Ileal Pouch-anal Canal Anastomosis Research Articles

Efficacy of transanal drainage tube placement in preventing anastomotic leakage after ileal pouch-anal anastomosis in patients with ulcerative colitis.

Transanal drainage tube (TDT) is used to prevent anastomotic leakage after surgery for rectal cancer. However, it remains unclear whether intraoperative TDT placement is also useful in preventing anastomotic leakage after ileal pouch-anal or ileal pouch-anal canal anastomosis (IPAA) in patients with ulcerative colitis (UC). This study aimed to evaluate the efficacy of intraoperative TDT placement in preventing anastomotic leakage after IPAA in patients with UC. Patients with UC who underwent proctectomy with IPAA in the study institution between January 2000 and December 2021 were enrolled in this retrospective cohort study. The relationship between TDT placement and anastomotic leakage was evaluated by logistic regression analysis. The study population included 168 patients. TDT was placed intraoperatively in 103 of the 168 patients (61.3%). The rate of anastomotic leakage was significantly lower in the TDT group than in the non-TDT group (7.8% vs 18.5%, p = 0.037). Reoperation was not needed in any patient in the TDT group whereas two reoperations were necessary in the non-TDT group (3.1%). By logistic regression analysis, intraoperative TDT placement was an independent protective factor for anastomotic leakage. TDT placement was significantly associated with anastomotic leakage of IPAA in patients with UC undergoing surgery. Although two-stage surgery with ileostomy is usually preferred in UC surgery, our findings suggest that TDT placement might contribute to the improvement of postoperative outcomes after UC surgery.

Non-invasive Monitoring of Pouchitis After Total Proctocolectomy Using Fecal Calprotectin Levels.

Fecal calprotectin (FC) is the most widely used marker for evaluating the disease activity of ulcerative colitis (UC). However, studies on FC in pouchitis after total proctocolectomy are scarce. We aimed to examine the correlations between the FC level and clinical findings and Pouchitis Disease Activity Index (PDAI) in UC patients who underwent total proctocolectomy (TP) with ileal pouch-anal canal anastomosis (IPAA) or ileal pouch-anal canal anastomosis (IACA). Between April 2008 and March 2018, 15 patients, consisting of 8 males and 7 females, with an average age at operation of 46.5 years, participated in this study. The average observation period was 68.3 months. The subjects underwent FC level measurements and endoscopic examinations. The mean FC level was 418.69 μg/g (range: 10-1650 μg/g). Pouchitis was found in one (6.6%) patient, as detected by endoscopy. Among the 15 cases, FC levels were positively correlated with white blood cell count as well as albumin and C-reactive protein levels. There was a significant positive correlation between the PDAI score and FC levels (p<0.05). The median FC level was 111 mg/g in those with pouchitis, which was significantly higher than the 16 mg/g in those without pouchitis (p<0.05). Moreover, a significant positive correlation was found between the endoscopic findings of inflammation and FC levels (p<0.00005). FC levels were correlated with the PDAI score, blood testing data, and endoscopic findings, suggesting that the FC level could be a useful index of postoperative pouchitis and ileal pouch condition in patients undergoing TP with IPAA as UC treatment.

Afferent limb syndrome after total proctocolectomy and ileal pouch-anal canal anastomosis

BackgroundSmall bowel obstruction (SBO) is a common postoperative complication of ulcerative colitis (UC). There have been a few recent reports of afferent limb syndrome (ALS) as a rare occurrence in cases of SBO. We present a case of ALS with recurrent SBO that was successfully managed surgically.Case presentationWhen this male patient was 55 years old, he underwent laparoscopy-assisted anus-preserving total proctocolectomy, the creation of a J-type ileal pouch, ileal pouch-anal canal anastomosis (IPAA), and creation of ileostomy for intractable UC. Three months later, ileostomy closure was performed. The first onset of SBO was observed 5 months after ileostomy closure. SBO occurred repeatedly, and the patient was hospitalized nine times in approximately 2 years. Each SBO was improved by non-surgical treatment. A computed tomography (CT) scan revealed that the afferent limb was narrowing and twisted, and gastrografin enema confirmed narrowing at the proximal portion of the pouch inlet. Endoscopy showed a sharp angulation at the pouch inlet. We suspected ALS and decided on a surgical policy and performed pouchopexy and ileopexy to the retroperitoneum by suturing with excision of the remaining blind end of the ileum. Endoscopy 3 days after surgery showed neither twist nor stricture in the fixed ileal pouch or the afferent limb. At the time of writing, the patient remains free of SBO symptoms.ConclusionClinicians should consider ALS when examining a patient with recurrent intermittent SBO after IPAA surgery. When ALS is suspected, the patient is indicated for surgery such as surgical pexy.

