Ileoanal Pull-through Procedure Research Articles

Endoscopic needle knife fistulotomy technique for ileal pouch-to-pouch fistula

A 19-year-old woman with refractory pan-ulcerative colitis, diagnosed in 2004, underwent a total proctocolectomy in 2006, followed by a two-stage ileoanal pull-through procedure. Severe pouchitis led to a two-stage J-pouch reconstruction in 2012. In June 2014, magnetic resonance enterography showed a pre-sacral abscess, which was drained percutaneously.

Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis

Background/Purpose: The ileoanal pull-through procedure (IAP) is gaining increasing favor and use in the surgical treatment of children with ulcerative colitis (UC) and familial adenomatous polyposis (FP). Although physiological studies have been performed to assess the outcome of these children, no long-term quality-of-life assessment after the procedure has been performed. Methods: Forty-three patients were identified who had an IAP at our institution in the last 10 years and were at least 6 months postsurgery. Thirty-four were contacted, and 32 agreed to participate in the survey, which was approved by the Human Studies Committee. Participants completed the standardized Medical Outcome Study Short Form-36 (SF-36), which has well-established normative values. Several supplemental questions were prepared in a similar format dealing with issues specific to the ileoanal pull-through procedure. Results: Of the 32 participants, 19 (59%) were girls and 26 (81%) had ulcerative colitis. Mean age at the time of survey was 18.1 years with 12 less than 18 years and 20≥18 years. Data from the latter group could be compared with national normative values for this age. The study group was not statistically different from age-appropriate US population normal values on all assessable scales of physical and mental health in the SF-36 survey including physical functioning, role limitations-physical, bodily pain, general health, vitality, social functioning, role limitations-emotional, and mental health (all P > .05 or mean difference SD units < 0.8). The supplemental questionaire demonstrated little adverse effect of the surgery. There was limited consumption of medications to control bowel frequency and little restriction of activity because of the frequency of bowel movements or fear of incontinence. The surgical scar was the sole negative factor of significance. Conclusions: The ileoanal pull-through procedure is an excellent surgical option for children with ulcerative colitis or familial adenomatous polyposis, and it produced minimal, if any, adverse effects on their long-term quality of life.

Preoperative terminal ileal and colonic resection histopathology predicts risk of pouchitis in patients after ileoanal pull-through procedure.

This study seeks to compare the histopathology of preoperative terminal ileal and colonic resection specimens with pouch biopsies after the ileoanal pull-through (IAPT) procedure. Pouchitis is the most frequent complication of transanal continent reservoirs in patients after IAPT. The authors conducted 751 consecutive pouch biopsies on 73 patients with inflammatory bowel disease or familial adenomatous polyposis who underwent IAPT by a single surgeon over a 10-year period. In this preliminary report, a pathologist, in blinded fashion, has graded 468 of the IAPT pouch biopsies and 67 of the patients' preoperative terminal ileal and colonic resection histopathology to date. Colonic histopathology was graded by the extent and severity of disease, terminal ileal and pouch histopathology by active inflammation, chronic inflammation, lymphocyte aggregates, intraepithelial lymphocytes, eosinophils, and villous blunting. Extent of colonic disease (gross and microscopic) was a significant predictor of active inflammation in subsequent IAPT pouch biopsy specimens. Also, the gross extent of colonic disease exhibited a significant linear association with pouch inflammation. However, the severity of colonic disease was not significantly predictive of active inflammation in subsequent IAPT pouch biopsies. Terminal ileal active and chronic inflammation were significant predictors of subsequent IAPT pouch inflammation. Although lymphocyte aggregates and intraepithelial lymphocytes were not predictive, terminal ileum eosinophils and villous blunting were significant predictors of active inflammation in subsequent IAPT pouch biopsy specimens. Preoperative terminal ileal and colonic histopathology predicts active inflammation of pouches after IAPT. Patients who are preoperatively assessed to have extensive disease of the colon, ileal disease ("backwash ileitis"), or both appear to be at greater risk for the development of pouchitis after IAPT.

