Ileal Pouch-anal Anastomosis Surgery Research Articles

Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers.

The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications. Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment betweenJanuary 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6weeks after surgery via contrast enema and pouchoscopy. One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3years and average body mass index was 24.9kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of theileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemiaand theleak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7weeks. ICG perfusionassessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

P199 Ileal pouch-anal anastomosis in women of childbearing age affected by ulcerative colitis: a single-centre study on the risk factors for infertility and outcomes of pregnancy over 17 years

Abstract Background The impact of Ileal Pouch-Anal Anastomosis (IPAA) on the fertility of women affected by ulcerative colitis (UC) is still debated in the literature. The primary aim of this study was to assess the risk factors for infertility in women undergoing IPAA. The second aim was compare the outcomes of pregnancy before and after IPAA. Methods Retrospective study including women (18–45 years) undergoing IPAA for UC (2004–2020). Univariate comparison was carried out as appropriate. Cox regression analysis was used to identify significant predictors of infertility over the follow-up (defined as the conceiving time starting one year after IPAA surgery). Results Some 149 patients answered the questionnaire and were included in the study. Table 1 shows the comparison between fertile (23, 15.5%) and infertile (20, 13.4%) women after IPAA surgery. At the cox regression analysis, only the Mayo endoscopic score of 3 was associated with the risk of postoperative infertility (OR 4.16, 95% CI 1.07–16.6, p=0.040). Table 2 shows the comparison between pregnancies before (72) and after (27) IPAA. Pregnancies after IPAA were more likely to require assisted conception treatment (25.9% vs 2.7%, p<0.001), and to be carried out without any UC drug regimen (85.2% vs 61.1%, p=0.17), since they were less likely to trigger an exacerbation of the disease both during (8% vs 22.2%, p=0.09) and after pregnancy (24% vs 45.8%, p=0.044). Of the 61 nulliparous women who did not try to conceive after IPAA, 11 (18%) feared physical consequences, 10 (16.4%) were afraid to transmit the disease, while 3 (4.9%) were recommended by their gynecologist. Conclusion IPAA surgery is associated with a reduction of the fertility of 46.5%, and the preoperative severity of the disease seems to be the strongest predictor of infertility. Although the pregnancy after IPAA requires a longer conceiving time, it is safe for both the mother and the child, at least when carried out through caesarean delivery. A great proportion of women of childbearing age affected by UC still refer confusion regarding the risks of complications and infertility associated with IPAA. A dedicated counsel pathway should be mandatory in all referral centres. A larger multicentric study will be required to assess the outcomes in a larger population.

P346 Chronic pouch failure rates after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis

Abstract Background During restorative (completion) proctectomy and Ileal pouch-anal anastomosis (IPAA), rectal dissection can be performed in either the total meso-rectal excision (TME) plane with anterolateral exception, or as a full close rectal dissection (CRD). CRD showed lower postoperative morbidity and better short-term quality of life (QOL) when compared to TME. We aimed to compare the incidence of chronic pouch failure (PF) in patients undergoing TME or CRD during proctectomy followed by IPAA for inflammatory bowel diseases (IBD). Methods This mono-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC from January, 2002 to October, 2017 in a tertiary IBD referral centre. Outcomes of this study were chronic pouch failure (PF) rates and PF-free survival between patients who underwent CRD and TME. Chronic PF was defined as a pouch-related complication occurring <, 3 months after IPAA surgery requiring pouch-redo surgery, -excision or definitive ileostomy without excision. PF-free survival was defined as months between date of functional pouch and date of surgical PF. Multivariable cox- regression was used to determine whether CRD as dissection type had impact on PF-free survival, when compared to TME. (Chronic) anastomotic ileal pouch-anal leakage and fistula were also included in analyses as confounding factors, which is in line with available literature1. Results Out of, 293 patients that underwent pouch surgery, 123 (42.0%) had a proctectomy in the CRD plane, and, 170 (58.0%) in the TME plane. As the median operation year for CRD was, 9 years later (2006 vs, 2015), a significantly shorter postoperative follow-up for CRD patients was reported (74 vs, 172 months, p<0.01). PF occurred in, 27 (9.2%) patients, of which six (4.9%) underwent CRD and, 21 (12.4%) underwent TME (p=0.03). Both the mean PF-free survival in months (162 vs, 195, p=0.31) and PF-free survival rate after, 36 months (98.1% vs, 92.1%) were comparable among patients who underwent CRD and TME (Figure, 1, p=0.31). CRD was not associated with developing chronic PF (Odds ratio = 0.96, CI, 95%:, 0.35–2.61) after multivariable cox-regression analysis. Figure, 1. PF-free survival curve for patients who underwent CRD (red) and TME (blue) Conclusion In the current study, we did not observe a significant difference in chronic PF after either CRD or TME. Although data on long-term functional outcomes and QOL are necessary to draw final conclusions, results of this study suggest that long-term outcomes of CRD were comparable to outcomes after TME. As an earlier study concluded CRD is beneficial when it comes to postoperative morbidity and short-term QOL, surgeons should consider performing close rectal dissection during IPAA surgery for IBD.

