Permanent End Ileostomy Research Articles

S1150 Recurrence of Inflammatory Bowel Disease is Unlikely but Possible After Permanent End-Ileostomy for Ulcerative Colitis

S1150 Recurrence of Inflammatory Bowel Disease is Unlikely but Possible After Permanent End-Ileostomy for Ulcerative Colitis

Dietary Interventions and Supplementation in Patients With an Ileal Pouch-Anal Anastomosis: A Systematic Review.

Lay Summary The restorative proctocolectomy with ileal pouch–anal anastomosis is the preferred surgery for patients with medically refractory ulcerative colitis. Although the ileal pouch–anal anastomosis provides gastrointestinal continuity and is an excellent alternative to a permanent end ileostomy, it is not without its complications including acute pouchitis, which occurs in up to 80% of patients. Diet may have a significant impact on pouch function and the development of pouchitis by virtue of its impact on motility and the microbiome. Multiple studies have evaluated the ability of different diets and supplements to improve pouch function and manage pouchitis, yet results are conflicting; thus, evidence-based dietary recommendations are lacking. Patients with an ileoanal pouch routinely ask about dietary interventions to maintain pouch health, and it is crucial that concrete evidence-based recommendations are identified to provide guidance. The goal of this systematic review is to summarize the available data on dietary patterns in patients with an ileoanal pouch, dietary interventions in this cohort, and the impact of supplements on pouch function and pouchitis.

Development of a specialist ileoanal pouch surgery pathway: a multidisciplinary patient-centred approach

BackgroundRestorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch...

S2123 Refractory Case of Malignant Eosinophilic Colitis Leading to Ischemic Colitis

Introduction: Eosinophilic colitis (EC) is a rare inflammatory condition involving eosinophilic infiltration of the mucosa in the absence of a secondary cause or peripheral eosinophilia. Clinically, EC presents with non-specific symptoms. We present a case of malignant EC that is refractory to different therapies. Case Description/Methods: A 30 years old male with known EC on azathioprine, pulmonary embolism and superior mesenteric venous (SMV) thrombosis onrivaroxaban, had multiple admissions with abdominal pain and hematochezia secondary to Clostridioides difficile (C. diff). His rivaroxaban and azathioprine were held given his hematochezia and recurrent infections. He presented a month later with worsening symptoms but C. diff was negative. CT abdomen/pelvis showed non-occlusive SMV and portal venous (PV) thrombosis with signs of ischemia of the sigmoid colon (Figure 1b). Patient underwent percutaneous transhepatic SMV/PV aspiration thrombectomy that was complicated by a large right hemothorax, causing hemorrhagic shock. Subsequent flexible sigmoidoscopy showed signs of colonic ischemia (Figure 1a). Colonic biopsies demonstrated active colitis without evidence of chronicity, and 60 eosinophils per high powered field. Patient underwent a subtotal colectomy with end ileostomy with clinical improvement immediately postoperatively. He was discharged on a steroid taper and apixaban. He was started on the interleukin-5 (IL-5) inhibitor benralizumab for his EC. Outpatient follow-up was notable for continued rectal bleeding. Flexible sigmoidoscopy showed diffuse severe erythema, contact bleeding, and friable mucosa throughout the rectal pouch (Figure 1c). Vedolizumab was started in combination with benralizumab, however, on long-term outpatient follow-up, no notable clinical or endoscopic improvements were noted on combination therapy. Multi-disciplinary decision in conjunction with patient resulted in planned proctocolectomy with permanent end ileostomy. Discussion: There are currently no FDA approved management options for EC. The IL-5 inhibitor Benralizumab is FDA approved for treatment of eosinophilic asthma and therefore it was worth a trial in this patient. In a small number of case reports, Vedolizumab has shown some clinical improvement as well as reduction in eosinophilia in EC patients. Due to the rarity of EC diagnosis, data for therapies in EC is severely lacking. To our knowledge, this is the first case of a patient with severe refractory EC that led to the development of ischemic colitis.Figure 1.: (a) shows an endoscopic image of ischemic colitis. (b), the red arrow points at the portal vein thrombosis and (c) shows diffuse severe erythema, contact bleeding, and friable mucosa throughout the rectal pouch.

