Dysplasia in the ileoanal pouch

Formation of an ileo‐anal pouch is an accepted technique following colectomy in the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The configuration of pouches and anastomotic techniques has varied over the last two decades. The increased use of stapling devices in formation of the pouch‐anal anastomosis avoids the need for endoanal mucosal stripping and may contribute to improved functional results, but leaves a ‘columnar cuff’ of residual rectal mucosa in situ. Concerns regarding the long‐term safety of the ileo‐anal pouch have been raised by reports of the occurrence of dysplasia in the pouch mucosa and 15 cases of adenocarcinoma. In UC, persistence of underlying disease in the residual rectal mucosa, anal transition zone and columnar cuff provides the site for development of dysplasia and malignancy. Pouchitis is unlikely to be a major cause of dysplasia or malignancy, as long‐term follow‐up of patients with Koch pouches has demonstrated. In FAP, any persistent rectal mucosa and mucosa of the small intestine is at risk of adenomatous dysplasia due to the genetic alterations causing the disease. Long‐term surveillance should focus on all FAP pouch patients, and in UC patients should be directed towards the diagnosis of residual rectal mucosa in the area distal to the pouch anastomosis. Specialist histopathological opinion is essential in the diagnosis of dysplasia in the ileo‐anal pouch.     

J pouch with ileoanal anastomosis

The physical inconvenience and adverse psychological impact of ileostomy on patients led surgeons to seek a more normal and acceptable alternative. This is a report of the Mayo Clinic experience with, and modifications of, the ileoanal reservoir procedure. The hospital charts of 188 patients who had a J-pouch construction were reviewed. The operative technique is described. There were no hospital deaths. In 10 patients the operation was a failure. Complications included pelvis sepsis (21 patients), anastomotic sinus (15), anastomotic stricture (22), small-bowel obstruction (43), peritonitis after ileostomy closure (10) and pouchitis (15). Careful patient selection for the procedure is important. Crohn's disease is a contraindication. Of the patients studied, 95% found life more acceptable with an ileoanal anastomosis than with a loop ileostomy.     

Crohn's disease of the ileoanal pouch

Crohn's disease of the ileoanal pouch is a known albeit infrequent outcome of restorative proctocolectomy with ileoanal reservoir for inflammatory bowel disease colitides. Although an adverse outcome, many patients will benefit from a combined medical-surgical multidisciplinary approach to pouch retention. In this review article, we will discuss inflammatory disorders of the body of the pouch and the rectal cuff which lay on a spectrum, including pouchitis, cuffitis and Crohn's disease of the ileoanal pouch. It is imperative that readers fully understand conditions on both sides of the spectrum as treatments often overlap and it is necessary to undergo many of the mentioned treatments, or at least consider them, before undergoing what can be complex, re-operative abdominopelvic surgery with permanent re-diversion with the pouch left in situ, pouch excision or rarely pouch revision. We will also discuss outcomes of intentional ileoanal pouch for isolated Crohn's colitis.     

Results of 50 ileoanal J pouch operations

Fifty ileo-anal J pouches were constructed in 26 males and 24 females for ulcerative colitis (n = 45) and familial adenomatous polyposis (n = 5). Two-thirds had proctocolectomy and pouch formation as a one-stage procedure. Thirty patients had a handsewn pouch and anastomosis and 20 were stapled. Forty-five patients had their defunctioning ileostomy closed for at least 2 months, of whom three have not been recently reviewed. One pouch was defunctioned for ischaemic stricture. The median time between pouch construction and ileostomy closure was 15 weeks and the time between closure and assessment ranged from 2 to 50 months (median 18 months). Median stool frequency was six per 24h in both the handsewn and stapled groups. Faecal incontinence occurred in 20% of patients with a handsewn anastomosis but in no patient with a stapled anastomosis (P less than 0.02). Soiling was also more common in the former group. Some 76% of patients noted an improvement in pouch function with time. In all, 67% of males and 78% of females reported unchanged or increased sexual activity since pouch surgery. Pouchitis has occurred in 20% of patients; 10% have had complications related to the pouch or anastomosis; 10% related to the ileostomy; and 6% have had small bowel obstruction. There have been no deaths. Overall, 88% of patients have had a good result, but none of the five patients with a poor result will revert to an ileostomy.     

