Long-term functional outcome after restorative proctocolectomy in patients with ulcerative colitis

Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis

Objective

This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure.

Background

Previous studies demonstrated wide variation in postoperative complication rates following IPAA.

Methods

A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman's correlations.

Results

Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56-10.59) and 10.3% (95% confidence intervals: 7.24-14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1-17%), pelvic sepsis (2-18%), fistula (1-30%), stricture (1-34%), pouchitis (11-61%), and Crohn's disease of the pouch (0-18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01).

Conclusions

The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak.

Mini abstract

This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure.

Bowel Function After J-Pouch May Be More Complex Than Previously Appreciated: A Comprehensive Analysis to Highlight Existing Knowledge Gaps

BACKGROUND

Functional outcomes following J-pouch for ulcerative colitis have been studied, but lack standardization in which symptoms are reported. Furthermore, the selection of symptoms studied has not been patient centered.

OBJECTIVE

This study aimed to utilize a validated bowel function survey to determine which symptoms are present after J-pouch creation, and whether patients display a functional profile similar to low anterior resection syndrome.

DESIGN

This study is a retrospective analysis of a prospectively maintained single-center database.

SETTINGS

This study was conducted at the colorectal surgery center of a tertiary care academic hospital PATIENTS:: Included were 159 patients with J-pouch, ≥6 months after ileostomy reversal.

MAIN OUTCOME MEASURES

The primary outcomes were individual answers to the Memorial Sloan Kettering Cancer Center Bowel Function Instrument. The original Bowel Function Instrument validation cohort was used as an historical comparison (n = 127).

RESULTS

The mean total Bowel Function Instrument score for the J-pouch cohort was 59.9 ± 9.7 compared with a reported average score of 63.7 ± 11.6 for patients with low anterior resection in the validation cohort (p < 0.001), indicating worse bowel function in patients with J-pouch. When evaluating the Bowel Function Instrument subscales, patients with J-pouch reported frequency subscale scores of 18.2 ± 3.8, diet scores of 12.2 ± 3.8, and urgency scores of 15.9 ± 3.7, compared with 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001), and 15.0 ± 3.9 (p = 0.04) for patients undergoing rectal resection. Furthermore, 90.4% of patients with J-pouch state that they are sometimes, rarely, or never able to wait 15 minutes to get to the toilet. In addition, 56.4% of patients report having another bowel movement within 15 minutes of the last bowel movement, sometimes, always, or most of the time, and 50.6% of patients say that they sometimes, rarely, or never feel like their bowels have been totally emptied after a bowel movement.

LIMITATIONS

This study is limited because it took place at a single center and the Bowel Function Instrument was only validated for patients undergoing rectal resection.

CONCLUSIONS

Patients that undergo J-pouch surgery exhibit a constellation of bowel function symptoms that is more complex than fecal incontinence and frequency alone, despite the focus on these functional outcomes in the literature. See Video Abstract at http://links.lww.com/DCR/B73. LA FUNCIÓN INTESTINAL DESPUÉS DE LA BOLSA EN J PUEDE SER MÁS COMPLEJA DE LO QUE SE APRECIABA ANTERIORMENTE: UN ANÁLISIS EXHAUSTIVO PARA RESALTAR LAS BRECHAS DE CONOCIMIENTO EXISTENTES: Se han estudiado los resultados funcionales después de la bolsa en J para la colitis ulcerosa, pero carecen de estandarización en la que se informen los síntomas. Además, la selección de los síntomas estudiados no se ha centrado en el paciente.Utilizar una encuesta validada de la función intestinal para determinar qué síntomas están presentes después de la bolsa en J y si los pacientes muestran un perfil funcional similar al síndrome de resección anterior baja.Análisis retrospectivo de una base de datos de un solo centro mantenida prospectivamente.Centro de cirugía colorrectal de un hospital académico de atención terciaria.159 pacientes con bolsa en J, ≥6 meses después de la reversión de ileostomía.Instrumento para la función intestinal del "Memorial Sloan Kettering Cancer Center"; cohorte de validación original de instrumentos de función intestinal utilizada como comparación histórica (n = 127).La puntuación media total del instrumento de función intestinal para la cohorte de bolsa J fue 59.9 ± 9.7 en comparación con un puntaje promedio reportado de 63.7 ± 11.6 para pacientes con resección anterior baja en la cohorte de validación (p < 0.001), lo que indica peor función intestinal en pacientes con bolsa en J. Al evaluar las subescalas del instrumento de función intestinal, los pacientes con bolsa en J informaron puntuaciones de subescala de frecuencia de 18.2 ± 3.8, puntuaciones de dieta de 12.2 ± 3.8 y puntuaciones de urgencia de 15.9 ± 3.7, en comparación con 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001) y 15.0 ± 3.9 (p = 0.04) respectivamente para pacientes con resección rectal. Además, el 90.4% de los pacientes con bolsa en J afirman que a veces, rara vez o nunca pueden esperar 15 minutos para llegar al baño. Además, el 56.4% de los pacientes reportan haber tenido otra evacuación intestinal dentro de los 15 minutos posteriores a la última evacuación intestinal, a veces, siempre o la mayor parte del tiempo, y el 50.6% de los pacientes dicen que a veces, rara vez o nunca sienten que sus intestinos han sido vaciados totalmente después de una evacuación intestinal.Estudio en un solo centro, instrumento de función intestinal validado solo para pacientes con resección rectalLos pacientes que se someten a una bolsa en J exhiben una constelación de síntomas de la función intestinal que es más compleja que la incontinencia fecal y la frecuencia sola, a pesar del enfoque en estos resultados funcionales en la literatura.Consulte Video Resumen en http://links.lww.com/DCR/B73. (Traducción-Dr. Gonzalo Federico Hagerman).

