Male sexual function improves after ileal pouch anal anastomosis

PURPOSE: Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis. However sexual functional disturbances after this procedure can be a concern for patients. Therefore the aim of this study was to determine the outcome of sexual-function related quality of life in male patients undergoing restorative proctocolectomy. METHODS: One hundred and twenty-two male patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis between 1995 and 2000 were evaluated by the validated International Index of Erectile Function (IIEF) scoring instrument. This index scale examines sexual function in five categories. These are erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. The IIEF instrument was administered after surgery and then scores before and after RP/IPAA were evaluated and compared. The significance of age at the time of the surgery, type of surgery, type of anastomotic technique (mucosectomy vs stapled) and septic complications on sexual functional outcome were also investigated. RESULTS: Mean age at the time of the surgery was 39.9 +/- 11.5 years. The mean follow-up period (time between pouch surgery and IIEF completed) was 3.6 +/- 1.8 years. There was statistically significant improvement in 4 of 5 categories of sexual function (erectile function, sexual desire, intercourse satisfaction, and overall satisfaction) where patients had improved scores after surgery compared to prior to surgery. The mean erectile function score increased pre to post surgery by 2.12 points (P = 0.02), which indicates better sexual results. Anastomotic technique and septic complication did not influence the results, however, older age had a negative impact on results. CONCLUSIONS: Despite some adverse sexual functions, male patients who undergo RP/IPAA for the surgical management of their colitis may preserve or improve their overall sexual functional outcome.     

Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery

OBJECTIVE: To identify risk factors associated with ileal pouch failure and to develop a multifactorial model for quantifying the risk of failure in individual patients.SUMMARY BACKGROUND DATA Ileal pouch anal anastomosis (IPAA) has become the treatment choice for most patients with ulcerative colitis and familial adenomatous polyposis who require surgery. At present, there are no published studies that investigate collectively the interrelation of factors related to ileal pouch failure, nor are there any predictive indices for risk stratification of patients undergoing IPAA surgery. METHODS: Data from 23 preoperative, 7 intraoperative, and 10 postoperative risk factors were recorded from 1,965 patients undergoing restorative proctocolectomy in a single center between 1983 and 2001. Primary end point was ileal pouch failure during the follow-up period of up to 19 years. The "CCF ileal pouch failure" model was developed using a parametric survival analysis and a 70%:30% split-sample validation technique for model training and testing. RESULTS: The median patient follow-up was 4.1 year (range, 0-19 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.4-96.7). The following risk factors were found to be independent predictors of pouch survival and were used in the final multivariate model: patient diagnosis, prior anal pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture and separation. The model accurately predicted the risk of ileal pouch failure with adequate calibration statistics (Hosmer Lemeshow chi2 = 3.001; P = 0.557) and an area under the receiver operating characteristics curve of 82.0%. CONCLUSIONS: The CCF ileal pouch failure model is a simple and accurate way of predicting the risk of ileal pouch failure in clinical practice on a longitudinal basis. It may play an important role in providing risk estimates for patients wishing to make informed choices on the type of treatment offered to them.     

Ileal pouch anal anastomosis without ileal diversion

OBJECTIVE: To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion. SUMMARY BACKGROUND DATA: Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure. METHODS: Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. RESULTS: Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction). CONCLUSIONS: The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.     

双吻合器法改进回肠贮袋肛管吻合术后肛门功能的研究

目的 探讨应用双吻合器法改进传统的回肠贮袋肛管吻合术,术后长期的肛门功能情况.方法 同顾性分析2002年1月-2011年3月完成的45例双吻合器法同肠贮袋肛管吻合术患者的临床资料,其中家族性息肉病患者16例和溃疡性结肠炎患者29例.应用Kirwan评分及Oresland贮袋特异性功能评分评估术后远期肛门功能.结果 平均随访65个月(12 ～ 110个月)后,2例恶性家族性息肉病患者死亡,其余患者中2例出现不典型息肉增生,4例患者出现轻到中度的吻合口狭窄,1例患者出现严重的吻合口狭窄,需再次手术干预,16例患者出现贮袋炎的临床症状.本组45例患者中无肛门失禁发生,术后1年、2.5年、5年的中位Oresland贮袋特异性功能评分分别为6分、3分和2分.结论 应用双吻合器法改进回肠贮袋肛管吻合术后大便控制能力满意,无肛门失禁发生.     

