Journal of Visceral Surgery (2014) 151, 281—288
Available online at
ScienceDirect www.sciencedirect.com
REVIEW
Ileal pouch-anal anastomosis: Points of controversy A. Trigui ∗, F. Frikha , H. Rejab , H. Ben Ameur , H. Triki , M. Ben Amar , R. Mzali Department of general and digestive surgery, Habib Bourguiba Teaching Hospital, 3029 Sfax, Tunisia Available online 3 July 2014
KEYWORDS Ileal pouch anal anastomosis; Ulcerative colitis; Familial adenomatous polyposis; Indeterminate colitis; Crohn’s disease
Summary Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current ‘‘hot topics’’ for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn’s disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues. © 2014 Published by Elsevier Masson SAS.
Introduction Ileal pouch-anal anastomosis (IPAA) is currently a well-codified surgical procedure, and can be proposed for treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The theoretical value of IPAA in these settings is to achieve definitive cure the disease, prevent the risk of malignant degeneration and ensure adequate continence with defecation while avoiding a permanent stoma. Progressive improvements in surgical technique have led to satisfactory functional outcomes with low associated mortality and morbidity. The goal of this update is to identify the points of controversy arising in the management of patients requiring an IPAA.
∗
Corresponding author. E-mail address: [email protected] (A. Trigui).
http://dx.doi.org/10.1016/j.jviscsurg.2014.05.004 1878-7886/© 2014 Published by Elsevier Masson SAS.
282
Indications for IPAA Total coloproctectomy (TCP) with IPAA is the reference treatment for UC and FAP. Although generally contraindicated in colonic Crohn’s disease (CD), IPAA can also be proposed in some highly selected patients.
Ulcerative colitis (UC) Subtotal colectomy with ileo-rectal anastomosis (IRA) allows preservation of postoperative fertility in the female similar to that of the overall population. Functional results are better than with ileo-anal anastomosis (IAA) (frequency of bowel movements, nighttime and daytime seepage, anal incontinence), but the quality of life is not necessarily improved [1]. IRA can also be proposed in case of technical difficulties, when doubt persists between the diagnosis of UC and CD or in patients with altered sphincter function, in particular, patients older than 70. IRA is also indicated in the young female with hopes of procreation since fertility is better preserved [2]. IRA can only be performed when the rectum is not fibrotic and when there are no extra-intestinal manifestations, dysplasia or colorectal malignancy or when the duration of disease is less than 10 years. The patient must adhere to a strict surveillance program for the remnant rectum (level of evidence 3). At 10 years, the risk of secondary proctectomy is estimated to be around 20% [3].
Familial adenomatous polyposis (FAP) The choice of anastomotic technique (ileo-anal vs. ileorectal) is based on several criteria: • age; • sphincter function; • possibility of regular surveillance; • degree of dysplasia and the severity of colonic and rectal involvement: ◦ in case of severe polyposis (> 1000 colonic adenomas and/or > 20 rectal adenomas), first-line IRA is recommended (grade of recommendation C) [4], ◦ in case of non-severe polyposis (< 1000 colonic polyps and < 5 rectal polyps), subtotal colectomy with IRA is recommended, particularly in young patients wanting pregnancy after the operation (grade C) [5], ◦ for patients with 6—19 rectal polyps, irrespective of the number of polyps elsewhere in the colon, the indication must be discussed case by case (grade C) [5]. However, whenever maintenance of a program of rigorous rectal surveillance seems impossible, an IAA is recommended, irrespective of the degree of colorectal involvement (grade C) [5].
Is there an age limit to performance of IAA? Because of the complexity of the operation and the absence of prospective studies with long-term results, IAA has long been reserved for young patients capable of tolerating the consequences of altered intestinal and sphincter function inherent in such a procedure. On one side, ageing with consequent muscular atrophy, fibrosis and neurologic disorders have a deleterious effect on pelvic floor and anal sphincter function [6,7], leading to decreased anal pressure and rectal compliance. On
A. Trigui et al. the other, aged patients are more vulnerable to sphincter traumatism during IAA because of slower recuperation of muscular elasticity [7]. Consequently, the functional outcome of IAA is less satisfactory in the elderly with more seepage than in younger patients [8,9]. One prospective study from the Mayo Clinic including 2002 patients with an average follow-up of 10 years, divided patients into three age-defined groups [< 45-yearsold (n = 1688), between 46 and 55-years-old (n = 249), and > 55-years-old (n = 65)]. The authors concluded that the postoperative complication rate was similar among the three groups. The functional outcomes as well as the quality of life were evaluated by a yearly questionnaire. The reservoir failure rate for patients older than 55 was 1.6% at 10 years, without any statistically significant difference compared to the other age categories. The quality of life as evaluated by social, professional, sexual and sports activities was also similar among the three age categories. Quality of life was thought to be satisfactory for most patients. Daytime and nighttime seepage nevertheless occurred more frequently for patients > 55-years-old: 5.6% and 13.3%, respectively (P = 0.002) [10]. Nine studies, five of which were prospective (Table 1), evaluated the impact of age on morbidity, quality of life and functional outcome. The authors concluded that the rate of readmission for dehydration was statistically significantly higher in older patients. The daytime and nighttime rates of seepage were higher for the older patients, but the differences were not statistically significant [10,11]. Digital anorectal examination is the investigation of choice to evaluate preoperative sphincter function. Anorectal manometry should be proposed in case of sphincter disorders and should be considered in patients over 70 [7]. Evaluation of sphincter function should take into account anal incontinence secondary to rectal fibrosis, which does not contra-indicate TCP with IAA. In conclusion: IAA can be proposed to elderly patients who want to avoid a definitive ileostomy, as long as preoperative sphincter function is preserved.
