Restorative Proctocolectomy Research Articles

Laparoscopic Robotic-Assisted Restorative Proctocolectomy and Ileal J-Pouch-Anorectal Anastomosis in Children: Shifting to a Two Stage-Approach.

Background: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the gold standard surgical treatment for patients with ulcerative colitis (UC) unresponsive to medical therapy and those with familial adenomatous polyposis. Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. The feasibility of IPAA without ileostomy has been demonstrated in adult in the modified two-stage approach. Aim: The aim of the study was to examine feasibility, outcomes, and complications of robotic modified two-stage approach for RPC with IPAA in pediatric patients comparing it with robotic three-stage approach. Methods: All patients aged 4-18 years who underwent operative treatment for medically refractory UC were included. Demographic and clinical features, age at colectomy and at reconstructive surgery, intraoperative details and complications, and postoperative outcomes were analyzed. Results: Thirteen patients were included in the study (6 males, 7 females). Ileostomy was fashioned in 8 patients at the time of RPC and IPAA (Group 1); in 5 patients the bowel continuity was reintegrated at the time of IPAA (Group 2). No intraoperative complications and no conversions were recorded. One patient of Group 1 had a postoperative pouch complication. The 5 patients who underwent a two-stage procedure did not show short-term complications. No statistical differences were found between the groups in short-term (P = .48) and long-term complications (P = .07). Conclusions: Modified two-stage IPAA is a safe and feasible option in pediatric patients with UC, and RALS offers advantages over other techniques for the precision of rectal dissection and ileo-anal anastomosis.

Temporary loop end ileostomy reduces the risk of stoma outlet obstruction: a comparative clinical study in patients undergoing restorative proctocolectomy and ileal pouch-anal anastomosis.

Stoma outlet obstruction (SOO) is a serious complication of restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA). When the ileal mesentery to the pouch is under excessive tension, the ileum near the ileostomy twists easily, causing SOO. Loop-end ileostomy (EI) for fecal diversion was introduced in 2021 to prevent SOO, and we aimed to verify whether temporary EI reduces the incidence of SOO in RPC and IPAA patients relative to loop ileostomy (LI). This study included 106 consecutive RPC and IPAA patients with a diverting ileostomy and categorized them into LI (n = 75) or EI (n = 31) groups. The clinical characteristics of the patients were analyzed and compared. Patient characteristics were similar between the groups, except for higher preoperative steroid use in the LI group (38.7%; p = 0.0116). There were no significant differences between the groups in anatomical factors, such as abdominal wall thickness and the height-adjusted distance between the root of the superior mesenteric artery and the bottom of the external anal sphincter. There were no significant differences in surgery-related factors, with ≥ 90% of the patients in each group undergoing laparoscopic procedures. A multivariate logistic regression analysis revealed that EI significantly reduced the risk of SOO relative to LI (OR, 0.18; 95% CI 0.03-0.92; p = 0.0399). EI reduced SOO levels after RPC and IPAA and may be beneficial for cases in which anastomosis is challenging.

What Is the Optimal Strategy for Pouch Salvage at Time of Redo Ileal-Pouch Anal Anastomosis? Pouch Repair with Reanastomosis vs Pouch Excision with Neopouch.

The long-term risk of pouch failure after restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) range from 5% to 15%. Salvage surgery for failing IPAA may be achieved by disconnecting the IPAA and either repairing and reusing the existing pouch (REP) or constructing a neopouch (NEO). We aimed to evaluate whether there are differences in long-term functional pouch survival and functional outcomes between the REP group and the NEO group. We hypothesized that patients undergoing REP have higher long-term pouch survival rates compared with patients who require NEO pouch construction. Our prospectively maintained Pouch Registry was queried for patients who underwent a pouch salvage surgery with either pouch REP or NEO from 1988 to 2020. Patients who underwent pouch repair without disconnection from the anus were excluded. The primary endpoint was long-term pouch survival after redo pouch surgery. Secondary outcomes were patient-reported quality of life and pouch function. Of 653 patients undergoing redo IPAA, 462 met inclusion criteria of transabdominal redo surgery with pouch reconnection: 243 (52.6%) had REP and 219 (47.4%) had NEO. Median age was 39 years and 59% were women. Median time between index and redo IPAA was 34 months for REP vs 54 months for NEO (p = 0.002). The 5-year pouch survival after redo IPAA was similar between REP (79.5%) and NEO (76.8%) groups (p = 0.4). Fewer patients in the REP group reported nighttime pad use (51.4% vs 68.2%, p = 0.04). Pouch survival and functional outcomes after salvage surgery for failing ileoanal pouch was similar regardless of pouch salvage procedure. When performing redo pouch surgery, surgeons should not hesitate to construct a new pouch if indicated.

