). RESULTS A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience. CONCLUSION This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Phillip F Yang
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Alves Martins BA, Shamsiddinova A, Alquaimi MM, Worley G, Tozer P, Sahnan K, Perry-Woodford Z, Hart A, Arebi N, Matharoo M, Warusavitarne J, Faiz O. Creation of an institutional preoperative checklist to support clinical risk assessment in patients with ulcerative colitis (UC) considering ileoanal pouch surgery. Frontline Gastroenterol 2024; 15:203-213. [PMID: 38665796 PMCID: PMC11042438 DOI: 10.1136/flgastro-2023-102503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/26/2023] [Indexed: 04/28/2024] Open
Abstract
Background Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most established restorative operative approach for patients with ulcerative colitis. It has associated morbidity and the potential for major repercussions on quality of life. As such, patient selection is crucial to its success. The main aim of this paper is to present an institutional preoperative checklist to support clinical risk assessment and patient selection in those considering IPAA. Methods A literature review was performed to identify the risk factors associated with surgical complications, decreased functional outcomes/quality of life, and pouch failure after IPAA. Based on this, a preliminary checklist was devised and modified through an iterative process. This was then evaluated by a consensus group comprising the pouch multidisciplinary team (MDT) core members. Results The final preoperative checklist includes assessment for risk factors such as gender, advanced age, obesity, comorbidities, sphincteric impairment, Crohn's disease and pelvic radiation therapy. In addition, essential steps in the decision-making process, such as pouch nurse counselling and discussion regarding surgical alternatives, are also included. The last step of the checklist is discussion at a dedicated pouch-MDT. Discussion A preoperative checklist may support clinicians with the selection of patients that are suitable for pouch surgery. It also serves as a useful tool to inform the discussion of cases at the MDT meeting.
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Affiliation(s)
- Bruno Augusto Alves Martins
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasilia, Brazil
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
| | - Amira Shamsiddinova
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Manal Mubarak Alquaimi
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of General Surgery, King Faisal University, Al-Hasa, Saudi Arabia
| | - Guy Worley
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
| | - Phil Tozer
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kapil Sahnan
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Zarah Perry-Woodford
- Pouch and Stoma Care, St Mark's the National Bowel Hospital and Academic Institute, London, UK
| | - Ailsa Hart
- IBD Unit, St Mark's the National Bowel Hospital and Academic Institute, London, UK
| | - Naila Arebi
- IBD Unit, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Manmeet Matharoo
- Wolfson Endoscopy Unit, St Mark's the National Bowel Hospital and Academic Institute, London, UK
| | - Janindra Warusavitarne
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Omar Faiz
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Sica GS, Sensi B, Siragusa L, Blasi F, Crispino B, Pirozzi B, Angelico R, Biancone L, Khan J. Surgical management of colon cancer in ulcerative colitis patients with orthotopic liver transplant for primary sclerosing cholangitis. A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106922. [PMID: 37210276 DOI: 10.1016/j.ejso.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Colon cancer in ulcerative colitis patients with liver transplant (UCCOLT) due to primary sclerosing cholangitis carries significant treatment challenges. Aim of this literature search is to review management strategies and provide a framework to facilitate the decisional process in this clinical setting. METHODS PRISMA-compliant systematic search was followed by critical expert commentary of the results and development of a surgical management algorithm. Endpoints included surgical management, operative strategies, functional and survival outcomes. Technical and strategics aspects with particular regard to the choice of reconstruction were evaluated to tentatively develop an integrated algorithm. RESULTS Ten studies reporting treatment of 20 UCCOLT patients were identified after screening. Nine patients underwent proctocolectomy and end-ileostomy (PC) and eleven had restorative ileal pouch-anal anastomosis (IPAA). Reported results for perioperative outcomes, oncological outcomes, and graft loss were comparable for both procedures. There were no reports of subtotal colectomies and ileo-rectal anastomosis (IRA). CONCLUSIONS Literature in the field is scarce and decision-making is particularly complex. PC and IPAA have been reported with good results. Nevertheless, IRA may also be considered in UCCOLT patients in selected cases, reducing the risks of sepsis, OLT and pouch failure; furthermore, in young patients, it has the advantage of preserving fertility or sexual function. The proposed treatment algorithm may represent a valuable support in guiding surgical strategy.
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Affiliation(s)
- G S Sica
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy.
| | - B Sensi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - L Siragusa
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - F Blasi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - B Crispino
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - B Pirozzi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - R Angelico
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - L Biancone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - J Khan
- Portsmouth Hospitals, NHS Trust, Portsmouth, UK
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Spinelli A, Carrano FM, Laino ME, Andreozzi M, Koleth G, Hassan C, Repici A, Chand M, Savevski V, Pellino G. Artificial intelligence in colorectal surgery: an AI-powered systematic review. Tech Coloproctol 2023; 27:615-629. [PMID: 36805890 DOI: 10.1007/s10151-023-02772-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
Artificial intelligence (AI) has the potential to revolutionize surgery in the coming years. Still, it is essential to clarify what the meaningful current applications are and what can be reasonably expected. This AI-powered review assessed the role of AI in colorectal surgery. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic search of PubMed, Embase, Scopus, Cochrane Library databases, and gray literature was conducted on all available articles on AI in colorectal surgery (from January 1 1997 to March 1 2021), aiming to define the perioperative applications of AI. Potentially eligible studies were identified using novel software powered by natural language processing (NLP) and machine learning (ML) technologies dedicated to systematic reviews. Out of 1238 articles identified, 115 were included in the final analysis. Available articles addressed the role of AI in several areas of interest. In the preoperative phase, AI can be used to define tailored treatment algorithms, support clinical decision-making, assess the risk of complications, and predict surgical outcomes and survival. Intraoperatively, AI-enhanced surgery and integration of AI in robotic platforms have been suggested. After surgery, AI can be implemented in the Enhanced Recovery after Surgery (ERAS) pathway. Additional areas of applications included the assessment of patient-reported outcomes, automated pathology assessment, and research. Available data on these aspects are limited, and AI in colorectal surgery is still in its infancy. However, the rapid evolution of technologies makes it likely that it will increasingly be incorporated into everyday practice.
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Affiliation(s)
- A Spinelli
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, MI, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy.
| | - F M Carrano
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, MI, Italy
| | - M E Laino
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, 20089, Rozzano, MI, Italy
| | - M Andreozzi
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - G Koleth
- Department of Gastroenterology and Hepatology, Hospital Selayang, Selangor, Malaysia
| | - C Hassan
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, MI, Italy
| | - A Repici
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, MI, Italy
| | - M Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - V Savevski
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, 20089, Rozzano, MI, Italy
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
- Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
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Hassan Y, Connell WR, Rawal A, Wright EK. Review of long-term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease. ANZ J Surg 2023. [PMID: 37095321 DOI: 10.1111/ans.18490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/12/2023] [Accepted: 04/16/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND In medically refractory Ulcerative Colitis (UC), proctocolectomy with ileoanal pouch procedure (IAPP) is the preferred continence-preserving surgical option. Functional outcomes post-surgery and long-term complication rates in the biologic era remain ambiguous. This review primarily aims to provide an update on these outcomes. Secondarily, risk factors associated with chronic pouchitis and pouch failure are explored. METHODS Two online databases (MEDLINE and EMBASE) were searched on 4 October 2022 for English studies from 2011-present relating to long-term outcomes of IAPP in inflammatory bowel disease (IBD) patients. Adult patients with 12 month follow-up were included. Studies focused on 30-day post-operative outcomes, non-IBD patients or studies including less than 30 patients were excluded. RESULTS Following screening and full-text review of 1094 studies, 49 were included. Median sample size was n = 282 (IQR: 116-519). Median incidences for chronic pouchitis and pouch failure were 17.1% (IQR: 12-23.6%) and 6.9% (IQR: 4.8-10.8%), respectively. Upon multivariate analysis, chronic pouchitis development was most significantly associated with pre-operative steroid use, pancolitis and extra-intestinal IBD manifestations, whilst pouch failure was most significantly associated with pre-operative diagnosis of Crohn's disease (compared to UC), peri-operative pelvic sepsis and anastomotic leak. Overall patient satisfaction was very high with four included studies reporting greater than 90% satisfaction rates. CONCLUSION Long-term complications for IAPP were common. However, despite this, patient satisfaction post-IAPP was high. Up-to-date knowledge of complication rates and their risk factors improves pre-operative counselling, management planning and patient outcomes.
