Restorative Proctocolectomy With Ileal Pouch-anal Anastomosis Research Articles

Laparoscopic Restorative Total Proctocolectomy with Ileal Pouch-Anal Anastomosis for Familial Adenomatous Polyposis and Ulcerative Colitis.

Although laparoscopic total proctocolectomy with ileal pouch-anal anastomosis has recently been used for this group of patients, there are rare reports of its treatment outcomes and postoperative complications. For this purpose, the very aim of the present study was to evaluate the complications of this surgery after 6 months in patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC). The present cross-sectional study was performed on 20 patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) for FAP or UC during 2009-2014. Outcomes of patients were recorded 6 months after surgery for complications and satisfaction. There were 11 (60%) males and 9 (40%) females with a mean age of 30.65 ± 9.59 years. There were 12 patients (60%) with FAP and eight patients (40%) with UC. The length of stay (LOS) ranged from 4 days to 10 days with the mean of 6.40 ± 1.76 days. The incidence of complications including leak, urinary retention, and wound infection were 10%, 5%, and 10%, respectively. Moreover, no postoperative mortalities occurred. Male patients had no problems during sexual activity or micturition. All patients were highly satisfied with the outcome of the surgery. According to the results of the present study, laparoscopic RPC-IPAA was a surgery with the least complications and the highest level of satisfaction for young patients with FAP and UC. Therefore, it seems that this surgery can be a suitable surgical method for the mentioned patients.

Study of late complications of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis operated at a tertiary care center and factors affecting to that.

Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is usually preferred surgical treatment for ulcerative colitis (UC). Although treated primarily medically, some refractory and complicated cases of UC may require surgical intervention. It eliminates chronic UC and the risk of colonic cancer. This research aims to study the risk factors associated with the development of postoperative complications. For this cohort study, we included all the patients who underwent RPC-IPAA in the Department of Gastroenterology, Sheth Vadilal Sarabhai General Hospital, Ahmedabad, over 6 years. Data of the patients were obtained retrospectively from the medical records. We collected the data and analyzed using appropriate statistical tests to look for preoperative patient variables associated with late complications. Late complications were defined as those developed after 1 month. Out of 32 patients, 19 were male and 13 were female, with an average age of 32.3 years at the time of operation. Thirteen patients developed complications such as pouchitis (n = 6), incisional hernia (n = 3), bowel obstruction (n = 2), pouch leakage (n = 1), and erectile dysfunction (n = 1). We found serum albumin <3 mg/dl and pancolitis associated with more postoperative late complications with P = 0.007 and 0.04, respectively, which is statistically significant. This study demonstrates that low preoperative albumin level and pancolitis are risk factors for late complications of IPAA. Preoperative nutritional support, especially albumin, could reduce late complications.

Better characterization of operation for ulcerative colitis through the National surgical quality improvement program: A 2-year audit of NSQIP-IBD

IntroductionThere is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail. MethodsWe queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity. Results430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity. ConclusionsOur data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity. Short summaryWe applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.

Dual arterial blood supply D-pouch in a patient with ulcerative colitis undergoing proctocolectomy and ileal pouch-anal anastomosis

Introduction:Pouchitis is the most common complication in Ulcerative colitis (UC) patients after restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) and ischemia may be a significant contributing factor. Tension and blood supply are the primary concerns while performing the procedure. A dual arterial blood supply technique is designed to decrease tension while ensuring sufficient blood perfusion.Patient concerns:A 61-year-old female patient with 14 years history of UC wanted to seek surgical treatment.Diagnoses:Ulcerative colitis.Interventions:After physical examination and treatment of parenteral nutrition, the patient underwent a D-pouch with dual arterial blood supply after total proctocoloectomy.Outcomes:The patient recovered well and was discharged 10 days after her procedure. Postoperatively dual arterial blood supply to the D-pouch was demonstrated by computed tomography angiography (CTA).Conclusion:D-pouch with dual arterial blood supply is feasible and safe in patients with UC undergoing RP-IPAA.