回肠储粪袋-肛管吻合在全结肠-直肠切除中的应用

目的 探讨回肠储粪袋－肛管吻合在全直肠结肠切除中的应用及效果。方法 回顾性总结１９８０～１９９８年进行的１５例全结肠直肠切除、回肠储粪袋－肛管吻合患者。其中溃疡性结肠炎患者９例,家族性腺瘤性息肉病患者６例,结果 “Ｓ”形储粪袋１０例全结肠直肠切除“Ｊ”储粪袋５例,无死亡病例。手术后发生粘连性肠梗阻４例、伤口感染２例、储粪袋瘘１例、肛瘘１例。随访１２例,随访时间１～１４年。排便次数的中位数为５次／２     

Laparoscopic rectopexy for recurrent volvulus of J pouch after total proctocolectomy and ileal pouch anal anastomosis

Ileal‐pouch anal anastomosis (IPAA) is most commonly performed after total proctocolectomy for ulcerative colitis and familial adenomatous polyposis. Small‐bowel obstruction is one of the complications that can occur years after the operation, but intestinal obstruction due to volvulus of the J pouch is a rare condition. We report a case of recurrent volvulus in a patient who had undergone IPAA after total proctocolectomy for cancer of the rectum and multiple colonic polyps. The patient underwent laparoscopic rectopexy and had no recurrence of volvulus.     

Influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis

This study was designed to determine the influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis. A total of 24 patients who had undergone ileal pouch-anal anastomosis (J pouch) for ulcerative colitis were studied. The 24-hour stool frequency was found to be inversely correlated with the sensitivity threshold volume (STV), maximal tolerance volume (MTV), and distensibility, but was independent of the maximal resting pressure and maximal squeeze pressure. Patients experiencing nocturnal fecal incontinence had maximal resting pressures that were significantly lower than those of nocturnally continent patients. Among the patients with fecal incontinence, those with frequent soiling had lower resting pressures, STV, and distensibility than the patients with intermittent spotting. In addition, the STV in patients needing nocturnal evacuation were lower than those of patients who did not evacuate after falling asleep. The conclusions are as follows. Both stool frequency and the need for nocturnal pouch evacuation correlated directly with pouch volume. Anal incontinence was more common in patients with low internal sphincteric function. In addition, frequent and gross nocturnal incontinent patients demonstrate a worse function in both the anal sphincter and reservoir than those with intermittent spotting.     

The ParkS S ileal pouch and anal anastomosis after colectomy and mucosal proctectomy

Attention to detail is crucial to the success of the operation described. Surgeons contemplating performing it should first be experts in pelvic surgery and are advised to personally observe and participate in the procedure performed by surgeons currently experienced in this technique.     

Fertility is reduced after restorative proctocolectomy with ileal pouch anal anastomosis: a study of 300 patients

BACKGROUND: Restorative proctocolectomy and ileal pouch anal anastomosis (RP/IPAA) has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis and familial adenomatous polyposis. The aims of this study were to evaluate the fertility rates before and after RP/IPAA, to compare them with the reproductive data of the general United States population, and to determine surgical parameters that might influence subsequent fertility. METHODS: Three hundred women of reproductive age who underwent RP/IPAA between 1983 and 2001 completed a mailed questionnaire regarding their reproductive function before and after the procedure. Additional information was obtained from the pelvic pouch database. The reproductive information was compared to age-matched historical control subjects from the United States general population. The associations between changes in fertility and surgical parameters were also investigated. RESULTS: The median (25th, 75th percentile) age at surgery was 28 (24, 33) years. Out of 300 women, 206 attempted to conceive. Before operation, 48 (38%) of 127 patients were unsuccessful after 1 year of unprotected intercourse, whereas after operation, 76 (56%) of 135 patients were unsuccessful. This infertility rate was higher after operation than before (P <.001). For the subgroup of 56 women who tried to get pregnant both before and after operation, the infertility rate was higher after operation than before (69% vs 46%; P=.005). Also, a higher percentage of these patients who had an intraoperative transfusion were infertile after operation compared to patients who did not have an intraoperative transfusion (54% vs 21%; P=.023). CONCLUSIONS: There was an increase in the infertility rate after RP/IPAA. Intraoperative blood transfusion had a negative impact on the fertility rate after operation in patients who tried to conceive both before and after RP/IPAA.     