Initial disease Studies comparing IAA for UC vs. indeterminate colitis (IC) One prospective study reported by Murrell et al. compared 334 patients undergoing IAA, 236 for UC and 98 for IC. The authors concluded that there was no statistically significant difference in the incidence of acute or chronic pouchitis between the two groups [18]. Dayton et al. prospectively evaluated postoperative morbidity in 723 patients undergoing IAA of whom 79 had IC and 565 had UC. No statistically significant difference could be found between the two groups for anastomotic leak (5.1% vs. 2.3%, P = 0.15), intra-abdominal abscess (0 vs. 1.1%, P = 0.36) or anastomotic stricture (7.6% vs. 4.8%, P = 0.29) [19]. Revision of diagnosis from indeterminate colitis to CD seems to be a risk factor for IAA failure, as the reservoir failure rate increases from 4 to 28% [19]. Patients with IC without any clinical signs of CD preoperatively seem to have similar functional outcomes and failure rates after IAA compared to patients with UC [20,21]. In conclusion: patients with IC have functional results and failure rates similar to those patients with UC.
Ileal pouch-anal anastomosis: Points of controversy Table 1
283
Comparative studies in patients older than 50 years. Number of patients > 50years-old
Number of patients > 60years-old
Conclusions
100
18
NS
Age is not a contra-indication to IAA
1996 (Prospective)
455
32 (> 55)
NS
Functional outcome ± safe Preferable to ileostomy
Bauer et al. [14]
1997
392
66
NS
Functional outcome and morbidity are similar. The incidence of dysplasia and cancer is higher in the elderly
Tan et al. [15]
1997
227
28
15
Functional outcome similar for patients older than 50 years Caution warranted in patients > 70-years-old
Takao et al. [7]
1998 (Prospective)
122
17
No significant differences in manometric parameters in relation to younger patients Slower return of intestinal function
Delaney et al. [16]
2003 (Prospective)
1895
327
91
Age is not a contra-indication to IAA
Chapman et al. [10]
2005 (Prospective)
2000
65 (> 55)
NS
Satisfactory postoperative functional outcome and quality of life at all ages Deterioration of continence after 55 years of age
Ho et al. [17]
2005 (Retrospective)
330
103
17 (> 70)
Postoperative morbidity and functional outcome similar in patients > 70 years of age
Pinto et al. [11]
2009 (Prospective)
401
NS
33 (> 65)
Increased co-morbidities, dysplasia and malignancy Similar morbidity for patients > 65-years-old, except for re-admissions for dehydration
Authors and references
Years (Studies)
Lewis et al. [12]
1993
Dayton and Larsen [13]
n
IAA: ileo-anal anastomosis; NS: non significant.
Studies comparing IAA for UC vs. CD For certain selected Crohn’s patients without anoperineal or small bowel involvement, IAA can be proposed as an alternative to definitive ileostomy when rectal resection is indispensable [22]. Fazio et al. studied the functional outcome and quality of life in 150 patients undergoing IAA for CD. Functional outcome and quality of life were good or excellent in 95% of patients, irrespective of whether their underlying disease was CD, UC, FAP or IC [23]. In the Mayo Clinic series [24], considering 37 patients with CD who underwent IAA with at least 10 years of follow-up, the incidence of immediate postoperative complications was similar to the outcome when IAA was performed for other indications. Eleven patients (30%) developed complex perineal fistulas after an average follow-up of 29 months. Seven patients were able to retain their reservoir bypassed by ileostomy. Reservoir ablation was performed in 10 patients, leading to an overall failure rate of 45%. In the 55% of patients who retained their reservoir, functional outcome was satisfactory (mean 7 bowel movements per day). The conclusions of this series were similar to those of Fazio et al. demonstrating that IAA for CD was associated with acceptable long-term functional outcome when the reservoir was retained in situ, i.e. in one out of two patients. Likewise, similar results were found in the study by Mylonakis et al. [25], comparing the outcome of 23 patients who underwent
IAA to that of 35 patients who underwent IRA for colonic CD. After an average follow-up of 10 years, the rate of reservoir takedown was 48% and among the patients undergoing reoperation, 73% had persistent perineal sinus. Satisfactory functional outcome was found in patients whose reservoir could be preserved (Table 2). An update by Reese et al. included 3103 patients with IAA, 225 of whom underwent operation for CD (four prospective and six retrospective studies). The authors concluded that the reservoir failure rate IPAA was higher when the procedure was performed for CD than for UC (32% vs. 4%; P < 0.001) [28]. In conclusion: IPAA for CD can be envisioned in wellselected patients with acceptable long-term functional outcome when the reservoir can be left in situ.
