Restorative proctocolectomy: one surgeon's experience of a now routine procedure in a district general hospital

Restorative proctocolectomy is now the operation of choice for the definitive management of ulcerative colitis and familial adenomatous polyposis coli. The aim of this review is to evaluate clinical and functional results of the first fifty patients treated with restorative proctocolectomy over a period of seven years. A total of 50 patients (28 males, 22 females) underwent restorative proctocolectomy over a period of seven years in our district general hospital. A retrospective analysis of hospital notes was undertaken and supplemented with a patient questionnaire. Forty-three patients had ulcerative colitis and seven had familial adenomatous polyposis coli. Two pouch designs were used, a four limbed "pear pouch" (94%) and a two limb "J" pouch (6%). The majority (98%) of patients had a stapled ileal pouch-anal anastomosis and a similar number had a defunctioning ileostomy. There was no mortality. Early complications (within 30 days of operation) occurred in 18(36%) patients. Late complications were seen in 22 (44%) patients. The median number of daily bowel movements was four (range 1-10). Pouchitis was seen in ten patients (20%). Restorative proctocolectomy is a safe procedure for patients with ulcerative colitis and familial adenomatous polyposis coli. Although total morbidity is appreciable, functional results are generally good and patient satisfaction is high.     

全大肠切除回肠贮袋肛管吻合术的远期疗效评价

目的　探讨全大肠切除回肠贮袋肛管吻合术治疗溃疡性结肠炎 (UC)和家族性腺瘤性息肉病 (FAP)的远期疗效。方法　 1985～ 2 0 0 2年间共对 6 1例患者行全结肠直肠切除回肠贮袋肛管吻合术 ,其中UC 2 5例、FAP 34例、其他 2例 ,应用S袋 2 5例、S J袋 13例、J袋 17例以及W袋 6例 ,术后随诊 1～ 18年、平均 8年 ,比较分析术后控便功能及并发症。结果　全部患者存活。并发症发生率为 16 % ( 10 / 6 1) ,其中UC患者 ( 2 4 % ,6 / 2 5 )高于FAP患者 ( 12 % ,4 / 34) ,W袋高于其他各袋 ,手法吻合 ( 2 0 % ,8/ 4 1)高于吻合器吻合 ( 10 % ,2 / 2 0 ) ,但差异均无显著性 (P >0 0 5 )。术后 2 4h大便次数平均为 4 2次。日间 84 % ( 4 3/ 5 1)、夜间 75 % ( 38/ 5 1)的患者排便能自控 ,6 % ( 3/ 5 1)的患者有明显的大便失禁。大部分患者对目前的生活质量表示满意。结论　全大肠切除回肠贮袋肛管吻合术治疗可维持UC与FAP患者肛管自控功能和可接受的大便次数 ,术后并发症较少 ,是较为理想的手术方式     

Immediate and long-term results in ileoanastomosis with reservoir in 335 consecutive cases

Restorative proctocolectomy with ileal pouch anal anastomosis is the first choice procedure for the treatment of ulcerative colitis and familial adenomatous polyposis. The introduction of the stapled technique has shortened the duration of the procedure and reduced the complication rates. Data on 335 consecutive patients undergoing ileal pouch anal anastomosis for ulcerative colitis (277 pts), Indeterminate colitis (20 pts) and familial adenomatous polyposis (38 pts) between 1984 and 1998 were prospectively collected. Parameters evaluated included diagnosis, surgical technique, functional outcome, early and late complications and their management and results. Twenty-nine patients (8.6%) presented with pelvic sepsis. Twelve patients (3.5%) experienced late perianal fistulas. The pouch failure rate was 3.4%. Six patients required a re-do pouch procedure, with 75.9% preservation of sphincter function. No correlation was found between complication rates and diagnosis. The mean number of stools was 5.2/24 h. The study confirmed the safety and effectiveness of the procedure. In particular, morbidity rates are comparable to those of major abdominal procedures and the long-term functional results are satisfactory. However, a number of technical aspects, such as the anastomosis technique, the need for temporary ileostomy and the treatment of indeterminate colitis, still remain controversial.     

