Ileorectal Anastomosis For Ulcerative Colitis Research Articles

Ileorectal anastomosis in ulcerative colitis: what do surgeons and patients need to know? A systematic literature review.

Ileal pouch-anal anastomosis (IPAA) is currently the gold standard for restoration of gastrointestinal continuity after colectomy for ulcerative colitis in the UK. However, with further experience of the risks relating to IPAA, the use of ileorectal anastomosis (IRA) is being revisited. Decisions regarding restorative surgery after colectomy are individual to every patient's circumstances, and this paper aims to provide a comprehensive review of the literature to guide a full discussion of the risks and benefits of IRA. A systematic literature review was conducted of papers published from 2000 onwards relating to IRA and ulcerative colitis, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The papers were reviewed by two independent surgeons for information it was felt that patients and surgeons would want to know about the operation (cancer risk, bowel function, sexual and urinary function, fecundity/fertility and postoperative complications). Seventeen papers were identified for inclusion as they reported original data on one or more of the categories identified for discussion. The median ten-year cancer risk after IRA was 2.8% and the median failure rate at ten years was 21%. IRA was generally found to have lower postoperative complication rates and better bowel function than IRA, with sexual function similar and fecundity not commented on in any paper. For some patients, IRA can offer restorative surgery in the short or long term, with acceptable cancer risk, failure rate and postoperative complications, while avoiding the higher risks associated with IPAA.

Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort.

Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort.

P277 Ileo-rectal anastomosis vs. ileoanal pouch in ulcerative colitis: clinical outcome in a real-life experience

Abstract Background In ulcerative colitis (UC) surgery is required in about 10–20% of patients (patients). Evidence regarding the long-term outcome of Ileo-rectal anastomosis (IRA) vs. the recently proposed ileal pouch (IPAA) are still lacking. In a real-life, retrospective, single-centre study, we aimed to assess the clinical outcome of all UC patients with IRA or IPAA. Methods In a retrospective study, clinical records of UC patients with IPAA or IRA in regular follow-up from January 2001 to September2019 were reviewed. Inclusion criteria: (1) UC diagnosis; (2) Age ≥18 years; (3) IPAA or IRA for UC;4)Detailed clinical history; (5) follow up ≥1 year after surgery. The following parameters were reported: demographic and clinical characteristics, hospitalisation, additional surgery, mortality, dysplasia/cancer of the ileum and/or rectum, number of endoscopies and outpatient visits, stool frequency and treatments. The quality of life (QoL) are being evaluated. Data were expressed as median (range), differences among groups assessed by chi-squared test or unpaired T-test. Results A total 84(4%) UC patients with IPAA (n = 47) or IRA (n = 37) were detected among 2136 UC patients. Among these 84 UC patients, in a preliminary assessment, clinical outcome was evaluated in 31 patients (16 IPAA,15 IRA) with a median follow up of 72 [12–180] months (mos) and a median time interval from surgery of 63 [1–348] mos. Considering the 16 patients with IPAA (8 M, 9 F) vs. the 15 with IRA (5 M,10 F), the median age at first assessment was 44 [range 30–56] vs. 48 [range 23–82] in patients with IPAA or IRA, respectively (p = 0.2123). The median follow up after surgery was 65 [range 12–132] vs. 79 [range 12–180] mos (p = 0.1955). The median time interval from surgery to first clinical assessment after surgery was 48 [range 1–312] vs. 78 [range 2–348] mos (p = 0.1955). Indication for surgery was refractory UC in 30 patients and endoscopic perforation in 1 pt. During the follow up, the following outcomes after surgery were recorded in patients with IPAA vs. IRA: hospitalised patients (n = 6 vs. n = 6 patients, p = 0.8864); additional intestinal surgery (n = 0 vs. n = 4 patients, p = 0.0269), mortality (n = 0 vs. n = 1 patients,p = 0.2938); occurrence of dysplasia/cancer of the ileum and/or rectum (n = 0 vs. n = 2 patients, p = 0.1310), number endoscopies after surgery (mean: 4 vs. n = 3.75, p = 0.316348), number visits after surgery (mean: 2.4/year vs. n = 1.7/year, p = 0.2429), mean stool frequency (n = 8.08 vs. n = 4.36; (p = 0.0005), need of biologics, n = 5 vs. n = 1 (p = 0.0834). Conclusion In a real-life experience, the need for intestinal surgery was significantly higher in patients with IRA vs. IPAA; the mean daily stool frequency was significantly higher in patients with IPAA vs. IRA.No statistically significant differences were found among the two groups in terms of hospitalisation, mortality, cancer/dysplasia and need for biologics.

