Comparing continent ileostomy (CI) conversion to repair/redo IPAA: favorable outcomes

PURPOSE

This study aims to compare the outcomes of repair/redo ileal pouch-anal anastomosis (repair/redo-IPAA) with the conversion of IPAA to continent ileostomy (CI) in an effort to prevent the need for a permanent ileostomy (IS) following IPAA failure.

METHODS

This research involved a retrospective analysis of surgical records, employing descriptive statistics and Kaplan-Meier survival analysis.

RESULTS

Among 57 patients with an IPAA, up to three revisions were necessary due to complications or complete failure. Ultimately, repair/redo-IPAA preserved the IPAA in 14 patients (24.6%), conversion to CI salvaged the pouch in 21 patients (36.8%), and IS was unavoidable in 22 patients (38.6%). The cumulative probability of requiring conversion surgery was calculated to be 54.0% at 20 years, thereby reducing the cumulative risk of IS to 32.3%. The 20-year cumulative probability of pouch salvage by repair/redo IPAA was only 21.9%. However, this rate increased to 67.7% when conversion procedures were considered. Following repair/redo-IPAA, only 8.3% of patients reported evacuation frequencies of ≤ 4 during the day, and 16.7% were evacuation-free at night. In contrast, after conversion to CI, 98.0% of patients reported a maximum of four evacuations in a 24-h period. After undergoing repair/redo IPAA, between half and two-thirds of patients reported experiencing incontinence or soiling, while complete continence was achieved in all patients following conversion to CI. Notably, the majority of patients expressed overall satisfaction with their respective procedures. A positive correlation was identified between very high subjective satisfaction and positive objective surgical outcomes exclusively in patients who underwent conversion to CI.

CONCLUSION

When complications or failure of IPAA occur, conversion to CI emerges as a highly viable alternative to repair/redo IPAA. This conclusion is supported by the observation that patient satisfaction appears to be closely tied to stable surgical outcomes. To reinforce these findings, further prospective studies are warranted.

State-of-the-art surgery for ulcerative colitis

Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.

Surgical Management of Ulcerative Colitis

Ulcerative colitis can be managed by surgical resection of the colon and rectum. The final reconstruction options of traditional end ileostomy, continent ileostomy, ileorectal anastomosis, or ileal pouch anal anastomosis (IPAA). We maintain that the IPAA is the gold standard management of ulcerative colitis and should be performed in stages. This article includes descriptions of technique, management alternatives, and intraoperative and postoperative management of pouch issues.

Evolution of continent ileostomy

Continent ileostomy can be defined as a surgical procedure that facilitates planned intermittent evacuation of a bowel reservoir through an ileostomy. It was devised by Nils Kock in 1969. Subsequently, continent ileostomy (or Kock pouch) became a viable alternative in the management of patients who had traditionally required an end ileostomy. Kock pouch appeared to provide substantial physical and psychosocial benefits over a conventional ileostomy. The procedure became popular until ileal pouch anal anastomosis (IPAA) was introduced in 1980. Despite its benefits, continent ileostomy had many short term complications including intubation problems, ileus, anastomotic leaks, peritonitis and valve problems. Operative mortalities have also been reported in the literature. Most of these problems have been eliminated with increasing experience; however, valve-related problems remain as an “Achilles’ heel” of the technique. Many modifications have been introduced to prevent this problem. Some patients have had their pouch removed because of complications mainly related to valve dysfunction. Although revision rates can be high, most of the patients who retain their reservoirs are satisfied with regard to their health status and quality of life. Today, this procedure is still appropriate for selected patients for whom pouch surgery is not possible or for patients who have failed IPAA. Both the patient and their physician must be highly motivated to accept the risk of failure and the subsequent need for revisional operations.

Continent ileostomy: current status

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached its height of popularity in the late 1960s and early 1970s, but has been supplanted by restorative proctocolectomy, an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for restorative proctocolectomy, for whom restorative proctocolectomy or end ileostomy have failed, and in a few other selected cases. Complication rates have decreased during the past three decades following technical improvements, but remain significant. In this review, the author summarizes the current indications for continent ileostomy, examines recent technical modifications, and discusses the management of complications.

Clinical aspects of continent ileostomies

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached the height of its popularity soon after its introduction in 1969, but subsequently was supplanted by ileal pouch-anal anastomosis (IPAA), an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for IPAA or for whom IPAA or end ileostomy have failed. Complication rates that initially were high have decreased during the past three decades following the steady introduction of technical improvements.