Short-term outcomes in children undergoing restorative proctocolectomy with ileal-pouch anal anastomosis

IntroductionPatients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) commonly undergo restorative proctocolectomy with ileal-pouch anal anastomosis (RP-IPAA). We sought to describe patient characteristics and postoperative outcomes in this patient population. MethodsUsing the National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who were 6–18years old who underwent RP-IPAA for FAP or UC were identified. Postoperative morbidity, including reoperation and readmission were quantified. Associations between preoperative characteristics and postoperative outcomes were analyzed. ResultsA total of 260 children met the inclusion criteria, of which 56.2% had UC. Most cases were performed laparoscopically (58.1%), and the operative time was longer with a laparoscopic versus open approach (326 [257–408] versus 281 [216–391] minutes, p=0.02). The overall morbidity was 11.5%, and there were high reoperation and readmission rates (12.7% and 21.5%, respectively). On bivariate analysis, preoperative steroid use was associated with reoperation (22.5% versus 10.9%, p=0.04). On multivariable regression analysis, obesity was independently associated with reoperation (odds ratio: 3.34 [95% confidence intervals: 1.08–10.38], p=0.04). ConclusionsChildren who undergo RP-IPAA have high rates of overall morbidity, reoperation, and readmission. Obesity was independently associated with reoperation. This data can be used by practitioners in the preoperative setting to better counsel families and establish expectations for the postoperative setting. Type of StudyRetrospective Comparative Study. Level of EvidenceLevel III.

P541 Intestinal failure: a rare but significant outcome of restorative proctocolectomy

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) removes the entire colon & rectum, while preserving the anal sphincter, maintaining intestinal continuity1–4. RPC-IPAA is offered to patients with ulcerative colitis (UC) refractory to treatment or associated with dysplasia, and some patients with familial adenomatous polyposis (FAP). Complications are well described, but intestinal failure (IF) requiring parenteral support (PS) is an uncommon complication of this surgery that carries with it significant morbidity & mortality. We report of the complication of IF as a complication of RPC-IPAA. Methods: Adult patients with RPC-IPAA as an underlying cause of IF who were treated at our institution, were identified between 1/1/1998 & 1/1/2016. Information on complications, small intestinal length & pathophysiological causes of IF were recorded7. Date & cause of death were also recorded. Comparison was made with other patients who had received PS for IF at the same unit during the same time period. Patients were excluded if RPC-IPAA was not a direct cause of IF, or if the cause of the IF was due to malignancy. Results: Of 807 in the IF database, 35 were identified with a RPC-IPAA and met the inclusion criteria. There were 13 male patients in the pouch group with IF. The pouch was formed for UC in 26, FAP in 6, & other reasons in 3. The pathophysiological classification of IF was short bowel in 49% (n=17), mechanical obstruction in 29% (n=10), intestinal fistulae in 14% (n=5), intestinal dysmotility in 6% (n=2) & small bowel mucosal disease in 3% (n=1). Survival was 96% at 1 year and 75% at, 5 years. This compared to 76% & 48% respectively in the non-pouch group (p=0.02). IF was a potentially avoidable complication in three patients (9%) with a pouch. Two developed IF due to short bowel after index pouch formation (residual small bowel length of 50–100cm). One patient underwent a pouch originally for ulcerative colitis but developed IF due to small bowel Crohn's disease with no prior small bowel imaging prior to pouch formation was documented. Figure 1. Survival pouches with IF vs non pouches with IF. Conclusions: IF is a rare complication of RPC-IPAA surgery, but carries with it a high disease burden. Our data has shown that survival is better in RPC-IPAA patients compared to patients who have IF for other conditions. We recommend documenting the pre and post-operative bowel length, with appropriate pre-operative imaging of the small bowel as standard practice in RPC-IPAA surgery.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: A narrative review.