Long-term Follow-up After Ileorectal Anastomosis for Ulcerative Colitis: A GETAID/GETAID Chirurgie Multicenter Retrospective Cohort of 343 Patients.

To determine the cumulative incidence and the prognostic factors of ileorectal anastomosis (IRA) failure after colectomy for ulcerative colitis (UC). Although ileal pouch-anal anastomosis is recommended after colectomy for UC, IRA is still performed. This was a multicenter retrospective cohort study, which included patients with IRA for UC performed between 1960 and 2014. IRA failure was defined as secondary proctectomy and/or rectal cancer occurrence. Uni- and multivariate survival analyses were performed using Cox-proportional hazards models. A total of 343 patients from 13 French centers were included. Median follow up after IRA was 10.6 years. IRA failure rates were estimated at 27.0% (95% confidence interval, CI, 22-32) and 40.0% (95% CI 33-47) at 10 and 20 years, respectively. Median survival time without IRA failure was estimated at 26.8 years. Two thirds of secondary proctectomies were performed for refractory proctitis, and 20% for rectal neoplasia. Univariate analysis identified factors associated with IRA failure: IRA performed after 2005, a longer duration of disease at the time of IRA, indication for colectomy and having received immunomodulative agents before IRA. In multivariate analysis, treatment with both immunosuppressant (IS) and anti-TNF before colectomy was independently associated with IRA failure (HR=2.9, 95% CI 1.2-7.1). Conversely, colectomy for severe acute colitis was associated with decreased risk of IRA failure (HR=0.6, 95% CI 0.4-0.97). Patients with UC have a high risk of IRA failure, particularly when colectomy is performed for refractory disease. However, IRA could be discussed after colectomy for severe acute colitis, or in patients naive to IS and anti-TNF.

Risk of Rectal Neoplasia after Colectomy and Ileorectal Anastomosis for Ulcerative Colitis

Colectomy can be required in the management of ulcerative colitis [UC]. While ileal-pouch anal anastomosis [IPAA] is the recommended reconstruction technique, ileorectal anastomosis [IRA] is still performed and might present some advantages. However, the risk of rectal neoplasia might limit its indication. The aims of our study were to determine the incidence of rectal neoplasias following IRA for UC and to identify risk factors associated with rectal carcinomas. We performed a multicenter retrospective study including patients who underwent IRA for UC from 1960 to 2014 in 13 centers. Cox-proportional hazard models were used to determine carcinoma-associated risk factors. A total of 343 patients were included, with a median follow-up of 10.4 years after IRA. At the end of follow-up, 38 rectal neoplasias (including 19 carcinomas) were diagnosed, and 7 patients [2%] had either died from rectal carcinoma or had a metastatic disease. Incidences of rectal carcinoma after IRA for UC were estimated at 3.2% at 10 years and at 7.3% at 20 years, whereas incidences of neoplasia were estimated at 7.1% and 14% at 10 and 20 years, respectively. In multivariate analysis, age at IRA, IBD duration, primary sclerosing cholangitis [PSC] and history of prior colonic carcinoma were independently associated with the risk of rectal carcinoma following IRA. The risk of rectal carcinoma in patients with IRA for UC remains, and this justifies long-term endoscopic surveillance. Either IPAA or end ileostomy should be considered in 'high-risk' patients i.e. those with PSC and/or with prior colonic neoplasia.

DOP018. Long-term follow-up after ileorectal anastomosis in ulcerative colitis (UC) identified factors associated with rectal outcome: a multicentre retrospective cohort of 343 patients from the GETAID/GETAID Surgery

DOP018. Long-term follow-up after ileorectal anastomosis in ulcerative colitis (UC) identified factors associated with rectal outcome: a multicentre retrospective cohort of 343 patients from the GETAID/GETAID Surgery

A reappraisal of the ileo-rectal anastomosis in ulcerative colitis.

Colectomy is still frequently required in the care of ulcerative colitis. The most common indications are either non-responding colitis in the emergency setting, chronic active disease, steroid-dependent disease or neoplastic change like dysplasia or cancer. The use of the ileal pouch anal anastomosis has internationally been the gold standard, substituting the rectum with a pouch. Recently the use of the ileorectal anastomosis has increased in frequency as reconstructive method after subtotal colectomy. Data from centres using ileorectal anastomosis have shown the method to be safe, with functionality and risk of failure comparable to the ileal pouch anal anastomosis. The methods have different advantages as well as disadvantages, depending on a number of patient factors and where in life the patient is at time of reconstruction. The ileorectal anastomosis could, together with the Kock continent ileostomy, in selected cases be a complement to the ileal pouch anal anastomosis in ulcerative colitis and should be discussed with the patient before deciding on reconstructive method.