P644 Factors and salvage surgery for treatment of pouch failure after restorative proctocolectomy for ulcerative colitis – a single-institution study

Background: For many patients with ulcerative colitis (UC), total colectomy and pouch surgery (ileal pouch-anal canal anastomosis (IACA), ileal pouch-anal anastomosis (IAA)) are performed, improving the quality of life (QOL). However, pouch failure occurs in some patients, markedly reducing their QOL. In this study, we examined the course of patients with pouch failure. Methods: Of 1,156 patients who underwent total colectomy and pouch surgery under a preoperative diagnosis of UC between 1992 and 2015, the subjects were 26 patients (2.2%) in whom pouch-associated complications led to pouch failure (ileostomy state for 2 years or more or pouch resection). Total colectomy was indicated for 14 patients with refractory UC, 12 with severe UC, and 1 with cancer/dysplasia. Concerning techniques, IACA was selected for 21 patients, and IAA for 5. The median age at the time of pouch surgery was 31 years. The median interval from surgery until the appearance of complication-related symptoms was 19.5 months. The median follow-up period from pouch failure was 60 months. Results: Among complications causing pouch failure, fistulae from the anastomotic site accounted for 38% (10 patients), the highest percentage. In 4 of these, suture failure was noted as an early complication. In addition, anal canal-associated complications were observed in 34% (9 patients: 7 with anal fistulae, 1 with a vaginal fistula, and 1 with a pouch fistula (5%)). The final outcomes consisted of anal and pouch excision in 11 patients (after re-ileal pouch anal anastomosis in 2), pouch vacant in 14, and redo ileal pouch anal anastomosis in 1 (12%, 3/26). Of these, 1 required additional ileostomy. Finally, concerning the pouch function after stoma closure, the frequency of defecation was 10 to 15 times/day in both patients, facilitating rehabilitation. Conclusions: In UC patients with pouch failure, the incidence of complications related to fistulae from the anastomotic site was high, suggesting the possibility of early suture failure. For 92% of the subjects, permanent ileostomy was selected. However, redo ileal pouch anal anastomosis was possible in some patients, and closure was possible after temporary ileostomy in others. Treatment methods must be examined in accordance with individual patients.

Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: investigation of a simple predictive method using computed tomography.

This study aimed to assess the ability of preoperative axial computed tomography (CT) to predict surgical difficulty in bringing the ileal pouch to the level of the anus during restorative proctocolectomy (RPC). Patients who underwent RPC with an ileal pouch-anal anastomosis (or ileal pouch-anal canal anastomosis) in our institution between January 2008 and April 2014 were enrolled. The patients were divided into two groups, including those in whom CT indicated potential difficulty in extending the pouch downwards (extension difficult (ED) group) and patients with no CT evidence of potential difficulty (normal group). The groups were compared for clinical factors and the thickness of the slices of CT showing the root of the superior mesenteric artery, the point of communication of the ileocaecal artery with the marginal artery (tICA) and the anal verge (AV). Receiver-operating characteristic analysis was performed, and a cut-off value was calculated for predicting the degree of difficulty in bringing the ileal pouch down to the anal canal. Thirty-four patients were entered in the study. The ED group included significantly taller patients and more with familial adenomatous polyposis than the normal group. The distance between tICA and AV was significantly longer in the ED group, with a cut-off of 21cm giving a sensitivity of 100% and a specificity of 83.3%. The distance between tICA and AV measured by axial CT can be a useful predictor for the difficulty in bringing the ileal pouch down to the anus during RPC.