Open vs. laparoscopic vs. robotic pouch excision: unveiling the best approach for optimal outcomes.

Despite advantages for patients with ulcerative colitis, Crohn's disease, and familial adenomatous polyposis, restorative proctocolectomy with ileal pouch-anal anastomosis carries a risk of pouch failure, necessitating pouch excision. The traditional open approach is associated with potential complications. Robotic and laparoscopic techniques are emerging, but comparative outcome data are limited. We conducted a retrospective study of consecutive adult patients undergoing robotic, laparoscopic, and open ileal pouch excision at Mayo Clinic, Rochester, MN, between January 2015 and December 2023. We analyzed data on patient characteristics, perioperative variables, and postoperative outcomes, focusing on short-term complications. Statistical analysis included appropriate tests. The study included 123 patients: 23 underwent robotic-assisted pouch excision, 12 laparoscopic, and 82 open. The robotic approach had the longest median operative time (334 ± 170min, p = 0.03). However, it demonstrated significantly lower estimated blood loss than open (150 ± 200ml vs. 350 ± 300ml, p = 0.002) and laparoscopic surgery (250 ± 250ml, p = 0.005). Robotic and laparoscopic groups required fewer preoperative ureteral stents than the open group (p = 0.001). Additionally, the robotic approach utilized fewer pelvic drainages (p < 0.0001) and had a lower rate of lysis of adhesions > 60min compared to open surgery (p = 0.003). Robotic procedures had significantly lower 30-day postoperative complications than the open approach (30.4% vs. 65.9%, p = 0.002) while also demonstrating fewer 30-day reoperations than the laparoscopic group (p = 0.04). Robotic-assisted pouch excision offered significant benefits, including decreased EBL, reduced need for preoperative ureteral stents, and significantly fewer 30-day postoperative complications compared to open surgery.

Impact of diverting ileostomy on functional outcome and quality of life after restorative proctocolectomy and ileal pouch anal anastomosis.

Diverting ileostomy (DS) after restorative proctocolectomy (RPC) can be omitted in selected patients. Its omission could improve functional outcomes and quality of life (QoL), as has been demonstrated in patients after proctectomy. The aim of this study was to report the impact of diverting ileostomy on functional outcomes and QoL after ileal pouch-anal anastomosis (IPAA). This was a retrospective study including all patients operated (2015-2020) for RPC with IPAA. Functional outcome was evaluated by validated scores (LARS, Wexner, Öresland, pouch functional score [PFS] and the ileoanal pouch syndrome severity [IPSS] score). Global health-related QoL was evaluated with the SF-36. We also analysed demographic characteristics, morbidity, correlation between functional outcomes and QoL. Among 179 eligible patients, 150 responded (84%): S- (no stoma = 78; 52%) and S+ (had stoma = 72; 48%). Overall morbidity and anastomotic leak rates were 46% and 9.3%, respectively without difference between the groups. Medians for the functional scores were comparable between the S- and S+ group, respectively: 18 [12.5-31] versus 18 [11-31], p = 0.48 for LARS; 9 [7-11] versus 9 [7-12], p = 0.23 for Wexner's score; 6 [3-13] versus 8 [5-11], p = 0.22 for Öresland's score, 6 [3-13] versus 6.8 [4-12], p = 0.174 for PFS score, and 40 [35-45] versus 46 [42-51], p = 0.045 for IPSS score. The SF-36 summary score was comparable between the two groups without any difference in eight specific health dimensions. After propensity score matching, results were still comparable between the two groups for all scores. Linear regression found a significant correlation between all QoL domains and all functional scores (p < 0.001). DS for IPAA does not alter either functional outcomes or QoL and can be omitted in selected patients.