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Affiliation(s)
- Yusuf Hassan
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - William R Connell
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
| | - Alisha Rawal
- General HMO Stream, Grampians Health, Ballarat, Australia
| | - Emily K Wright
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
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Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis. Tech Coloproctol 2023; 27:297-307. [PMID: 36336745 PMCID: PMC10008209 DOI: 10.1007/s10151-022-02713-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND During ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC), rectal dissection can be performed via close rectal dissection (CRD) or in a total mesorectal excision plane (TME). Although CRD should protect autonomic nerve function, this technique may be more challenging than TME. The aim of this study was to compare long-term outcomes of patients undergoing CRD and TME. METHODS This single-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC between January 2002 and October 2017. Primary outcomes were chronic pouch failure (PF) among patients who underwent CRD and TME and the association between CRD and developing chronic PF. Chronic PF was defined as a pouch-related complication occurring ≥ 3 months after primary IPAA surgery requiring redo pouch surgery, pouch excision or permanent defunctioning ileostomy. Secondary outcomes were risk factors and causes for chronic PF. Pouch function and quality of life were assessed via the Pouch dysfunction score and Cleveland global quality of life score. RESULTS Out of 289 patients (155 males, median age 37 years [interquartile range 26.5-45.5 years]), 128 underwent CRD. There was a shorter median postoperative follow-up for CRD patients than for TME patients (3.7 vs 10.9 years, p < 0.01). Chronic PF occurred in 6 (4.7%) CRD patients and 20 (12.4%) TME patients. The failure-free pouch survival rate 3 years after IPAA surgery was comparable among CRD and TME patients (96.1% vs. 93.5%, p = 0.5). CRD was a no predictor for developing chronic PF on univariate analyses (HR 0.7 CI-95 0.3-2.0, p = 0.54). A lower proportion of CRD patients developed chronic PF due to a septic cause (1% vs 6%, p = 0.03). CONCLUSIONS Although differences in chronic PF among CRD and TME patients were not observed, a trend toward TME patients developing chronic pelvic sepsis was detected. Surgeons may consider performing CRD during IPAA surgery for UC.
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Xu W, Wang Y, Hua Z, Hu H, Chen W, Cai Z, Cui L, Wu X, Lian L, Ding Z, Du P. Risk Factors and Quality of Life in Patients with Diffuse Pouchitis After Ileal Pouch Anal Anastomosis According to the Chicago Classification for J Pouch: a Retrospective Multicenter Cohort Study in China. J Gastrointest Surg 2023; 27:766-776. [PMID: 36596961 DOI: 10.1007/s11605-022-05563-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pouchitis is a common late complication in patients with ulcerative colitis (UC) who undergo ileal pouch-anal anastomosis (IPAA). The heterogeneous nature of the clinical and endoscopic presentations could affect the evaluation of therapeutic interventions for pouchitis. Thus, identifying the risk factors and clinical outcomes of pouch inflammation at different sites and severity is becoming increasingly important for colorectal surgeons. METHODS Data on patients who underwent IPAA January from 2008 to June 2022 in our three pouch centers affiliated with the China UC Pouch Center Union were retrospectively collected. Pouchitis was categorized as a different phenotype according to the Chicago Classification. J pouches were classified into short (14 ± 2 cm) and long pouches (22 ± 2 cm) according to the distribution of ileal pouch length in our institute. RESULTS Altogether, 143 patients with a median follow-up time of 5.0 years (interquartile range: 2.0-8.0) were enrolled. Among them, 41 patients (28.7%) developed pouchitis and 32 patients (78%) had diffuse inflammation of the pouch. Patients with diffuse pouchitis had a higher pouchitis disease activity index and more seriously impaired improvement of long-term quality of life than those with pouch phenotypes. A short J pouch, recurrent UC, and preoperative high white blood cell count were independent risk factors for diffuse pouchitis. Furthermore, a short J pouch could effectively predict the occurrence of diffuse pouchitis with an area under the receiver-operating characteristic curve of 0.614, a sensitivity of 62.5%, and a specificity of 60.4% (p = 0.049) and significantly decreased the overall diffuse pouchitis-free survival compared to a long J pouch (p = 0.0002). CONCLUSION Diffuse pouchitis is a common phenotype of pouchitis that seriously impairs long-term prognosis. For colorectal surgeons, decision-making regarding pouch construction with an appropriate length should be considered to prevent the development of diffuse pouchitis.
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Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Hang Hu
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Wenhao Chen
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Zerong Cai
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Xiaojian Wu
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Lei Lian
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China. .,China UC Pouch Center Union, Shanghai, China.
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China. .,China UC Pouch Center Union, Shanghai, China.
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9
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Kroesen AJ. [Complications and corrective surgery after ileal pouch-anal reconstruction?]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:1037-1043. [PMID: 35918545 DOI: 10.1007/s00104-022-01688-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
Proctocolectomy with ileal J‑pouch-anal and rectal reconstruction is the standard surgical treatment for ulcerative colitis, selected cases of Crohn's disease, FAP and multilocular colon carcinoma. Although this treatment has been continuously developed over the last 40 years, the long-term success rate is 80-90% of the treated patients. The reasons for this are manifold: chronic pouchitis, incontinence, secondary diagnosis of Crohn's disease, fistulas, severe surgical complications, rectal stump left for too long, chronic abscess and surgical technical errors. This article deals with the control of acute complications and with the management of long-term complications. Some of the triggering complications for pouch failure do not generally imply failure of the method. A correction, closure of the fistula and in individual cases also a completely new pouch creation can restore a good pouch function in about 75% of cases. Various indications, techniques and results are presented.
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Affiliation(s)
- Anton J Kroesen
- Allgemein‑, Viszeral‑, Tumor- und koloproktologische Chirurgie, Krankenhaus Porz am Rhein, Urbacher Weg 19, 51149, Köln, Deutschland.
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10
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Flemming S, Kelm M, Germer CT, Wiegering A. [Ileal pouch after restorative coloproctectomy]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:1030-1036. [PMID: 36036850 DOI: 10.1007/s00104-022-01708-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
The continuous development of pouch surgery has enabled continence-preserving treatment after coloproctectomy. The ileoanal J‑pouch is nowadays the standard reconstruction after restorative coloproctectomy with excellent functional long-term results. Taking the relative contraindications and a suitable patient selection into consideration, pouch placement can be indicated not only for ulcerative colitis and familial adenomatous polyposis, but also for patients with nonfistular Crohn's disease. Due to a high treatment density with immunosuppressants, the surgical treatment regimen should be subdivided into a multistage procedure, whereby according to current data a modified two-stage procedure should be favored.
