Ileal Pouch-anal Anastomosis Creation Research Articles

Laparoscopic ileal pouch-anal anastomosis reduces the risk of surgical site infections: An ACS-NSQIP study

Previous literature related to postoperative outcomes after laparoscopic vs. open ileal pouch-anal anastomosis (IPAA) is primarily based on small numbers of patients from single institutions. The aim of this study is to evaluate these outcomes in a large number of patients using propensity score matching (PSM). The ACS-NSQIP Program data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation. The impact of surgical approach on operative and postoperative outcomes were evaluated. 1:1 propensity score matching (PSM) on all patient characteristics was used to obtain matched groups. Fisher's Exact/Chi-Squared tests were used to compare outcomes between groups. A Bonferroni correction was applied to the outcomes, with a p-value of 0.0031 representing statistical significance. 1802 patients were identified, with 1001 patients in the laparoscopic group and 801 patients in the open group. PSM yielded 702 patients in each matched group. Median operative time was longer for laparoscopic IPAA (278vs218.5 minutes, p<0.001). Laparoscopic IPAA patients were less likely to develop superficial and deep SSIs (3.0% vs 6.6% p=0.003). There were no differences in in-hospital mortality (0.4% vs 0.0%, p=0.3), anastomotic leak (4.0% vs 3.3%, p=1.0), organ-space SSI (6.7% vs 6.0, p=1.0), or reoperation (5.7% vs 4.0%, p=0.2) between groups. Length of stay was lower after laparoscopic IPAA (5.0 vs 6.0 days, p=0.004). There were no differences between groups in other postoperative complications. These data suggest that when matched for other confounding variables, laparoscopic IPAA is associated with reduced length of stay and superficial/deep SSIs when compared to open IPAA. Other surgical complications, including in-hospital mortality and anastomotic leak, are similar. Given the recovery benefit of the laparoscopic approach and the reduced SSI, laparoscopy should be the method of choice for the majority of patients undergoing IPAA.

The effect of diversion on readmission following ileal pouch-anal anastomosis in children

BackgroundReadmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation. MethodsChildren (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed. ResultsNinety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation.Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone. ConclusionReadmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates. Level of EvidenceLevel III.

Utilization of Maneuvers to Increase Mesenteric Length Employed in Children Undergoing Ileal Pouch-Anal Anastomosis.

Background: Operative maneuvers to increase mesenteric length during ileal pouch-anal anastomosis (IPAA) are frequently utilized in adults, but limited data exist on the need for their use in children. Materials and Methods: A retrospective chart review of children (age <18) considered for IPAA creation at two affiliated tertiary referral centers from 2007 to 2017 was conducted, and patient factors, operative details, and 30-day postoperative complications were abstracted. Body mass index (BMI) was normalized to BMI percentile-for-age-and-sex and classified as underweight (BMI <5th percentile), healthy weight (5th ≤ BMI percentile <85th), or overweight/obese (BMI ≥85th percentile). Maneuvers were identified from operative notes. Univariate analysis and multivariable logistic regression were performed to determine independent factors associated with the use of maneuvers. Results: A total of 94 patients underwent attempt at IPAA creation, which was successful in 91 (97%). Fourteen (15%) of 91 patients were classified as overweight or obese. The 3 failures occurred secondary to inability to reach in 3 patients, with specific mention of patients' obesity in 2 and pouch ischemia in 1. Sixty (66%) patients required maneuvers to lengthen the mesentery. Overweight/obese patients required maneuvers more often than nonoverweight/obese patients (93% versus 61%, P = .03). There were no differences in 30-day maximum Clavien-Dindo scores between patients with and without maneuvers performed (P = .83). Being overweight/obese was an independent risk factor for requiring maneuvers (odds ratio: 9.3, 95% confidence interval: 1.1-82.8) after adjusting for age, sex, height, operative stage, and surgeon. Conclusion: Surgeons should be prepared to perform mesenteric lengthening maneuvers when operating on pediatric patients to ensure minimal tension on the IPAA, and more so when operating on obese children. Whether these maneuvers have an impact on long-term pouch function is undetermined.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

Pouch-vaginal fistula

Pouch-vaginal fistula is a dreaded complication after ileal pouch-anal anastomosis creation and can greatly impact patients’ quality of life. Success rates with surgical closure vary in the literature and there is no single gold standard surgical method for closing the fistula. This is a complex condition that requires detailed history taking and examination. Success may not be always achieved and recurrences are common. Consideration should be given for treating this group of women in specialized centers by expert surgeons.

Who gets a pouch after colectomy in New York state and why?

