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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. High but decreasing rates of reconstruction after total proctocolectomy for ulcerative colitis, and evidence of a direct volume outcome relationship. ANZ J Surg 2024. [PMID: 38525855 DOI: 10.1111/ans.18986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Total (procto)colectomy is indicated in 15%-20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian-based population-level data, and factors influencing reconstruction. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1-year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression. RESULTS Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5-year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time-period (2014-2019) (aHR 0.68[95% CI 0.54-0.86]), and where index (procto)colectomy was performed in low-volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43-0.82]). CONCLUSIONS NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time-period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres.
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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, Royal Prince Alfred Hospital, 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
| | - 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, 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
| | - 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
| | - Joe Van Buskirk
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19-year New South Wales data linkage study. ANZ J Surg 2023; 93:2686-2696. [PMID: 37449791 DOI: 10.1111/ans.18588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. RESULTS The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. CONCLUSIONS The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.
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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
| | - 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, 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, 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, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Maspero M, Hull TL. Clinical approach to patients with an ileal pouch. Abdom Radiol (NY) 2023; 48:2918-2929. [PMID: 37005915 DOI: 10.1007/s00261-023-03888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.
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Affiliation(s)
- Marianna Maspero
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Esckilsen S, Kochar B, Weaver KN, Herfarth HH, Barnes EL. Very Early Pouchitis Is Associated with an Increased Likelihood of Chronic Inflammatory Conditions of the Pouch. Dig Dis Sci 2023:10.1007/s10620-023-07947-9. [PMID: 37148442 DOI: 10.1007/s10620-023-07947-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/03/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Chronic inflammatory conditions of the pouch are common after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). AIMS We aimed to investigate the relationship between acute pouchitis within 180 days of the final stage of IPAA surgery (very early pouchitis) and the future development of chronic antibiotic dependent pouchitis (CADP) and Crohn's-like disease of the pouch (CLDP). METHODS We performed a retrospective cohort study, evaluating patients who underwent proctocolectomy with IPAA between January 1, 2004 and December 31, 2016. Multivariable logistic regression was used to evaluate the relationship between very early pouchitis and the development of CADP and CLDP. RESULTS Among 626 patients undergoing IPAA for UC, 137 (22%) developed very early pouchitis, 75 (12%) developed CADP, and 59 (9%) developed CLDP in a median follow-up of 5.18 years (interquartile range 0.94-10.8 years). Very early pouchitis was associated with a significant increase in the odds of developing CADP (adjusted odds ratio [aOR3.65, 95% CI 2.19-6.10) as was primary sclerosing cholangitis (aOR 3.97, 95% CI 1.44-11.0). Very early pouchitis was associated with increased odds for developing CLDP (aOR 2.77, 95% CI 1.54-4.98) along with a family history of inflammatory bowel disease (aOR 2.10, 95% CI 1.11-3.96). CONCLUSION In this cohort, very early pouchitis was associated with an increased risk of developing CADP and CLDP. These findings highlight very early pouchitis as a unique risk factor for chronic inflammatory conditions of the pouch and the need for future studies evaluating potential strategies for secondary prophylaxis strategies in this population.
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Affiliation(s)
- Scott Esckilsen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Translational Epidemiology Unit, The Mongan Institute, Boston, MA, USA
| | - Kimberly N Weaver
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Campus Box #7080, Chapel Hill, NC, 27599-7080, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Campus Box #7080, Chapel Hill, NC, 27599-7080, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Campus Box #7080, Chapel Hill, NC, 27599-7080, USA.
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Alharbi RA. A long-term follow-up after open ileal J pouch volvulus repair in a FAP patient - A case report. Int J Surg Case Rep 2022; 90:106653. [PMID: 34915439 PMCID: PMC8683725 DOI: 10.1016/j.ijscr.2021.106653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Most patients with familial adenomatous polyposis (FAP) undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouch volvulus is one of the very rare complication of open IPAA surgery that can mimic small bowel obstruction secondary to adhesion. High index of suspicion and proper investigation is required. PRESENTATION OF CASE The patient is a 44-year-old female with FAP who is currently on the mend after a 2-stage total proctocolectomy with ileal pouch-anal anastomosis. Presented eight years after indexed surgery with pouch volvulus, successfully treated with bowel resection without pouchopexy. DISCUSSION The surgery of choice for most patients with FAP is IPAA. Pouch volvulus is a rare complication of laparoscopic IPAA surgery and extremely rare after open surgery which can be treated surgically in various ways. But it can be catastrophic if not treated in timely manner. This case report presents a FAP patient with pouch volvulus after open IPAA treated with bowel resection and obliteration of space between the pouch mesentery and the sacral space without standard pouchopexy. CONCLUSION Volvulus is a rare side effect of an IPAA. Managing the initial procedure successfully is critical in order to avoid recurrence and consequences. The goal of this study is to identify symptoms and a successful management strategy for pouch volvulus.
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Affiliation(s)
- Reem A Alharbi
- Department of Clinical Surgery, College of Medicine, Princess Nourah Bint Abdulrahman University, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia.