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Affiliation(s)
- S Flemming
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Kelm
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - C-T Germer
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - A Wiegering
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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11
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Westberg K, Olén O, Söderling J, Bengtsson J, Ludvigsson JF, Everhov ÅH, Myrelid P, Nordenvall C. Primary Versus Staged Reconstruction and Risk of Surgical Failure in Patients With Ulcerative Colitis: a Nation-wide Cohort Study. Inflamm Bowel Dis 2022; 28:1301-1308. [PMID: 34792582 DOI: 10.1093/ibd/izab263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Restorative surgery after colectomy due to ulcerative colitis (UC) may be performed simultaneously with colectomy (primary) or as a staged procedure. Risk factors for failure after restorative surgery are not fully explored. This study aimed to compare the risk of failure after primary and staged reconstruction. METHODS This is a national register-based cohort study of all patients 15 to 69 years old in Sweden treated with colectomy due to UC and who received an ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) between 1997 and 2017. Failure was defined as a reoperation with new ileostomy after restorative surgery or a remaining defunctioning ileostomy after 2 years. Risk of failure was calculated using the Kaplan-Meier method and Cox regression adjusted for sex, age, calendar period, primary sclerosing cholangitis, and duration of UC. RESULTS Of 2172 included patients, 843 (38.8%) underwent primary reconstruction, and 1329 (61.2%) staged reconstruction. Staged reconstruction was associated with a decreased risk of failure compared with primary reconstruction (hazard ratio, 0.73; 95% CI, 0.58-0.91). The 10-year cumulative risk of failure was 15% vs 20% after staged and primary reconstruction, respectively. In all, 1141 patients (52.5%) received an IPAA and 1031 (47.5%) an IRA. In stratified multivariable models, staged reconstruction was more successful than primary reconstruction in both IRA (hazard ratio, 0.75; 95% CI, 0.54-1.04) and IPAA (hazard ratio, 0.73; 95% CI, 0.52-1.01), although risk estimates failed to attain statistical significance. CONCLUSIONS In UC patients undergoing colectomy, postponing restorative surgery may decrease the risk of failure.
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Affiliation(s)
- Karin Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Division of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet and Department of Pediatric Gastroenterology and Nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Bengtsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm and Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Åsa H Everhov
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet and Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Faculty of Health, Linköping University, Linköping, Sweden
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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12
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Feasibility of Novel Software-Based Perfusion Indicators for the Ileal J-Pouch-On the Path towards Objective and Quantifiable Intraoperative Perfusion Assessment with Indocyanine Green Near-Infrared Fluorescence. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081144. [PMID: 36013324 PMCID: PMC9410361 DOI: 10.3390/life12081144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND In restorative proctocolectomy with ileal J-pouch, perfusion assessment is vital to prevent complications such as anastomotic leak (AL). Indocyanine green near-infrared fluorescence (ICG-NIRF) is gaining popularity, while its interpretation and relevance remain subjective. This study aimed to evaluate a standardized ICG-NIRF imaging protocol combined with a novel, software-based assessment to detect areas of impaired perfusion and a possible correlation with AL of the pouch. METHODS In this prospective study, patients undergoing ileal J-pouch for ulcerative colitis at an inflammatory bowel disease (IBD) referral center were included. Intraoperatively, strictly standardized ICG-NIRF visualization was performed and video-recorded. Postoperatively, a specific software was utilized to determine the change in fluorescence intensity per second (i/s) for systematic regions of interest, generating perfusion-time curves and a pixel-to-pixel map. These were analysed in detail and correlated with clinical outcome (primary end point: AL within 30 days; clearly defined and screened for by pouchoscopy). RESULTS Four out of 18 included patients developed AL of the ileal pouch-anal anastomosis (IPAA). In the AL group, the perfusion curves on the area adjacent to the IPAA (pouch apex) displayed considerably lower ingress/inflow (median = 1.7; range = 8.5; interquartile-range = 3.8 i/s) and egress/outflow (median = -0.1; range = 0.7; interquartile-range = 0.5 i/s) values than in the non-AL group (ingress: median = 4.3; range = 10.3; interquartile-range = 4.0 i/s); egress: median = (-1.1); range = 3.9; interquartile range = 1.0 i/s). This was confirmed by further novel parameters of pouch perfusion (maximum ingress; maximum egress) and pixel-to-pixel analysis. CONCLUSIONS This study presents the feasibility of a novel methodology to precisely assess pouch perfusion with ICG-NIRF, identifying comparable, quantifiable, and objective parameters to potentially detect perfusion-associated complications in surgery in real-time.
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13
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Perfusion Visualization during Ileal J-Pouch Formation—A Proposal for the Standardization of Intraoperative Imaging with Indocyanine Green Near-Infrared Fluorescence and a Postoperative Follow-Up in IBD Surgery. Life (Basel) 2022; 12:life12050668. [PMID: 35629337 PMCID: PMC9147668 DOI: 10.3390/life12050668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/16/2022] Open
Abstract
Background: An anastomotic leak (AL) after a restorative proctocolectomy and an ileal J-pouch increases morbidity and the risk of pouch failure. Thus, a perfusion assessment during J-pouch formation is crucial. While indocyanine green near-infrared fluorescence (ICG-NIRF) has shown potential to reduce ALs, its suitability in a restorative proctocolectomy remains unclear. We aimed to develop a standardized approach for investigating ICG-NIRF and ALs in pouch surgery. Methods: Patients undergoing a restorative proctocolectomy with an ileal J-pouch for ulcerative colitis at an IBD-referral-center were included in a prospective study in which an AL within 30 postoperative days was the primary outcome. Intraoperatively, standardized perfusion visualization with ICG-NIRF was performed and video recorded for postoperative analysis at three time points. Quantitative clinical and technical variables (secondary outcome) were correlated with the primary outcome by descriptive analysis and logistic regression. A novel definition and grading of AL of the J-pouch was applied. A postoperative pouchoscopy was routinely performed to screen for AL. Results: Intraoperative ICG-NIRF-visualization and its postoperative visual analysis in 25 patients did not indicate an AL. The anastomotic site after pouch formation appeared completely fluorescent with a strong fluorescence signal (category 2) in all cases of ALs (4 of 25). Anastomotic site was not changed. ICG-NIRF visualization was reproducible and standardized. Logistic regression identified a two-stage approach vs. a three-stage approach (Odds ratio (OR) = 20.00, 95% confidence interval [CI] = 1.37–580.18, p = 0.029) as a risk factor for ALs. Conclusion: We present a standardized, comparable approach of ICG-NIRF visualization in pouch surgery. Our data indicate that the visual interpretation of ICG-NIRF alone may not detect ALs of the pouch in all cases—quantifiable, objective methods of interpretation may be required in the future.
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14
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Endoscopic Phenotype of the J Pouch in Patients With Inflammatory Bowel Disease: A New Classification for Pouch Outcomes. Clin Gastroenterol Hepatol 2022; 20:293-302.e9. [PMID: 33549868 PMCID: PMC8339185 DOI: 10.1016/j.cgh.2021.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pouchitis is a common complication of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis who have undergone colectomy. Pouchitis has been considered a single entity despite a broad array of clinical and endoscopic patterns. We developed a novel classification system based on the pattern of inflammation observed in pouches and evaluated the contributing factors and prognosis of each phenotype. METHODS We identified 426 patients (384 with ulcerative colitis) treated with proctocolectomy and IPAA who subsequently underwent pouchoscopies at the University of Chicago between June 1997 and December 2019. We retrospectively reviewed 1359 pouchoscopies and classified them into 7 main pouch phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted 6 months after ileostomy takedown. Logistic regression analysis was used to assess factors contributing to each phenotype. Pouch survival was estimated by the log-rank test and the Cox proportional hazards model. RESULTS Significant contributing factors for afferent limb involvement were a body mass index of 25 or higher and hand-sewn anastomosis, for inlet involvement the significant contributing factor was male sex; for diffuse inflammation the significant contributing factors were extensive colitis and preoperative use of anti-tumor necrosis factor drugs, for cuffitis the significant contributing factors were stapled anastomosis and preoperative Clostridioides difficile infection. Inlet stenosis, diffuse inflammation, and cuffitis significantly increased the risk of pouch excision. Diffuse inflammation was associated independently with pouch excision (hazard ratio, 2.69; 95% CI, 1.34-5.41; P = .005). CONCLUSIONS We describe 7 unique IPAA phenotypes with different contributing factors and outcomes, and propose a new classification system for pouch management and future interventional studies.