2-Stage and 3-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis show comparable short- and long-term outcomes

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) represents the standard treatment for therapy-refractory, malignant or complicated ulcerative colitis (UC) and can be performed as a 2-stage or 3-stage procedure. This study aimed to compare the short- and long-term outcomes after 2- and 3-stage IPAA in patients with UC in our department. A retrospective analysis of 176 patients with UC who received 2- or 3-stage restorative proctocolectomy with IPAA at our institution from 2001 to 2021 was performed. Outcomes for short-term (morbidity, longer hospital stay, readmission) and long-term (pouch failure and quality of life) parameters were compared between the 2- and 3-stage procedure. Regarding short-term outcomes for all patients, in-hospital morbidity and readmission rates after any surgical stage were observed in 69% and 24%, respectively. Morbidity and readmission did not differ significantly between the 2- and 3-stage procedure in uni- and multivariate analysis. Median length of hospital stay for all stages was 17 days. The 3-stage procedure was identified as an independent factor for longer hospital stay (OR 3.8 (CI 1.3–10.8), p = 0.014). Pouch failure and failure of improved quality of life during long-term follow-up occurred both in 10% of patients, with no significant differences between the 2- and 3-stage procedure in uni- and multivariate analysis. Our data suggest that both the 2- and 3-stage proctocolectomy with IPAA demonstrate favourable and comparable postoperative short- and long-term outcomes, with a high rate of improved quality of life in patients with UC.

The prevalence of pouch fistulas in ulcerative colitis following restorative proctocolectomy: a systematic review and meta-analysis.

One complication of restorative proctocolectomy with ileo-anal pouch anastomosis is fistula formation in the pouch. Fistulas can be associated with significant morbidity and pouch failure. We conducted a systematic review with meta- analysis to try and understand the prevalence of pouch fistulas in patients with ulcerative colitis following restorative proctocolectomy. The Embase, Embase Classic, and PubMed databases were searched between January 1979 and April 2022. Studies were included if there were cross-sectional, case-controlled, population-based or cohort studies reporting on prevalence of pouch fistulas in ulcerative colitis. Studies had to report the number of patients with pouch fistulas using either clinical, endoscopic, or radiological diagnosis in an adult population. Thirty-three studies screened met the inclusion criteria. The pooled prevalence of developing at least 1 fistula was 0.05 (95% confidence interval [CI], 0.04-0.07). The pooled prevalence of pouch failure in patients with pouch fistula was found to be 0.24 (95% CI, 0.19-0.30). The pooled prevalence of developing a pouch fistula at 3 years, 5 years and more than 5 years was 0.04 (95% CI, 0.02-0.07), 0.05 (95% CI, 0.02-0.07), and 0.05 (95% CI, 0.02-0.10), respectively. This is the first systematic review and meta-analysis to report the prevalence of pouch fistula. It also provides a pooled prevalence of pouch failure in these patients. These results can help to shape future guidelines, power future studies, and help counsel patients.

Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis.

Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state. We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery. During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%). In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.

Role of ileal diversion in pediatric inflammatory bowel disease.

Surgical intervention is often indicated in pediatric inflammatory bowel disease (IBD) for medically refractory disease or complications of severe disease. Specifically, surgical intervention via ileal diversion allows for fecal flow to be redirected away from diseased distal bowel and through an ileostomy. It is utilized in patients who have medically refractory colitis, severe perianal disease, or irreversible bowel damage. In patients with ulcerative colitis, it is primarily performed during a restorative proctocolectomy with ileal pouch anal anastomosis to protect the high-risk anastomoses. In the setting of Crohn's disease, ileal diversion reduces the exposure of diseased distal intestine to pro-inflammatory stool. During perioperative planning, it is crucial for the gastroenterologist to partner early with a multidisciplinary team including surgeons, nutritionists, wound ostomy care nurses, psychologists, and social workers. Patients should be assessed for malnutrition and should be optimized nutritionally with enteral or parenteral nutrition. As they are associated with increased risk of postoperative complications, corticosteroids should be significantly reduced or completely discontinued preoperatively. Though ileal diversion may reduce the complications associated with anastomosis, serious postoperative complications can include diversion colitis and high-output fistulae. This review aims to provide an overview of the role of ileal diversion in the treatment of pediatric IBD to pediatric gastroenterologists to inform their medical decision-making and discussions with patients and families.