Clinical outcomes of ileorectal anastomosis for ulcerative colitis

Clinical outcomes of ileorectal anastomosis for ulcerative colitis

Clinical outcomes of ileorectal anastomosis for ulcerative colitis

The aim of this study was to determine the fate of the rectum, functional results and quality of life after ileorectal anastomosis (IRA) in ulcerative colitis. Patients with ulcerative colitis and indeterminate colitis who underwent IRA from 1971 to 2006 were evaluated retrospectively. Twenty-two patients with an IRA were matched by age, sex and follow-up duration with 66 patients with an ileal pouch-anal anastomosis (IPAA) and compared for functional outcomes and quality of life. Eighty-six patients with an IRA were included. Median follow-up was 9 (range 1-36) years. Rectal dysplasia and cancer rates were 17 and 8 per cent respectively. The rectum was resected in 46 patients (53 per cent) because of refractory proctitis in 24, rectal dysplasia in 15 and rectal cancer in seven. The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 per cent respectively. Patients with an IRA had fewer bowel movements (P = 0.020) and less night-time seepage (P = 0.020) but increased urgency (P < 0.001) compared with patients with an IPAA, whereas quality of life was similar. In selected patients with ulcerative colitis IRA gives an acceptable quality of life and functional outcome that are comparable to those in patients with an IPAA. Owing to the risk of cancer, surveillance of the rectum is mandatory.

Cancer of the rectum following colectomy and ileorectal anastomosis for ulcerative colitis.

The case notes of all patients treated for ulcerative colitis by colectomy and ileorectal anastomosis at the Gordon Hospital under the care of Mr S. O. Aylett from 1952 to 1976 have been reviewed. Three hundred and seventy-four patients left hospital with an ileorectal anastomosis and have been followed for periods up to 23 years. Twenty-two patients are known to have developed a carcinoma of the rectum. Within 10 years of the onset of the disease, no rectal carcinoma was found in 3534 patient-years. The risk was 1 in 185 patient-years between the tenth and twentieth years and 1 in 115 patient-years between the twentieth and thirtieth years. The cumulative risk was 6 per cent (+/- 2 per cent) at 20 years and 15 per cent (+/- 4 per cent) at 30 years. The need for meticulous follow-up is emphasized. The finding of dysplasia in rectal mucosal biopsies will, it is hoped, identify the patient at particularly high risk and enable rectal excision to be undertaken before carcinoma develops.

Ulcerative colitis and Crohn's disease: results after colectomy and ileorectal anastomosis.

Eighty-one patients who had had colectomy and ileorectal anastomosis for ulcerative colitis or Crohn's disease of the colon from 1 to 13 years previously were interviewed and examined by a surgeon with whom they had had no previous contact. Sixty-four patients (79 per cent) had a satisfactory result. In 12 patients the operation had failed and an ileostomy had been established, and in a further 5 patients the result was considered unsatisfactory. Despite a high incidence of frequent loose stools and minor anorectal complications, most of the patients were satisfied with the result and would not contemplate the alternative of an ileostomy. No patient had developed rectal cancer. Provided that the rectum is examined regularly for pre-malignant or malignant change, colectomy and ileorectal anastomosis offer a satisfactory alternative to proctocolectomy and ileostomy for many patients with ulcerative colitis or Crohn's disease.

The effect of systemic sterioids on ileorectal anastomosis in ulcerative colitis.

The effect of systemic sterioids on ileorectal anastomosis in ulcerative colitis.

Fate of the Rectum after Colectomy with Ileorectal Anastomosis in Ulcerative Colitis

Aim of the study was to evaluate the cumulative success of colectomy and ileorectal anastomosis in 20 patients with ulcerative colitis. Data were collected from patient histories and cumulative success was calculated by the Kaplan-Meier method. Seven of 20 (35%) ileorectal anastomoses were lost. Cumulative success rate was 84% at 5 years, 69% at 10 years and 56% at 20 years. Most common indication for proctectomy was disabling proctitis. Other reasons for failure were postoperative ileal necrosis and persisting presacral infection. Patients with advanced colonic cancer managed relatively well with ileorectal anastomosis until death. No cases of rectal cancer were detected during postoperative follow-up but one moderate dysplasia was treated locally. Ileorectal anastomosis can be chosen for patients who are not suitable for ileoanal operation. Rectal endoscopies are mandatory postoperatively.