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15
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Reijntjes MA, Bocharewicz EK, Hompes R, Buskens CJ, Bemelman WA. Incidence and causes of failure in various anatomical pouch designs 20 years after surgical primary ileal-pouch anal anastomosis construction. Int J Colorectal Dis 2022; 37:2491-2499. [PMID: 36357735 PMCID: PMC9741566 DOI: 10.1007/s00384-022-04280-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Since the introduction of ileo-pouch anal anastomosis (IPAA) surgery, various pouch designs have been applied. Recently, there has been renewed interest in creating larger pouch designs to reduce defecation frequency after pouch surgery. The aim of this study was to assess chronic pouch failure (PF) rates and causes in alternative S or septated (SP) pouches when compared to J pouches and B- shaped adaptations. METHODS This retrospective cohort study included patients that underwent primary IPAA construction surgery from 1978-2000. Pouch designs were subdivided in J and B (J/B), and larger pouches (S/SP). PF included need for a pouch excision, redo pouch procedure, revisional pouch surgery, or permanent ileostomy surgery. Outcomes of this study were incidence and causes for PF per pouch design group. RESULTS Out of 200 patients who underwent IPAA surgery, 19 had an S/SP design and 181 had a J/B design. After a follow-up of 27.0 (IQR 23.3 - 29.0) years, 45/200 (22.5%) patients who underwent IPAA surgery between 1975-2000 developed PF. Some 78.9% of patients with an S/SP pouch developed PF, compared to 16.7% of patients with a J/B pouch (p < 0.01). Mechanical outlet issues occurred more often in S/SP pouches when compared to J/B (42.1% vs. 1.1%, p < 0.01), and were predominantly caused by septal- or pouch wall intussusception and efferent loop kinking (S-pouch). CONCLUSION Despite an inevitable proportion of bias, the current study revealed that S/SP pouches were characterized by an increased PF incidence due to emptying problems after long-term follow-up when compared to J/B pouches. Constructing an S pouch or large septated reservoir at index surgery should therefore be questioned because of a shorter longevity.
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Affiliation(s)
- Maud A. Reijntjes
- grid.7177.60000000084992262Department of Surgery, Amsterdam UMC, University of Amsterdam, IBD Unit Ospedale San Raffaele, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Eva K. Bocharewicz
- grid.7177.60000000084992262Department of Surgery, Amsterdam UMC, University of Amsterdam, IBD Unit Ospedale San Raffaele, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Roel Hompes
- grid.7177.60000000084992262Department of Surgery, Amsterdam UMC, University of Amsterdam, IBD Unit Ospedale San Raffaele, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Christianne J. Buskens
- grid.7177.60000000084992262Department of Surgery, Amsterdam UMC, University of Amsterdam, IBD Unit Ospedale San Raffaele, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Willem A. Bemelman
- grid.7177.60000000084992262Department of Surgery, Amsterdam UMC, University of Amsterdam, IBD Unit Ospedale San Raffaele, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands ,grid.15496.3f0000 0001 0439 0892Gastroenterology and Endoscopy, IBD Unit, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
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16
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Bektaş M, Tuynman JB, Costa Pereira J, Burchell GL, van der Peet DL. Machine Learning Algorithms for Predicting Surgical Outcomes after Colorectal Surgery: A Systematic Review. World J Surg 2022; 46:3100-3110. [PMID: 36109367 PMCID: PMC9636121 DOI: 10.1007/s00268-022-06728-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Machine learning (ML) has been introduced in various fields of healthcare. In colorectal surgery, the role of ML has yet to be reported. In this systematic review, an overview of machine learning models predicting surgical outcomes after colorectal surgery is provided. METHODS Databases PubMed, EMBASE, Cochrane, and Web of Science were searched for studies using machine learning models for patients undergoing colorectal surgery. To be eligible for inclusion, studies needed to apply machine learning models for patients undergoing colorectal surgery. Absence of machine learning or colorectal surgery or studies reporting on reviews, children, study abstracts were excluded. The Probast risk of bias tool was used to evaluate the methodological quality of machine learning models. RESULTS A total of 1821 studies were analysed, resulting in the inclusion of 31 articles. A vast proportion of ML algorithms have been used to predict the course of disease and response to neoadjuvant chemoradiotherapy. Radiomics have been applied most frequently, along with predictive accuracies up to 91%. However, most studies included a retrospective study design without external validation or calibration. CONCLUSIONS Machine learning models have shown promising potential in predicting surgical outcomes after colorectal surgery. However, large-scale data is warranted to bridge the gap between calibration and external validation. Clinical implementation is needed to demonstrate the contribution of ML within daily practice.
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Affiliation(s)
- Mustafa Bektaş
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jurriaan B. Tuynman
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jaime Costa Pereira
- Department of Computer Science, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
| | - George L. Burchell
- Medical Library, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Donald L. van der Peet
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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17
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Guyton K, Kearney D, Holubar SD. Anastomotic Leak after Ileal Pouch-Anal Anastomosis. Clin Colon Rectal Surg 2021; 34:417-425. [PMID: 34853564 DOI: 10.1055/s-0041-1735274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Kristina Guyton
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David Kearney
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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18
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Akiyama S, Rai V, Rubin DT. Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment. Intest Res 2020; 19:1-11. [PMID: 33138344 PMCID: PMC7873408 DOI: 10.5217/ir.2020.00047] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) occasionally need a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) because of medically refractory colitis or dysplasia/cancer. However, pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. About 10% of patients with IBD who develop pouchitis require pouch excision, and several risk factors of the failure have been reported. A phenotype that has features similar to Crohn’s disease may develop in a subset of ulcerative colitis patients following proctocolectomy with IPAA and is the most frequent reason for pouch failure. In this review, we discuss the diagnosis and prognosis of pouchitis, risk factors for pouchitis development, and treatment options for pouchitis, including the newer biological agents.
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Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Victoria Rai
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
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19
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Re-operation surgery following IPAA: is there a role for laparoscopy? Surg Endosc 2020; 35:1591-1596. [PMID: 32266546 DOI: 10.1007/s00464-020-07537-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Restorative proctocolectomy with ileal J pouch anal anastomosis (IPAA) has become the standard of care for mucosal ulcerative colitis and Familial Adenomatous Polyposis. Some patients require re-operation, including pouch revision, advancement, or excision. Re-operative procedures are technically demanding and usually performed only by experienced colorectal surgeons in a small number of referral centers. There is a paucity of data regarding feasibility, safety, and outcomes of laparoscopic re-operative IPAA surgery. This study aimed to determine the safety and feasibility of laparoscopic approach for re-operative IPAA, trans-abdominal surgery. METHODS Retrospective analysis of IRB-approved prospective database for patients who underwent trans-abdominal re-operative IPAA from 2011 to 2018. Patient demographics and operative reports were reviewed to classify type of re-operation into pouch excision, revision, or advancement and further classify as laparoscopic, laparoscopic converted to open, or open surgery. Main outcome measures were post-operative morbidity and mortality. RESULTS Seventy-six patients met the inclusion criteria: 19 underwent attempted laparoscopic re-operative IPAA surgery, 12 of whom underwent successful laparoscopic surgery while 7 were converted to laparotomy, for an overall laparoscopic intent to treat 63% success rate. The remaining operations (n = 57) were performed through midline laparotomy. Length of stay (LOS) for patients who underwent laparoscopic surgery was significantly shorter (5.5 vs 9.7 days, p < 0.001) as were abdominal superficial surgical site infections (SSI) (0% vs 18%, p < 0.001) and deep SSI (0% vs 17%, p < 0.001). Laparotomy was performed by 6 colorectal surgeons at our institution while laparoscopy was successfully performed only by the senior author. There was no significant difference in overall complications, re-admission, re-operation, or mortality. CONCLUSION Re-operative, trans-abdominal, laparoscopic IPAA is both feasible and safe and has clear benefits compared to laparotomy in terms of LOS and superficial and deep SSI. However, this approach needs to be undertaken only by very experienced, high-volume laparoscopic IPAA surgeons.