Health related quality of life (HRQOL) in patients after the ileo-anal pull-through procedure (IAPT)

Health related quality of life (HRQOL) in patients after the ileo-anal pull-through procedure (IAPT)

Results of a thirty-year study of familial adenomatous polyposis coli.

This study was designed to estimate the efficiency of the various methods used to treat familial adenomatous polyposis coli. Three hundred ninety patients (219 males) underwent surgery for familial adenomatous polyposis coli; postoperative follow-up was from 1 to 30 years. Coloproctectomy with preservation of the anal sphincter and coloproctectomy with ileoanal pull-through procedures resulted in development of anal canal cancer in 3 (4.1 percent) of 74 patients. Follow-up revealed development of cancer in the large bowel in 26 (10.7 percent) of 242 patients, in whom colectomy with preservation of various colonic segments was performed. The occurrence rate of cancer is not significantly related to patients' gender, age, length of preserved colonic segment, presence of cancer in the removed colonic segment, or postoperative follow-up period; however, presence of polyps in the colonic segments preserved during surgery significantly increased the risk of development of cancer at a later time.

Long-term results after colectomy and ileoanal pull-through procedure in children.

To review the clinical experience with colectomy and ileoanal pull-through procedure in children from 1 hospital. Since 1977, 116 children 18 years of age or younger underwent colectomy and ileoanal pull-through procedure at University of California-Los Angeles Medical Center. Ninety-four children had ulcerative colitis, 17 had familial polyposis coli, and 5 had Hirschsprung disease. Sixty-two children had a lateral pouch, 47 a J-pouch, and 7 a straight pull-through. A diverting ileostomy was used for 4 months for all patients except 9 with polyposis coli and 2 with Hirschsprung disease. During the same period, an additional 414 patients older than 18 years underwent the ileoanal pull-through procedure. Forty-eight children (41%) developed complications; the most common was pouchitis, which occurred in 18 patients with ulcerative colitis. Forty-two children underwent reoperation; 38 had ulcerative colitis. There were no deaths. Six children (5.2%) (3 with Crohn disease) required a permanent ileostomy. Six straight pull-throughs were converted to J-pouches because of stool frequency; 19 patients with lateral pouches underwent pouch reconstruction or spout resection because of stasis. With a mean follow-up of 7.1 years, 107 children (92.2%) were progressing well. Ulcerative colitis is a more severe disease in children. The ileoanal pull-through procedure is the preferred operation for children with ulcerative colitis, polyposis coli, and selected patients with Hirschsprung disease. The J-pouch is preferred because of simplicity of construction and scarcity of complications.

Optimizing results and techniques of mesenteric lengthening in ileal pouch-anal anastomosis

The techniques for ileoanal pull-through procedures have been well described previously. However, little attention has been given to the techniques to maximize ileal mesenteric length. Furthermore, no studies have provided data that support the technical recommendations. The purposes of this study are to describe our technique for ileal pouch construction and ileal mesenteric lengthening, and to provide data supporting our recommendations. The operative summaries of 74 consecutive ileal J-pouch-anal anastomoses procedures were reviewed with attention to the management of the mesenteric vasculature. Complete data with respect to the handling of the mesenteric circulation were available for 66 cases. Ileal J-pouch-anal anastomoses were achieved with both the ileal branch of the superior mesenteric artery and the ileocolic artery intact in 23% of cases. The ileocolic artery was divided in 48% of cases, and the ileal branch of the superior mesenteric artery was divided in 29% of cases. In addition, one or more distal arcade vessels between the vasa recta and the ileocolic artery were divided in 18% of cases. Ileal J-pouch-anal anastomosis was possible in all 74 patients. These data emphasize the variability in mesenteric circulation and the complexity of pouch construction in patients undergoing ileoanal pull-through procedures. However, with attention to the techniques described, ileal J-pouch-anal anastomoses should be possible in virtually all patients.

