Temporal changes in functional outcomes of stapled and hand-sewn ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis

AIM

Little is known about how ileal pouch-anal anastomosis (IPAA) influences anorectal manometric data. This study aimed to clarify temporal changes in anorectal manometric data and faecal incontinence in IPAA.

METHODS

We examined 32 patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) undergoing restorative proctocolectomy with stapled or hand-sewn IPAA. Maximum resting pressure (MRP) and maximum squeezing pressure (MSP) were analysed before and 1-3, 6-9, and 12-24 months after IPAA. Cleveland Clinic Florida-Faecal Incontinence Score (CCF-FIS) was measured 6-9 and 12-24 months after IPAA.

RESULTS

Fourteen patients underwent stapled IPAA and 18 patients underwent hand-sewn IPAA. MRP decreased 1-3 months after stapled IPAA (median: 42.3 mmHg vs. 60.0 mmHg at preoperative value, p = 0.039), but recovered afterwards. In hand-sewn IPAA, the median MRP decreased to 29.5 mmHg at 1-3 months after IPAA (baseline: 64.8 mmHg, p < 0.0001), and remained unchanged thereafter. Stapled IPAA did not affect MSP; however, hand-sewn IPAA caused a reduction in the median MSP from 191.3 mmHg to 141.3 mmHg at 1-3 months (p = 0.035), which gradually increased afterwards. The median CCFFIS was 5.5 points at 6-9 months and 2 points at 12-24 months after stapled IPAA. The score was high (11 points) at 6-9 months but decreased to 5 points at 12-24 months after hand-sewn IPAA (p = 0.022).

CONCLUSION

We present time trends in functional outcomes of IPAA. MRP showed a transient decrease after stapled IPAA, whereas it remained low after hand-sewn IPAA. CCFFIS was high only at 6-9 months after hand-sewn IPAA.

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment

This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.

Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre

Background

Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes.

Methods

Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed.

Results

Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data.

Conclusions

In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Transabdominal Pouch Salvage for Failed Minimally Invasive Versus Open IPAA: A Case-Matched Study

BACKGROUND

Modality of index IPAA creation may affect the results after redo IPAA surgery for IPAA failure. To our knowledge, there is no study evaluating the effects of modality of index IPAA creation on redo IPAA outcomes.

OBJECTIVE

This study aimed to compare short- and long-term outcomes of transabdominal redo IPAA surgery for failed minimally invasive IPAA and open IPAA.

DESIGN

This was a retrospective cohort study.

SETTINGS

This investigation was based on a single-surgeon experience on redo IPAA.

PATIENTS

Patients undergoing transabdominal redo IPAA for a failed minimally invasive IPAA and open IPAA between September 2007 and September 2017 were included.

MAIN OUTCOME MEASURES

Short-term complications and long-term outcomes were compared between 2 groups.

RESULTS

A total of 42 patients with failed index minimally invasive IPAA were case matched with 42 failed index open IPAA counterparts. The interval between index IPAA and redo IPAA operations was shorter in patients who had minimally invasive IPAA (median, 28.5 vs 56.0 mo; p = 0.03). A long rectal stump (>2 cm) was more common after minimally invasive IPAA (26% vs 10%; p = 0.046). Redo IPAAs were constructed more commonly with staplers in the laparoscopy group compared with open counterparts (26% vs 10%; p = 0.046), and other intraoperative details were comparable. Although short-term morbidity was similar between 2 groups, abscess formation (7% vs 24%; p = 0.035) was more frequent in patients who had index IPAA with open technique. Functional outcomes were comparable. Redo IPAA survival for failed minimally invasive IPAA and open IPAA was comparable.

LIMITATIONS

This study was limited by its retrospective, nonrandomized nature and relatively low patient number.