Usefulness of Hand-assisted Laparoscopic Restorative Proctocolectomy for Ulcerative Colitis in the Era of Laparoscopic Surgery - A Single-center Observational Study.

Hand-assisted laparoscopic surgery (HALS) combines the benefits of laparoscopic surgery with the tactile feedback from open surgery. In the current era of laparoscopic surgery, the significance of HALS as a technical transition has diminished. This study clarified the usefulness of HALS in restorative proctocolectomy (RPC) for ulcerative colitis (UC) in the era of laparoscopic surgery. The 212 patients who underwent RPC with ileal pouch-anal anastomosis between 2007 and 2023 were included in this study. The patients were divided into three groups, open surgery (OS), HALS, and conventional laparoscopic surgery (LAP), and their characteristics, surgical outcomes, surgical complications, and functional outcomes were compared. The number of surgical techniques was OS in 21 cases, HALS in 184 cases, and LAP in 7 cases. The number of surgeons was two for OS and HALS, and four for LAP, with OS and HALS having fewer surgeons than LAP. The length of the skin incision was 13, 7, and 3 cm for OS, HALS, and LAP, respectively, and the operation times was 250, 286, and 576 minutes for OS, HALS, and LAP, respectively, with LAP having the longest operation time. The postoperative complications and function did not differ markedly among the three groups. In RPC for UC, HALS involved fewer surgeons and a shorter operative time than LAP. Even in the era of laparoscopic surgery, HALS remains a useful option, especially when a shorter operation time is required or when the number of available surgeons is insufficient.

Endoscopic Balloon Dilatation of Ileal Pouch-Anal Anastomosis Strictures in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for medically refractory inflammatory bowel disease (IBD). In this systematic review and meta-analysis, we assess outcomes and safety of endoscopic balloon dilatation (EBD) for IPAA strictures. A systematic search of numerous databases was performed through June 2023 to identify studies reporting on the outcomes of EBD in pouch-related strictures. Outcomes included technical success, clinical success at index dilation and in pouch retention, recurrence of symptoms post-EBD, and adverse events of EBD. Meta-analysis was performed using a random-effects model, and results were expressed in terms of pooled rates along with relevant 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran Q statistical test with I2 statistics. Seven studies with 504 patients were included. The pooled rate of technical success and clinical success of index dilatation was 98.9% (95% CI, 94.8-99.8%; I20%) and 30.2% (95% CI, 7.1-71%; I20%), respectively. The pooled rate of clinical success in pouch retention without the need for additional surgery was 81.4% (95% CI, 69.6-89.3%; I272%). The pooled failure rate of EBD was 18.6% (95% CI, 10.7-30.4%, I272%). The pooled rate of recurrence of symptoms after index dilatation was 58.9% (95% CI, 33.3-80.5%; I213%). The pooled rate of serious adverse events was 1.8% (95% CI, 1-3.5%, I20%). No deaths related to EBD were reported. Endoscopic balloon dilatation is safe and highly effective for management of IPAA strictures. Additional studies are needed to compare its efficacy with surgical interventions.

Endoscopic management of patients with familial adenomatous polyposis after prophylactic colectomy or restorative proctocolectomy - systematic review of the literature.