Surgical resections of ulcerative colitis associated with dysplasia or carcinoma

BackgroundUlcerative colitis (UC) patients have an increased risk of colorectal dysplasia and carcinoma. The purpose of this study was to analyze the clinical features and surgical treatment of ulcerative colitis associated with dysplasia or carcinoma.MethodsWe operated on 41 UC patients since April 2000. Twelve of the cases were associated with dysplasia or carcinoma. Ten patients were male and two were female; the median age was 58.0 years, and the average duration of disease was 19.2 years. Nine cases were pancolitis type and three were left-sided type. Six cases were remission-relapsing type and six were chronic inflammation type. In 10 of 12 cases, dysplasia or carcinoma was diagnosed before the operations. Nine cases were primary operations and two were second-time operations.ResultsAmong ten patients who underwent primary operations, four patients had open surgery and six patients had hand-assisted laparoscopic surgery (HALS). Seven patients received anus/anal sphincter-preserving operations with reconstruction by the ileal pouch technique. Ileal pouch anal-canal anastomosis (IPACA) was performed in five cases and ileal pouch anal anastomosis (IPAA) in two cases. Abdomino-peritoneal resection was performed in two cases, proctcolectomy with permanent ileostomy in one case, and right hemicolectomy in one case. A 39-year-old patient was unresectable due to dissemination of the carcinoma. A 55-year-old patient who underwent IPACA showed night soiling postoperatively. Other patients who received IPAA and IPACA showed favorable anal function postoperatively. Histological examination showed low-grade dysplasia in two cases, high-grade dysplasia in three cases, and adenocarcinoma in seven cases. In the seven cases of adenocarcinoma, four, two, and one cases were stage 1, 3, and 4 according to TNM classification. Three of five cases with dysplasia were detected by surveillance colonoscopy. All patients with carcinoma were symptomatic and did not undergo surveillance colonoscopy.ConclusionsIPACA by HALS was safely performed as an anal-preserving operation in UC patients with dysplasia or carcinoma. Non-anal-preserving operations for aged patients showed a preferable postoperative course. Surveillance colonoscopy is essential for detecting dysplasia before the development of carcinoma.

Long-term outcomes of ileal pouch-anal canal anastomosis in children with ulcerative colitis

Long-term outcomes of ileal pouch-anal canal anastomosis in children with ulcerative colitis

Minimally invasive straight laparoscopic total proctocolectomy for ulcerative colitis

Introduction: We have performed straight laparoscopic total proctocolectomy for ulcerative colitis, in which all procedures, including transection of the rectum and anastomosis, were performed in the abdominal cavity. The primary objective of this study was to evaluate whether straight laparoscopic total proctocolectomy is technically feasible and safe. Methods: A retrospective database identified 22 consecutive patients who underwent straight laparoscopic total proctocolectomy for ulcerative colitis between March 1998 and September 2007. Patients were excluded if they required emergency surgery. First, to create a stoma site, a mini-laparotomy to insert a 15 mm trocar was performed. Seven other trocars, 5 mm in diameter, were then inserted. Mobilization and dissection of the colorectum and anastmosis were performed completely intracorporeally under laparoscopic guidance. Anastomosis of an ileal J-pouch to the anal canal was performed using the double-stapling technique. Results: Nineteen patients were underwent ileal pouch anal canal anastomosis; two underwent ileorectal anastomosis; and one underwent abdominoperineal resection. The median operation time was 355 min (range 255–605); the median blood loss was 50 g (range 0–800); and the median postoperative hospital stay was 24.5 d. Postoperative complications occurred in eight patients, including three (13.6%) with bowel obstruction, two (9.1%) with portal vein thrombosis, one (4.5%) with anastomotic leakage, and one (4.5%) with postoperative hemorrhage. The morbidity rate was 36.4%. There were no intraoperative complications or conversions to conventional surgery. Conclusion: In the context of this study, we have shown that straight laparoscopic total proctocolectomy is technically feasible and safe in patients with ulcerative colitis.