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) is the gold standard surgical treatment for ulcerative colitis. However, despite the widespread use of RP-IPAA, many aspects of this treatment still remain controversial, such as the approach (open or laparoscopic), number of stages in the surgery, type of pouch, and construction type (hand-sewn or stapled ileal pouch-anal anastomosis). The present narrative review aims to discuss current evidence on the short-, mid-, and long-term results of each of these technical alternatives as well as their benefits and disadvantages. A review of the MEDLINE, EMBASE, and Ovid databases was performed to identify studies published through March 2016. Few large, randomized, controlled studies have been conducted, which limits the conclusions that can be drawn regarding controversial issues. The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases. Regarding 2- and 3-stage RP-IPAA, patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables, making any comparisons extremely difficult. The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly, although the J pouch is generally preferred by surgeons. Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages, and there is no clear benefit of one technique over the other.

Reoperative transabdominal surgery for ileoanal pouch salvage

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is performed for surgical management of ulcerative colitis (UC) familial adenomatous polyposis (FAP), indeterminate colitis, and an extremely selected subset of patients with Crohn׳s disease (CD). Around one-tenth of ileoanal pouches fail in long term due to septic, mechanic, functional, or biologic complications. Transanal, transabdominal, or combined approaches are safe and feasible to salvage ileoanal pouch. This article focuses on reoperative transabdominal surgery for ileoanal pouch salvage. Transabdominal redo IPAA surgery is technically complex and a patient-driven procedure. The success of transabdominal redo IPAA surgery is highly correlated with patient׳s motivation, physician's experience, institutional infrastructure, and caseload.

PTU-282 Dysplasia following stapled restorative procto-colectomy for ulcerative colitis: is there a correlation between pre-op colorectal dysplasia and development of post-op dysplasia in the rectal cuff mucosa?

Introduction Preserved rectal cuff mucosa following restorative proctocolectomy with ileal-pouch anal anastomosis (RPC-IPAA) in mucosal ulcerative colitis (MUC) carries the risk of malignant transformation and/or recurrent active inflammation (cuffitis). This study aimed to determine: any correlation between pre-op colorectal dysplasia or malignancy and post-op rectal cuff dysplasia; overall risk of post-op dysplasia development in MUC patients after stapled RPC-IPAA; patient compliance with annual rectal cuff biopsies; any potential post-op period during which rectal cuff dysplasia is more prevalent. Method After IRB approval, all MUC patients who underwent stapled RPC-IPAA were identified. Review of demographics, risk factors, operative details and pathology reports (pre- and post-op surveillance biopsies as well as operative specimens) was conducted. Results 611 MUC patients [mean age 46.7 (11–89 years), 368 (60%) males] underwent stapled RPC-IPAA from 1988–2011. Pathology reports were unavailable in 45 and 239 patients had no post-op surveillance biopsies. Among a cohort of 566 patients with obtainable perioperative reports, 16 (2.8%) were histologically diagnosed with “Crohn’s disease (CD)”, 104 (18.4%) with “dysplasia/indefinite for dysplasia without malignancy” and 44 (7.8%) with “adenocarcinoma with or without dysplasia”. Incidental small bowel carcinoid tumours were detected in operative specimens of 6 (1%) patients. 327 patients (58%) had a mean of 8.5 (1–16) identifiable annual post-op rectal cuff biopsies. 282/327 patients (86.2%) had ≤5 post-op surveillance years records available. Post-op rectal cuff dysplasia was identified in 5 patients (1.5%): 2 had no history of dysplasia, 1 had pre-op dysplasia by biopsy, 1 was diagnosed with CD without dysplasia and 1 with adenocarcinoma. One incidence of malignant lymphoma was identified in a post-op pouch surveillance biopsy of a patient who had a previous incidental appendiceal carcinoid. All histologically abnormal post-op surveillance specimens were detected in the first 5 postoperative years. Conclusion The incidence of dysplasia in the rectal cuff after stapled RPC-IPAA in MUC patients was very low (1.5%). There was no correlation between pre-op colorectal dysplasia/malignancy and post-op rectal cuff dysplasia. 327 patients (58%) had a mean of 8.5 (1–16) identifiable annual post-op rectal cuff biopsies. Although no histologically abnormal lesions were detected after 5 post-op surveillance years, 13.8% of patients continued follow up beyond 5 years. Disclosure of interest None Declared.