OP13 Modified 2-stage vs. 3-stage ileal pouch-anal anastomosis result in equivalent long-term functional outcomes and pouch survival: A matched-pair analysis

Abstract Background Long-term outcomes data after modified 2-stage ileal pouch anal anastomosis (IPAA), defined as completion proctectomy (CP) and IPAA without loop ileostomy, is lacking. We aimed to describe long-term functional results, patient satisfaction, and pouch survival in a cohort of patients from a high-volume center. We hypothesized selective m2-stage can result in comparable long-term pouch survival relative to a 3-stage approach. Methods Our institutional ileal pouch database was retrospectively reviewed to identify patients who underwent index IPAA surgery from 1983–2019. Adults >18 years of age who underwent CP with IPAA were included. At our specialized institution, m2-stage is performed selectively based on surgeon judgement. Patients were stratified into 2 groups (3-stage vs m2-stage) and matched on a 1:1 basis based on age ±5, year of operation ±3, gender, preoperative diagnosis, double-stapled vs handsewn, and laparoscopy. Primary outcome was pouch survival, with pouch failure defined as permanent diversion, pouch excision, or conversion to a Kock pouch. Results In total, 2,433 patients were included, of whom 2,198 (90.3%) underwent 3-stage IPAA and 235 (9.7%) m2-stage IPAA. Matching resulted in 223 matched pairs, and long-term pouch survival (95.5% vs 93.2%, p=0.32) did not significantly differ (Figure 1). Short-term outcomes in the matched pairs revealed a shorter postoperative length of stay in the 3-stage patients (5 vs 8 days, p<0.001), but no significant difference in postoperative complications (12.1% vs 17%, p=0.09) was seen between the matched 3-stage and m2-stage patients, respectively. Functionally, there was no difference in the number of stools/24 hours (7 vs 7, p=0.33) or in proportion of patients requiring seepage protection at night (29.7% vs 24.6%, p=0.31). However, 3-stage patients required significantly more seepage protection during the day (25.1% vs 15.0%, p=0.02). Regarding pouchitis, there was no difference in the proportion of patients reporting recent symptoms (33.4% vs 33.3%, p=1.0), episodes in the last year (0 vs 0, p=0.51), or pouchitis requiring continuous medication (16.7% vs 10.1%, p=0.10). Patient satisfaction was similar as no difference in the proportion of those who would have surgery again (90.4% vs 93.7%, p=0.34), those who would recommend surgery (94% vs 95.5%, p=0.68), or overall patient satisfaction with surgery on a scale of 1 – 10 (highest) (3 vs 7, p=0.07) was reported. Figure 1: Kaplan-Meier curve for pouch survival (matched pairs) Conclusion Long-term outcomes were similar in patients who underwent modified 2-stage and 3-stage IPAA. Modified 2-stage IPAA is an alternative for selected patients with limited options if performed at high-volume centers in experienced hands.