Clinical experiences of five cases with ulcerative colitis and recto- or anovaginal fistula

Clinical aspects, treatment and outcome of five patients with ulcerative colitis recto- or anovaginal fistula and were studied retrospectively. All patients had total colitis (relapse and remission type) and more than a 5 year history of ulcerative colitis. They all had anorectal complications, such as periproctal abscess, stenosis of fistula. Four patients had total colectomy with an ileal pouch anal canal anastomosis for intractability or dysplasia. One was treated conservatively. Complete closure of fistula was obtained in two patients;in one patient rectum was resected below the fistula and in one patient defect of the vaginal posterior wall was reconstructed by using a gluteal fold flap following colectomy. Recto- or anovaginal fistula complicating ulcerative colitis is rare but may occur in the patients with severe rectal inflammation and they can be managed by restorative proctocolectomy with an ileal pouch anal or anal canal anastomosis.

General session VII Moderated by Chifumi Yoshida: A Case of Ulcerative Colitis with Peristomal Pyoderma Gangrenosum

Introduction: Pyoderma gangrenosum is a skin disease that can result in progressive necrosis and formation of painful ulcers. This is to report on a case where the patient developed the disease around a stoma.Case: A 40‐year‐old female patient developed ulcerative colitis (UC) when she was 25. At the age of 38, the exacerbation of UC required a colectomy and ileal pouch anal canal anastomosis (IACA), following which, a permanent ileostomy was constructed due to pouchitis. In April 2003, she developed redness around the stoma with pain, which resulted in the gradual formation of an ulcer. She was hospitalized with a diagnosis of peristomal pyoderma gangrenosum (PPG). After admission to the hospital, the dosage of predonine was increased to 30 mg/day, and dapsone was concomitantly administered. Clobetasol propionate and sulfadiazine silver were topically administered 1–4 times daily. The wound region adjacent to the stoma was protected with a gauze dressing. Although the gauze was changed each time, it was contaminated with fecal matter, the suffering thereby inflicted on the patient was too severe due to the associated smell and staining of her clothing. For this reason, she alternatively started wearing a stoma bag, which enabled periodic replacement once daily. Following a gradual improvement of the ulcer, she was discharged from the hospital two months after admission. Her recovery was confirmed four months after onset.Conclusion: PPG is accompanied by pain, and treatment also involves suffering by the patient. We need to make the diagnosis and determine the treatment method while the disease is still in its early stages. The selection of the method of care should be made with consideration of the practical aspect of the patient's defecation control.

炎症性腸疾患に対する外科治療の長期予後 ＩＩ．潰よう性大腸炎に対する大腸全摘，回腸嚢こう門管吻合術後の長期予後

潰瘍性大腸炎に対する大腸全摘,回腸嚢肛門管吻合術の長期予後を術後10年以上経過した25例で検討した.手術に関連した死亡はなく,10年後,回腸嚢は全例で機能し,一日最多排便回数は平均7回,漏便は軽度なものを含め8%に認めた.一般的合併症では腸閉塞(36%)が最も多く,大腸全摘後の代謝性合併症では胆嚢結石(20%),脱水症(12%),尿路結石(8%)があった.回腸嚢炎(25%),残存直腸炎(25%),吻合部狭窄(20%)を認めたが,外科的治療を要した例はなかった.23例(92%)(のべ80回)の内視鏡で採取した下部直腸,肛門管と回腸嚢の粘膜に癌またはdysplasiaはなかった.本術式では回腸嚢,吻合部に関連する合併症が少ないため回腸嚢機能率が高く,排便回数,漏便からみた排便機能は良好であった.残存する下部直腸,肛門管の炎症は保存的に治療でき,癌またはdysplasiaのriskは少ないと考えられた.