Ileostomy or ileal pouch-anal anastomosis for ulcerative colitis: patient participation and decisional needs

BackgroundUp to 30% of patients with ulcerative colitis will undergo surgery resulting in an ileal pouch-anal anastomosis (IPAA) or permanent end ileostomy (EI). We aimed to understand how patients decide between these two options.MethodsWe performed semi-structured interviews with ulcerative colitis patients who underwent surgery. Areas of questioning included the degree to which patients participated in decision-making, challenges experienced, and suggestions for improving the decision-making process. We analyzed the data using a directed content and thematic approach.ResultsWe interviewed 16 patients ranging in age from 28 to 68 years. Nine were male, 10 underwent IPAA, and 6 underwent EI. When it came to participation in decision-making, 11 patients felt independently responsible for decision-making, 3 shared decision-making with the surgeon, and 2 experienced surgeon-led decision-making. Themes regarding challenges during decision-making included lack of support from family, lack of time to discuss options with the surgeon, and the overwhelming complexity of the decision. Themes for ways to improve decision-making included the need for additional information, the desire for peer education, and earlier consultation with a surgeon. Only 3 patients were content with the information used to decide about surgery.ConclusionsPatients with ulcerative colitis who need surgery largely experience independence when deciding between IPAA and EI, but struggle with inadequate educational information and social support. Patients may benefit from early access to surgeons and peer guidance to enhance independence in decision-making. Preoperative educational materials describing surgical complications and postoperative lifestyle could improve decision-making and facilitate discussions with loved ones.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis.

Glasgow prognostic score is a predictive index for postoperative infectious complications after total proctocolectomy in ulcerative colitis patients.

Glasgow prognostic score is a systemic inflammatory-based score. The aim of this study was to determine whether the Glasgow prognostic score was a useful predictor of short-term outcomes in patients who undergo total proctocolectomy for ulcerative colitis. eighty ulcerative colitis patients who underwent a total proctocolectomy with ileal pouch-anal anastomosis or permanent end ileostomy from June 2014 to March 2020 were retrospectively analyzed. Patients were divided into a lower Glasgow prognostic score group and a higher Glasgow prognostic score group. postoperative infectious complication occurred more frequently in the higher Glasgow prognostic score group (8.3 % vs 29.5 %, p = 0.018). According to the univariate and multivariate analysis, only a higher Glasgow prognostic score was associated with an increased risk of postoperative infectious complication (OR: 5.478, 95 % CI: 1.236-24.279). Glasgow prognostic score is a simple and useful indicator of postoperative infectious complications.

P086 Kock pouches in the 21st century: A descriptive study of short-term (30-day) outcomes in a national cohort of 177 patients

BACKGROUND: In 1972, Professor Nils Kock in Gothenburg Sweden developed the continent ileostomy (Koch pouch or KP) as an alternative to permanent end ileostomy. However, the KP was largely supplanted by the ileal pouch-anal anastomosis (IPAA). In the 21st century, KP's are rarely performed, and often only in highly select patients who are a not candidate for an IPAA. Presently, there are only single institution case series with which to guide surgeons' and patients' expectations for postoperative outcomes including length of stay, readmission and complication rates. Thus we aimed to report surgical outcomes in a large national retrospective cohort using the National Surgical Quality Improvement Project (NSQIP). METHODS: Using the NSQIP Participant User File from 2005 to 2017 we identified patients who underwent a KP (CPT 44386). Baseline characteristics, operative variables, and postoperative outcomes are reported. Figures represent frequency (proportion) or median (interquartile range). RESULTS: Over an 11-year period, a total of 907,146 colorectal operations were performed; of these, we identified a sample of 177 patients who underwent Kock pouch procedures. The median age was 56 (46–76), 50.2% were women, and the median body mass index was 25.3 (22–29.6) kg/m2. Any comorbidity was present in 105 (59%), with a median of 1 (0–2) comorbidities. A total of 13 (7.3%) and 16 (8.5%) were on steroids or had recent weight loss, respectively, and the median albumin was 3.8 (2.9–4.1) mg/dL. Most patients were ASA class 2 (78, 44%). Operative time was 198 (129.5–298.5) minutes, and 127 (72%) had other procedures by the same surgical team, while only 24 (14%) had concurrent procedures by a different surgical team. In terms of short-term outcomes, reoperation was required in 19 (10%) of patients, the post-operative length of stay was 8 (5–14) days. Readmission occurred in 14 (7.9%) of patients. VTE occurred in 4 patients (2.3%). Overall any complication of any severity occurred in 67 (38%) patients. The 30-day mortality rate was 3.4% (6 patients). CONCLUSION(S): The Kock pouch procedure, despite its technical complexity, has an acceptable short-term safety profile, and remains an option for a selective group of motivated patients who cannot have IPAA and/or who defer end-ileostomy.