Proctocolectomy and ileoanal pouch anastomosis without conservation of a rectal muscular cuff

The technique of proctocolectomy and formation of an ileal reservoir with ileoanal anastomosis is well described. It is believed that the conservation of a rectal muscular cuff is necessary for continence but no data are available to support this contention. The aims of this study were to describe the clinical and physiological aspects of continence after proctocolectomy and ileal J pouch anastomosis without conservation of a rectal muscular cuff. Eighteen consecutive patients (mean age 37.3 years, 16 ulcerative colitis, two familial polyposis) who underwent proctocolectomy and ileoanal anastomosis on the dentate line were studied 6 months after closure of the loop ileostomy. The 18 patients and eight controls underwent: (a) anal manometry; (b) determination of maximum tolerable volume (MTV); (c) liquid continence test (infusion of NaCl at 60 ml/min for 25 min) with simultaneous measurement of ileal reservoir pressure. The volume evacuated during 5 min after the continence test was also measured. The frequency of bowel actions was (mean +/- s.e.m.) 5.3 +/- 0.4 per 24 h (nocturnal 1.14 +/- 0.26). Seventeen of 18 patients (94 per cent) had normal continence and defaecation; one patient was incontinent. A decrease in resting anal canal pressure (102.5 +/- 4 versus 47.5 +/- 6 cmH2O) was observed after ileoanal anastomosis. A rectoanal inhibitory reflex was elicited in one of the 18 patients (6 per cent). Patients were able to retain 1023 +/- 68 ml saline during the liquid continence test. The percentage evacuation of the ileal reservoir was 61 +/- 4.5 per cent. Correlations were found (P = 0.05) between daily stool frequency and the volume of saline retained during the liquid continence test. It is concluded that conservation of a rectal muscular cuff is not necessary for the achievement of good clinical results.     

Surgical techniques for mesenteric lengthening in ileoanal pouch surgery: a systematic review

Aim

The key to successful construction of an ileal pouch–anal anastomosis (IPAA) following proctocolectomy in patients with ulcerative colitis or familial adenomatous polyposis is the ability of the pouch reservoir to reach the anus well vascularized and without tension. The aim of this systematic review was to provide an overview of previously described different surgical lengthening techniques to achieve adequate length for a tension-free IPAA.

Method

Pubmed, Embase and Cochrane Library databases were systematically searched. Two reviewers conducted a systematic search with combinations of keywords for the surgical procedure and surgical lengthening techniques. All publications that reported one or more surgical lengthening techniques during IPAA surgery in adult patients were selected, consisting of reviews, cohort studies, case reports, human cadaver studies and expert opinions. The primary outcomes measured were the different surgical lengthening techniques and the step-by-step approach they involve that can be used during surgery to achieve adequate length for an IPAA.

Results

Of 1577 records reviewed, 19 articles were included in this systematic review describing at least 1181 patients (i.e. one review, four retrospective studies, five human cadaver studies, two case reports and seven expert opinions). A total of six different surgical lengthening techniques with various subtechniques were found and described, consisting of pouch folding, construction of different types of pouches, stepladder incisions, skeletonization of vessels, division and ligation of mesenteric vessels and using an interposition vein graft. No prospective or randomized controlled trials were performed regarding this topic. Quality assessment showed a medium quality of the included studies.

Conclusion

Different surgical lengthening techniques are described in a step-by-step approach to create adequate mesenteric length during IPAA surgery, in patients in whom the ileal pouch cannot reach the dentate line.     

Proctocolectomy and ileoanal anastomosis with J-shaped or S-shaped ileal pouch

This article reports an experience of 150 ileoanal anastomoses with pelvic ileal pouches performed between January, 1982 and March, 1986. The pouches were J-shaped in 70 patients, and S-shaped in 80 (with an exit conduit not longer than 2.5 cm). In most of the former group, a long cuff of rectal muscle coat (10 cm from the pectinate line) was preserved, while only a short cuff (2 cm from the pectinate line) was retained in some of the former group and all of the latter group, a modification which had considerable technical advantages and seemed to carry no detriment to subsequent function. An attempt was made to assess the influence of these variations in operative technique on the quality of the functional result by a special study of 82 patients: 39 with a J pouch and long rectal cuff, 2 with an S pouch and long rectal cuff, 28 with a J pouch and short cuff, and 13 with an S pouch and short cuff. At an initial survey, the patients with J pouches reported more urgency and frequency of defecation and more frequent disturbances at night than did those with S pouches. Almost all these differences disappeared 8 months later. At this stage, 94% of the patients were very pleased with the outcome of their surgery and glad to have avoided an ileostomy, but, even so, most of them continued to have some bowel complaints.