Patients with familial adenomatous polyposis (FAP) develop early colorectal adenomas and if left untreated, progression to cancer is an inevitable event. Prophylactic surgery does not prevent further development of cancer in the rectal remnant, rectal cuff in patients with ileal pouch anal anastomosis (IPAA) and even on the ileal mucosa of the pouch body. The aim of this review is to assess long-term rates of cancer and adenoma development in patients with FAP after prophylactic surgery and to summarise current recommendations for endoscopic management and surveillance of these patients. A systematic literature search of studies from January 1946 through to June 2023 was conducted using the PRISMA checklist. The electronic database PubMed was searched. Fifty-four papers involving 5010 patients were reviewed. Cancer rate in the rectal remnant was 8.8-16.7% in the western population and 37% in the eastern population. The cumulative risk of cancer 30 years after surgery was 24%. Mortality due to cancer in the rectal remnant is 1.1-11.1% with a 5-year survival rate of 55%. The adenoma rate after primary IPAA was 9.4-85% with a cumulative risk of 85% 20 years after surgery and a cumulative risk of 12% for advanced adenomas 10 years after surgery. Cumulative risk for adenomas after ileorectal anastomosis (IRA) was 85% after 5 and 100% after 10 years. Adenomas developed more frequently after stapled (33.9-57%) compared to hand-sewn (0-33%) anastomosis. We identified reports of 45 cancers in patients after IPAA of which 30 were in the pouch body and 15 in the rectal cuff or at the anastomosis. There was a significant incidence of cancer and adenomas in the rectal remnant and ileal pouch of FAP patients during the long-term follow-up. Regular endoscopic surveillance is recommended, not only in IRA patients, but also in pouch patients after proctocolectomy.

Salvage surgery for pouch-related complication after ileal pouch–anal anastomosis: a report of two cases

BackgroundPouch-related complications (PRCs), such as pelvic abscesses and perianal complex fistulas, can occur after ileal pouch–anal anastomosis (IPAA) in ulcerative colitis (UC). They are often difficult to treat and require salvage surgery. We report two cases of PRC associated with fistulas.Case presentationFirst case: A 38-year-old man was diagnosed with UC at age 26 years. Four months after the diagnosis of UC, the patient underwent hand-assisted laparoscopic restorative proctocolectomy, IPAA, and ileostomy for acute fulminant UC. Two years after the closure of the ileostomy, the patient developed a perianal abscess and underwent ileostomy reconstruction. He was referred to our department at 35 years of age, because his symptoms did not improve despite repeated seton drainage of a complicated perineal fistula. We diagnosed PRC with a pelvic abscess and complicated pouch fistula and performed salvage surgery. This diagnosis was revised to Crohn’s disease. Second case: A 50-year-old man was diagnosed with UC at age 18 years and was administered high doses of steroids; however, his symptoms did not improve. He underwent restorative proctocolectomy, IPAA, and ileostomy at another hospital. The ileostomy was closed, and his condition stabilized thereafter. At 35 years of age, perianal pain developed, and he was diagnosed with a complicated pouch–perineal fistula. A fistula was observed near the staple line of the ileal end closure on the head side of the pouch. Reconstruction of the ileostomy and seton drainage were performed; however, his symptoms did not improve, and he was referred to our hospital. We diagnosed PRC with a pelvic abscess and a complicated pouch fistula and performed salvage surgery. The resected specimen showed strictures in two locations: at the oral site of the afferent limb (at the pouch) and at the IPAA. Both patients returned to society and are currently outpatients.ConclusionsWe encountered two cases of PRC after IPAA that did not improve with seton drainage or ileostomy. Pouch resection was performed after considering the patient’s quality of life and reintegration into society.

Pouchitis: pathophysiology and management.

Pouchitis is an acute or chronic inflammatory disease of the ileal reservoir. It is common after restorative proctocolectomy with ileal pouch-anal anastomosis, and treatment of chronic antibiotic-refractory pouchitis has proven challenging. Most cases of acute pouchitis evolve into chronic pouchitis. The aetiology of acute pouchitis is likely to be partly related to the gut microbiota, whereas the pathophysiology of chronic pouchitis involves abnormal interactions between genetic disposition, faecal stasis, the gut microbiota, dysregulated host immunity, surgical techniques, ischaemia and mesentery-related factors. Pouchoscopy with biopsy is the most valuable modality for diagnosis, disease monitoring, assessment of treatment response, dysplasia surveillance and delivery of endoscopic therapy. Triggering or risk factors, such as Clostridioides difficile infection and use of non-steroidal anti-inflammatory drugs, should be modified or eradicated. In terms of treatment, acute pouchitis usually responds to oral antibiotics, whereas chronic antibiotic-refractory pouchitis often requires induction and maintenance therapy with integrin, interleukin or tumour necrosis factor inhibitors. Chronic pouchitis with ischaemic features, fistulae or abscesses can be treated with hyperbaric oxygen therapy.