CONCLUSIONS

A long rectal cuff after minimally invasive IPAA is a potential and preventable risk factor for failure. Due to its technical and patient-related complexity, handsewn anastomoses in redo IPAA are associated with increased risk of abscess formation. See Video Abstract at http://links.lww.com/DCR/B252. RESCATE DEL RESERVORIO ILEO-ANAL POR VIA TRANSABDOMINAL EN CASOS DE FUGA ANASTOMÓTICA ENTRE ABORDAGE MINIMAMENTE INVASIVO Y ABORDAJE ABIERTO: ESTUDIO DE EMPAREJAMIENTO DE MUESTRAS Y CASOS: La creación de modalidades e índices de Reservorios Ileo-Anales (RIA) pueden afectar los resultados después de rehacer la cirugía de RIAs por fallas en el reservorio. Hasta donde sabemos, no hay ningún estudio que evalúe los efectos de la modalidad de creación de índices RIA en los resultados para el rescate del reservorio.Este estudio tuvo como objetivo comparar los resultados a corto y largo plazo de la cirugía transabdominal redo RIA en casos de fracaso por via mínimamente invasiva (MI-RIA) o por la vía abierta (A-RIA).Estudio de cohortes tipo retrospectivo.Investigación basada en la experiencia de un solo cirujano en redo del Reservorio Ileo-Anal.Se incluyeron aquellos pacientes sometidos a re-operación transabdominal y re-confección de un RIA por fallas en el MI-RIA y en el A-RIA durante un lapso de tiempo entre septiembre 2007 y septiembre 2017.Las complicaciones a corto plazo y los resultados a largo plazo se compararon entre los dos grupos.Un total de 42 pacientes con índice fallido de MI-RIA fueron emparejados con 42 homólogos con índice fallido de A-RIA. El intervalo entre las operaciones de RIA y redo RIA fué más corto en pacientes que tenían MI-RIA (mediana, 28,5 meses frente a 56 meses, p = 0,03). Un muñón rectal largo (> 2 cm) fue más común después de MI-RIA (26% vs 10%, p = 0.046). Redo RIAs se construyeron más comúnmente con engrampadoras en el grupo Minimalmente Invasivo en comparación con la contraparte abiertas (26% vs 10%, p = 0.046). Aunque la morbilidad a corto plazo fue similar entre los dos grupos, la aparición de abscesos (7% frente a 24%, p = 0.035) fue más frecuente en pacientes que tenían RIA con técnica abierta. Los resultados funcionales fueron comparables. La sobrevida de las redo RIAs para MI-RIA y A-RIA fallidas, también fué comparable.Este estudio estuvo limitado por su naturaleza retrospectiva, no aleatoria y el número relativamente bajo de pacientes.Un muñon rectal largo después de MI-RIA es un factor de riesgo potencial y previsible para el fracaso. Debido a su complejidad técnica y relacionada con el paciente, las anastomosis suturadas a mano en redo RIA están asociadas con un mayor riesgo de formación de abscesos. Consulte Video Resumen en http://links.lww.com/DCR/B252.

Colorectal family polyadenomatous diseases. What management in 2020?

Nearly 5% of colorectal cancers are hereditary colorectal cancers, including adenomatous polyposis. The aim of this review was to highlight the current management of adenomatous polyposis. The two main genetic conditions responsible for adenomatous polyposis are familial adenomatous polyposis (FAP) (caused by an autosomal dominant mutation of the APC gene) and MUTYH-associated polyposis (MAP) (caused by bi-allelic recessive mutations of the MUTYH (MutY human homolog) gene). FAP is characterized by the presence of >1000 polyps and a young age at diagnosis (mean age of 10). In the absence of screening, the risk of colorectal cancer at age 40 is 100%. It is recommended to start screening at the age of 10-12 years. For patients with FAP and MAP, it is also recommended to screen the upper gastrointestinal tract (stomach and duodenum). In FAP, prophylactic surgery aims to reduce the risk of death without impairment of patient quality of life. The best age for prophylactic surgery is not well-defined; in Europe, prophylactic surgery is usually performed at age 20 as the risk of cancer increases sharply during the third decade. There are three main surgical procedures employed: total colectomy with an ileorectal anastomosis, restorative coloproctectomy with a J pouch anastomosis and coloproctectomy with a stoma. Restorative coloproctectomy with J pouch anastomosis is the reference procedure; however, disease can vary in severity from one patient to another and this must be taken into account to decide which procedure should be performed. In conclusion, the management of adenomatous polyposis is complex but is well-defined by guidelines, particularly in France.