全结直肠切除回肠贮袋肛管手缝吻合术在溃疡性结肠炎治疗中的临床价值

目的 评价全结直肠切除回肠贮袋肛管手缝吻合术（HIPAA）治疗溃疡性结肠炎的临床价值.方法 回顾性分析1989年1月至2013年12月天津医科大学总医院收治的191例溃疡性结肠炎患者的临床资料,采用开腹和腹腔镜辅助手术行HIPAA.末次手术后3个月和12个月进行问卷调查,依据24h和夜间排便次数、Bristol粪便分类表和Kirwan分级评价贮袋肛门功能.依据克利夫兰生命质量表评价生命质量;依据贮袋炎活动指数诊断贮袋炎.随访时间截至2014年4月.独立样本比较采用t检验,多组比较采用方差分析,两两比较采用LSD-t检验,计数资料比较采用x2检验.结果 191例患者中有180例行开腹手术,11例行腹腔镜手术.175例行二期手术,9例行一期手术,7例行三期手术.181例采用J型贮袋,9例采用H型贮袋,1例采用W型贮袋.患者无围手术期死亡,术后早期8例患者腹腔感染,7例切口感染,应用抗生素后治愈.术后1～2周发生贮袋吻合口出血4例,吻合口漏4例,给予止血处理后治愈.6例患者术后出现高位肠梗阻,经对应处理后缓解.8例患者发生贮袋炎,经饮食调节或抗生素治疗后缓解.2例患者发生性功能障碍.所有患者获得随访,随访时间1～25年.术后贮袋肛门功能不断改善,术后3个月24 h和夜间排便次数、Bristol粪便分类和Kirwan分级分别为（6.5±2.8）次,（2.9±1.5）次,Ⅳ类86例、Ⅴ类89例、Ⅵ类16例,Ⅰ级160例、Ⅱ级19例、Ⅲ级12例;术后12个月分别为（3.7±1.4）次,（1.3±0.5）次,Ⅳ类107例、Ⅴ类76例、Ⅵ类8例,Ⅰ级177、Ⅱ级8例、Ⅲ级6例,两者比较,差异有统计学意义（=12.36,3.98,x2=7.76,29.27,P＜0.05）.克利夫兰生命质量表评分：术前为（0.37±0.19）分,术后3个月为（0.67±0.16）分,术后12个月为（0.82±0.13）分,3者比较,差异有统计学意义（F=6.011,P＜0.05）.术后3个月与术前和术后12个月比较,差异有统计学意义（t=16.69,10.06,P＜0.05）;术后12?     

Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients

OBJECTIVE: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. BACKGROUND: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. METHODS: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > or = 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. RESULTS: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. CONCLUSIONS: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures.     

Manometric and functional comparison of ileal pouch anal anastomosis with and without anal manipulation

We report the results of postoperative physiologic and functional evaluation of 153 patients with ileal pouch anal-anastomosis (IPAA). Ninety-nine patients had anal manipulation for either mucosal proctectomy, transanal placement pursestring suture with stapled IPAA, or handsewn IPAA (manipulation). Fifty-four patients had stapled IPAA with anal pursestrings placed transabdominally without mucosectomy (no manipulation). Patients with transabdominal anal pursestring placement and stapled IPAA without mucosectomy had a higher mean maximum anal resting pressure than patients who had endoanal manipulation. This correlates with improved continence and a reduced need to wear a pad. Avoidance of anal manipulation preserves anal canal resting tone and improves the functional result after IPAA.     

Can a failed ileal pouch anal anastomosis be left in situ?

OBJECTIVE: Failure after ileal pouch-anal anastomosis (IPAA) is reported with a frequency of 10-20%. The failed IPAA can be excised or defunctioned. Indications for excision and further management of an indefinitely diverted pouch are poorly described. The aim of the present investigation was to investigate pouch-related problems and the histopathological pattern of the pouch mucosa in this group of patients. METHOD: In a cohort of 620 patients having IPAA with a median follow-up of 14 years, 56 patients with failure were identified. The patients with defunctioned pouches were assessed with regard to pouch-related problems and endoscopy with biopsies was performed. Biopsies were stained with haematoxylin-eosin, PAS for neutral mucins and Alcian blue/high iron diamine for sialomucins/sulphomucins. Morphological changes were grouped into three types modified according to Veress and assessed for dysplasia. RESULTS: Twenty-two patients with an indefinitely diverted pouch were found. The follow-up time after surgery for failure was 10 years. Thirteen patients completed the follow-up. Except for two patients with pelvic/perineal pain, there were no clinical problems. The majority of patients displayed mild to moderate macroscopic signs of inflammation. Morphologically, findings ranged from a preserved mucosal pattern to intense inflammatory reaction. No case of dysplasia or carcinoma was found. CONCLUSION: Most patients with an indefinitely diverted pouch had no complaints regarding the pouch. There was no case of dysplasia. Indefinite diversion may be preferable to pouch excision, especially given the associated morbidity.     

Bowel obstruction in a pregnant patient with ileal pouch–anal anastomosis

Bowel obstruction is a rare but serious complication of pregnancy for both the mother and the developing fetus. This report describes the case of 17-year-old girl with ileal pouch–anal anastomosis (IPAA). She presented at 36 weeks’ gestation with a complete small-bowel obstruction. Because conservative management was unsuccessful, labour was induced to relieve the obstruction or simplify surgery. Soon after spontaneous vaginal delivery she began to pass copious amounts of flatus and stool. The bowel obstruction resolved within hours. This report illustrates how IPAA alters the anatomy of the gastrointestinal tract, placing the ileal pouch at risk from compressive obstruction by the gravid uterus. Induction of labour in a near-term fetus is a reasonable initial method of management in such women.     