Standardization of ileoanal J-pouch surgery technique: Quality assessment of minimally invasive ileoanal J-pouch surgery videos

BackgroundIleal pouch anal anastomosis is a complex procedure associated with significant morbidity, with several complications after ileal pouch anal anastomosis surgery leading to pouch failure. The aim of the study is to evaluate the heterogeneity surrounding the technique of ileoanal J-pouch surgery by assessing the safety and quality of published online peer-reviewed surgical videos. MethodsIleal pouch anal anastomosis videos published on peer-reviewed surgical journals and video channels were edited and anonymized to demonstrate specific steps of the surgical procedure: mobilization and division of the rectum, formation of the ileoanal J-pouch reservoir, anastomosis, and lengthening techniques. The anonymized videos were presented to a group of reviewers with expertise in ileal pouch anal anastomosis blinded to the names and affiliations of the surgeons performing the procedure. Primary outcome was the rate of interobserver variability in the assessment of specific technical steps of the ileal pouch anal anastomosis surgery procedure. Secondary outcome was the appropriateness of the use of surgical videos review as an assessment tool for ileal pouch anal anastomosis surgery, measured as rate of reviewers being unable to answer for poor video quality. ResultsIn total, 29 video fragments were distributed, and 13 assessors completed a 60-item survey, organized in 7 major domains. The survey completion rate was 93.4%. Out of a total 729 answers, in 23 (3.2%) the reviewers indicated they were unable to comment due to poor video image, and in 48 (6.5%) were unable to comment due to the particular step not being shown in the procedure. The proportion of assessors rating rectal mobilization technically appropriate ranged from 30.7% to 92.3% and from 7.7% to 69.2% for safety. The level of rectal division was considered appropriate in 0 to 53.8% of the videos, whereas the stapling technique used for rectal division was appropriate in 0 to 70% of the videos. ConclusionOur study assessed published peer-reviewed videos on ileal pouch anal anastomosis surgery and reported heterogeneity in the safety of the demonstrated techniques. Blind assessment of published peer-reviewed ileal pouch anal anastomosis videos reported a high rate of unsafe or inappropriate technique for rectal mobilization and transection in the reviewed videos, with fair interobserver agreement among reviewers. There is a need for consensus on what is considered safe and appropriate in ileal pouch anal anastomosis surgery. Peer review of ileal pouch anal anastomosis surgery videos could facilitate training and accreditation in this complex procedure.

A long-term follow-up after open ileal J pouch volvulus repair in a FAP patient - A case report.

IntroductionMost 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 caseThe 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.DiscussionThe 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.ConclusionVolvulus 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.

Management of pouch related symptoms in patients who underwent ileal pouch anal anastomosis surgery for adenomatous polyposis.

BACKGROUNDAdenomatous polyposis syndromes (APS) patients with ileal pouch anal anastomosis (IPAA) suffer frequent symptoms with scarce signs of inflammation, distinct from ulcerative colitis patients. While the management of pouchitis in ulcerative colitis patients is well established, data regarding response to treatment modalities targeting pouch-related disorders in APS patient population is scarce.AIMTo assess clinical, endoscopic and histologic response to various treatment modalities employed in the therapy of pouch related disorders. METHODSAPS patients who underwent IPAA between 1987-2019 were followed every 6-12 mo and pouch-related symptoms were recorded at every visit. Lower endoscopy was performed annually, recording features of the pouch, cuff and terminal ileum. A dedicated gastrointestinal pathologist reviewed biopsies for signs and severity of inflammation. At current study, files were retrospectively reviewed for initiation and response to various treatment modalities between 2015-2019. Therapies included dietary modifications, probiotics, loperamide, antibiotics, bismuth subsalicylate, mebeverine hydrochloride, 5-aminosalicylic acid compounds and topical rectal steroids. Symptoms and endoscopic and histologic signs of inflammation before and after treatment were assessed. Pouchitis disease activity index (PDAI) and its subscores was calculated. Change of variables before and after therapy was assessed using Wilcoxon signed rank test for continuous variables and using McNemar's test for categorical variables.RESULTSThirty-three APS patients after IPAA were identified. Before treatment, 16 patients (48.4%) suffered from abdominal pain and 3 (9.1%) from bloody stools. Mean number of daily bowel movement was 10.3. Only 4 patients (12.1%) had a PDAI ≥ 7. Mean baseline PDAI was 2.5 ± 2.3. Overall, intervention was associated with symptomatic relief, mainly decreasing abdominal pain (from 48.4% to 27.2% of patients, P = 0.016). Daily bowel movements decreased from a mean of 10.3 to 9.3 (P = 0.003). Mean overall and clinical PDAI scores decreased from 2.58 to 1.94 (P = 0.016) and from 1.3 to 0.87 (P = 0.004), respectively. Analyzing each treatment modality separately, we observed that dietary modifications decreased abdominal pain (from 41.9% of patients to 19.35%, P = 0.016), daily bowel movements (from 10.5 to 9.3, P = 0.003), overall PDAI (from 2.46 to 2.03, P = 0.04) and clinical PDAI (1.33 to 0.86, P = 0.004). Probiotics effectively decreased daily bowel movements (from 10.2 to 8.8, P = 0.007), overall and clinical PDAI (from 2.9 to 2.1 and from 1.38 to 0.8, P = 0.032 and 0.01, respectively). While other therapies had minimal or no effects. No significant changes in endoscopic or histologic scores were seen with any therapy.CONCLUSIONAPS patients benefit from dietary modifications and probiotics that improve their pouch-related symptoms but respond minimally to anti-inflammatory and antibiotic treatments. These results suggest a functional rather than inflammatory disorder.

