Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis

Prevalence of pouchitis in both ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis

AIM

Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis with its prevalence varying in the literature. Pouchitis is thought to occur more commonly in patients with ulcerative colitis (UC) than in patients with familial adenomatous polyposis (FAP). We conducted a systematic review with meta-analysis of all published literature to report the prevalence of pouchitis in all pouch patients as well as specifically in UC and FAP. We also investigated the prevalence of acute and chronic pouchitis in UC and FAP.

METHODS

A meta-analysis was conducted by searching the Embase, Embase Classic and PubMed databases between 1978 and 2021 exploring the prevalence of pouchitis in UC and FAP. We then performed a random effects model in order to find the pooled prevalence of pouchitis and used odds ratios to report differences in the prevalence of pouchitis in UC and FAP.

RESULTS

Fifty-nine full papers and conference abstracts were included in the meta-analysis comprising 18 117 patients with UC and 860 with FAP. The prevalence of pouchitis in UC was 0.32 (95% CI 0.27-0.37) and in FAP was found to be 0.06 (95% CI 0.03-0.15). The odds ratio of pouchitis in UC patients compared with FAP patients was 4.95 (95% CI 3.17-7.72, P < 0.0001).

CONCLUSIONS

Our findings support the consensus that the prevalence of pouchitis is higher in UC than in FAP. More significantly our findings suggest that the true prevalence of pouchitis is higher than commonly reported in the literature. This literature may help counsel patients prior to undergoing restorative proctocolectomy.

Surgical results and quality of life of patients submitted to restorative proctocolectomy and ileal pouch-anal anastomosis

PURPOSE

restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice in some cases of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). IPAA allows complete removal of the diseased colon and rectum, however, it is associated with substantial morbidity and potential consequences to patients' quality of life (QoL).

AIMS

to evaluate the surgical results, functional outcomes and QoL after IPAA; and to examine the impact of surgical complications upon QoL.

METHODS

we reviewed the records of 55 patients after IPAA, with emphasis on surgical outcomes. Forty patients answered the questionnaires. The Cleveland Global Quality of Life (CGQL), Inflammatory Bowel Disease Questionnaire (IBDQ), and Short Form 36 Health Survey Questionnaire (SF36).

RESULTS

the average age was 42.1±14.1 years. 63.6% of the patients were male, and 69.1% had FAP. Operative mortality was 1.8% and overall morbidity was 76.4%. Anastomotic leakage was the most frequent early complication (34.5%). Pouchitis (10.8%) and small bowel obstruction (9.1%) were the most common late complications. Patients with UC had the most severe complications (p=0.014). Pelvic complications did not have a negative effect on functional outcomes or QoL scores. Female patients had decreased pouch evacuation frequency, fewer nocturnal bowel movements, decreased bowel symptom impact on QoL (p=0.012), and better CGQL (p=0.04). Patients with better education had better QoL scores, and patients who had their pouches for more than five years scored lower.

CONCLUSION

the high morbidity has no impact on function or QoL. Bowel function is generally acceptable. QoL is good and affected by sex, education and time interval since IPAA.

Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties

Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.

INTESTINAL AND EXTRAINTESTINAL NEOPLASIA IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN A TERTIARY CARE HOSPITAL

Context The development of neoplasia is an important concern associated with inflammatory bowel disease (IBD), especially colorectal cancer (CRC). Objectives Our aim was to determine the incidence of intestinal and extraintestinal neoplasias among patients with inflammatory bowel disease. Methods There were retrieved information from 1607 patients regarding demographics, disease duration and extent, temporal relationship between IBD diagnosis and neoplasia, clinical outcomes and risk factors for neoplasia. Results Crohn's disease (CD) was more frequent among women (P = 0.0018). The incidence of neoplasia was higher in ulcerative colitis (UC) when compared to CD (P = 0.0003). Eight (0.99%) patients developed neoplasia among 804 with CD: 4 colorectal cancer, 2 lymphomas, 1 appendix carcinoid and 1 breast cancer. Thirty (3.7%) patients developed neoplasia among the 803 UC: 13 CRC, 2 lymphomas and 15 extraintestinal tumors. While CRC incidence was not different among UC and CD (1.7% vs 0.5%; P = 0.2953), the incidence of extraintestinal neoplasias was higher among UC (2.1% vs 0.5%, P = 0.0009). Ten (26.3%) patients out of 38 with neoplasia died. Conclusions CRC incidence was low and similar in both diseases. There was a higher incidence of extraintestinal neoplasia in UC when compared to CD. Neoplasias in IBD developed at a younger age than expected for the general population. Mortality associated with malignancy is significant, affecting 1/4 of the patients with neoplasia.