Postoperative functional outcomes and complications of partially intraanal canal anastomosis in stapled ileal pouch anal anastomosis for ulcerative colitis

AIM

For ulcerative colitis (UC), stapled ileal pouch anal anastomosis (IPAA) reportedly results in better bowel function than does IPAA with mucosectomy. However, a potential cancer risk in the remnant mucosa has been observed. The clinical results of IPAA by double stapling technique (DS-IPAA) in which the anastomotic line was on the dentate line at posterior wall and the top of anal canal at anterior wall ("Partially intraanal canal anastomosis": PICA) to reduce the remnant mucosa were evaluated.

METHODS

Clinical results of PICA were retrospectively compared with those by DS-IPAA with anastomosis at above the anal canal on 1 year after open surgery. Of 211 UC cases that underwent DS-IPAA, 146 cases (69%) with PICA who were confirmed by the squamous epithelium on the posterior part of the distal donuts were included. Sixty-five cases with anastomosis above the anal canal were evaluated as the control. One stage surgery underwent in 95% of PICA and 93% of control.

RESULTS

One year after surgery, each group had six bowel movements daily. Nighttime evacuation was found in 16% of PICA and in 20% of control. Soiling was found in 1% of PICA and 4.8% of control. After one stage operation, anastomotic leakage that needed ileostomy was observed in 0.7% of PICA and 3% of control.

CONCLUSION

Partially intraanal canal anastomosis (PICA) can reduce anal canal mucosa with the same postoperative bowel function and complication rate as DS-IPAA above the anal canal. This procedure may be feasible for UC patients who can tolerate this procedure in terms of decreasing postoperative cancer risk.

Morbidity related to diverting ileostomy after restorative proctocolectomy in patients with ulcerative colitis

AIM

Restorative proctocolectomy with ileal pouch-anal anastomosis is considered by many surgeons to be the standard procedure for surgical management of ulcerative colitis. There is controversy about whether or not a covering ileostomy should be constructed. The aim of this study was to evaluate the outcomes and morbidity for patients with ulcerative colitis who underwent restorative proctocolectomy with or without a diverting ileostomy.

METHOD

This is a retrospective study of a consecutive series of 510 patients with ulcerative colitis who were operated on in Helsinki University Hospital between January 2005 and June 2016. A diverting ileostomy was performed in 119 patients (the stoma group) compared with 391 patients with no stoma.

RESULTS

Dehydration and intestinal obstruction occurred more often in the stoma group (P < 0.0001). Clinical anastomotic leakage was more common among patients without an ileostomy (6.6% vs 1.7%, P = 0.04). However, the need for re-laparotomy because of any early complication did not differ between the groups (P = 0.58). Within 3 months, 50 patients with ileostomy (42.0%) and 51 patients without (13.0%) were readmitted (P < 0.0001). In total, 35 patients (29.3%) had a complication relating to ileostomy closure and four of them required surgery. There was no difference in the rate of fistulas, pouchitis or pouch failure between the groups.

CONCLUSION

Our study shows that a diverting ileostomy is associated with considerable morbidity but it does not seem to prevent later failure of the pouch. We suggest that a diverting ileostomy should only be constructed for high-risk patients.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

[The technique of restorative proctocolectomy with ileal J‑pouch : Standards and controversies]

BACKGROUND

Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC).

OBJECTIVES

This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC.

RESULTS

RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated.

CONCLUSION

The evidence in regard to controversial points remains limited.

Long-Term Functional Outcome and Quality of Life After Restorative Proctocolectomy With Mucosectomy and Hand Suture IPAA: 20 Years' Experience in 326 Patients

This paper was designed to evaluate the functional outcome and assess the long-term quality of life (QoL) of patients who underwent restorative proctocolectomy with mucosectomy and hand suture ileal pouch-anal anastomosis (IPAA) over 20 years. Restorative proctocolectomy with IPAA is the surgical treatment of choice to all familial adenomatous polyposis (FAP) patients and those with ulcerative colitis (UC) not responding to conservative management. The procedure has been modified from a transanal hand-suture IPAA after mucosectomy to a stapled IPAA without mucosectomy, but the benefits are still debatable. We studied retrospectively all UC and FAP patients subjected to the procedure between 1987 and 2006, using the SF-36 Health Survey, the Wexner score for incontinence, and an additional questionnaire evaluating various aspects of functional outcome and late complications.