Surgical approach Laparoscopy offers the advantages of a mini-invasive approach with less blood loss during dissection. Moreover, laparoscopy is associated with earlier return of intestinal transit, less postoperative pain, shorter hospital stay, earlier return to normal activities and, in the long-term, fewer adhesions and fertility disorders in women [29—31]. The correlation between fewer postoperative adhesions and a lower incidence of small bowel obstruction, however, remains to be shown in colorectal surgery [32,33].
284 Table 2
A. Trigui et al. Long-term recurrence in Crohn’s disease after IAA.
Authors, years and references
Number of patients
Mean follow-up (years)
Clinical recurrences (%)
Definitive ileostomy rate (%)
Mylonakis et al. 2001 [25]
23
10
30
48
Regimbeau et al. 2001 [26]
41
10
35
10
Fazio et al. [27]
67
3
—
25
Sagar et al. [24]
37
10
54
45
IAA: ileo-anal anastomosis.
Beyer-Berjot et al. [34] studied the impact of laparoscopy on infertility in 56 women undergoing IPAA. The average age of patients was 31 ± 9-years-old. The average followup after IPAA was 68 ± 33 months. Twenty-eight patients had at least one full-term delivery before undergoing IPAA. Fifteen patients wanted another pregnancy after their IPAA. Eleven out the 15 became pregnant, leading to ten successful deliveries and one miscarriage. No statistically significant difference in fertility was found compared with 14 controls (laparoscopic appendectomy) or during the same period (90% vs. 86% at 36 months, P = 0.397). The authors concluded that the infertility rate was lower after laparoscopy than after traditional surgery. One prospective randomized study [35] compared the postoperative course and quality of life (SF-36 and GIQLI scores) in 60 patients after laparoscopy and laparotomy. No significant differences were found in terms of postoperative complications (20% vs. 17%, P = 0.74), or medium term quality of life. However, duration of operation was longer in the laparoscopic group (210 min vs. 133 min; P < 0.001). In conclusion: the laparoscopic approach seems to have value in fertile woman. Postoperative morbidity and quality of life seem to be equivalent to those observed after laparotomy with, however, earlier return of transit, less postoperative pain and shorter hospital stay [5].
Type of anastomosis There are two anastomotic techniques for IPAA, manual and mechanical, reported in the literature: • manual anastomosis consists of construction of a J-pouch with anastomosis to the dentate line after endoanal mucosectomy [5]. This procedure has the advantage of removing all diseased or potentially diseased mucosal tissues; • the stapled ileo-anal anastomosis is performed 1 to 2 centimeters above the dentate line respecting the transitional mucosa [5]; • this technique has the theoretical advantage of lessening the risk of anal sphincter damage, and consequently, decreasing the rate of postoperative anal incontinence. Moreover, the transitional mucosa has a rich sensory innervation, which is implicated in the discrimination between feces and gas, and consequently inhibits the anorectal reflex. Moreover, it results in less tension on the mesentery and this could be important in patients with short mesenteries. Six controlled studies and two meta-analyses have compared these two techniques of IPAA. In the meta-analysis reported by Lovegrove et al. [36] (21 studies, 4183 patients
with FAP and UC), the authors compared the outcome of 2699 patients with hand-sewn IPAA to 1484 patients undergoing stapled anastomosis; they concluded that more patients with hand-sewn anastomosis had nighttime incontinence and seepage, and used protective pads. The risk of malignant degeneration of the transitional mucosa was not statistically significantly higher in the stapled anastomosis arm (odds ratio = 0.42, P = 0.08), but follow-up was variable, ranging from four to 155 months in the studies (Table 3). In their prospective study, Kirat et al. [37] divided 3109 patients into two comparable groups: group A (hand-sewn anastomosis; n = 474) and group B (stapled anastomosis; n = 2635). The median follow-up was 7.1 years. In group A, more ileostomies were performed (P = 0.001) and hospital stay was longer (P < 0.001). Postoperatively, anastomotic stricture, septic complications, intestinal obstruction and reservoir failure occurred more frequently in group A (P = 0.002, 0.019, 0.027 and < 0.001, respectively). However, the rates of abdominal wall infection and pouchitis were similar (P = 0.42 and 0.59, respectively). Concerning the functional