Histopathological evaluation and risk factors related to the development of pouchitis in patients with ileal pouches for ulcerative colitis

OBJECTIVE

Many changes in mucosal morphology are observed following ileal pouch construction, including colonic metaplasia and dysplasia. Additionally, one rare but potential complication is the development of adenocarcinoma of the reservoir. The aim of this study was to evaluate the most frequently observed histopathological changes in ileal pouches and to correlate these changes with potential risk factors for complications.

METHODS

A total of 41 patients were enrolled in the study and divided into the following three groups: a non-pouchitis group (group 1) (n = 20; 8 males; mean age: 47.5 years) demonstrating optimal outcome; a pouchitis without antibiotics group (group 2) (n = 14; 4 males; mean age: 47 years), containing individuals with pouchitis who did not receive treatment with antibiotics; and a pouchitis plus antibiotics group (group 3) (n = 7; 3 males; mean age: 41 years), containing those patients with pouchitis who were administered antibiotics. Ileal pouch endoscopy was performed, and tissue biopsy samples were collected for histopathological analysis.

RESULTS

Colonic metaplasia was found in 15 (36.6%) of the 41 patients evaluated; of these, five (25%) were from group 1, eight (57.1%) were from group 2, and two (28.6%) were from group 3. However, no correlation was established between the presence of metaplasia and pouchitis (p = 0.17). and no differences in mucosal atrophy or the degree of chronic or acute inflammation were observed between groups 1, 2, and 3 (p>0.45). Moreover, no dysplasia or neoplastic changes were detected. However, the degree of mucosal atrophy correlated well with the time of postoperative follow-up (p = 0.05).

CONCLUSIONS

The degree of mucosal atrophy, the presence of colonic metaplasia, and the degree of acute or chronic inflammation do not appear to constitute risk factors for the development of pouchitis. Moreover, we observed that longer postoperative follow-up times were associated with greater degrees of mucosal atrophy.

Role of ileostomy in restorative proctocolectomy

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

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION AND DATA EXTRACTION

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

DATA SYNTHESIS

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

RESULTS

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

CONCLUSION

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

The Effect of Pelvic Septic Complications on Function and Quality of Life after Ileal Pouch-Anal Anastomosis: A Single Center Experience

Ileal pouch-anal anastomosis (IPAA) has become the procedure of choice for surgical treatment of intractable ulcerative colitis (UC). Surgical complications occurring in the short-term, like pelvic sepsis, are responsible for pouch dysfunction. We prospectively evaluated 118 patients with IPAA for UC operated on between 1987 and 2002. Follow-up intervals were at 3, 6, and 12 months in the first year, then every year for at least 5 years. Patients answered a questionnaire 1 and 5 years after ileostomy closure. One hundred and seventeen patients completed the early follow-up. Nine patients developed early pelvic sepsis (7.69%); six required pouch salvage procedure. In about 33.3 per cent of cases more than one procedure was necessary. Eighty-eight patients were available for 5-year functional evaluation. Patients developing early sepsis (n = 9) showed worse long-term functional results compared with the remaining study population (n = 79): stool frequency; night evacuation; perfect day/night continence; discrimination; antidiarrhoeals need; pad usage; and sexual restriction were significantly different ( P < 0.05). Quality of life and satisfaction after surgery were good in all patients. This observation did not correlate with function. Eighty-eight and 97 per cent would undergo IPAA again and would recommend it to others respectively, in septic group and controls. Functional outcome after IPAA may be influenced by early septic complications. Overall quality of life and satisfaction with surgery are comparable with those of controls.

Role of biological mesh in surgical treatment of paracolostomy hernias

BACKGROUND

Paracolostomy hernia is a frequent complication of intestinal stoma. Its correction can be made through relocation of the colostomy or by keeping it in place and performing abdominal wall reinforcement through direct suturing with or without a prosthesis.

METHOD

Results of surgical treatment of paracolostomy hernias were analyzed in 22 patients who underwent surgery in our hospital during the past 15 years, with or without biological mesh (bovine pericardium). All patients had terminal colostomies after abdominoperineal excision of the rectum.

RESULTS

In 15 (68.2%) patients, hernia correction was made by maintaining the colostomy in place, in 2 of them (9.1%) without reinforcement, and in the other 13 (59.1%) through reinforcement of the aponeurosis with biological mesh. In the 7 (31.8%) other patients, hernia correction was accomplished by relocation of the colostomy. The mean follow-up period was 50.2 months. Recurrence was observed in 3 (13.6%) patients after a median of 16 months post-correction.

CONCLUSION

Paracolostomy hernia remains a surgical challenge due to its high recurrence rate. Primary repair using a prosthesis of biological material may be preferable since muscle-aponeurotic weakness is frequently observed.