A total of 326 patients (53% male) were included in the study. Pouchitis was recorded in 31% of UC and 5% of FAP patients. Anastomotic stricture was observed in 24% of UC and 8% of FAP patients. IPAA-related pouch failures occurred in 9% of UC and 3% of FAP. The median number of bowel movements per 24 hours was 6 (range: 2–20) with 1 (range: 0–8) bowel motion occurring at night. Wexner score was 3.27 (±0.32) for UC and 1.22 (±0.36) for FAP. The overall norm-based SF-36 score for physical/mental health status was 52.85/50.31 and 57.29/50.05 respectively. Restorative proctocolectomy with mucosectomy and hand suture IPAA is a safe procedure with good functional results and quality of life in well-satisfied patients. Pouchitis, anastomotic strictures, and pouch failures were mainly observed in the UC group.

Female sexual function and fertility after ileal pouch-anal anastomosis

PURPOSE

A potential complication in women after ileal pouch-anal anastomosis (IPAA) is sexual impairment and reduced fertility. The aim was to evaluate sexual function and fertility after IPAA.

METHODS

All female patients who underwent an IPAA between 2004 and 2013 were retrospectively included. Sexual function, fertility, and continence were explored by the female sexual function index (FSFI), telephonic interview, and Wexner's score.

RESULTS

Among 127 women included, 93 responded to the questionnaires (73.2%). Seventy five were sexually active, and 48 (64%) had normal sexual function (FSFI > 26). In univariate analysis, there was a significant relationship between ulcerative colitis (p = 0.0161), age > 40 years (p = 0.01311), number of bowel movements (p = 0.0238), nocturnal pouch activity (p = 0.0094), use of loperamide (p = 0.0283), and existence of sexual dysfunction. After multivariate analysis, age and nocturnal pouch activity were associated with a worse sexual function (p = 0.0235, OR = 3.3 (1.2-9.9) and p = 0.0094, OR = 4.1 (1.4-13.5)). Of 16 patients who wished to have children, 10 (63%) became pregnant without recourse to in vitro fertilization, of whom 3 had two or more pregnancies. In total, there were 13 children born after IPAA. The mean time between the first pregnancy and surgery was 24.8 ± 22 months. At 12 and 24 months after cessation of contraception, 57 and 67% had at least one pregnancy.

CONCLUSIONS

While sexual function is impaired in a limited number of patients, the impact of surgery can be regarded as modest. Age and nocturnal pouch activity were some independent factors of worse sexual function. The risk of infertility should not preclude consideration of IPAA as a treatment option.

Inflammatory bowel disease meta-evidence and its challenges: is it time to restructure surgical research?

AIM

The aim of this study was to compare the methodological quality and input paper characteristics of systematic reviews and meta-analyses reported in the medical and surgical literature by performing a systematic 'overview of reviews'. Ulcerative colitis (UC) and Crohn's disease (CD) were used as the framework for this comparison as they are relatively common serious conditions, with both medical and surgical options for therapy.

METHOD

Medline, Embase, CINHAL and the Cochrane Database were searched to November 2013. Eligible papers were systematic reviews or meta-analyses that considered a question of therapy in CD or UC. Two independent reviewers selected the papers, extracted the data and scored their methodology using the AMSTAR scoring system. The papers were categorized into medical therapy (M), surgical therapy (S) or medical and surgical therapy (MS) groups. Following retrieval of the sample of meta-evidence papers, the original input studies used in their creation were identified and a search of Medline, Embase, CINHAL and the Cochrane Database was performed. A team of researchers then examined the collection of papers for bibliographic and financial information.