This study identified variation and factors associated with ileal pouch-anal anastomosis after total colectomy for ulcerative colitis. The Statewide Planning & Research Cooperative System was used to identify patients with ulcerative colitis who underwent total colectomy in New York state from 2000-2013. Bivariate and mixed-effects multivariable analyses were performed to assess patient, surgeon, and hospital-level factors as well as surgeon and hospital-level variation associated with ileal pouch-anal anastomosis after total colectomy. Across 2,203 patients, the rate of ileal pouch-anal anastomosis was 34%. Overall, 465 surgeons and 148 hospitals performed at least one total colectomy for ulcerative colitis from 2000-2013, and 178 surgeons and 80 hospitals performed at least one ileal pouch-anal anastomosis for ulcerative colitis during the study period. The median rate of ileal pouch-anal anastomosis creation was 14% (range=6% to 69%) across surgeons and 14% (range=7% to 63%) across hospitals. Patient-level factors independently associated with ileal pouch-anal anastomosis were younger age, lower comorbidity burden, and elective total colectomy. Surgeon and hospital-level factors independently associated with ileal pouch-anal anastomosis were colorectal surgery board-certification, surgeon ileal pouch-anal anastomosis volume, and hospital ileal pouch-anal anastomosis volume. Patient-level factors explained 43% of the surgeon and 47% of the hospital variation in ileal pouch-anal anastomosis creation while surgeon-level factors explained 26% of the surgeon and 21% of the hospital variation. These findings suggest that variation in ileal pouch-anal anastomosis creation for ulcerative colitis is influenced largely by provider practices/preferences or lack of referral of patients after colectomy to surgeons and centers that perform ileal pouch-anal anastomosis. Providers and hospitals that do not routinely perform ileal pouch-anal anastomosis should refer patients to centers with ileal pouch-anal anastomosis expertise after total colectomy.

Possible Overuse of 3-Stage Procedures for Active Ulcerative Colitis

There is an assumption that patients treated with 3-stage procedures for active ulcerative colitis are undergoing a safer surgical approach and thus spared the complications associated with a 2-stage procedure. However, there is a paucity of data addressing the validity of this assumption, and the optimal staging approach for patients traditionally considered at high risk for anastomotic leak remains unclear. To identify factors associated with 3- vs 2-stage procedures and to determine their impact on surgical outcomes. Retrospective analysis of patients who underwent 2-stage or 3-stage ileal pouch-anal anastomosis (IPAA) surgery for active ulcerative colitis due to failure of medical management over a 10.5-year period (September 1, 2000, to March 30, 2011). The mean (SEM) follow-up was 5.15 (0.24) years (range, 0.26-11.09 years). Single large academic medical center. One hundred forty-four patients treated with 3- or 2-stage IPAA surgery for active ulcerative colitis. Among these patients, 77 were male and 67 were female. The mean (SEM) age was 34.6 (1.0) years (range, 11-67 years). Of the 144 patients, 116 (80.6%) had a 2-stage procedure and 28 (19.4%) had a 3-stage procedure. Two-stage vs 3-stage IPAA procedures for active ulcerative colitis. Factors leading to decision for 3-stage procedure, postoperative outcomes with 3-stage vs 2-stage procedures, and risks for complications in patients undergoing 3-stage vs 2-stage procedures. RESULTS Of 144 patients, only 19.4% had a 3-stage procedure. Decision to perform a 3-stage vs 2-stage procedure was affected by emergent status (P < .001) and hemodynamic instability (P = .04) but not by age, sex, body mass index, use of steroids, or use of anti-tumor necrosis factor agents. For patients with 2-stage procedures, multivariate regression revealed that the number of perioperative complications was affected by surgeon experience (P = .02) but not by emergent status, use of steroids, or use of anti-tumor necrosis factor agents. Two-stage procedures were associated with more perioperative complications on univariate analysis (P = .05), but multivariate regression suggested that this difference was due to surgeon experience (P = .02) rather than to creation of an IPAA at the first operation (P = .55). Importantly, 2-stage procedures did not change the risk of anastomotic leak when all operations were taken into account (odds ratio = 1.09; P = .94). In the long term (mean [SEM], 5.2 [0.2] years), patients who underwent 2-stage surgery had a lower risk of anal stricture (odds ratio = 8.21; P = .01) and no differences in fistula or abscess formation or in pouch failure. In patients with active ulcerative colitis, use of steroids and anti-tumor necrosis factor agents alone do not appear to justify the decision to avoid IPAA creation at the first operation provided that it is performed by a high-volume inflammatory bowel disease surgeon.