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20
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Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A, Ellul P, Fiorino G, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gisbert JP, Gomollon F, González Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Kucharzik T, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B, Zmora O. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2020; 14:155-168. [PMID: 31742338 DOI: 10.1093/ecco-jcc/jjz187] [Citation(s) in RCA: 273] [Impact Index Per Article: 68.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Alessandro Armuzzi
- IBD Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS - Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland; Department of Human Medicine, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | | | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa', IIS Aragón, CIBEREHD, Zaragoza, Spain
| | | | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Sub-department of Gastroenterology and Hepatology, University Hospital Bratislava and Faculty of Medicine, Comenius University Bratislava, Slovakia
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal Medicine, Riga Stradiņš University, Riga, Latvia
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Faculty of Medicine, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
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21
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Helavirta I, Lehto K, Huhtala H, Hyöty M, Collin P, Aitola P. Pouch failures following restorative proctocolectomy in ulcerative colitis. Int J Colorectal Dis 2020; 35:2027-2033. [PMID: 32592093 PMCID: PMC7541371 DOI: 10.1007/s00384-020-03680-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Restorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision. METHODS The number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016. RESULTS Out of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn's disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn's disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I-II). CONCLUSIONS Eleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn's disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.
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Affiliation(s)
- Ilona Helavirta
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland.
| | - Kirsi Lehto
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, FI-33014, Tampere, Finland
| | - Marja Hyöty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Petri Aitola
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
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22
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Abstract
Elective abdominal surgery for inflammatory bowel disease is common. Surgery for Crohn's disease is not curative, and treatment must be individualized to the disease process. Surgery for ulcerative colitis generally is curative but consideration of patient-specific factors is important for staging of the procedure and determining whether ileal pouch-anal anastomosis is appropriate.
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23
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Ritter KA, Burke JP, Stocchi L, Aiello A, Holubar S, Ashburn JH, Lipman JM, Shawki S, Hull T. Postoperative Steroid Taper Is Associated With Pelvic Sepsis After Ileal Pouch-anal Anastomosis. Inflamm Bowel Dis 2019; 25:1383-1389. [PMID: 30597024 DOI: 10.1093/ibd/izy388] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We hypothesized that postoperative oral steroid taper after ileal pouch-anal anastomosis for inflammatory bowel disease would not be associated with pelvic septic complications. BACKGROUND Recent data has emphasized the possible association between biologic medication use and pelvic sepsis following ileal pouch-anal anastomosis. Limited contemporary data exist examining the effects of steroid use on these complications. METHODS Consecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease at a single institution from January 2009 to December 2013 were included. Factors associated with anastomotic leak and pelvic sepsis were assessed using univariate and multivariate analysis. RESULTS A total of 686 patients were included (mean age 39.5 years, 59% males). Postoperative oral steroid taper was associated with both anastomotic leak and pelvic sepsis on univariate analysis. Stress dose intravenous steroid use was not associated with complications. Multivariate analysis indicated total proctocolectomy (odds ratio [OR] 2.2; confidence interval [CI] 1.01-4.7, P = 0.047), and postoperative oral steroid taper (OR 2.3; CI 1.06-5.1; P = 0.035) as independent factors significantly associated with pelvic sepsis. CONCLUSIONS Prolonged postoperative oral steroid taper after ileal pouch-anal anastomosis should be avoided. If preoperative steroid weaning is not possible before a planned total proctocolectomy and ileal pouch-anal anastomosis, patients should undergo an initial total abdominal colectomy.
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Affiliation(s)
- Kaitlin A Ritter
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - John P Burke
- Beaumont Hospital, Department of Colorectal Surgery, Dublin, Ireland
| | - Luca Stocchi
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Alexandra Aiello
- Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, Ohio, USA
| | - Stefan Holubar
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Jeremy M Lipman
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Sherief Shawki
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Tracy Hull
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
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24
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Spinelli A, Carvello M, Kotze PG, Maroli A, Montroni I, Montorsi M, Buchs NC, Ris F. Ileal pouch-anal anastomosis with fluorescence angiography: a case-matched study. Colorectal Dis 2019; 21:827-832. [PMID: 30873703 DOI: 10.1111/codi.14611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/02/2019] [Indexed: 12/12/2022]
Abstract
AIM An anastomotic leak in ileoanal pouch surgery may lead to pouch failure. Constructing a tension-free ileal pouch-anal anastomosis (IPAA) reduces this risk but can be technically challenging, balancing pouch vascularization with ileal mesenteric length and site of vessel ligation. Fluorescence angiography (FA) may help the clinician make a more balanced judgement. METHODS Thirty-two patients undergoing minimally invasive completion proctectomy with FA-guided IPAA at two academic centres were matched and compared on a 1:1 basis to a historical group undergoing the same procedure without the use of this technique. RESULTS Ligation of the ileocolic vessels was safely performed in 15/32 (47%) of FA patients compared with 5/32 (16%) of historical controls. One patient underwent intra-operative IPAA reconstruction after FA detected ischaemia. No anastomotic leak occurred with FA but there was only one in the historical controls (P = 0.31). The postoperative complication rate was similar between the two groups (P = 0.60). CONCLUSION FA is applicable to IPAA surgery and may help to reduce perfusion-related anastomotic leaks. A prospective randomized trial is warranted.
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Affiliation(s)
- A Spinelli
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - M Carvello
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy
| | - P G Kotze
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná, Curitiba, Brazil
| | - A Maroli
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy
| | - I Montroni
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy
| | - M Montorsi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of General Surgery, Humanitas Research Hospital, Milan, Italy
| | - N C Buchs
- Service of Visceral Surgery, Department of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - F Ris
- Service of Visceral Surgery, Department of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
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25
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Lachance S, Abou-Khalil M, Vasilevsky CA, Ghitulescu G, Morin N, Faria J, Boutros M. Outcomes of Ileal Pouch Excision: an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Analysis. J Gastrointest Surg 2018; 22:2142-2149. [PMID: 30066066 DOI: 10.1007/s11605-018-3844-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/13/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study aimed to define the incidence and risk factors of postoperative morbidity and mortality after pouch excision (PE). METHODS ACS-NSQIP database was queried for patients who underwent PE between 2005 and 2015. Main outcome measures were 30-day mortality, major morbidity, overall surgical site infections (SSI), reoperation, and length of stay (LOS). Risk factors associated with these outcomes were assessed using multivariate logistic or quantile regression. RESULTS Three hundred eighty-one patients underwent PE (mean age 47.7(±15.3) years; 51.7% female). Mean body mass index (BMI) was 24.6(±5.7) kg/m2, 55.4% were ASA class 1-2 and 18.4% were immunosuppressed. Mean operative time was 252(±112.7) min, 98% were elective cases, and median LOS was 7(5-11) days. Twenty-eight percent experienced major morbidity, including SSIs (21.5% overall, 9.2% superficial, 3.7% deep, 10.3% organ space), sepsis (9.5%), urinary tract infection (5.8%), and postoperative pneumonia (2.4%). The observed venous thromboembolism rate was low, with 0.5 and 0.8% of patients suffering pulmonary embolism and deep vein thrombosis, respectively; 5.5% required reoperation. Postoperative mortality was 0.8%. On multivariate logistic regression, smoking (OR 3.03 [95% CI 1.56, 5.88]) and operative time (OR 1.003 [95% CI 1.0003, 1.0005) were associated with increased odds of major morbidity. Smoking (OR 3.29 [95% CI 1.65, 6.54]) and operative time (OR 1.002 [95% CI 1.000, 1.004]) were independent risk factors for overall SSI. LOS was significantly increased in patients with major morbidity (3.29 days [95% CI 1.60, 4.99]) and increased operative time (0.013 days [95% CI 0.007, 0.018]). CONCLUSIONS PE is an operation with significant risk of morbidity. However, mortality was low in the present cohort of patients. Patients who were smokers and had longer operative time had increased risk of overall infectious complications and major morbidity. Furthermore, major morbidity and operative time were associated with increased hospital length of stay following PE.