Colorectal cancer and high grade dysplasia complicating ulcerative colitis in Italy. A retrospective co-operative IG-IBD study.

Ulcerative colitis is a well-known risk factor for colorectal cancer. To take a census of the cases of colorectal cancer in ulcerative colitis patients observed in Italy and to evaluate the clinical presentation of neoplastic complication. Experts from 28 Italian centres specialised in the management of inflammatory bowel disease or malignancies participated to the study. They were invited to send clinical data of patients with ulcerative colitis complicated by colorectal cancer or high-grade dysplasia consecutively observed between 1985 and 2000. One hundred and twelve patients (92 with cancer and 20 with high-grade dysplasia) were collected. Fourteen of them had undergone colectomy and ileo-rectal anastomosis for ulcerative colitis. Data of surgical patients were analysed separately. The mean age at diagnosis of ulcerative colitis and colorectal cancer patients was 39.3 and 53.2 years, respectively, and the mean duration between diagnosis of ulcerative colitis and cancer was 13.9 years (range 0-53). Inflammation was proximal to the splenic flexure in 71 cases (76.3%). One hundred and three colorectal cancers were registered (93 patients with single lesion and five patients with two synchronous cancers), with 76.7% of cancers being located in the left colon. As to the surgical patients, the mean age at diagnosis of ulcerative colitis and cancer was 28.9 and 47.0 years, respectively, and the mean diagnostic interval for ulcerative colitis and cancer was 18.1 years. Only 51 out of 112 patients were in follow-up. An early diagnosis of neoplasia (high grade dysplasia, stage A or B sec. Dukes) occurred in 72.5% of patients who were subjected to endoscopic surveillance and in 48.0% of patients who did not undergo endoscopic surveillance (p=0.02). These data show an earlier diagnosis of cancer in patients who had undergone endoscopic surveillance. The poor compliance to the follow-up program, however, reduces its effectiveness. Moreover, total colectomy allows an easier follow-up, with only the rectum being controlled. Colectomy with ileo-rectal anastomosis or proctocolectomy with ileo-anal anastomosis, could represent a valid alternative in patients at high risk of cancer who refuse endoscopic surveillance.

Rectal lymphoma after colectomy for ulcerative colitis.

Primary colonic lymphoma is an increasingly recognised complication of ulcerative colitis. We report the first known case of rectal lymphoma occurring after colectomy and ileorectal anastomosis in ulcerative colitis.

Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm County

The long-term results of ileorectal anastomosis in patients with ulcerative colitis in Stockholm County over a 30-year period, 1955 to 1984, were investigated. During this time, 486 patients underwent colectomy and ileorectal anastomosis was performed in 60 of those patients (12 percent). A retrospective histologic examination of the slides of the operative specimens in the latter group revealed that nine patients had Crohn's disease. Of the 51 remaining patients with ulcerative colitis, the colectomy and ileorectal anastomosis was performed as an elective procedure in 44 cases (86 percent) and as a one-stage procedure in 48 patients (94 percent). Complications occurred in 7 of 43 patients (16 percent) undergoing an elective, one-stage procedure. There were two postoperative deaths (4 percent). There were 22 patients (43 percent) who had their ileorectal anastomosis in function at the time of follow-up, with a mean time of observation of 13 years. The cumulative probability of having the ileorectal anastomosis in function at 10 years was 51 percent. The causes of total excision were recurrent inflammation in the retained rectum (N = 23), dysplasia (N = 3), and postoperative complications (N = 3). No rectal carcinoma occurred. Patients with preoperative mild rectal disease had a better outcome (ileorectal anastomosis in function at time of follow-up) compared with patients with moderate rectal disease (P less than 0.001). The functional outcome of ileorectal anastomosis was, if anything, better than what is stated in the literature following pelvic pouch procedure.

Total colectomy and ileorectal anastomosis for ulcerative colitis.

AbstractThe pros and cons of total colectomy and ileorectal anastomosis for ulcerative colitis are discussed based on the author's experience and on the collective results with this operation at St. Mark's Hospital, London, over a 20‐year period. Its chief merits are that it is easy to perform, carries a low operative mortality and morbidity, and, when it works well, usually affords excellent anorectal function. It has 2 main disadvantages: in a proportion of cases it proves unable to control the disease because of continuous or recurrent activity of the residual proctitis, and occasionally a carcinoma may develop in the rectal stump. But patients who have failed with it can easily be salvaged, as a rule, by proceeding to a proctectomy and ileoanal anastomosis (or ileostomy). As for the risk of cancer arising in the rectum, fortunately, this can now be largely contained by regular follow‐up attendances, at which rectal biopsies are taken to look for evidence of the premalignant change of severe epithelial dysplasia, a precaution that is absolutely essential after this operation.Important points in the technique of ileorectal anastomosis are emphasized, and the suitability of the operation for colitis in various clinical settings is examined.