Outcome after ileal pouch-anal anastomosis for familial adenomatous polyposis compared to mucosal ulcerative colitis in a Middle Eastern population

BACKGROUND AND OBJECTIVESTo compare the complications and outcome after ileal pouch-anal anastomosis (IPAA) for mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP).DESIGN AND SETTINGSThis is a retrospective study. The study was conducted at a single tertiary referral center.METHODSAll patients who underwent restorative proctocolectomy with IPAA at a tertiary center in Saudi Arabia from 2001 till 2009 were retrieved. Data was obtained regarding preoperative status, postoperative complications, and functional outcome.RESULTSA total of 40 patients underwent IPAA, of which 21 cases were of FAP and 19 cases of MUC. Median age at operation for FAP and MUC was 31 (range: 16–45) and 43 (range: 15–65) years, respectively (P<.05). Median length of stay was 10 days (range: 6–42) for FAP and 12 days (range: 9–27) for MUC (P=.1). Postoperative morbidity was noted in 4 cases of FAP and 6 cases of MUC (P=.36). Specifically, wound infection was noted in 2 cases of FAP compared to 3 cases of MUC (P=.55); 1 MUC case had an anastomotic leak (P=.29). One mortality was recorded among the FAP cases (P=.35). The time between the creation of IPAA and the closure of ileostomy was 4.5 and 5 months for FAP and MUC, respectively (P=.87). Median follow-up was 36 months. Median bowel frequency per 24 hours was 6 (range: 3–24) for FAP and 7 (range 3–17) for MUC (P=.54). Intestinal obstruction was reported in 3 cases of FAP and 5 cases of MUC (P=.38). One pouch was excised in a FAP patient. One case of MUC developed pouchitis.CONCLUSIONSThe outcome after IPAA was inferior for MUC compared to FAP, but it was not statistically significant due to the small sample size. The morbid status of the MUC cases and their older age contributed to the minor differences.

Preoperative pelvic radiation increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer

Background and aimsTo evaluate the impact of preoperative radiation on pouch outcomes in patients with colitis-associated cancer (CAC). MethodsCAC patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1984 to 2009 were identified from our registry. The impact of preoperative pelvic radiation for CAC or other pelvic cancer on pouch related outcomes was evaluated. ResultsSixty-three pouch patients with confirmed CAC were included (37 male, 58.7%). The mean age at pouch construction was 46.9±10.6years. Seven patients were excluded due to the presence of persistent diverting ileostomy (n=2) or no follow-up (n=5). The remaining 56 patients were analyzed, including 9 who received pelvic radiation prior to IPAA creation for CRC or other cancers. Preoperative pelvic radiation was significantly associated with chronic pouchitis (P=0.024). There was, however, no correlation between pelvic radiation and pouch/anal transitional zone neoplasia, pouch stricture, pelvic abscess and pouch fistula/sinus. Pouch failure occurred in 13 patients after a median follow-up of 66.4 (range: 2.7–322.2) months. Although a simple statistical analysis based on the number of patients with pouch failure did not achieve significance (4/9 vs. 9/47, P=0.19), Kaplan–Meier analysis showed a strong association between preoperative pelvic radiation and the risk for pouch failure (P<0.001). A subgroup analysis of rectal cancer patients revealed that 3/7 patients (42.9%) with radiation and 3/17 (17.6%) without had pouch failure (P=0.31). Again, the association between pelvic radiation and pouch failure was confirmed using Kaplan–Meier analysis (P=0.02). ConclusionsPelvic radiation administered prior to IPAA creation appears to be associated with poor pouch outcomes. Oncological benefits and pouch functional outcomes should be carefully balanced before pelvic radiation is considered prior to restorative proctocolectomy.

CT depiction of portal vein thrombi after creation of ileal pouch-anal anastomosis.

To determine the presence and location of portal vein thrombi in patients who have undergone ileal pouch-anal anastomosis (IPAA) and who were scanned with computed tomography (CT). During a 4-year period, 92 of 702 patients underwent contrast medium-enhanced CT after a total proctocolectomy with an IPAA. These CT scans were retrospectively reviewed for portal vein thrombus presence, location, and occlusive nature, as well as any accompanying enhancement abnormalities of the hepatic parenchyma. Only 13 patients who had initial CT scans that were positive for thrombi underwent follow-up examinations, and these were reviewed for resolution or progression of the original findings. Portal vein thrombi were present in 41 (45%) of the 92 patients; 24 (59%) of the 41 were isolated, often multiple, segmental right lobe thrombi. Five patients had both right and left segmental vein involvement. Eleven patients had various combinations of main portal vein, right and left portal vein, or segmental vein thrombi. One patient had an isolated superior mesenteric vein thrombus. Twenty-two of 25 superior mesenteric vein, main portal vein, and right and left portal vein thrombi were nonocclusive, while most (63 of 86) of the segmental vein thrombi were occlusive. Wedge-shaped, peripheral areas of hepatic parenchymal hyperenhancement that were distal to the thrombi were present in 30 (73%) of the 41 patients. Follow-up scans obtained in the 13 patients with portal vein thrombi showed thrombi resolved in five patients, progression to cavernous transformation occurred in one patient, and parenchymal enhancement changes persisted in seven patients. In the seven patients with persistent enhancement changes, four had complete resolution of thrombi. Portal vein thrombi appear to be relatively common after IPAA surgery and are most likely segmental, multiple, and occlusive. Peripheral wedge-shaped areas of hepatic parenchymal hyperenhancement commonly accompany these thrombi.