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Affiliation(s)
- Sebastien Lachance
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Maria Abou-Khalil
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Carol-Ann Vasilevsky
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Gabriela Ghitulescu
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nancy Morin
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Julio Faria
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Marylise Boutros
- Division of Colorectal Surgery, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, QC, H3T 1E2, Canada.
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26
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Characterization of megapouch in patients with restorative proctocolectomy. Surg Endosc 2018; 33:2293-2303. [PMID: 30327916 DOI: 10.1007/s00464-018-6523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Megapouch is a rare functional complication of restorative proctocolectomy with ileal pouch-anal anastomosis characterized by pouch ± small bowel dilatation with no evidence of obstruction on endoscopy and imaging. Little is known about clinical characteristics and outcomes of this entity. METHODS We included all patients diagnosed with megapouch at our institution, identified from a pouch database. Data on baseline characteristics, management, and outcomes were documented and analyzed from electronic medical records. Appropriate statistical measures were used. p < 0.05 was considered significant. RESULTS Twenty-three patients with megapouch were identified. The mean age was 40.7 years; 95.6% had underlying ulcerative colitis; most common indication for colectomy was medically refractory disease (56.5%). Abdominal pain (82.6%) and bloating (52.2%) were most common presenting symptoms. Most common finding on pouchoscopy was pouch dilatation (81.8%), while barium or gastrografin enemas and MRI/CT mostly revealed dilatation of pouch and/or small bowel. Fourteen (66.7%) patients required some forms of surgery-six patients required pouch excision and three required either pouch redo or revision. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically versus those managed medically (p = 0.007 and 0.024, respectively), while need for escalation of IBD-therapy was comparable between the groups (p = 0.133). No deaths were reported and no patient had recurrence of megapouch. IPAA revision or redo did not lead to more IBD-related morbidity. CONCLUSIONS Majority of our patients with megapouch required surgery. In selected patients, redo pouch offered cure. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically.
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27
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Helavirta I, Hyöty M, Oksanen P, Huhtala H, Haapamäki J, Aitola P. Health-Related Quality of Life after Restorative Proctocolectomy: A Cross-Sectional Study. Scand J Surg 2018; 107:315-321. [PMID: 29774794 DOI: 10.1177/1457496918772362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS: Patients undergoing restorative proctocolectomy have often suffered from active ulcerative colitis which should be remembered when assessing quality of life after operation. The aim of this study was to explore health-related quality of life after restorative proctocolectomy in those with poor or good pouch function and to compare that to patients with active or inactive ulcerative colitis and to the general population. MATERIAL AND METHODS: Altogether, 282 restorative proctocolectomy patients were investigated. The control group comprised 408 ulcerative colitis patients from the local register. Generic 15D and disease-specific inflammatory bowel disease questionnaire health-related quality of life instruments were used. Population-based data were available for 15D. Pouch function was evaluated with Öresland score and colitis activity with simple clinical colitis activity index. RESULTS: 15D results showed that patients with good pouch function had health-related quality of life similar to that of the general population. Health-related quality of life with inflammatory bowel disease questionnaire was equally good in patients with good pouch function (n = 131; 70%) and inactive colitis (n = 95; 63%), and equally impaired in patients with poor pouch function (n = 56; 30%) and active colitis (n = 18; 12%). CONCLUSION: The majority of patients had health-related quality of life comparable to that in general population. Most patients with active ulcerative colitis are likely to improve their health-related quality of life after successful surgery. These findings are important when informing colitis patients about life after surgery.
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Affiliation(s)
- I Helavirta
- 1 School of Medicine, University of Tampere, Tampere, Finland.,2 Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - M Hyöty
- 2 Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - P Oksanen
- 1 School of Medicine, University of Tampere, Tampere, Finland.,2 Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - H Huhtala
- 3 School of Health Sciences, University of Tampere, Tampere, Finland
| | - J Haapamäki
- 4 Department of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - P Aitola
- 2 Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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28
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Noh GT, Han J, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Factors affecting pouch-related outcomes after restorative proctocolectomy. PLoS One 2017; 12:e0186596. [PMID: 29049337 PMCID: PMC5648184 DOI: 10.1371/journal.pone.0186596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
Purposes Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the procedure of choice for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) despite morbidities that can lead to pouch failure. We aimed to identify factors associated with pouch-related morbidities. Methods A retrospective analysis of patients who underwent RPC with IPAA was performed. To investigate the factors associated with pouch-related morbidities, patients' preoperative demographic and clinical factors, and intraoperative factors were included in the analysis. Results A total of 49 patients with UC, FAP, and colorectal cancer were included. Twenty patients (40.8%) experienced leakage-related, functional, and/or pouchitis-related morbidities. Patients with American Society of Anesthesiologists (ASA) grade 2 or 3 had a higher risk of functional morbidity than those with grade 1. Intraoperative blood loss exceeding 300.0 mL was associated with an increased risk of pouchitis-related morbidity. Conclusions Our study demonstrated associations of higher ASA grade and increased intraoperative blood loss with poor functional outcomes and pouchitis, respectively.
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Affiliation(s)
- Gyoung Tae Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeonghee Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Soo Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
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29
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[Surgical strategy to save ileoanal pouch reconstruction]. Chirurg 2017; 88:574-581. [PMID: 28573532 DOI: 10.1007/s00104-017-0444-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Restorative proctocolectomy under formation of an ileoanal/ileorectal J‑pouch has become the procedure of choice in the therapy of ulcerative colitis. Although patients experience a dramatic improvement of their quality of life, surgery is not successful in about 5-10% of all treated patients. The reasons for failure are chronic pouchitis, incontinence, delayed diagnosis of Crohn's disease, fistula, surgical complications, too long remnant rectal stump, chronic abscess, and surgical technical errors. Some of the reasons do not always prevent the loss of a well-functioning ileoanal pouch. In many cases, correction, closure of fistulas or even a complete reconstruction of the ileoanal pouch are possible. Based on a review of the literature and our own experience, we show in 887 patients a success rate of 75% with acceptable pouch function. Indications, technics, and results are presented.