Cut-off value of ulcerative colitis endoscopic index of severity (UCEIS) score for predicting the need for pouch construction in ulcerative colitis: results of a multicenter study with long-term follow-up.

BackgroundTotal proctocolectomy with ileal pouch–anal anastomosis (IPAA) was the first choice for the surgical treatment of the ulcerative colitis (UC) patients. The data on the predictive value of the ulcerative colitis endoscopic index of severity (UCEIS) for the need for IPAA in UC patients is scarce. We aimed to establish the UCEIS cut-off value to further analyse whether the UCEIS cut-off was suitable for predicting the need for IPAA in UC patients.MethodsThe clinical data of UC patients from June 1986 to March 2020 at our institute were retrospectively assessed. The UCEIS scores recorded at the time of the first colonoscopy after hospitalization were used in the study. Receiver operating characteristic curve analysis was performed to determine the UCEIS cut-off value for predicting the need for IPAA.ResultsA total of 283 UC patients were included in the study, with a median UCEIS of 4. During a median follow-up of 13 years, 80 patients (28.3%) received surgery invention, among whom 75 (93.8%) underwent IPAA surgery and 5 (6.2%) received subtotal colectomy with permanent ostomy. A UCEIS cut-off of 6 had the most significant area under the curve of 0.769 for predicting the need for IPAA (P < 0.001), with a sensitivity of 72.0% and specificity of 81.8%. UCEIS ≥6 was an independent predictive factor for the need for IPAA (P < 0.001) and malignant transformation (P = 0.010). Patients with UCEIS ≥6 had a significantly shorter IPAA-free survival time than those with UCEIS <6 (P < 0.001).ConclusionsUCEIS ≥6 may be a threshold value for decision-making for IPAA and should be recommended for UC patients for reducing the incidence of malignant transformation.

THE CUMULATIVE INCIDENCE OF POUCHITIS AND POUCH-RELATED COMPLICATIONS IN PEDIATRIC PATIENTS WITH ULCERATIVE COLITIS

Despite highly effective therapies, many children develop medically refractory ulcerative colitis (UC) and undergo proctocolectomy with ileal pouch anal anastomosis (IPAA). There is little real world evidence regarding IPAA outcomes in pediatric UC patients. We sought to determine the risk of pouchitis, recurrent pouchitis, and change in diagnosis to Crohn’s disease (CD) within two years of IPAA surgery among pediatric patients with UC using a large, geographically diverse insurance claims database.

Mesenteric lengthening during pouch surgery: technique and outcomes in a tertiary centre.

Anastomotic complications after ileal pouch-anal anastomosis (IPAA) are often associated with excessive tension and poor blood supply. Carrying out a tension-free IPAA might prove difficult in a proportion of cases, especially if mucosectomy and hand-sewn anastomosis are necessary. The aim of the study was to analyse the outcomes of mesenteric lengthening in patients undergoing IPAA in a tertiary centre. Consecutive patients who required mesenteric lengthening during IPAA surgery between 2000 and 2019 were retrospectively included. Short and long-term outcomes were analyzed. Chi square, Fisher's exact test and Wilcoxon rank sum test were used as appropriate. Kaplan-Meier analysis was carried out to report the long-term rate of pouch failure. Some 131 patients (78 UC, three indeterminate colitis, 50 FAP) were included. The need for mesenteric lengthening, due to short mesentery or intraoperative complications, was unpredictable in 15 patients. The rate of surgical complications was 20.6%; eight patients required a reoperation, two of them experienced postoperative pouch ischemia. After a median follow-up time of 9.4years, the risk of pouch failure in FAP and UC patients was 7.2% and 13% at 10years. Despite the indication to mucosectomy has been reducing over the years, mesenteric lengthening is still required in a significant proportion of UC and FAP patients, also because of unforeseeable intraoperative conditions necessities.