Perceived food intolerances and its impact on diet quality in patients with an ileoanal pouch

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with medically-refractory ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Whilst quality of life is generally good, as many as 83% of patients associate dietary factors with the onset of symptoms(1) and around two-thirds employ some form of dietary restriction post-pouch creation(2,3). There is growing interest to understand the role of diet (as a whole) on pouch function and how it can be used therapeutically. It is imperative that we know the dietary characteristics of pouch patients before attempting to introduce strategies altering their food choice. Since there is good rationale to assess overall diet quality to identify potential avenues for targeting dietary strategies, this study aimed to examine the frequency of perceived food intolerances and diet quality in patients with an ileoanal pouch and the relationship between these two indices. In this cross-sectional study, patients with an ileoanal pouch completed a food intolerance questionnaire and a validated 297-item semi-quantitative food frequency questionnaire (Monash Comprehensive Nutritional Assessment Questionnaire). Dietary data was used to score diet quality using the 2013 Dietary Guidelines Index (DGI), a scoring system which compares how closely an individual’s dietary intake aligns with the Australian Dietary Guidelines (ADG). The DGI also comprises of 11 subcomponents (scored out of 10 respectively) based on each of the ADG guidelines and provides a total score of 110, with higher scores reflecting greater compliance to the ADG. In order to determine if perceived dietary intolerances was negatively associated with the intake of specific dietary factors, univariable and multivariable linear regression analysis of the correlation of intolerance and diet quality was performed. Of the 58 (10 FAP and 48 UC) patients studied, 81% of UC and 80% of FAP patients reported dietary intolerances. Mean total DGI score was 78 (95% CI: 74-80) of 110 in the overall pouch cohort with no differences across pouch sub-groups. However, only 5% of patients achieved a full score for food variety. Both uni- [OR −0.94 (−1.7,-0.10); p = 0.02] and multivariable analysis (adjusting for age and sex) showed that only intolerances to dairy products were associated with reduced intake of lactose-containing dairy [OR −0.29 (−1.8,-0.08); p=0.03]. No other significant correlations were found for overall or subcomponents of DGI scores. High rates of perceived food intolerances were observed in patients with an ileoanal pouch. However, only those with perceived dairy intolerances restricted their intake of lactose-containing dairy products. Additionally, patients with ileoanal pouch scored highly for overall diet quality but specific gaps in achieving better diet quality, particularly for diet variety were observed. These results provide some starting points for targeted dietary counselling to optimise nutritional health and potentially to improve pouch function these patients.

Ouch, my pouch! a clinician's guide to pouchitis

Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.

Extensive Disease and Exposure to Multiple Biologics Precolectomy Is Associated with Endoscopic Cuffitis Post-Ileal Pouch-Anal Anastomosis in Patients With Ulcerative Colitis.

To better inform the risk of cuffitis in patients with ulcerative colitis (UC), we aimed to identify its occurrence and associated precolectomy factors in a large multicenter cohort of patients who underwent restorative proctocolectomy (RPC) with stapled ileal pouch-anal anastomosis (IPAA). This study was a retrospective cohort analysis of individuals diagnosed with UC or indeterminate colitis who underwent RPC with IPAA for refractory disease or dysplasia at Mount Sinai Hospital or the University of Chicago followed by at least 1 pouchoscopy with report of the pouch-anal anastomosis. The primary outcome was cuffitis defined as ulceration of the cuff as reported in each pouchoscopy report. The pouch-anal anastomosis was mentioned in the pouchoscopy reports of 674 patients, of whom 525 (77.9%) had a stapled anastomosis. Among these, cuffitis occurred in 313 (59.6%) patients a median of 1.51 (interquartile range 0.59-4.17) years after final surgical stage. On multivariable analysis, older age (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01-1.02), extensive disease (HR, 1.34; 95% CI, 1.01-1.78), exposure to biologics before colectomy (HR, 2.51; 95% CI, 1.93-3.27), and exposure to at least 2 or more biologics before colectomy (HR, 2.18; 95% CI, 1.40-3.39) were significantly associated with subsequent cuffitis. In this multicenter study of patients who underwent RPC with stapled IPAA and at least 1 follow-up pouchoscopy, cuffitis occurred in approximately 60% and was significantly associated with extensive disease and exposure to multiple biologics precolectomy.