The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis

Objective The aim of this study was to evaluate functional outcome and quality of life (QOL) in patients undergoing proctocolectomy ileal pouch anal anastomosis (IPAA), to assess the correlation between functional outcome and QOL, and to identify factors influencing functional outcome and QOL in these patients. Background IPAA is now considered the procedure of choice for ulcerative colitis. Functional outcome and QOL are important factors in evaluating operative outcome. Methods All patients with UC who had undergone IPAA at our institute during the period 1990–2001 were included. QOL and functional outcome were evaluated by mailed questionnaires. QOL was scored using the Short Form 36 (SF‐36). Global Assessment of Function Scale was used to evaluate functional outcome. Results Data were obtained in 77 of 99 patients (78%), with the median age of 38 years. Median follow up time was 4.25 years. The QOL in patients after pelvic pouch procedure was excellent, with scores equal to published norms for the Israeli general population in most scales. Functional outcome and QOL scores correlated strongly (r > 0.5; P < 0.0001) in all dimensions. Older age was associated with lower scores in both functional outcome and QOL scales (P < 0.0001). Conclusions This study demonstrates a strong association between functional outcome and QOL in patients after IPAA. These patients, however, have a QOL that is comparable with the general population. Age at time of surgery strongly influences both functional outcome and QOL. This finding has to be taken into consideration in pre‐operative counseling.     

Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome

INTRODUCTION

Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique.

PRESENTATION OF CASE

A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal.

DISCUSSION

There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients.

CONCLUSION

J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.     

Octreotide for the treatment of diarrhoea in patients with ileal pouch anal anastomosis: a placebo-controlled crossover study

Aim Diarrhoea with urgency is a debilitating long‐term complication of ileal pouch anal anastomosis (IPAA) after a proctocolectomy. Somatostatin analogues are used to control diarrhoea and high‐output ostomies. Hence, we designed a prospective, double‐blind, crossover trial to explore the efficacy and tolerability of octreotide to reduce diarrhoea in adult patients with IPAA. Method Patients were randomized to octreotide subcutaneously (SC), 500 μg three times daily (t.i.d.), or matching placebo SC for 7 days. Responders (a reduction in stool frequency of three or more stools per 24‐h period and with a reduction in stool frequency of at least 30% after 7 days of treatment compared with baseline; the primary end‐point) remained in the same group and nonresponders could cross over to the alternative treatment for 7 days. Open‐label octeotide LAR 30 mg was offered to all responders on day 14. Flexible pouchoscopy with biopsies was performed at baseline in all patients and was repeated on days 7 and 14 in patients with pouchitis. Results Fifteen patients (11 men, median age 52 years), all with ulcerative colitis, were randomized. Three patients were withdrawn for side effects during the blinded phase. Response was achieved by two of 12 and two of 11 patients treated with octreotide or placebo, respectively (including crossover, P = 0.9). The median stool frequency remained stable in both groups [Δoctreotide: 0 (IQR, ?4 to 0), Δplacebo: ?1 (IQR, ?1 to 1), P = 0.45]. Octreotide had no effect on the modified pouch disease activity index (mPDAI), and pouchitis persisted in five of six subjects with pouchitis at onset. One subject received open‐label octreotide LAR. Conclusion Octreotide has no clear beneficial effect on the stool pattern or on pouchitis severity in patients with high stool frequency after IPAA.     

Hospital costs and risk factors associated with complications of the ileal pouch anal anastomosis

BACKGROUND: The purpose of this study was to estimate the costs associated with the most common complications of the ileal pouch anal anastomosis (IPAA) and identify factors that predispose to them. METHODS: Hospital costs of 135 patients undergoing the IPAA were combined with information abstracted from charts. Logistic and linear regression modeling were used to estimate the marginal costs for the most common IPAA complications and determine factors predisposing to their occurrence. RESULTS: The average overall cost for the IPAA was $20,865. Just more than half (53%) of patients experienced complications, the 3 most common being small-bowel obstruction (24.4%), pelvic/abdominal sepsis (6.7%), and dehydration (5.9%). The average cost to treat an episode of small-bowel obstruction was $6709. Treatment of pelvic/abdominal sepsis averaged $9268 per occurrence, whereas dehydration averaged $4860. Steroid use > 3 months before colectomy significantly increased the risk for any complication (P =.02). No factors were found to be good predictors of bowel obstruction. However, age > 42 years and low patient hematocrit were significant predictors of dehydration as a complication (P <.05). Trending toward significance were urgent operation and weight loss greater than 5%. CONCLUSIONS: The most common complications of the IPAA are small-bowel obstruction, pelvic/abdominal sepsis, and dehydration. Complications were responsible for approximately 44% of the overall cost of an IPAA. Factors that increase risk of IPAA complications are steroid use, low hematocrit, age > 42 years, nonelective procedures, and preoperative weight loss.