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Resumen El artículo registra la experiencia con 150 anastomosis ileoanales con bolsas ileales pélvicas, realizadas entre enero de 1982 y marzo de 1986. Las bolsas fueron del tipo en J en los primeras 70 pacientes, y del tipo en S (con un conducto de egreso no mayor de 2.5 cm) en los Últimos 80. En la mayoría de los casos del primer grupo, se preservó un mango largo de capa muscular (10 cm a partir de la línea pectínea), mientras que en algunos del primer grupo y en todos los del segundo sólo se preservó un mango corto (2 cm a partir de la línea pectínea), una modificación técnica que exhibe considerables ventajas técnicas y que parece no acarrear problemas en cuanto al resultado funcional.Se realizó la evaluación de la influencia de estas variaciones en la técnica operatoria sobre la calidad del resultado funcional mediante el estudio de 82 pacientes: 39 con bolsa de tipo J y un mango rectal largo, 2 con bolsa de tipo S y un mango largo, 28 con bolsa de tipo J y un mango corto, y 13 con bolsa de tipo en S y un mango corto. En una revisión inicial los pacientes con bolsas en J informaron mayor urgencia y frecuencia en las defecaciones y mayores dificultades durante la noche que los pacientes con bolsas en S. Sin embargo, a los 8 meses casi todas estas diferencias habían desaparecido. En la actualidad, 94% de los pacientes se halla muy satisfecho con el resultado de la operación y complacido con haberse evitado una ileostomá, pero aÚn así la mayoría de ellos continuó con algunos problemas intestinales.

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Résumé Cet article concerne une expérience de 150 anastomoses iléorectales avec un réservoir iléal pelvien réalisées de janvier 1982 à mars 1986. Les 70 premiers réservoirs avaient une forme en J, les 80 dernières une forme en S (avec un conduit d'évacuation long de 2.5 cm au plus). Dans la majorité des cas du premier groupe, un long manchon de la paroi musculaire rectale (10 cm depuis la ligne pectinée) fut conservé cependant que dans quelques cas du premier groupe et la totalité des cas du second groupe un court manchon (2 cm depuis la ligne pectinée) fut préservé, modification qui eut des avantages techniques considérables et ne parut avoir aucun effet nocif fonctionnel.Une étude a été faite pour apprécier l'effet de ces variations techniques sur les résultats fonctionnels chez 82 opérés: 39 porteurs d'un réservoir en J avec un long manchon rectal, 2 avec un réservoir en S et un long manchon, 28 avec un réservoir en J et un court manchon, et 13 avec un reservoir en S et un court manchon. Au moment de l'étude initiale, les opérés porteurs d'un réservoir en J ont fait état d'une défécation plus fréquente et plus pressante, de troubles nocturnes plus nombreux que les opérés porteurs d'un réservoir en S. Huit mois plus tard presque toute différence avait disparu et 94% des opérés étaient satisfaits et heureux d'avoir évité une iléostomie encore que la plupart d'entre eux se plaignaient de quelques troubles intestinaux.

     

Proctocolectomy and ileoanal anastomosis with an S pouch: functional results

Patients with total colonic ulcerative colitis or familial polyposis traditionally require a proctocolectomy. In an effort to preserve the normal pathway for defecation and avoid the nuisance of an abdominal stoma, a continence-preserving procedure involving a pelvic reservoir has been performed at the University of Minnesota Hospitals on 120 patients. The majority were operated on for colonic ulcerative colitis. There were no deaths. The mean hospital stay after restorative proctocolectomy was 10 days and after ileostomy takedown the mean stay was 7 days. Functional results were assessed in 52 patients. Daytime bowel movements averaged 6.4 and night-time movements 1.4. Major daytime incontinence occurred in 6% of the patients, 21% had moderate soiling at night and 70% wore a perineal pad in the evening. Ninety-two percent of the patients expressed satisfaction with the procedure. The most serious complication was pelvic sepsis. It occurred in nine patients, six of whom required subsequent surgery. The Parks S pouch provides a means of maintaining anal continence. This series and others have shown that young, healthy, well-motivated persons will benefit most from a restorative proctocolectomy.     

Influence of dietary calcium supplements on ileoanal pouch function and cytokinetics.