The Handling of the Rectal Stump Does Not Affect Severe Morbidity After Subtotal Colectomy For Ulcerative Colitis: A Retrospective Cohort Study

Background and Aims:

Colectomy due to ulcerative colitis is associated with complications. One severe complication is the risk for blow-out of the remaining rectal remnant. The aim of this study was to compare the frequency and severity of complications in patients with the rectal remnant left subcutaneously versus patients with the rectal remnant left intra-abdominally. A secondary aim was to identify risk factors for complications.

Materials and Methods:

Consecutive patients at two tertiary centers in Sweden were retrospectively reviewed regarding surgical procedures; complications classified according to Clavien–Dindo; and possible risk factors for complications such as preoperative medication, emergency surgery, and body mass index.

Results:

307 patients were identified. Minor complications were more common than previously reported (85%–89%). Severe surgical complications were not related to the handling of the rectal remnant. Leaving the rectal remnant subcutaneously was associated with local wound problems. Risk factors for severe complications were emergency surgery and preoperative medication with 5-aminosalicylic acid.

Conclusion:

Minor complications after colectomy for ulcerative colitis are very common and need to be addressed. Leaving the rectal stump intra-abdominally seems safe and may be advantageous to reduce local wound morbidity.

Long-term functional outcome after restorative proctocolectomy: a cross-sectional study

OBJECTIVE

Restorative proctocolectomy is the procedure of choice in the surgical treatment of ulcerative colitis. Functional outcome is the key result of surgery. The aim of this study was to evaluate the long term-functional outcome after the procedure.

MATERIAL AND METHODS

The study comprised 282 ulcerative colitis patients over 18 years of age who underwent restorative proctocolectomy between1985 and 2009. The median follow-up time was 13 years (range 4-28). Functional outcome of the pouch was evaluated by the disease-specific Öresland questionnaire with a score 0-15; 15 being the worst, and score <8 considered well-functioning.

RESULTS

The mean functional score was 5.5 (men 5.6, women 5.0). Seventy per cent of the patients had a well-functioning pouch. Those with poor function had had significantly more pouchitis than the patients with well-functioning pouches, 51.0 vs. 25.6% respectively (p = .001). No association was found between functional score and the time since the operation. In multiple regression analysis only the occurrence of pouchitis was associated with poor functional results.

CONCLUSIONS

The functional results were good and remained stable in the majority of the patients. Pouchitis seemed to have a negative impact on the functional results. Elderly patients especially need careful planning and counselling before restorative proctocolectomy.

溃疡性结肠炎的外科微创治疗

外科治疗是溃疡性结肠炎(ulcerative colitis, UC)的重要组成部分, 全结直肠切除、回肠贮袋肛管吻合术(ileal pouch-anal anastomosis, IPAA)已成为标准术式. 近年来在微创外科技术的迅猛发展与普及下, 越来越多医疗中心开展腹腔镜IPAA手术. 腹腔镜IPAA手术相比于开腹手术的在术后近、远期疗效中的优势逐渐突显, 且其安全有效性已达成共识. 目前更多更为微创的技术也陆续尝试应用于IPAA手术. 但是由于UC患者自身疾病的特点和IPAA术式的复杂性, 腹腔镜IPAA手术仍未达到标准化、规范化水平. 本文主要针对UC微创外科术后疗效和合理应用的研究进展作一述评.

Ileal pouch-anal anastomosis 20 years later: is it still a good surgical option for patients with ulcerative colitis?