The Informational Needs and Preferences of Patients Considering Surgery for Ulcerative Colitis: Results of a Qualitative Study.

Patients considering surgery for ulcerative colitis (UC) face a difficult decision as surgery may or may not improve quality of life. National Institute for Health and Care Excellence guidelines for UC emphasize the importance of providing quality preoperative information to patients but note no quality studies for the desired content of this information. Our aim was to explore patient information preferences prior to undergoing surgery for ulcerative colitis. Semistructured interviews with patients who underwent an operation and patients who considered but declined an operation were conducted. Interviews explored informational preferences, with emphasis on preoperative information given, preoperative information desired but not received, and retrospective informational desires. Interviews were transcribed and coded using an inductive thematic analysis using NVivo software. Data saturation was assessed after 12 interviews, with interviews continuing until saturation was achieved. Ethical approval was gained prior to interviews commencing (16/NW/0639). A total of 16 interviews were conducted before data saturation was achieved (male n = 7, female n = 9). Eight patients declined surgery, and 8 opted for subtotal colectomy with permanent end ileostomy (n = 5) or ileoanal pouch (n = 3). A total of 4 themes and 14 subthemes were identified. Three dominant subthemes of informational shortcomings emerged: "long-term effects of surgery," "practicalities of daily living," and "long-term support." Peer support was desired by patients but was infrequently supported by health care professionals. Current preoperative information does not address patient informational needs. Surgical consultations should be adapted to suit patient preferences. Clinical practice may need to be altered to ensure that patients are better supported following surgery.

Long-term Quality of Life of Patients With Permanent End Ileostomy: Results of a Nationwide Cross-Sectional Survey.

Patients with permanent end ileostomy are at high risk for detrimental stomal effects on their quality of life. However, little is known about the long-term quality of life of these patients. The purpose of this study was to assess long-term quality of life in patients with permanent end ileostomy. Registration at the German self-help organization ILCO was used for this study. Selection included a cross-sectional survey of 1434 patients with permanent end ileostomy. Quality of life was assessed using the Medical Outcomes Study Short Form 36, including physical and mental component summary scores, the Gastrointestinal Quality of Life Index, and the Cleveland Global Quality of Life Index. Multivariate risk factor analysis was performed. A total of 783 responders were included. Indications for ileostomy included ulcerative colitis (44%), Crohn's disease (38%), and colorectal cancer (7%). Adverse effects on daily life because of stoma were reported by 72% of participants. Quality of life was significantly impaired compared with the general population on all of the summary scores and several subscales (physical component summary: 44.6 ± 10.4 (mean ± SD) vs 50.2 ± 10.2, p < 0.001; mental component summary: 47.5 ± 10.7 vs 51.5 ± 10.2, p < 0.001; Gastrointestinal Quality of Life Index: 94.4 ± 16.4 vs 126.0, p < 0.001). Stoma care problems affecting quality of life were reported by 63% of respondents. These included parastomal hernia (p < 0.001), stenosis (p = 0.003), and prolapse (p = 0.008). Vitamin B12, iron, and zinc deficiencies were also associated with diminished quality of life; in particular, vitamin B12 deficiency was associated with reduced mental and emotional quality of life. Not all patients undergoing ileostomy in Germany are registered at ILCO, and there were many nonresponders. In addition, the inherent limitations of cross-sectional studies should be considered, including the response-shift phenomenon. Quality of life was markedly impaired in patients with permanent end ileostomy as compared with the general population. The main reasons were stoma-associated morbidity and nutritional deficiency syndromes. These findings highlight the importance of prevention, screening, and adequate treatment.

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis.

Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients. We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD. We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness. IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy. In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.