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Abstract
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.
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Affiliation(s)
- Michael J Grieco
- Department of Surgery, New York University Langone Medical Center, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY 10016, USA.
| | - Feza H Remzi
- Department of Surgery, Inflammatory Bowel Disease Center, NYU Langone Health, New York University School of Medicine, NYU Inflammatory Bowel Disease Center, 305 East 33rd Street, New York, NY 10016, USA
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Bismar N, Knod JL, Patel AS, Schindel DT. Outcomes following two-stage surgical approaches in the treatment of pediatric ulcerative colitis. J Pediatr Surg 2019; 54:1601-1603. [PMID: 30414691 DOI: 10.1016/j.jpedsurg.2018.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/11/2018] [Accepted: 09/16/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Surgery for the treatment of ulcerative colitis (UC) can be performed in one-, two-, or three-stage procedures [1]. The more traditional approach is a total proctocolectomy and creation of an ileo pouch-anal anastomosis and diverting stoma at the initial operation, followed by ileostomy closure several weeks later (TIPPA) [1]. An alternative is an initial subtotal colectomy and end ileostomy [2]. In this alternative approach (NIPAA), a completion proctectomy and definitive ileo pouch-anal anastomosis can be performed without a diverting stoma. We hypothesize that functional outcomes following a NIPAA approach when performed in children, in our experience, are likely similar or improved when compared to those treated by TIPAA. METHODS After IRB approval, a review of patients who underwent a two-stage Laparoscopic IPAA from 2004 to 2017 occurred. Data included demographics, diagnosis, surgical intervention time to full diet, level of continence, use of antidiarrheals and complications. RESULTS N = 41 (NIPAA = 14, TIPAA = 27). After establishment of bowel continuity, no significant differences in appetite recovery, continence, or complications were noted. The number of antidiarrheals prescribed were significantly higher in the TIPAA group (p = 0.01). Thirteen patients (31.7%) had pouchitis: 4 NIPAA and 9 TIPAA (p = NS). Of the 41 patients, 11 required subsequent surgery; 2 patients (18.2%) received NIPAA and 9 (81.8%) received TIPAA (p = 0.20). Two TIPAA patients received a diverting ileostomy owing to chronic anal pain and failure to achieve continence. CONCLUSION This study suggests children with medically refractory UC treated by NIPAA or TIPAA have similar outcomes. Minimal differences in overall outcome were noted following either approach. However, NIPAA may reduce reliance on antidiarrheals to achieve satisfactory defecation outcomes. LEVEL OF EVIDENCE III Retrospective comparative study.
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Affiliation(s)
- N Bismar
- University of Texas Southwestern Medical Center, Pediatric Surgery, Dallas, TX, USA
| | - J L Knod
- University of Texas Southwestern Medical Center, Pediatric Surgery, Dallas, TX, USA
| | - A S Patel
- University of Texas Southwestern Medical Center, Pediatric Surgery, Dallas, TX, USA; Children's Medical Center, Pediatric Surgery, Dallas, TX, USA
| | - David T Schindel
- University of Texas Southwestern Medical Center, Pediatric Surgery, Dallas, TX, USA; Children's Medical Center, Pediatric Surgery, Dallas, TX, USA.
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Bhattacharya A, Shen B, Regueiro M. Endoscopy in Postoperative Patients with Crohn's Disease or Ulcerative Colitis. Does It Translate to Better Outcomes? Gastrointest Endosc Clin N Am 2019; 29:487-514. [PMID: 31078249 DOI: 10.1016/j.giec.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article discusses the use of endoscopy in patients with Crohn disease and ulcerative colitis in the postoperative setting. Endoscopy is the most sensitive and validated tool available in the diagnosis of recurrence of Crohn disease in the postoperative setting. It is also the most effective diagnostic modality available for evaluating complications of pouch anatomy in patients with ulcerative colitis. In addition to diagnosis, management postoperatively can be determined through endoscopy.
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Affiliation(s)
- Abhik Bhattacharya
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA.
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Chen YJ, Grant R, Lindholm E, Lipskar A, Dolgin S, Khaitov S, Greenstein A. Is fecal diversion necessary during ileal pouch creation after initial subtotal colectomy in pediatric ulcerative colitis? Pediatr Surg Int 2019; 35:443-448. [PMID: 30661100 DOI: 10.1007/s00383-019-04440-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pediatric patients with medically refractory ulcerative colitis (UC) often undergo an initial subtotal colectomy end ileostomy (STC-I). The role of fecal diversion in the subsequent completion proctectomy/ileal-pouch anal anastomosis (CP-IPAA) remains controversial. METHODS A multi-institutional retrospective review was performed of pediatric UC patients who underwent an STC-I followed by CP-IPAA from 2008 to 2016. 37 patients were included [diverted (n = 20), undiverted (n = 17)]. RESULTS Children who underwent undiverted CP-IPAA had a longer length of stay (days) compared to the diverted group (9, 6.5-13 vs. 6, 5-6, p = 0.002). The 30-day complication rate was significantly higher in the undiverted group (p = 0.003) although the difference in anastomotic leak, readmission rate, unplanned computer tomography use, and reoperation was not statistically significant. Three patients with undiverted CP-IPAA required additional surgery in the perioperative period for fecal diversion. The mean long-term follow-up was 25.68 ± 21.56 months. There were no significant differences in functional pouch outcomes. CONCLUSIONS Patients who underwent an undiverted CP-IPAA after initial STC-I had significantly more complications in the immediate postoperative period compared to diverted patients, although this did not translate into long-term differences in functional outcomes. Questions remain regarding careful patient selection and counseling for undiverted pouches in the pediatric UC population.