Ileorectal Anastomosis for Ulcerative Colitis: Prevention of Relapses and Neoplasia of the Rectal Stump with Topical Treatment

We studied the effect of topical treatment with sulfasalazine and corticosteroids on the fate of the rectal stump after ileorectal anastomosis (IRA) for ulcerative colitis. From 1972 to 1986, 31 patients with ulcerative colitis underwent colectomy and IRA. Macroscopically, 93.5% of them had only minor involvement of the rectal mucosa; microscopically, mild or moderate inflammation. Only 2 patients had low-grade dysplasia before surgery. Postoperatively, all patients had a continuous topical treatment with sulfasalazine and corticosteroids. They were monitored carefully for relapses, development of dysplasia and cancer in the rectal stump by endoscopy and histological examination. No proctectomy was performed 1–15 years after the operation; only 29% of the patients had flare-ups of ulcerative colitis in the rectum and 2 patients developed precancerous lesions, and the 2 patients who had preoperative dysplasia have no dysplasia at present. Therefore, we think that topical treatment with sulfasalazine and steroids is useful to improve the results of IRA for ulcerative colitis.

A prospective study of dysplasia and carcinoma in the rectal biopsies and rectal stump of eight patients following ileorectal anastomosis in ulcerative colitis

The present study concerns eight patients with ulcerative colitis treated by total colectomy and ileorectal anastomosis and subjected to follow-up rectal biopsies who later developed precancer (two cases) or carcinoma in the retained rectum. We report the results of the biopsies and the detailed mapping of lesions in the resected rectal stump to highlight certain features which may lead to increased detection rate of early malignancy. Two groups of patients emerged. Group A: in all four cases the follow-up biopsies showed increasing severity of dysplasia; altered mucin secretion with predominance of sialomucins was seen in the biopsies even in the absence of inflammation or dysplasia; the biopsy findings (morphological and secretory) mirrored those observed in the rectal stump; in three, the lesions were villous polypoid growths, of which two were invasive carcinomas. Group B: in none of the cases was dysplasia seen in the biopsies and mucus secretion was normal; similar features were seen in the rectal stump; all had invasive carcinoma of which three were flat ulcerated lesions. The different behaviour of carcinoma in the two groups almost certainly reflects the different tumour phenotype characteristics and this is a matter for further study. From the practical point of view we emphasize the risk of relying on biopsy evidence of dysplasia alone as an indicator of malignancy and the need for additional immunological or histochemical tests to assess the individual risk of cancer in colitis.

Sialomucins in the assessment of dysplasia and cancer-risk patients with ulcerative colitis treated with colectomy and ileo-rectal anastomosis.

The clinical notes and histology of 374 patients treated by colectomy and ileo-rectal anastomosis for ulcerative colitis were reviewed. Only those with definite diagnosis of ulcerative colitis and follow-up rectal biopsies were included (171 cases). Morphology and patterns of mucin secretion were investigated to assess whether abnormal mucin with predominance of sialomucins is a useful indicator of malignancy-risk. Carcinoma has developed in six patients and 'precancer' in seven. The results show coexistence of dysplasia and sialomucin even in the absence of inflammation in all but three biopsies; in contrast the presence of both dysplasia and normal mucin profile was found in less than 1%. A significant correlation was noted between an inflamed mucosa and the development of cancer or precancer, the presence of sialomucins and the appearance of dysplasia. Sialomucins showed a greater sensitivity in detecting cancer than dysplasia (75% versus 30%). However, dysplasia was notably more specific (94% compared with 50%), hence its greater predictive value as indicator of malignancy (50% as against 15% for a positive sialomucin result). Mucin stains on routine fixed paraffin-embedded tissue provide a simple screening method to sharpen the assessment of dysplasia and cancer-risk in patients with ulcerative colitis despite the limitations referred to above. The lack of definite evidence of dysplasia in four patients who developed malignancy without premalignant changes in the rectal biopsies emphasises the need for frequent multiple biopsies in patients with an ileo-rectal anastomosis for ulcerative colitis.