空腸瘻形成を繰り返した潰瘍性大腸炎術後遅発性腹腔内膿瘍の1例

We report a case of jejunal fistula due to late-appearing intraabdominal abscesses following ulcerative colitis (UC) surgery. A 52-year-old man who underwent total colectomy and ileal pouch anal canal anastomosis after perforation of the descending colon and panperitonitis during steroid treatment for ulcerative colitis. Histological examination of the resected specimen showed acute fulminating type of UC. He was admitted due to fever 6 months after surgery. Ultrasonography (US) and computed tomography (CT) showed an intraabdominal abscess in the upper left quadrant. X-ray examination with contrast medium showed an abscess cavity and 2 fistulas between the abscess cavity and jejnum, necessitating partial resection of the jejunam and drainage of the abscess cavity. Resected specimens did not show ulcerative colitis or Crohn's disease. After discharge, he was readmitted for fever and leukocytosis. X-ray examination with contrast medium showed the abscess cavity and an other fistula between the abscess cavity and jejnum. We conducted further partial resection of the jejunum and drainage after abscess curettage. The resected specimen did not show ulcerative colitis or Crohn's disease. The man has had no recurrence of symptoms or diagnostic imaging signs since discharge.

大腸亜全摘・回腸嚢肛門管吻合を施行したS状結腸癌合併潰瘍性大腸炎の1例

大腸亜全摘・回腸嚢肛門管吻合を施行したS状結腸癌合併潰瘍性大腸炎の1例

Bile acid absorption after near-total proctocolectomy in dogs: ileal pouch vs. jejunal pouch—distal rectal anastomosis

Bile acid malabsorption is often present in patients after near-total proctocolectomy and ileal pouch—anal canal anastomosis, suggesting ileal dysfunction. Experiments were performed in dogs to compare bile acid absorption after a modified procedure, in which a jejunal pouch was interposed between the terminal ileum and the distal rectum, with that after a conventional ileal pouch operation. Fecal bile acid output (equivalent to hepatic bile acid biosynthesis) and composition were determined by gas chromatography/mass spectrometry in five jejunal pouch dogs and in five ileal pouch dogs more than 6 months after operation. Fecal bile acid output in the jejunal pouch dogs (mean ± standard deviation) was 215 ± 59 mg/day (10.1 ± 2.7 mg/kg-day), a value similar to that obtained in the ileal pouch dogs (261 ± 46 mg/day [12.8 ± 3.1 mg/kg-day]; P >0.05). These values were also similar to those reported by others for healthy unoperated dogs, indicating that increased bile acid biosynthesis occurring in response to bile acid malabsorption was not present. Fecal bile acids in pouch dogs were completely deconjugated and extensively 7-dehydroxylated (jejunal pouch = 90.4% dehydroxylated; ileal pouch = 88.6% ± 6.6% dehydroxylated) and consisted predominantly of deoxycholic acid derivatives. We conclude that when either a jejunal pouch or an ileal pouch is used as a rectal substitute in dogs, an anaerobic pouch flora develops that efficiently deconjugates and dehydroxylates bile acids, rendering them membrane permeable. The resultant passive absorption of unconjugated bile acids appears to compensate for any loss of active ileal absorption of conjugated bile acids, and bile acid malabsorption does not occur.

Functional outcome of stapled ileal pouch-anal canal anastomosis versus handsewn pouch-anal anastomosis.

This study was conducted to determine whether stapled ileal pouch-anal canal anastomosis (IACA) preserving the anal transitional zone (ATZ) or hand-sewn ileal pouch-anal anastomosis with mucosectomy (IPAA) is more beneficial in achieving disease eradication and better postoperative function. IACA was performed in 10 patients with ulcerative colitis (UC) and 10 patients with familial adenomatous polyposis (FAP), 15 of whom were examined proctoscopically. IPAA was performed in 4 patients with UC and 8 patients with FAP. The mean maximum resting pressure (MRP) was 55 mmHg in the IACA group and 34 mmHg in the IPAA group (P < 0.01). The anorectal inhibitory reflex was positive in 18 patients (90%) from the IACA group and 5 (42%) from the IPAA group (P < 0.05). The pre- and postoperative MRPs were 61 mmHg and 55 mmHg, respectively, in the IACA group vs 63 mmHg and 34 mmHg, respectively, in the IPAA group (P < 0.01). Whereas 16 (80%) of the 20 IACA patients could discriminate feces from gas, only 4 (33%) of the 12 IPAA patients could (P < 0.05). The mean observation period was 2.3 years, the mean length of the columnar cuff was 2.8 cm, and no case of dysplasia or adenoma was seen. Postoperative function is more favorable following IACA than following IPAA, both physiologically and symptomatically. However, long-term surveillance of the residual mucosa is necessary before making a final recommendation.