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.

Evidence-Based Approach to Chronic Antibiotic Refractory Pouchitis: A Review.

Chronic antibiotic refractory pouchitis after restorative proctocolectomy with IPAA, characterized by at least 4 weeks of pouchitis symptoms that have not responded to standard antibiotic therapy, presents a therapeutic challenge for patients and health care providers. The aim of this narrative review was to summarize the current evidence regarding the management of chronic antibiotic refractory pouchitis. Studies were identified through a search of the PubMed database from the National Library of Medicine. We included case series, cohort studies, randomized controlled trials, and systematic reviews with meta-analyses that addressed chronic antibiotic refractory pouchitis management, with prioritization of data published within the past 3 to 5 years. Studies examining pharmacologic and select nonpharmacologic interventions were included. Outcomes measures included clinical, endoscopic, and histologic end points. Mesalamine has demonstrated efficacy in symptom improvement but no improvement in quality of life. Budesonide has demonstrated high rates of clinical remission that have mostly been sustained in a small number of patients. Anti-tumor necrosis factor therapies have demonstrated efficacy in reaching clinical and even endoscopic end points, although rates of treatment discontinuation were not insignificant. Limited evidence is encouraging for the use of ustekinumab in achieving clinical response. Data for vedolizumab are favorable across clinical, endoscopic, and histologic end points, including one of the only randomized, placebo-controlled trials. Nonmedication therapies, including hyperbaric oxygen therapy and fecal microbiota transplant, have undergone limited evaluation, and concerns about the ultimate accessibility of these therapies remain. Overall, studies assessing therapeutic options for chronic antibiotic refractory pouchitis are mostly limited to case series and retrospective studies with small sample sizes. Biologic therapies have demonstrated efficacy in the management of chronic antibiotic refractory pouchitis and offer a steroid-sparing option for refractory disease. Nonpharmacologic therapies, including hyperbaric oxygen and fecal microbiota transplant, require further exploration. See video from symposium .

Long-term mental and physical quality of life outcomes following ileal pouch anal anastomosis surgery.

This study presents the authors' experience over 14 years of performing restorative procto-colectomy with ileal pouch anal anastomosis (IPAA). The aim was to study the long-term quality of life outcomes and analyse the predictors of pouch function as well as physical and mental wellbeing. This is a single-centre retrospective study conducted in a specialised colorectal surgery unit in the UK. The study included patients who underwent two- or three-staged panproctocolectomy with defunctioning ileostomy for ulcerative colitis (UC) or familial adenomatous polyposis between 2004 and 2018. Data were collected from a prospectively, surgeon-maintained database. Pouch function and quality of life scores were obtained via validated questionnaires. A multivariate analysis was utilised to explore predictors of quality of life and pouch function. The study reports 105 patients who underwent IPAA with a covering ileostomy. The majority of operations were performed for UC (97, 92.4%). The median age of patients was 36 years and the male to female ratio was 1:1. Thirty patients (28.5%) suffered early post-IPAA complications, while pouch failure rate was 11.4% (12/105). Late complications were reported at a rate of 45%. On long-term follow-up, the median Pouch Function Score was 7 (IQR 3-14). Both the physical and mental sections of the quality of life score were at a median indistinguishable from the normal population but had different predictors associated with them. Our findings recognise the complex interplay between physical and psychological wellbeing after pouch surgery and advise psychological counselling where appropriate.