RESULTS

Five hundred papers were identified in the meta-evidence search, of which 118 were deemed eligible. There was a difference in the AMSTAR-rated average quality of the papers between the S and M group (S 7.36 vs M 8.75, P = 0.01). On average S papers were published in journals with a lower impact factor (S 3.26, M 5.04, MS 5.30, P < 0.001). S papers also showed more heterogeneity (I(2) ; S 37%, M 24%, MS 10%, P < 0.001). Some 25% of S meta-analyses used data-sets with significant heterogeneity (I(2) > 75%), compared with 8% of M meta-analyses and 3% of the MS meta-analyses. Some 5% of S papers were done on data sets that had I(2) values > 90%. There was no difference in the average number of papers assessed in each group, the average number of patients per meta-paper, the average time covered by the reviews, the average number of papers considered within each meta-analysis, or the average number of patients considered within each meta-analysis. Considering the conclusions of each meta-analysis, S meta-evidence was 50% more likely than M meta-evidence to be unable to make recommendations for practice. A total of 1499 original input papers were identified, of which 283 were used in more than one review. Within the non-repeated papers (n = 1023) the average impact factor within the S group was lower than that of the M and the MS groups (3.720 vs 11.230 vs 7.563, respectively; ANOVAP < 0.001). M papers had higher rates of pharmaceutical sponsorship than S papers (M 56% vs S 1%) and twice the level of government support (M 16% vs S 8%). Of note, 21% of M papers had corporate sponsorship but did not list any conflict of interest.

CONCLUSION

Compared with M meta-analyses, S meta-analyses in the UC and CD domain are more likely to be of poorer methodological quality, are of a greater degree of heterogeneity and less often offer a positive conclusion. The papers used to generate meta-evidence in M papers have a greater degree of corporate and government sponsorship, and are more likely to come from journals with higher impact factors.

Ileal pouch-anal anastomosis: Points of controversy

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current "hot topics" for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn's disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues.

Role of surgery in pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) has a more extensive and progressive clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent surgical treatments are needed. The therapeutic goal is to gain clinical and laboratory control of the disease with minimal adverse effects while permitting the patient to function as normally as possible. Approximately 5-10 % of patients with UC require acute surgical intervention because of fulminant colitis refractory to medical therapy. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This review will focus on the current issues regarding the surgical indications for pediatric UC, the technical details of procedures and results of most recent published series to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

History of and current issues affecting surgery for pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION AND DATA EXTRACTION

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

DATA SYNTHESIS

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

RESULTS

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

CONCLUSION

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

Oncologic outcome in patients with ulcerative colitis associated with dyplasia or cancer who underwent stapled or handsewn ileal pouch-anal anastomosis

PURPOSE

Ulcerative colitis is a risk factor for colorectal cancer. Restorative proctocolectomy with ileal pouch-anal anastomosis is a standard surgical management of patients with ulcerative colitis who have cancer or dysplasia, but the oncologic risk of stapled anastomosis vs mucosectomy with handsewn anastomosis is debated. We compare the risk of new cancer or recurrence in the pouch or rectal cuff in patients with ulcerative colitis undergoing stapled anastomosis vs mucosectomy with handsewn anastomosis.

METHODS

This study was performed as a retrospective analysis of the clinical database at a single center, Mount Sinai Hospital, Toronto, Canada. The patients with ulcerative colitis associated with colorectal dysplasia or cancer who underwent ileal pouch-anal anastomosis between 1981 and 2009 were evaluated. The development of dysplasia or cancer at ileoanal anastomosis or in the pelvic pouch was assessed.

RESULTS

Eighty-one patients underwent stapled (n = 59) or handsewn (n = 22) ileal pouch-anal anastomosis; 52 had evidence of dysplasia and 29 had colorectal cancer (24 colon; 5 rectum) at the time of surgery. Median follow-up was 76.1 months. Two of 10 (20%) patients with handsewn anastomosis and 0% patients with stapled anastomosis developed metastatic cancer. One patient with a 33-year history of colitis, a previously resected right-sided colon cancer, and subsequent high-grade dysplasia in the rectum underwent a handsewn pelvic pouch and developed an unresectable adenocarcinoma at the cuff 4 years later. A second patient with a 10-year history of colitis underwent handsewn pelvic pouch and developed dysplasia in the pouch 8 years after surgery. Nine patients were dead at last follow-up (11%). Of those patients, both colorectal cancer-related deaths were in patients with handsewn anastomoses. Differences in overall 5-year survival between the groups did not reach statistical significance. This study was limited by the sample size in subgroups and the few outcome events.