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Affiliation(s)
- Y Julia Chen
- The Moses Division of Colon and Rectal Surgery, The Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | - Robert Grant
- The Moses Division of Colon and Rectal Surgery, The Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA.
| | - Erika Lindholm
- Division of Pediatric Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Aaron Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Stephen Dolgin
- Division of Pediatric Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Sergey Khaitov
- The Moses Division of Colon and Rectal Surgery, The Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | - Alexander Greenstein
- The Moses Division of Colon and Rectal Surgery, The Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
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Sheedy SP, Bartlett DJ, Lightner AL, Trenkner SW, Bruining DH, Fidler JL, VanBuren WM, Menias CO, Reber JD, Fletcher JG. Judging the J pouch: a pictorial review. Abdom Radiol (NY) 2019; 44:845-866. [PMID: 30259096 DOI: 10.1007/s00261-018-1786-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.
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Affiliation(s)
- Shannon P Sheedy
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David J Bartlett
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amy L Lightner
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven W Trenkner
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Wendaline M VanBuren
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Joshua D Reber
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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11
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Kawahara H, Akiba T, Yanaga K. Cuff-less J Pouch Anal Stapling Anastomosis for Ulcerative Colitis. Anticancer Res 2017; 37:5743-5745. [PMID: 28982895 DOI: 10.21873/anticanres.12013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM For ulcerative colitis, J pouch anal anastomosis with preserved rectal cuff had been popularized with its acceptable defecation function. However, some complications associated with rectal cuff after surgery have been reported. We are performing a novel procedure, laparoscopic cuff-less J pouch anal stapling anastomosis. PATIENTS AND METHODS From January 2014 to December 2016, ten patients with ulcerative colitis, including three with concomitant cancer underwent this procedure. J pouch anal anastomosis was performed at the dentate line in all patients by our original procedure. In a manometric examination of all patients more than one year after the operation, maximum resting pressure was 68.0 (52-84) mmHg, maximum squeeze pressure was 101.7 (87-121) mmHg, length of high-pressure zone was 32.3 (30-35), and none had observed rectoanal reflex. Good defecation was confirmed by defecography. CONCLUSION Cuff-less J pouch anal stapling anastomosis seems to be a useful procedure for patients with ulcerative colitis.
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Affiliation(s)
- Hidejiro Kawahara
- Department of Surgery, Kashiwa Hospital, Jikei University School of Medicine, Chiba, Japan
| | - Tadashi Akiba
- Department of Surgery, Kashiwa Hospital, Jikei University School of Medicine, Chiba, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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Cai JX, Barrow J, Parian A, Brant SR, Dudley-Brown S, Efron J, Fang S, Gearhart S, Marohn M, Safar B, Truta B, Wick E, Lazarev M. Routine Pouchoscopy Prior to Ileostomy Takedown May Not Be Necessary in Patients with Chronic Ulcerative Colitis. Dig Dis 2017; 36:72-77. [PMID: 28595172 DOI: 10.1159/000475808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/28/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Creation of a J pouch is the gold standard surgical intervention in the treatment of chronic ulcerative colitis (UC). Pouchoscopy prior to ileostomy takedown is commonly performed. We describe the frequency, indication, and findings on pouchoscopy, and determine if pouchoscopy affects rates of complications after takedown. METHODS All UC or indeterminate inflammatory bowel disease patients with a J pouch were retrospectively evaluated from January 1994 to December 2014. Cases were defined as having routine (asymptomatic) pouchoscopy after pouch creation but before ileostomy takedown. Controls were defined as having no pouchoscopy or pouchoscopy on the same day as that of takedown. RESULTS The study included 178 patients (81.5% cases, 18.5% controls). Fifty two percent of pouchoscopies were reported as normal. Common abnormal endoscopy findings included stricture (35%), pouchitis (7%), and cuffitis (0.7%). Length of stay during takedown hospitalization was shorter for cases than controls (3 vs. 5 days; p = 0.001), but neither short- nor long-term complications were statistically different between cases and controls. Abnormalities on pouchoscopy were not predictive for short-term complications (p = 0.73) or long-term complications (p = 0.55). Routine pouchoscopy did not delay takedown surgery in any of the included patients. CONCLUSIONS Routine pouchoscopy may not be necessary prior to ileostomy takedown; its greatest utility is in patients with suspected pouch complications.
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Affiliation(s)
- Jennifer X Cai
- Department of Medicine, Division of Gastroenterology and Hepatology, Meyerhoff Inflammatory Bowel Disease Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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