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment.

OBJECTIVE: To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery. SUMMARY BACKGROUND DATA: Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications. METHODS: The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey. RESULTS: Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit. CONCLUSIONS: Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.     

The ileo-anal pouch procedure: Complications, quality of life, and long-term results

The ileo-anal pouch procedure: Complications, quality of life, and long-term results. Restorative proctocolectomy with construction of an ileal pouch-anal anastomosis (IPAA) has evolved as the surgical therapy of choice for patients with ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). 662 patients (493 UC, 169 FAP) consecutively received IPAA. Marked differences were observed between UC and FAP patients regarding the rates of overall complications (33.1 % vs. 12.5 %), pouchitis (29 % vs. 2 %), and pouch extirpation (3.2 % vs. 0.6 %). Pouchitis occurred as primary (79 %) and secundary (21 %) form, with acute (67.2 %) or chronic (32.8 %) course. Each form and course required specific therapy. Chronic pouchitis implies the risk of malignant transformation of the pouch mucosa. Quality of life improves significantly after IPAA in patients with UC and is equal to that in normal individuals, in UC and FAP, if postoperative complications are either prevented or under control.     

Rare complication after ileal pouch–anal anastomosis: Bilateral ureteral obstruction due to pelvic sepsis and retroperitoneal fibrosis

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the procedure of choice for the majority of patients who require surgery for ulcerative colitis, and the preferred operation for patients with familial adenomatous polyposis. Complications of IPAA are common, including septic, inflammatory, functional, neoplastic and metabolic complications. When early postoperative sepsis develops, subsequent failure over time is approximately five times the rate for the whole pouch population. The objective of this study was to report an uncommon complication of IPAA. We reported a case of a patient who developed bilateral ureteral obstruction due to retroperitoneal fibrosis secondary to pelvic sepsis after a pouch–anal anastomosis leak. To the best of our knowledge, no such case has ever been reported.     

RESTORATIVE PROCTOCOLECTOMY WITH ILEAL POUCH–ANAL ANASTOMOSIS IN 203 PATIENTS: THE AUCKLAND EXPERIENCE

Background : Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. Methods : Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. Results : Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn’s disease. The overall mortality was 1.5% (early = 2, late = 1) The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn’s disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3–8.7) during the day, and 0.7 (range 0–2.1) during the night. The fewer night-time stools (J = 1.0 ± 0.6; W = 0.4 ± 0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. Conclusions : The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.     

Surgical management of pouch-vaginal fistula after restorative proctocolectomy

BACKGROUND: Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. METHODS: After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. RESULTS: The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. CONCLUSIONS: Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.     

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.     

Laparoscopic restorative proctocolectomy

BACKGROUND: Restorative proctocolectomy is increasingly being performed using minimally invasive surgery. In published series laparoscopically assisted techniques have usually included a suprapubic incision to enable major parts of the operation to be done openly. METHODS: Fifty consecutive patients with familial adenomatous polyposis or ulcerative colitis underwent laparoscopic restorative proctocolectomy using only a small perumbilical incision of 4 cm or less for vascular dissection and pouch formation; all other steps were performed entirely laparoscopically. Logistic regression was used for statistical analysis. RESULTS: In four patients (8 per cent) the operation was converted to an open procedure. The diagnosis of ulcerative colitis was associated with a higher overall rate of complications (P = 0.011), and an increased body mass index (BMI) with a higher rate of major complications (P = 0.050). The occurrence of wound infection was related to the diagnosis of ulcerative colitis (P = 0.049). Conversion resulted in greater blood loss (P = 0.004), but not in a higher complication rate. No patient required a blood transfusion. Patients with an increased BMI and those taking immunosuppressive therapy had a longer hospital stay (P = 0.043). CONCLUSION: Laparoscopic restorative proctocolectomy is technically feasible. Patients with ulcerative colitis and increased BMI have a higher risk of complications. This minimally invasive technique may reduce the need for perioperative blood transfusion.     