THE CUMULATIVE INCIDENCE OF POUCHITIS AND POUCH-RELATED COMPLICATIONS IN PEDIATRIC PATIENTS WITH ULCERATIVE COLITIS

Abstract Background &amp; Aims Despite highly effective therapies, many children develop medically refractory ulcerative colitis (UC) and undergo proctocolectomy with ileal pouch anal anastomosis (IPAA). There is little real world evidence regarding IPAA outcomes in pediatric UC patients. We sought to determine the risk of pouchitis, recurrent pouchitis, and change in diagnosis to Crohn’s disease (CD) within two years of IPAA surgery among pediatric patients with UC using a large, geographically diverse insurance claims database. Methods Within the IQVIA Legacy PharMetrics Adjudicated Claims Database, we identified pediatric patients (age &amp;lt;18 years) with UC who underwent proctocolectomy with IPAA between January 1, 2007 and June 30, 2015. We utilized International Classification of Diseases (ICD-9-CM or ICD-10-CM) codes to identify patients with UC and Current Procedural Terminology III codes to identify IPAA. The primary outcome was the development of pouchitis in the first 2 years following surgery, as identified by a previously validated case-finding definition. Secondary outcomes included the incidence of recurrent pouchitis, and the cumulative incidence of a new diagnosis of Crohn’s disease (CD) in the first two years post-IPAA. A change in diagnosis to CD was identified by an ICD-9-CM or ICD-10-CM code for CD on at least three separate occasions. Bivariate analyses were used for all comparisons, utilizing chi-square and t-test as appropriate. Results A total of 68 patients with an IPAA with at least two years of continuous health plan enrollment following surgery were identified. Among all patients undergoing surgery, the median age was 15 years (interquartile range 11.5–16), with 29 (43%) female patients. In the first 2 years following IPAA, the cumulative incidence of pouchitis was 54%. Characteristics and prior medical treatments in patients without pouchitis and with ≥ one episode of pouchitis were similar (Table 1). The cumulative incidence of recurrent pouchitis during this period was 22%. The cumulative incidence of a new diagnosis of CD in the two years after IPAA for UC was 9%. Conclusions In a geographically diverse cohort from the United States, 54% of pediatric patients undergoing proctocolectomy with IPAA for UC developed pouchitis within the first two years after surgery. Furthermore, 9% had a change in diagnosis to CD. These data indicate that for many pediatric UC patients, surgery is non-curative and patients continue to have a substantial burden of illness. Future efforts should attempt to identify novel, actionable, predictors of pouchitis in this population.

Functional Anatomical Changes in Ulcerative Colitis Patients Determine Their Gut Microbiota Composition and Consequently the Possible Treatment Outcome.

Gut microbial composition alters in some special situations, such as in ulcerative colits (UC) after total proctocolectomy and ileal pouch-anal anastomosis (IPAA) surgery. The aim of our study was to determine the composition of the intestinal microbiome in UC patients after IPAA surgery, compared with UC patients, familial adenomatous polyposis (FAP) patients after IPAA surgery and healthy controls. Clinical data of patients, blood and faecal samples were collected. Faecal microbiota structure was determined by sequencing the V4 hypervariable region of the 16S rRNA gene. Overall, 56 patients were enrolled. Compared to the Healthy group, both the Pouch active and UC active groups had higher Enterobacteriaceae, Enterococcaceae and Pasteurellaceae abundance. The Pouch and UC groups showed distinct separation based on their alpha and beta bacterial diversities. The UC group had higher Prevotellaceae, Rikenellaceae, Ruminococcaceae abundance compared to the Pouch active group. Pouch and FAP participants showed similar bacterial community composition. There was no significant difference in the bacterial abundance between the active and inactive subgroups of the Pouch or UC groups. Gut microbiome and anatomical status together construct a functional unit that has influence on diversity, in addition to intestinal inflammation that is a part of the pathomechanism in UC.