CONCLUSIONS

Performing a stapled ileal pelvic anal anastomosis does not appear to be inferior to mucosectomy and handsewn anastomosis in oncologic outcome, and it seems appropriate in patients with ulcerative colitis associated with coexisting dysplasia or cancer.

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

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

Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy?

BACKGROUND AND AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Adenocarcinoma of the anal transitional zone after double stapled ileal pouch-anal anastomosis for ulcerative colitis

The development of adenocarcinoma in the anal transitional zone, after restorative proctocolectomy for ulcerative colitis, is rare. We report the first Asian and sixth known case. A 41-year-old Indian lady had a long standing history of ulcerative colitis. Restorative proctocolectomy and stapled ileal pouch-anal anastomosis without mucosectomy was performed. She remained asymptomatic until 3 years later when she complained of discomfort on defecation. A poorly differentiated adenocarcinoma in the anal transition zone was diagnosed and she subsequently underwent an abdomino-perineal resection. The previously reported cases in the literature are reviewed. We also discuss the suggested surveillance for high-risk patients who have undergone an ileal-anal pouch anastomosis.

Multimedia article. Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction without protective ileostomy

PURPOSE

Restorative proctocolectomy is a standard treatment for colorectal diseases over decades. At present, this technique is frequently performed via minimal invasive approach. Most reported techniques of laparoscopic restorative proctocolectomy involved a Pfannenstiel incision for the major part of the operation to be performed openly; a double-stapled pouch anal anastomosis technique and protective ileostomy. This study was designed to demonstrate the modification of this technique.

METHODS

This was a retrospective study of seven patients (4 had ulcerative colitis and 3 had familial adenomatous polyposis) who underwent laparoscopic restorative proctocolectomy at King Chulalongkorn Memorial Hospital between September 2004 and February 2007. The details of the procedure are shown in the video. The techniques involve the following: full mobilization of entire colon and rectum using medial to lateral approach, division of submesenteric arcades for ileal pouch elongation with preservation of three to four inner most arcades of distal ileum segment and preservation of both superior mesenteric and ileocolic trunk, ileal pouch construction via a small (3-4 cm) McBurney incision, transanal mucosectomy with removal of the entire rectum and colon transanally, and handsewn ileal pouch-anal anastomosis. None of the patients underwent protective ileostomy.

RESULTS

Mean surgical time was 360 (270-510) minutes, and median blood loss was 230 (100-400) ml. There were neither conversions nor intraoperative surgical complications. However, one patient developed small-bowel obstruction, which was successfully treated by laparoscopic approach. Anastomotic leakage was not found in this series. All patients have good control of their bowel movement as well as a very good cosmetic result during the follow-up period.

CONCLUSIONS

Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction, without protective ileostomy, is technically feasible and safe.

Ileal pouch-anal anastomosis

BACKGROUND

Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application.

METHODS AND RESULTS

Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

CONCLUSION

The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

Ileal pouch-anal anastomosis for ulcerative colitis: technical considerations

Total colectomy with ileal pouch-anal anastomosis has emerged as the preferred surgical treatment for ulcerative colitis. The operation has evolved over the last few decades. Various technical issues are discussed, including types of reservoir, options for mesenteric lengthening, method and level of ileoanal anastomosis (hand-sewn versus stapled), and rationale for staging. Anticipated postoperative problems and strategies for management are discussed.

Associated Neoplastic Disease in Inflammatory Bowel Disease

The development of intestinal carcinoma in the setting of inflammatory bowel disease (IBD) has been recognized as an unsavory outcome of chronic inflammation of the bowel. Numerous studies have recently documented the clinical and morphologic features of malignant transformation in this closely-followed group of patients. This article highlights the recent findings of these population-based studies with specific attention to surgical concepts and frames these data in the context of surgical approaches to cancer arising in inflammatory disease. Specifically, the authors address the pathobiology of malignant transformation, the management of colorectal cancer in inflammatory bowel disease, the development of dysplasia in ulcerative colitis, surveillance of patients who have IBD, chemoprevention of cancer, and special features of surgical oncologic management.