Restorative proctocolectomy

Restorative proctocolectomy is considered the procedure of choice in the surgical treatment of ulcerative colitis and familial adenomatous polyposis coli. It is considered a therapeutically option that can cure both diseases avoiding permanent ileostomy and having good functional results. The operative procedure consists of total rectocolectomy excepting the anus, preserving the sphincter but with rectal mucosectomy. Digestive continuity is established by an ileal pouch and ileal pouch-anal anastomosis. Despite the high morbidity rate, functional results after restorative proctocolectomy seems to be better after one year after closure of the diverting ileostomy.     

储袋炎及回肠肛管储袋功能障碍的诊断与治疗

对于经内科治疗无效或出现不典型增生的溃疡性结肠炎以及家族性腺瘤性息肉病患者．回肠储袋肛管吻合（IPAA）的重建性结直肠切除术已成为外科治疗的首选。但溃疡性结肠炎患者IPAA术后除了一般手术并发症外,还容易出现一系列炎性或非炎性并发症,如储袋炎、储袋克罗恩病、直肠残端封套炎或储袋易激综合征,从而影响患者的手术效果及生活质量。储袋炎是溃疡性结肠炎患者IPAA术后最常见的远期并发症．累计患病率可达50％。储袋镜是储袋功能障碍诊断及鉴别诊断的重要手段。储袋炎可根据病因分为“特发性”与“继发性”．其治疗也不尽相同。抗生素治疗是急性储袋炎的主要治疗方法．一些抗生素依赖的患者则需要长期的维持治疗。对抗生素耐药及依赖的储袋炎的处理是比较棘手的．另外．引起继发性储袋炎的病因亦需尽量发现并进行纠正。     

Long-term results of abdominal salvage surgery following restorative proctocolectomy

BACKGROUND: This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy. METHODS: Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine. RESULTS: One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32). CONCLUSION: Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.     

Etiology and pathogenesis of pouchitis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). While this surgical therapy is effective and results in good clinical outcomes and quality of life, patients experience complications, the most common of which is pouchitis. While most pouchitis is considered idiopathic, there is mounting evidence that pouchitis results from aberrant immune response to the bacterial populations found in the pouch in a genetically predisposed patient. Dysbiosis and decreased diversity of the microbiota seem to contribute to this process. Risk factors for pouchitis including inflammatory bowel disease and obesity provide further clues to the etiology of pouchitis. In conclusion, we seek to understand the pathogenesis of pouchitis as both a post-operative complication and a form of inflammatory bowel disease (IBD).     

Restorative proctocolectomy with and without protective ileostomy in a pediatric population

Purpose

This study aim was to review outcomes of pediatric patients after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes.

Methods

All patients who underwent rectal mucosectomy with ileal pouch reservoir and hand-sewn ileal pouch anal anastomosis (IPAA) during 19-year period were reviewed retrospectively.

Results

Eighty-three patients with ulcerative colitis and 7 patients with polyposis syndromes (ages 2.0-21.8 years) were reviewed. Sixty-eight patients underwent IPAA without diverting ileostomy. Fifty-six patients underwent restorative proctocolectomy as single-stage procedures, and 12 had abdominal colectomy and subsequent definitive IPAA without diverting ileostomy. Nineteen patients had IPAA with diverting ileostomy and subsequent closure of ileostomy. Three-stage procedures were performed in 3 cases. An ileal pouch leak or pelvic abscess occurred in 2 patients. Surgical pouch revision for retraction, efferent limb syndrome, prolapse, pouchitis, or perirectal infections occurred in 19 (6/62 J-pouch, 13/28 S-pouch). Fourteen patients (5/22 with diversion, 9/68 without diversion) developed small bowel obstruction. Overall, daytime and nighttime continence was excellent with rare nocturnal evacuations.

Conclusions

Restorative proctocolectomy without protective ileostomy is not associated with an increased morbidity, even in patients with active colitis, and may be appropriate most patients.     