A double-blind cross-over study was undertaken in 16 patients after panproctocolectomy and ileoanal pouch reconstruction to compare supplementary calcium (1.5 g/day) with placebo over 2 months with a 2-week washout period. Stool frequency was recorded and the effects on pouch mucosal crypt cellular proliferation were determined using an in vitro stathmokinetic technique which measures the crypt cell production rate (CCPR) and an immunohistochemical method using the Ki67 monoclonal antibody for proliferating nuclei. The median (interquartile range) diurnal stool frequency was reduced by calcium (4 (3-5) per day) compared with values obtained before treatment (7 (5-10) per day, P less than 0.002) and with placebo (7 (6-9) per day, P = 0.002). Similarly, calcium reduced nocturnal stool frequency (1 (0-1) per night) compared with pretreatment and placebo (both 2 (1-3) per night, P less than 0.05) values. Calcium reduced the mean(s.e.m.) CCPR to 1.88(0.41) cells per crypt per hour compared with pretreatment (3.63(0.53), P = 0.01) and placebo (3.24(0.43), P = 0.002) values. Median (interquartile range) Ki67 activity was also reduced by calcium (13.2 (9.7-16.7) per cent), compared with values obtained before treatment (27.3 (14.3-30.2) per cent, P = 0.001) and with placebo (26.0 (17.2-32.0) per cent, P = 0.001). Stool frequency was significantly correlated with the CCPR (diurnal: r = 0.37; nocturnal: r = 0.31, both P less than 0.05). Nine patients used antidiarrhoeal medication while receiving placebo compared with four patients receiving calcium (P = 0.032). This study has shown that supplementary oral calcium significantly reduced stool frequency in patients with pouches, a reduction that was associated with reduced cell proliferation. The mechanisms for this effect are not known.     

Outcomes in pediatric patients undergoing straight vs J pouch ileoanal anastomosis: a multicenter analysis

Background

Outcomes remain controversial for patients undergoing straight (SIAA) vs J pouch (JPAA) ileoanal anastomosis, particularly in children where fewer such cases are performed. Our 3 centers have had extensive experience with both techniques. Thus, we had the unique opportunity to compare outcomes within the same centers.

Methods

We retrospectively analyzed 250 children after proctocolectomy with either SIAA or JPAA, for the first 3 years after pull-through. A functional stooling score was developed to further assess outcomes. Data were analyzed using χ² tests and generalized linear mixed models for repeated measures.

Results

Two hundred three patients had sufficient data for complete analysis (42% males; mean surgery age, 15 ± 7years). Surgical indications were ulcerative colitis (168) and familial adenomatoid polyposis (35). Surgical procedures included SIAA (112) and JPAA (91). Daytime and nighttime stooling frequencies were significantly higher (P < .013) for SIAA patients at 1 to 24 months after pull-through; however, stooling frequencies began approximating each other by this time. Symptomatic pouchitis (compared to enteritis after SIAA) was significantly higher in JPAA patients (odds ratio, 4.5; confidence interval, 2.32-8.72). Frequency of pouchitis declined with time. There was no significant difference in the incidence of surgical complications between the 2 groups. Finally, continence rates were strikingly good in both groups compared to previously reported series.

Conclusion

Straight ileoanal anastomosis and JPAA are associated with considerable morbidity; SIAA has higher stool frequency and JPAA has increased pouchitis. Over time, we found that problems improved, and functional stooling scores became similar. JPAA had consistently lower stool frequency and better continence rates; however, these differences were small and may have minimal clinical significance. In addition, such differences need to be balanced against the high rate of pouchitis with JPAA. Continence was excellent regardless of the technique.     

Functional and morphologic changes of the ileal mucosa after ileoanal pouch procedure

BACKGROUND: Restorative proctocolectomy is used widely for treatment of ulcerative colitis and familial polyposis coli. Limited information is available regarding the morphologic and functional adaptation of the mucosa in a functioning ileoanal pouch. STUDY DESIGN: Ileal pouch specimens from patients who underwent pouch reconstruction (mean 7.5 years postcolectomy, n = 12) were compared with normal ileum (n = 15) and normal colon (n = 5). Amino-oligopeptidase (AOP) and maltase activity were measured as parameters of normal ileal function. Histologic samples were examined for the presence of neutrophils and plasma cells, the villus to crypt height ratio, and the degree of crypt hyperplasia, villus blunting, and goblet cell mass. Data were analyzed by analysis of variance. RESULTS: The AOP activity in the normal ileum was 73 +/- 32 units of enzymatic activity per gram of mucosal protein; the AOP activities of the pouch and colon were 21 +/- 22 and 16 +/- 10, respectively. The maltase activity of the normal ileum measured 254 +/- 116 units of enzymatic activity per gram of mucosal protein, and the maltase activities of the pouch and colon were 57 +/- 71 units and 29 +/- 25 units, respectively. The ileal pouch mucosa demonstrated little acute inflammation and varying degrees of chronic inflammation. Morphologically, the ileal pouch mucosa demonstrated a range of adaptations, including villus blunting and crypt hyperplasia. Several specimens contained immature epithelial cells. CONCLUSIONS: The AOP and maltase activities in mucosa from ileoanal pouches and colon were significantly lower than those in normal ileal mucosa. Ileoanal pouch mucosa from humans undergoes adaptive changes to resemble colonic mucosa both morphologically and functionally.