S0753 Children With a History of UC and IPAA Experience a More Rapid Progression to Pouch Failure Compared With Adults and Historical Controls

INTRODUCTION: Though there are significant differences in surgical outcomes between pediatric and adult ulcerative colitis (UC) patients undergoing colectomy1–3, counseling families on outcomes has largely been guided by data from adult cohorts. We compared differences in pouch survival between pediatric and adult patients undergoing total proctocolectomy with ileal-pouch anal-anastomosis (IPAA). METHODS: This is a retrospective single-center study of inflammatory bowel disease (IBD) patients treated with IPAA who subsequently underwent pouchoscopy at the University of Chicago Medical Center between 1980 and 2019. Data were collected for 426 subjects via electronic medical records. We stratified the study population based on age at UC diagnosis or age at IPAA using a cutoff of 19 years. Differences between groups were assessed using t-tests and Chi-square tests. Kaplan Meier curves were used to compare survival probabilities. RESULTS: We identified 111 patients diagnosed with UC before age 19 and 53 patients undergoing IPAA before age 19 (Table 1). Pouch failure in pediatric patients occurred twice as often compared with adult patients (18.3% vs 9.7%, P = 0.1). Pediatric IPAA patients were more likely to require anti-TNF post-colectomy (41.5%) compared to adult patients (25.8%, P < 0.05) and to pediatric counterparts who had surgery in adulthood (22.1%, P = 0.05). Analysis by decade of IPAA surgery revealed that children undergoing IPAA in the 1990s and 2000s had survival estimates above 75% until 12- and 25-years post-colectomy. However, for IPAA performed since 2010, this threshold remains only five-years post-colectomy (P < 0.001) (Figure 1). Comparing pediatric and adult patients with stratification by pre-operative anti-TNF exposure, we observe that pediatric IPAA patients receiving anti-TNF therapies pre-colectomy had the most rapid progression to pouch failure (P = 0.027) (Figure 2). CONCLUSION: There are lower rates of pouch survival for children with UC undergoing IPAA in the anti-TNF era compared to both historical pediatric controls and contemporary adults. While more work is needed to understand the mechanistic underpinnings associated with these findings, anticipatory guidance for pediatric patient families prior to surgery and plans for surveillance after should reflect these outcomes.Table 1.: Study Population Stratified by Age at IPAA (n = 383)Figure 1.: Kaplan Meier Pouch Survival Estimate for Pediatric Patients based on Decade of IPAA.Figure 2.: Kaplan Meier Pouch Survival Estimate for Adult and Pediatric Patients based on Anti-TNF Exposure Prior to IPAA.

Anastomotic leak does not affect long-term and longitudinal functional outcomes after ileal pouch surgery for ulcerative colitis when managed aggressively.

Ileal pouch-anal anastomosis (IPAA) is an effective surgical alternative to a permanent ileostomy following proctocolectomy in patients with ulcerative colitis (UC). Anastomotic leakage (AL) is a serious postoperative complication of an intestinal anastomosis that is associated with increased morbidity and mortality. The aim of this study was to evaluate the longitudinal long-term functional outcomes of patients who had IPAA that was complicated by AL. A retrospective longitudinal cohort study was performed of patients who had an IPAA procedure at a tertiary referral centre and a metropolitan private centre in Australia, over a 14-year period (October 2003-October 2017). The long-term functional outcome was assessed using objective clinical measures such as the number of bowel motions during the day and overnight, ability to defer defaecation and the presence of faecal incontinence, and repeated at annual intervals. A total of 138 patients [mean age 38.5 (± 16.9) years, 72 males] satisfied the inclusion criteria. AL was diagnosed in 14 (10%) patients [mean age 38.8 (± 17) years, 10 males], 11 (79%) of which were managed with surgery. The median bowel motion frequency during the day and overnight remained stable over a median of 62 (28-91) months follow-up, with no significant difference between those who had AL or not (p = 0.6, p = 0.1 respectively). The incidence of faecal incontinence remained low, and the majority of patients in both groups were able to defer defaecation for more than 60min. Six patients (4.3%) had their pouch excised. There is no statistical difference in longitudinal function between patients who experienced AL after IPAA surgery for UC compared with those who did not. Therefore, an acute AL does not negatively impact long-term functional outcomes in IPAA patients.