P-161 Cost-Effectiveness of Colectomy with IPAA versus Colectomy with Permanent End-Ileostomy for Crohnʼs Colitis

The economic burden of Crohn’s disease (CD) in the US exceeds 15 billion dollars annually with a significant portion of these costs related to surgery. Twenty percent of patients with CD have disease isolated to the colon. Traditionally, in medically refractory cases these patients undergo total colectomy with end-ileostomy (EI) or subtotal colectomy with ileorectal anastomosis. Recently, ileal pouch-anal anastomosis (IPAA) has been found to be an effective option for this population. We determined the cost effectiveness of different surgical strategies in the management of medically refractory Crohn’s colitis. We used a lifetime Markov model with 1 year cycles to simulate quality adjusted life years (QALYs) and cost comparing 2 different surgical strategies: total colectomy with permanent EI versus colectomy with IPAA. After undergoing EI, patients could move between the following health states: permanent EI without treatment, permanent EI on infliximab, and additional surgery (Fig. 1). In the IPAA strategy, patients could move between remission without treatment, remission on infliximab, acute pouchitis, and pouch resection with EI at which point they would move between the health states in EI (Fig. 1). One-way sensitivity analysis and tornado analysis were performed. We used the third-party payer perspective for the analysis. The EI surgical strategy was more cost effective than IPAA, with an incremental cost effectiveness ratio (ICER) of $13,080 per QALY gained. We identified the following variables of importance in our model: 1) the cost of the EI surgery, 2) the cost of ostomy care, and 3) the cost of infliximab. One-way sensitivity analysis showed that if the costs associated with EI surgery were greater than $67,000 (base case: $53,600), then IPAA became cost-effective with an ICER of $9,029 per QALY gained. All other variations of the model maintained EI as the more cost effective strategy. In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $67,000.

Quality of life following ileoanal pouch failure

This article describes a novel qualitative study exploring the lived experience of participants having undergone ileoanal pouch failure, on a background of ulcerative colitis (UC). It focuses on the impact of living with indefinite diversion of the pouch and a permanent end ileostomy. Six participants were interviewed with an aim to establish their experience of pouch failure and the support they required. Five pertinent themes emerged that suggested participants did not expect pouch failure and were unprepared for the regression towards UC. Some participants recommenced drug therapy, wore pads to manage leakage from the diverted pouch, avoided certain social settings or manipulated diet and lifestyle in order to gain an acceptable quality of life with a permanent ileostomy. Pouch failure potentially presents adverse effects on patients' quality of life, but currently there is a deficit in support and resources available in order to provide acceptable outcomes for patients experiencing pouch failure.

Quality of life following ileoanal pouch failure.

This article describes a novel qualitative study exploring the lived experience of participants having undergone ileoanal pouch failure, on a background of ulcerative colitis (UC). It focuses on the impact of living with indefinite diversion of the pouch and a permanent end ileostomy. Six participants were interviewed with an aim to establish their experience of pouch failure and the support they required. Five pertinent themes emerged that suggested participants did not expect pouch failure and were unprepared for the regression towards UC. Some participants recommenced drug therapy, wore pads to manage leakage from the diverted pouch, avoided certain social settings or manipulated diet and lifestyle in order to gain an acceptable quality of life with a permanent ileostomy. Pouch failure potentially presents adverse effects on patients' quality of life, but currently there is a deficit in support and resources available in order to provide acceptable outcomes for patients experiencing pouch failure.

Su1612 Long Term Outcomes of Continent Ileostomy Created in the Pediatric Age Group

Background/aim: Continent ileostomy (CI) is a surgically created intra-abdominal pouch in patients with a permanent end ileostomy. CI is one of the few surgical options that may be offered to patients who were fated to live with a permanent ileostomy, but want to avoid a stoma appliance at any cost. Data about durability, clinical and functional outcomes of CI created in pediatric patients are limited. In this study, we aimed to evaluate our 36-year operative experience on CI in pediatric patients with a 21 year median follow-up. Methods: Pediatric (≤21 years)* patients undergoing a CI procedure at a single institution from 19732009 were identified. CI revisions that required pouchotomy or re-construction following total or partial excision of CI were defined as major and those that did not require bowel resection were defined as minor revisions. CI failure was defined as excision of the pouch and formation of an end ileostomy. Results: 49 patients (26 male), median age 18 (12-21) years and median body mass index 22 (16-38.6) underwent CI. 10 (20%) patients had a CI at the time of total proctocolectomy. 12 (25%) patients underwent conversion of an ileoanal pouch (IPAA) to a CI. The majority of the patients (n=39, 80%) had ulcerative colitis or indeterminate colitis at the time of CI creation; however Crohn's disease were diagnosed in 4 patients postoperatively. There were no intra-operative or early post-operative deaths. One patients who underwent CI excision seven years after CI creation due to complicated Crohn's disease, died ten years after CI excision. Median follow-up time was 21(range 1-38) years. Valve slippage (33%), small bowel obstruction (25%), pouchitis (25%) and fistula (23%) were the common complications (table). 37 patients (76%) underwent at least 1 revision procedure after CI creation. 36 (74%) patients underwent major revision and 6 (12%) patients underwent minor revisions. Median pouch intubation was 6 (range 4-10) times per day. Pouch failure occurred in 9 (18%) patients with 7 out of 9 cases being due to complications from Crohn's disease. Conclusions: CI is safe and durable in pediatric patients. Development of Crohn's disease after CI creation seems to be a risk factor for failure. Since likelihood of further revisions is high, patients with CI should be followedup regularly. * Council on Child and Adolescent Health. Age Limits of Pediatrics. Pediatrics 1988;81:736. Primary diagnosis, complications and follow-up details