Preoperative perfusion of bypassed ileum does not improve postoperative function.

This study evaluated whether twice daily isotonic perfusion of the bypassed ileum for six weeks would enhance its motor activity and its absorption of fluids, electrolytes, and vitamin B12. The study also determined if patients undergoing perfusion had improved bowel function and decreased hospital stay after ileostomy closure. Following proctocolectomy, ileal pouch-anal canal anastomosis, and diverting loop ileostomy, six patients self-infused an isotonic solution (sucrose and sodium chloride) into the bypassed ileum twice daily, while seven patients did not (controls). Two months following proctocolectomy, and just prior to ileostomy closure, a manometric catheter assembly was placed into the unused distal ileum via the stoma and the distal ileum perfused with an isotonic sodium chloride solution for 3 hr during fasting and 3 hr after a meal. Absorption was measured, single and clustered pressure waves were identified, and a motility index was calculated. Water absorption, motility index, and cluster parameters did not improve in perfused patients compared to controls during fasting or after a meal, nor did perfused patients have improved vitamin B12 absorption. The perfused patients also did no better clinically following ileostomy takedown; the onset of bowel movements, their frequency, time to tolerate a diet, and hospital stay were similar to controls. We conclude that six weeks of twice daily isotonic perfusion did not improve motor activity or water, electrolyte, and vitamin B12 absorption in the bypassed distal ileum after proctocolectomy, ileal pouch-anal canal anastomosis, and loop ileostomy. The perfusion also did not improve bowel function after ileostomy takedown.

Epidural analgesia shortens postoperative ileus after heal pouch-anal canal anastomosis

A retrospective study was conducted to determine whether epidural analgesia would speed recovery from postoperative ileus in patients undergoing ileal pouch-anal canal anastomosis. Among 85 patients who underwent proctocolectomy with ileal pouch-anal canal anastomosis at the Mayo Medical Center between January 1, 1991 and October 31, 1992, 44 were treated for postoperative pain with continuous infusion of epidural fentanyl citrate supplemented by intravenous morphine on request, while 41 controls were given only systemic morphine sulfate as needed. The patients in the two groups were matched and similar with regard to preoperative and operative risk factors and postoperative morbidity. No operative mortality occurred. Epidural fentanyl analgesia resulted in less need for nasogastric suction and intravenous fluids, more rapid discharge of fecal content, more rapid return to oral intake, and shorter hospitalization. Epidural analgesia with fentanyl citrate shortened postoperative ileus after proctocolectomy and ileal pouch-anal canal anastomosis.

Prospectively evaluating anal sphincter function after ileal pouch-anal canal anastomosis

The decreased anal sphincter pressure that occurs after ileal pouch-anal canal anastomosis (IPAA) has usually been attributed to damage of the internal anal sphincter. We hypothesized that the operation damages both the internal and the external anal sphincter. Resting pressure in the anal canal (a function of internal and external sphincters), anal squeeze pressure (a function of external sphincter only), and the rectal-anal inhibitory reflex (involving the internal sphincter) were measured manometrically in 10 patients with ulcerative colitis (4 women and 6 men; mean age, 33 years; range: 20 to 49 years). The patients were studied while awake before IPAA, under general anesthesia with striated muscle blockade just before incision, awake 2 months later before ileostomy takedown, and again under anesthesia with blockade just before takedown. The operation decreased maximum resting anal pressure while awake and during anesthesia with blockade. The decrease was detected in the proximal anal canal but not in the distal anal canal. In addition, the operation impaired anal squeeze pressure and abolished the rectal-anal inhibitory reflex. We conclude that IPAA damages both the internal and the external anal sphincter.