Refractory Distal Ulcerative Colitis: Is Proctocolectomy Always Necessary?

Refractory distal ulcerative colitis (RDUC) is defined as persistence of symptoms caused by endoscopically proven colonic inflammation located at the rectum or left colon despite oral/topical steroids and 5-ASA. RDUC affects a small subset of patients and is associated with chronic disabling symptoms and increased social/medical costs. Moreover, patients with long-standing ulcerative colitis (UC) carry an elevated risk of developing colorectal cancer and colonic mucosa high-grade dysplasia. Alternative medical strategies in steroid refractory disease are unlikely to provide durable remission in all patients, carry potential severe side effects and, as immunosuppressants, the risk of other neoplasms, and may increase the short-term complication rate when surgery is finally required. Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) allows the complete removal of the diseased rectum and colon, virtually eliminating the risk of malignant transformation and reestablishing intestinal continuity with continence preservation. Since the introduction of this surgical procedure, morbidity and mortality rates have been drastically reduced. Despite the still notable rate of surgical complications, long-term quality of life assessment has shown excellent results in nearly all patients who have undergone RP-IPAA, comparing well with the general population. Furthermore, when performed for distal UC, RP-IPAA produces similar surgical outcomes with respect to pancolitis. In conclusion, RP-IPAA should always be considered in patients with RDUC, and multidisciplinary counseling should provide patients clear information about the advantages of surgery and possible complications as well as the chance to achieve disease remission with medical therapy.

Robotic-Assisted Laparoscopic “Salvage” Rectopexy for Recurrent Ileoanal J-Pouch Prolapse

Total restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) has become the standard of care for the surgical treatment of ulcerative colitis. Despite its correlation with an excellent quality of life and favorable long-term outcomes, RP/IPAA has been associated with several complications. Prolapse of the ileoanal pouch is a rare and debilitating complication that should be considered in the differential diagnosis of pouch failure. Limited data exist regarding the prevalence and treatment of pouch prolapse. We present the case of a recurrent J-pouch prolapse treated with a novel minimally invasive “salvage” approach involving a robotic-assisted laparoscopic rectopexy with mesh.

Anatomic extent of colitis and disease severity are not predictors of pouchitis after restorative proctocolectomy for mucosal ulcerative colitis

Pouchitis is a common complication following restorative proctocolectomy with ileal pouch anal anastomosis (RPC-IPAA) for mucosal ulcerative colitis (MUC). The aim of this study was to determine if perioperative anatomic extent and severity of disease are predictors of pouchitis. All consecutive patients who underwent RPC-IPAA for MUC between 1988 and 2002 were retrospectively studied. Pouchitis was classified as acute, recurrent or refractory. Colectomy specimen slides were histopathologically evaluated by a single blinded pathologist (MB), who assessed extent and severity of disease. Of 112 patients assessed, 70 (62.5%) had some form of pouchitis at a median follow-up of 38 months (range, 1-204 months). No association was found between the extent or severity of disease and subsequent development of acute or chronic pouchitis. A positive correlation was found between the histopathologic score and the occurrence of clinical pouchitis (p=0.014). The presence of colonic metaplasia in the pouch biopsy was significantly correlated with a histopathologic diagnosis of pouchitis (p<0.0001, r=-0.449). Following RPC for MUC, the extent and severity of disease do not predict the subsequent development of pouchitis.