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30
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Sahami S, Bartels SAL, D'Hoore A, Young Fadok T, Tanis PJ, de Buck van Overstraeten A, Wolthuis AM, Buskens CJ, Bemelman WA. External validation of a prognostic model of preoperative risk factors for failure of restorative proctocolectomy. Colorectal Dis 2017; 19:181-187. [PMID: 27315787 DOI: 10.1111/codi.13414] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 04/26/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- S Sahami
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - S A L Bartels
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - A D'Hoore
- Department of Surgery, University Hospitals Leuven, Leuven, Belgium
| | - T Young Fadok
- Department of Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona, USA
| | - P J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - A M Wolthuis
- Department of Surgery, University Hospitals Leuven, Leuven, Belgium
| | - C J Buskens
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Sahami S, Bartels SAL, D'Hoore A, Fadok TY, Tanis PJ, Lindeboom R, de Buck van Overstraeten A, Wolthuis AM, Bemelman WA, Buskens CJ. A Multicentre Evaluation of Risk Factors for Anastomotic Leakage After Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease. J Crohns Colitis 2016; 10:773-8. [PMID: 26417046 DOI: 10.1093/ecco-jcc/jjv170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/10/2015] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Saloomeh Sahami
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Sanne A L Bartels
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tonia Young Fadok
- Department of Surgery, Mayo Clinic College of Medicine, Scottsdale, AZ, USA
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Robert Lindeboom
- Divisions of Clinical Methods and Public Health, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Albert M Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
BACKGROUND The efferent limb on the S-pouch fits well into the anal canal while the body of the pouch lies on the levators. In contrast, the blunt end of a J-pouch may be distorted as it is forced into the muscular tube of the stripped anus. OBJECTIVE The aim of this study is to compare the clinical outcomes and quality of life between patients with S- and J-pouches with a handsewn IPAA. DESIGN This study was retrospective. SETTING This study was conducted at a high-volume tertiary referral center. PATIENTS Patients undergoing a primary handsewn IPAA from 1983 to 2012 were identified. MAIN OUTCOMES MEASURES Demographics, operative details, functional outcomes, and quality of life were abstracted. RESULTS A total of 502 patients, including 169 patients with an S-pouch (33.7%) and 333 patients with J-pouch (66.3%), met our inclusion criteria; 55.8% (n = 280) were men. Mean age at pouch construction was 37.8 ± 12.5 years. Patients with an S-pouch were younger (p = 0.004) and had a higher BMI (p = 0.035) at pouch surgery. There was no significant difference between patients with S- or J-pouches in other demographics. The frequencies of short-term complications in the 2 groups were similar (p > 0.05), but pouch fistula or sinus (p = 0.047), pelvic sepsis (p = 0.044), postoperative partial small-bowel obstruction (p = 0.003), or postoperative pouch-related hospitalization (p = 0.021) occurred in fewer patients with an S-pouch. At a median follow-up of 12.2 (range, 4.3-20.1) years, patients with an S-pouch were found to have fewer bowel movements (p < 0.001), less frequent pad use (p = 0.001), and a lower fecal incontinence severity index score (p = 0.015). The pouch failed in 62 patients (12.4%), but neither univariate nor multivariate analysis showed a significant association with pouch configuration. LIMITATIONS The use of data from a single tertiary referral center was a limitation of this study. CONCLUSION We recommend using an S-pouch when constructing an IPAA with a handsewn technique.
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Aytac E, Ozuner G, Isik O, Gorgun E, Remzi FH. Surgical management of patients with ulcerative colitis during pregnancy: maternal and fetal outcomes. J Crohns Colitis 2015; 9:82-5. [PMID: 25518046 DOI: 10.1093/ecco-jcc/jju001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Ulcerative colitis can develop during the reproductive years, and there are limited data about perinatal care for patients with ulcerative colitis. In this study, we analyzed perinatal follow-up, complications, and maternal and fetal outcomes in pregnant patients undergoing surgery for ulcerative colitis. METHODS Between January 1998 and July 2013, female patients who underwent surgery during pregnancy for abdominal complications of ulcerative colitis and followed up during their pregnancy in our institution were included in our study. Patient characteristics, complications, operations performed, maternal and fetal morbidity and mortality during the perinatal period, and type of delivery were analyzed. RESULTS There were nine female patients with a median (range) age of 30 (21-33) years. Indications for surgery were fulminant/refractory colitis (n = 6) and bowel obstruction (n = 3). Operations performed were subtotal colectomy with an end ileostomy (n = 3), Turnbull blowhole procedure (n = 3), adhesiolysis with small bowel resection (n = 1), detorsion and decompression of bowel (n = 1) and adhesolysis (n = 1). Median (range) postoperative length of stay was 11 (5-28) days and median (range) duration of pregnancy was 36 (32-40) weeks. There were only two patients who had a transvaginal delivery, while a cesarean section was performed in seven patients. Indications for cesarean section were as follows: physician's preference (n = 4), planned small bowel surgery with cesarean section (n = 2), and metabolic disorders (n = 1). There were no perinatal maternal or fetal deaths. CONCLUSIONS Surgery for ulcerative colitis complications can be performed safely if indicated during pregnancy under the care of a multidisciplinary team that includes gastroenterologists, obstetricians, and colorectal surgeons.
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Affiliation(s)
- Erman Aytac
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gokhan Ozuner
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ozgen Isik
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Browne C, Shaikh F, Iqbal N, McGovern B, Rowe S, Neary P. Quality of life, continence and frequency of pouchitis following laparoscopic versus open colectomy and ileal pouch-anal anastomosis: an Irish perspective. Ir J Med Sci 2014; 184:655-8. [PMID: 25422064 DOI: 10.1007/s11845-014-1233-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/17/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aims to assess quality of life outcomes, continence, rates of pouchitis and predictors of pouchitis for patients undergoing laparoscopic versus open three-stage ileal pouch-anal anastomosis (IPAA) surgery in our institution. METHODS Forty-two patients having had three-stage (IPAA) surgery were identified. One was excluded as they had undergone pouchectomy. A postal questionnaire followed by telephone contact was undertaken. The questionnaire was based on The Gastrointestinal Quality of Life Index (GIQLI) and Wexner/Cleveland Clinic Faecal Incontinence Symptom Severity Scoring Systems. AIMS Our aim was to assess morbidity, quality of life, incidence of pouchitis and continence following restorative panproctocolectomy and IPAA. RESULTS Thirty-five patients completed the response. The median age at colectomy of our patient population was 32 years. 57 % were male and 43 % were female. 54.3 % of cases were carried out laparoscopically. 8/19 patients who had laparoscopic surgery had pouchitis (42.1 %) versus 9/16 patients who had open surgery (56.3 %). The median Wexner score was 0. Nine patients (25.7 %) had a GIQLI score that was within or above the range reported for healthy controls. The rate of complications was 31.7 % for emergency cases and 25.7 % for elective cases. The rate of pouchitis in this group was 48.5 %. Overall pelvic sepsis rate was 12.8 %. CONCLUSIONS Ileal pouch-anal anastomosis is a successful and well-tolerated procedure with 94 % of patients opting to have the surgery again. Preliminary results do not show any significant difference in the incidence of pouchitis following laparoscopic surgery.
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Affiliation(s)
- C Browne
- Department of Colorectal and Minimally Invasive Surgery, Adelaide and Meath Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland,
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Differences in short-term outcomes among patients undergoing IPAA with or without preoperative radiation: a National Surgical Quality Improvement Program analysis. Dis Colon Rectum 2014; 57:1188-94. [PMID: 25203375 PMCID: PMC4161052 DOI: 10.1097/dcr.0000000000000206] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Single-institution studies demonstrate a correlation between preoperative pelvic radiation and poor long-term pouch function after IPAA. The rarity of the radiated pelvis before these procedures limits the ability to draw conclusions on the effects of preoperative radiation on short-term outcomes, which may contribute to long-term pouch dysfunction. OBJECTIVE The purpose of this work was to better understand the impact of pelvic radiation on short-term outcomes in patients undergoing IPAA. DESIGN We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). SETTINGS The study was conducted at all participating NSQIP institutions. PATIENTS The cohort was composed of patients undergoing nonemergent IPAA procedures. MAIN OUTCOME MEASURES Proportions of patients experiencing postoperative complications within 30 days were compared by Fisher exact and Wilcoxon rank-sum tests based on whether they received preoperative radiation. Multivariate logistic regression models controlled for the effects of multiple risk factors. RESULTS Included were 3172 patients receiving IPAA; 162 received pelvic radiation. The postoperative complication rate was not significantly different in patients receiving pelvic radiation versus not receiving pelvic radiation (p = 0.06). In a subset of patients with cancer diagnoses (n = 598), 157 received pelvic radiation; complication rates were not significantly different (p = 0.16). Patients receiving pelvic radiation had significantly lower rates of sepsis in both the overall and cancer diagnosis groups (p = 0.005 and p = 0.047), a finding which persisted after controlling for the effects of multiple risk factors (multivariate p values = 0.030 and 0.047). LIMITATIONS This was a retrospective database design with short-term follow-up. CONCLUSIONS Patients who received radiation before IPAA had no difference in overall 30-day complication rates but had significantly lower rates of sepsis when compared with patients not receiving pelvic radiation. The perceived inferior long-term pouch function in patients undergoing preoperative pelvic radiation does not appear to be attributable to increases in 30-day complications.