PURPOSE

Short-term results after ileo-pouch anal anastomosis (IPAA) are well established; data are conflicting in long-standing patients. We retrospectively evaluated long-term complications and functional results after follow-up longer than 20 years.

METHODS

Two hundred five patients with follow-up longer than 20 years have been identified out of 1112 IPAA performed in our institution; of these, 20 cases were lost at follow-up or decline to take part at the study. We evaluated long-term complications and failure rate also according to changes in histological diagnosis. Changes in functional results and quality of life (QoL) were analyzed at 5 and 20 years after IPAA.

RESULTS

Pouch failure rate was 10.8 % (35 % due to misdiagnosed Crohn). Incidences of fistulas, anastomotic stenosis, chronic pouchitis, and pre-pouch ileitis were 17.3, 12.9, 28.6, and 7.6 %, respectively. Most of the patients reported good functional outcomes. Day-time evacuations at 5 and after 20 years were 4.3 and 4.8 (p = n.s.) while during night-time were 0.8 and 1.2 (p < 0.05). Urgency was 6 and 9.4 % (p = n.s.), respectively; need of antimotility drugs was 16 and 35 % (p < 0.001). Dietary limitations and work restrictions were similar over time. Only sexuality got worse during follow-up. Satisfaction for surgery was always high and it did not change over time.

CONCLUSION

IPAA is still an excellent surgical option for UC with a low rate of pouch failure even after more than 20 years. Despite a slight worsening of functional results over time, the QoL remained high and most patients expressed satisfaction with the procedure and were willing to recommend it to others.

Role of laparoscopic surgery in the treatment of ulcerative colitis; short- and mid-term results

OBJECTIVES

Laparoscopy is used more widely for the surgery of ulcerative colitis. The objective of this study was a comparison of the surgical and 3-year follow-up results of patients treated with conventional and minimally invasive methods.

MATERIALS AND METHODS

A total of 45 patients received surgery for ulcerative colitis, 16 as emergency and 29 as elective cases. Laparoscopy was used in 23 and a conventional method in 22 cases. No difference was found between the two groups from the aspects of American Society of Anesthesiologists physical status (ASA) class, mean body mass index (BMI) and age. There were 4 emergency cases in the laparoscopy group, and 12 in the open group. Nineteen elective surgeries were performed in the laparoscopy group, and 10 in the open group.

RESULTS

There was no significant difference between the groups as concerns the length of hospital or intensive care unit (ICU) stay, the time to bowel function recovery, but the duration of open surgery was significantly shorter. There was no difference between the groups in the rate of early postoperative complications, whereas among potential late complications, the rates of intestinal obstruction (8.7% vs. 45%) and a septic condition (0% vs. 27%) were significantly lower in the laparoscopy group. There was a significant improvement in the quality of life after surgery in both groups, and better cosmetic results were observed in the laparoscopy group.

CONCLUSION

Laparoscopy can be used for ulcerative colitis both emergency and elective cases, it provides a good quality of life and the mid-term rate of complications is lower as compared with open surgery.

Long-term functional outcome after ileal pouch anal anastomosis in 191 patients with ulcerative colitis

BACKGROUND

A long-lasting good functional outcome of the pelvic pouch and a subsequent satisfying quality of life (QoL) are mandatory. Long-term functional outcome and QoL in a single-center cohort were assessed.

PATIENTS AND METHODS

A questionnaire was sent to all patients with an IPAA for UC, operated between 1990 and 2010 in our department. Pouch function was assessed using the Öresland Score (OS) and the 'Pouch Functional Score' (PFS). QoL was assessed using a Visual Analogue Score (VAS).

RESULTS

250 patients (42% females) with a median age at surgery of 38 years (interquartile range (IQR): 29-48 years) underwent restorative proctocolectomy. Median follow-up was 11 years (IQR: 6-17 years). Response rate was 81% (n=191). Overall pouch function was satisfactory with a median OS of 6/15 (IQR: 4-8) and a median PFS of 6/30 (IQR: 3-11). 24-hour bowel movement is limited to 8 times in 68% of patients (n=129), while 55 patients (29%) had less than 6 bowel movements. 12 patients (6.5%) were regularly incontinent for stools, while 154 patients (82%) reported a good fecal continence. Fecal incontinence during nighttime was more common (n=72, 39%). Pouch function had little impact on social activity (4/10; IQR: 2-6) and on professional activity (3/10; IQR: 1-6). 172 patients (90%) reported to experience an overall better health condition since their operation. The OS and the PFS correlated well (Pearson's correlation coefficient=0.83). Overall pouch function was stable over time.

CONCLUSION

Majority of patients report a good pouch function on the long-term with limited impact on QoL.

What we know now: pouch surgery 40 years on

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.

Should we recycle more than our plastic?

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.