Fecal continence outcomes are associated with the type, height, and stage procedure of ileal pouch-anal anastomosis

PurposeThis study aims to analyze the quality of life in patients with an ileal pouch-anal anastomosis (IPAA) and to investigate the association between height and type of the anastomosis, the number of stage procedures and age, and the fecal continence outcomes.MethodsThis is a cross-sectional retrospective study in patients who had undergone IPAA between 1992 and 2016 (N = 133). We sent questionnaires to 102 eligible patients (64% response rate). We used the Wexner score to assess fecal incontinence: 0 = no incontinence to 20 = complete incontinence. We used RAND-36 to measure quality of life.ResultsPatients who underwent mucosectomy with hand-sewn anastomoses (n = 11, 17%) had significantly higher median Wexner scores than patients with stapled anastomoses (10 versus 3, P = 0.003). Lower anastomoses correlated significantly with increasing Wexner scores (r = − 0.468, P < 0.001). Quality of life of incontinent patients was diminished. Patients who were older at the time of IPAA surgery had higher Wexner scores (P = 0.004), while the time between surgery and questionnaire did not influence their Wexner scores (P = 0.810). Considering the stage procedures, multiple linear regression showed that the two-stage procedure without diverting ileostomy was significantly associated with higher Wexner scores (B = 0.815, P = 0.02), adjusted for sex (P = 0.008) and anastomosis type (P = 0.002). The three-stage procedure showed equally low complications and anastomotic leakage rates.ConclusionMucosectomy with more distal, hand-sewn anastomosis and increasing age at IPAA surgery was associated with poorer fecal continence outcomes. The three-stage procedure appears to give the best fecal continence results without increasing complications. Furthermore, incontinence reduced patient’s quality of life.

RISK FACTORS FOR THE DEVELOPMENT OF COMPLICATIONS OF ILEAL POUCH IN PATIENTS WITH ULCERATIVE COLITIS

AIM: to reveal risk factors of complications after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC).PATIENTS AND METHODS: from September 2011 by July 2018, 144 patients, who underwent IPAA surgery for UC were included in the study. Univariate and multivariate analyses were performed to reveal the risk factors for complication of IPAA, such as pouchitis, cuffitis, pouch fistulas, anastomotic stricture, pouch leakage, bleeding from IPAA, incontinence and small bowel obstruction (SBO).RESULTS: multivariate regression analysis showed that left-sided UC (OR=12,5, 95% CI 1,7-92, p=0,01), patient's age ≤33 years (OR=5,7, 95% CI 1,54-21,3, p=0,009) and hormone-free period before the IPAA ≤10 months (OR=6,86, 95% CI 1,49-31,56, p=0,01) were associated with cuffitis. The fibrotic changes/wound infection in the anal canal (OR=5,02, 95% CI 1,02-24,69, p=0,04) and albumin &lt;35 g/l (OR=8,11, 95% CI 2,12-30,99, p=0,002) were associated with fistulas. Time between IPAA formation and preventive ileostomy closure &gt;5,6 months was associated with SBO (OR=2,82, 95% CI 1,01-8,31, p=0,0495). Steroid therapy at the time of IPAA surgery was associated with pouch leakage (OR=15,62, 95% CI 2,09116,64, p=0,007). Hand-sewn IPAA (OR=42,54, 95% CI 3,51-516,43, p=0,003) were associated with incontinence. Ulcerative defects in the distal part of the rectum according to transrectal ultrasound were associated with anastomotic stricture (OR=10,46, 95% CI 1,52-71,75, p=0,017). There were no statistically significant risk factors for pouchitis and IPAA bleeding.CONCLUSION: determination of the risk factors for complications of IPAA is a crucial clinical issue for patients with UC. We identified several factors associated with increased risk of complications after pouch formation. Nevertheless, it seems promising to continue the study in order to create the mathematical model that predicts the development of a specific pouch-related complication and determines a group of patients with UC in whom the formation of IPAA is not recommended due to high risk of complications and impaired quality of life.

Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis.

Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. Patients with pouchitis have a wide range of symptoms, endoscopic and histologic features, disease course, and prognosis. To date, there are no universally accepted diagnostic criteria in terms of endoscopy and histology; though, semi-objective assessments to diagnose pouchitis in patients with ileal pouch- anal anastomosis (IPAA) have been proposed using composite scores such as the Pouchitis Triad, Heidelberg Pouchitis Activity Score and Pouchitis Disease Activity Index (PDAI). In a systematic review that included four randomized trials evaluating five agents for the treatment of acute pouchitis, ciprofloxacin was more effective at inducing remission as compared with metronidazole. Rifaximin was not more effective than placebo, while budesonide enemas and metronidazole were similarly effective for inducing remission of acute pouchitis. Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. In patients with antibiotic-refractory pouchitis, secondary factors associated with an antibiotic-refractory course should be sought and treated. In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Rectal eversion: safe and effective way to achieve low transaction in minimally invasive Ileal pouch-anal anastomosis surgery, short- and long-term outcomes.

Ileal pouch-anal anastomosis remains a gold standard in restoring continence in patient with ulcerative colitis. Achieving low transection can be challenging and may require mucosectomy with a hand-sewn anastomosis. Rectal eversion (RE) technique provides a safe and effective alternative for both open and minimally invasive approaches. The purpose of this study is to evaluate short- and long-term outcomes of patients who underwent RE when compared to those who underwent conventional trans-abdominal transection. This is a retrospective review performed at tertiary care center. Patients undergoing proctectomy and pouch surgery by either standard approach or with RE from November 2004 to January 2017 were evaluated. Demographics, post-operative complications, as well as 1- and 3-year functional outcomes were analyzed. Total of 176 underwent proctocolectomy with creation of a J pouch and 88 (50%) had the RE technique utilized. The RE group had a higher rate of corticosteroid use at the time of surgery 59.1 versus 39.8% (p = 0.0156), but otherwise groups were statistically similar. 20 cases (26.1%) of RE group and 54 (61%) of conventional group cases were accomplished in minimally invasive fashion. There was no difference in the rates of 30- and 90-day complications. Functional outcomes data were available for up to 78.4% of patient with trans-abdominal approach and 64.7% in RE group. At 1 and 3 years after surgery, there was no difference in the number of bowel movements, fecal incontinence, or nocturnal bowel movements. The rates of returning to ileostomy or pouch revision were the same. RE technique is safe and effective way to achieve a low transaction in J pouch surgery. The technique provides similar functional outcomes at 1 and 3 years after surgery and can be particularly useful in minimally invasive approaches.

Preoperative exposure to anti-tumor necrosis factor therapy in ulcerative colitis patients undergoing ileal pouch-anal anastomosis (IPAA) is not associated with histological fibrosis: A case control study

BackgroundWe sought to determine whether preoperative exposure to anti-TNF therapy affects objective histological measures of fibrosis in the colorectum. MethodsUlcerative colitis (UC) patients who received infliximab as maintenance therapy pre IPAA surgery were identified and compared to anti-TNF-naïve matched controls by age, sex, BMI, disease duration, albumin levels, and post-operative leak outcome. Hematoxylin and eosin- (H&E) and trichrome-stained slides from the most distal, well-oriented, full-thickness section of colorectum from each patient's total colectomy specimen were evaluated. Blinded histopathological assessment of the degree of fibrosis was performed using a semi-quantitative pictorial scale. ResultsHistological fibrosis in 65 patients from the therapy group was compared to 65 patients from the matched control group. There were no statistically significant differences in the degree of fibrosis observed in any of the bowel layers. In the lamina propria, 29% of the control group and 28% of the treatment group had fibrosis scores ≥3. Fibrosis scores were higher in the submucosa, with both groups having 66% of patients showing scores ≥3. Similarly, in the region above the muscularis propria, 77% of the control group and 80% of the treatment group had fibrosis scores ≥3. In the subserosa, fibrosis scores were lower, with 25% of the control group and 32% of the treatment group having fibrosis scores ≥3. ConclusionResection specimens from UC patients treated with maintenance anti-TNF therapy who underwent IPAA surgery showed no significant differences in the degree of histologic fibrosis in any of the bowel layers compared to a matched control group.