Anatomic and functional characteristics of the rat ileal pouch

BACKGROUND: The definitive operation for chronic ulcerative colitis (UC) and familial adenomatous polyposis is total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Mild inflammation (pouchitis) is omnipresent in pouches and becomes severe in 50% of UC patients with IPAA. The etiology of pouchitis is likely due to combined genetic, microbial, and immunologic factors. Epithelial cell exposure to surgical trauma and/or to changes in intestinal bacterial composition may account for the inflammatory infiltrate. Progress in understanding pouchitis is restricted by the lack of suitable animal models. METHODS: An ileal pouch-rectal anastomosis [IPRA] in rats was developed to reproduce a model of human IPAA and clinical, gross and histologic criteria were determined. RESULTS: Many shared features with human ileal pouch were observed. CONCLUSION: IPRA is an important in vivo model to study mechanisms of repair, defense and immunity that may contribute to pouchitis.     

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.     

Laparoscopic proctocolectomy with ileal pouch-anal anastomosis

In recent years laparoscopic proctocolectomy with ileal pouch-anal anastomosis has been used as an alternative to conventional open techniques. However, many published series on proctectomy and ileal pouch-anal anastomosis are based on open experience. This paper presents our experience of laparoscopic proctocolectomy with ileal pouch-anal anastomosis to 23 patients with ulcerative colitis and familial adenomatous polyposis. In operations only sample exteriorization and pouch formation were performed using a small left flank incision of about 4 cm, all other steps were performed entirely laparoscopically. None of the laparoscopic procedures required conversion to an open operation, and there were no intraoperative complications. The median operative time was 315 minutes (240 to 460 min), the average blood loss was 130 mL (70 to 270 mL). Postoperative pain was minimal and no patients required analgesic drugs. Bowel function returned in a median of 2 days (1 to 3 d). Postoperative complications were encountered in 5 patients 22%). No patient required surgical reintervention. The median hospital stay was 9 days (7 to 16 d). In conclusion, laparoscopic proctocolectomy with ileal pouch-anal anastomosis is technically feasible and safe. The technique described in this study provides some potential advantages such as improved cosmetic result and less blood loss. It can be used in patients with familial adenomatous polyposis and ulcerative colitis.     

Role of surgery in patients with pouchitis

Restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) has been an ideal surgical option for patients with chronic ulcerative colitis (UC) and familial adenomatous polyposis for nearly 4 decades. In most cases, patients enjoy excellent quality of life with a durable surgical and functional result, avoiding the need for a lifelong ileostomy.Despite great success, patients with IPAA may suffer from several pouch-related complications that are a challenge for the patient and surgeon. Pouchitis is one such challenging complication that requires thoughtful consideration and judgment for successful management. Treatment of pouchitis has historically revolved around medical therapy, but the surgeon׳s role in a multidisciplinary approach to pouchitis is critical for diagnosis, treatment, and improvement of quality of life.The focus of this review is to provide a structured approach to the challenges that the surgeon encounters when faced with a patient with chronic or refractory pouchitis and to discuss the surgical options that mitigate the morbidity caused by pouchitis in parallel with or when medical treatments fail.     

Small intestinal obstruction complicating ileal pouch-anal anastomosis.

Small bowel obstruction remains the most common complication after proctocolectomy with ileal pouch-anal anastomosis. Of 626 patients who underwent this operation between January 1981 and October 1986 for ulcerative colitis (544 patients), familial adenomatous polyposis (72 patients), or indeterminate colitis (ten patients), 17% developed small bowel obstruction, 7.5% of whom required surgical intervention. The obstruction occurred either before or after closure of the temporary ileostomy. Patients who had a temporary Brooke ileostomy were more likely to develop obstruction (four of 32 patients, 12.5%) than those who had a loop ileostomy (25 of 564 patients, 4.6%) (p = 0.07). Also, patients who had had previous operations were at greater risk of obstruction (8.5%) than those who had not (2.2%) (p less than 0.04).