Surgical management of inflammatory bowel disease

Inflammatory bowel disease of the colon and gastrointestinal tract predominantly includes ulcerative colitis and Crohn's disease, both of which have characteristic features. The management of these conditions is essentially medical; surgical treatment is reserved for the management of complications or failure of medical therapy. This contribution discusses the principles of surgical management. The basis of surgery for ulcerative colitis is simple: no colon = no colitis. The surgical options include subtotal colectomy, panproctocolectomy with permanent end ileostomy or ileoanal pouch reconstruction. The principles of management of Crohn's disease include conservative surgery (preserve functional bowel length by minimal resection), drainage of sepsis and the preservation of continence.

Surgical pitfalls in a patient with type IV Ehlers-Danlos syndrome and spontaneous colonic rupture

This paper intends to stress the importance of early diagnosis and discuss surgical treatment of Type IV Ehlers-Danlos syndrome (EDS-4), an autosomal dominant connective tissue disease characterized by typical features of the face and extremities, inappropriate and easy bruising, and extreme tissue fragility, which may lead to dramatic and often fatal complications, mostly spontaneous arterial or intestinal rupture. We report the case of a 41-year-old female who presented with spontaneous perforation of the sigmoid colon. The patient was seen over a nine-year period, during which time she required six operations and presented with a great number of surgical complications including stenosis of an end-colostomy, repeated subocclusive episodes caused by intraperitoneal adhesions, and enterocutaneous fistulas, finally ending with an ileostomy and short bowel syndrome. It is only after a difficult laparotomy for ovarian cyst excision, marked by numerous adhesions and friable bowel, that the diagnosis of EDS-4 was considered and established. In case of "idiopathic" spontaneous perforation of the colon in a young adult, features of EDS-4 should be thoroughly looked into and, if found, skin fibroblast culture with collagen Type III analysis performed. The surgical treatment of choice consists of subtotal colectomy and permanent end-ileostomy. In case of patient refusal, a second-stage ileorectal anastomosis can be performed but carries the high risk of anastomotic leakage.

New surgical approaches to ulcerative colitis in children and adults

AbstractUlcerative colitis continues to be a devastating disease for the child and the young adult. In spite of intensive medical therapy with sulfasalazine and corticosteroids, the majority of patients with universal ulcerative colitis will ultimately require a total colectomy. The standard operation of a total proctocolectomy and a permanent end ileostomy is probably still the best procedure for the definitive management of this disease because all diseased tissue is removed with this operation; however, the resultant abdominal stoma can create significant psychological trauma in many of these patients. For that reason, sphincter‐saving operations were introduced in 1933 but were only marginally successful until 1977, when renewed interest in the endorectal pull‐through occurred. Since that time, several centers around the world have gained significant experience with the endorectal procedure, with or without the use of an ileal reservoir. Although the ileal reservoir appears to have certain advantages over the straight endorectal pull‐through, the procedure also is associated with a significant number of complications and is a far more complicated technical exercise.The experience at the University of Michigan with the straight endorectal pullthrough procedure in patients with ulcerative colitis and familial polyposis during the period from 1977 to 1984 is herein reported. All of the patients in our series are continent and experience a median stool frequency of 6 per 24 hours 1 year after the procedure. Patient satisfaction has been excellent with the majority of patients preferring their lifestyle without an ileostomy to that experienced with an ileostomy. At the present time, we can strongly recommend the endorectal pullthrough procedure to all patients with ulcerative colitis.