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Maconi G, Furfaro F, Sciurti R, Bezzio C, Ardizzone S, de Franchis R. Glucose intolerance and diabetes mellitus in ulcerative colitis: Pathogenetic and therapeutic implications. World J Gastroenterol 2014; 20:3507-3515. [PMID: 24707133 PMCID: PMC3974517 DOI: 10.3748/wjg.v20.i13.3507] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/26/2014] [Accepted: 03/06/2014] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus is one of the most frequent co-morbidities of ulcerative colitis patients. The epidemiological association of these diseases suggested a genetic sharing and has challenged gene identification. Diabetes co-morbidity in ulcerative colitis has also relevant clinical and therapeutic implications, with potential clinical impact on the follow up and outcome of patients. These diseases share specific complications, such as neuropathy, hepatic steatosis, osteoporosis and venous thrombosis. It is still unknown whether the coexistence of these diseases may increase their occurrence. Diabetes and hyperglycaemia represent relevant risk factors for postoperative complications and pouch failure in ulcerative colitis. Medical treatment of ulcerative colitis in patients with diabetes mellitus may be particularly challenging. Corticosteroids are the treatment of choice of active ulcerative colitis. Their use may be associated with the onset of glucose intolerance and diabetes, with difficult control of glucose levels and with complications in diabetic patients. Epidemiologic and genetic evidences about diabetes co-morbidity in ulcerative colitis patients and shared complications and treatment of patients with these diseases have been discussed in the present review.
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Charpentier C, Salleron J, Savoye G, Fumery M, Merle V, Laberenne JE, Vasseur F, Dupas JL, Cortot A, Dauchet L, Peyrin-Biroulet L, Lerebours E, Colombel JF, Gower-Rousseau C. Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study. Gut 2014; 63:423-32. [PMID: 23408350 DOI: 10.1136/gutjnl-2012-303864] [Citation(s) in RCA: 239] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Data on the natural history of elderly-onset inflammatory bowel disease (IBD) are scarce. METHODS In a French population-based cohort we identified 841 IBD patients >60 years of age at diagnosis from 1988 to 2006, including 367 Crohn's disease (CD) and 472 ulcerative colitis (UC). RESULTS Median age at diagnosis was similar for CD (70 years (IQR: 65-76)) and UC (69 years (64-74)). Median follow-up was 6 years (2-11) for both diseases. At diagnosis, in CD, pure colonic disease (65%) and inflammatory behaviour (78%) were the most frequent phenotype. At maximal follow-up digestive extension and complicated behaviour occurred in 8% and 9%, respectively. In UC, 29% of patients had proctitis, 45% left-sided and 26% extensive colitis without extension during follow-up in 84%. In CD cumulative probabilities of receiving corticosteroids (CSs), immunosuppressants (ISs) and anti tumor necrosis factor therapy were respectively 47%, 27% and 9% at 10 years. In UC cumulative probabilities of receiving CS and IS were 40% and 15%, respectively at 10 years. Cumulative probabilities of surgery at 1 year and 10 years were 18% and 32%, respectively in CD and 4% and 8%, respectively in UC. In CD complicated behaviour at diagnosis (HR: 2.6; 95% CI 1.5 to 4.6) was associated with an increased risk for surgery while CS was associated with a decreased risk (HR: 0.5; 0.3 to 0.8). In UC CS was associated with an increased risk (HR: 2.2; 1.1 to 4.6) for colectomy. CONCLUSIONS Clinical course is mild in elderly-onset IBD patients. This information would need to be taken into account by physicians when therapeutic strategies are established.
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Affiliation(s)
- Cloé Charpentier
- Gastroenterology Unit, EPIMAD Registry, Rouen University and Hospital, , Rouen, France
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Buskens CJ, Sahami S, Tanis PJ, Bemelman WA. The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: A review of current evidence. Best Pract Res Clin Gastroenterol 2014; 28:19-27. [PMID: 24485252 DOI: 10.1016/j.bpg.2013.11.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 11/20/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
Up to 35% of patients with ulcerative colitis will require surgery during the course of their disease. Nowadays, a total colectomy with ileal pouch-anal anastomosis is the preferred procedure, which can be performed open or via laparoscopic approach. Since the early '90s, minimally invasive techniques have gained popularity, but the extend of restorative procedures in these patients has restricted the use of laparoscopic approaches mainly to elective procedures in specialised centres. This review discusses the benefits and disadvantages of laparoscopic surgery when compared to open surgery. It presents the current evidence on short-term and long-term post-operative results, functional outcome, fecundity, and costs, for both elective and emergency indications. In addition, the value of new techniques (including single port surgery) and alternative laparoscopic approaches (e.g. ileo-rectal anastomosis, Kock-pouch and appendectomy) will be discussed.
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Affiliation(s)
- Christianne J Buskens
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
| | - Saloomeh Sahami
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
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Abstract
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.
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Wahbeh GT, Suskind DL, Lee SD, Waldhausen JT, Murray KF. The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist. Expert Rev Gastroenterol Hepatol 2013; 7:215-23. [PMID: 23445231 DOI: 10.1586/egh.12.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Ghassan T Wahbeh
- Inflammatory Bowel Disease Program, Seattle Children's Hospital, University of Washington, W7830, Gastroenterology, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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Williams J. What we know now: pouch surgery 40 years on. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2012; 21:S20-1. [PMID: 23123620 DOI: 10.12968/bjon.2012.21.sup16.s20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
For many patients, ileal pouch-anal anastomosis (also called ileo-anal pouch surgery) not only eradicates disease but also preserves the anal sphincter, enabling the patient to defecate in the normal way. Pouch surgery is approaching 40 years and within this time has become the 'gold standard' in surgical management for ulcerative colitis and familial adeomatous polyposis. Much of the research over the years has explored surgical techniques and pouch function, failure and satisfaction, as well as long-term follow-up; however, some pouch problems continue to be a mystery. This short article aims to bring us up to date with what we know now that might have been beneficial to know then.
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Vidall C. Should we recycle more than our plastic? BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2011; 20:S20. [PMID: 21647007 DOI: 10.12968/bjon.2011.20.sup9.s20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
For many patients, ileal pouch-anal anastomosis (also called ileoanal pouch surgery) not only eradicates disease but also preserves the anal sphincter, enabling the patient to defecate in the normal way. Pouch surgery is approaching 40 years and within this time has become the ‘gold standard’ in surgical management for ulcerative colitis and familial adeomatous polyposis. Much of the research over the years has explored surgical techniques and pouch function, failure and satisfaction, as well as long-term follow-up; however, some pouch problems continue to be a mystery. This short article aims to bring us up to date with what we know now that might have been beneficial to know then.
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