Factors associated with nighttime incontinence following ileoanal pullthrough

Minor nighttime incontinence following colectomy, mucosal proctectomy, and ileoanal pullthrough remains a bothersome and incompletely understood problem. Of 277 ileoanal pullthrough procedures performed at this institution between 1982 and 1989, 38 were performed on patients with polyposis coli syndrome. These 38 polyposis patients were selected to study nighttime incontinence because they represented a select population in which sphincter injury due to technically difficult mucosal stripping was minimized (compared with the difficult and hazardous mucosal stripping in inflamed tissues present in ulcerative colitis). In this series, 12 patients (32%) experienced nighttime incontinence after ileoanal pullthrough; in 9 of the 12 patients, this complication had resolved within 6 months postoperatively. Females had a significantly higher rate of minor nighttime incontinence (57%) than males (17%). Pouch size was significantly smaller in patients with nighttime incontinence (138 mL) than in continent ones (191 mL). Higher stool frequency soon after surgery also correlated with higher incontinence rates. Factors that did not show association with nighttime incontinence in this series were preoperative and postoperative resting and squeeze anal sphincter pressures, disease interval, parity, and previous surgery. We conclude that nighttime incontinence is a common complication that occurs even after “technically easy” mucosal proctectomies. Further investigation will almost certainly reveal it to be multifactorial in etiology.

Surgical therapy for rectovaginal fistulas in ulcerative colitis

During a 9-year period, six women with ulcerative colitis (UC) and rectovaginal fistulas were surgically treated. Three underwent ileoanal pull-through procedures with simultaneous repair of the rectovaginal fistulas. Two patients had Kock pouches, and one had a Brooke ileostomy because extensive destruction of the rectal sphincter prohibited ileoanal procedures. The three patients who had ileoanal procedures all had excellent functional results. There has been no evidence of Crohn's disease or fistula recurrence. We believe that rectovaginal fistulas occur more frequently in UC than is generally accepted, and they can be safely managed with current reconstructive techniques.

Diagnosis and treatment of primary sclerosing cholangitis.

PSC is a progressive chronic hepatobiliary disorder of unknown etiology for which no effective medical or surgical therapy now exists. This syndrome occurs most commonly in young men and is frequently associated with CUC. The diagnosis is best made utilizing endoscopic retrogradecopic retrograde cholangiography. Although liver histologic findings alone are infrequently diagnostic of PSC, it remains important to exclude other causes of chronic cholestasis. Although the etiology remains unknown, preliminary studies suggest that PSC is related to immunologic damage. Although viral infections can induce obliterative cholangitis in children, their role in the cause of PSC remains undefined. PSC progresses slowly from an asymptomatic stage to cirrhosis, portal hypertension, and premature death secondary to liver failure. Bile duct cancer appears to be a frequent complication of long-standing PSC. Since no therapy is of established efficacy, controlled clinical trials of both medical and surgical therapy should be encouraged. Fat-soluble vitamin deficiencies commonly occur in the advanced stages of PSC, and therefore serum levels of vitamins A, D, E, and prothrombin time should be monitored on a regular basis to prevent complications associated with these deficiencies. Liver transplantation is now a therapeutic option for the treatment of end-stage PSC. Palliative surgical biliary drainage procedures, proctocolectomy, and surgical decompressive shunts that increase the risk of liver transplants, therefore, should be avoided, if possible, in young PSC patients. If a total proctocolectomy is surgically indicated, we would strongly recommend performing a ileoanal pull-through procedure, thus, avoiding the formation of an abdominal ileostoma and the risk of developing bleeding peristomal varices.

Advantage of initial transanal mucosal stripping in ileo-anal pull-through procedures.

Advantage of initial transanal mucosal stripping in ileo-anal pull-through procedures.