outcome, incontinence, spotting, protective pad use, alimentary problems in professional activity were more prevalent in group A (P < 0.001, P < 0.001, < 0.001, < 0.001, and = 0.025, respectively). Consequently, the Cleveland Clinic overall quality of life score was higher in group B (P = 0.018). However, in the meta-analysis by Schuendler et al. [38] including four prospective randomized studies (86 patients in the hand-sewn group vs. 98 patients in the stapled anastomosis group), no statistically significant differences were found in terms of functional outcome or manometric sphincter continence (resting and contraction pressures). This meta-analysis concluded that stapled anastomosis provided similar results to hand-sewn anastomosis in terms of functional outcome and manometric findings. Connel et al. [39] reported a histologic study of 25 operative specimens of total coloproctectomy with mucosectomy; they found that mucosectomy was incomplete in 14% of patients. Moreover, after stapled anastomosis, the anal transitional area can easily be seen and biopsied during follow-up to detect dysplasia [40,41]. Additionally, the incidence of cancer was similar between patients with stapled or hand-sewn anastomoses. Of note, the incidence of cancer noted after stapled anastomosis is very limited (< 30 cases out of tens of thousands of IPAA performed worldwide) [42,43]. In conclusion: according to the 2012 ECCO recommendations, it is preferable to perform a stapled anastomosis but the surgeon should have mastery of both anastomotic techniques (grade D) [44].
Ileal pouch-anal anastomosis: Points of controversy Table 3
285
Comparison between mechanical and manual anastomoses.
Results
Number of patients
Number of studies
P value
Anastomotic leak
1774
10
0.96
Sepsis
1941
12
0.21
637
10
0.20
2842
11
0.31
Intestinal obstruction Medical treatment Surgical treatment
318 362
5 4
0.75 0.85
Pouchitis
525
9
0.81
Reservoir failure
1737
9
0.06
Overall morbidity
207
3
0.81
Bowel movement frequency Per 24 h Nighttime
909 344
11 6
0.44 0.62
Spotting Daytime Nighttime
288 465
4 9
0.12 < 0.001
Use of protective pads Daytime Nighttime
298 225
6 3
0.59 0.007
Incontinence
285
5
0.009
Anti-diarrheal drugs
215
6
0.61
Anorectal physiology Resting pressure Threshold volume Length of high pressure zone
341 168 197
7 2 4
< 0.001 0.98 0.10
Dysplasia
202
2
0.08
Inflammation
183
2
0.16
Neoplasm
118
1
0.75
Quality of life
151
2
0.50
Anastomotic stricture Fistula
[36]. Bold values are significantly different.
Protective ileostomy No impact on septic complications or mortality related to the absence of protective ileostomy in selected patients has been reported in the literature [45,46]. Moreover, neither the functional outcome nor the quality of life seems to be modified [47]. A protective stoma was performed routinely after IPAA throughout the early 1980’s. The Mayo Clinic published one of the first series available on IPAA without a protective stoma in 1986 [48]. Since then, several studies have confirmed that IPAA without a protective stoma was feasible. One metaanalysis including 17 studies (one randomized, and 11 non-randomized prospective studies) compared the results of 721 patients with ileostomy vs. 765 patients without [49]. The anastomotic fistula rate was significantly higher in the group without ileostomy (odds ratio: 2.37; P = 0.002) while anastomotic strictures were significantly more frequent in the group with stoma (odds ratio: 0.31; P = 0.045). Intestinal obstruction occurred more
frequently in the stoma group, but the difference did not reach statistical significance. The rates of pouchitis and pelvic sepsis and the functional outcomes were similar (Table 4). A second meta-analysis by Remzi et al. compared the results of IPAA with ileostomy (n = 1725 patients; group A) and without ileostomy (n = 277; group B) ileostomy [47]. Patients in group A were older (38 ± 13 vs. 34.3 ± 12.7, P < 0.001), more often male (59 vs. 44%, P < 0.001), had higher doses of steroids (≥ 20 mg) (22 vs. 5%, P = 0.007), had greater corporeal surfaces (1.87 m2 vs. 1.8 m2 , P < 0.001), required more blood transfusions during surgery (20% vs. 11%, P < 0.001) and were more often afflicted with FAP (18 vs. 6%, P < 0.05). The rates of anastomotic fistula and pelvic sepsis were similar between the two groups. However, the rates of pouch-vaginal fistula, intestinal obstruction, bleeding, anastomotic stricture and IPAA failure were higher in group A, while postoperative ileus was higher in group B (Table 5). The authors concluded that single stage IPAA had similar or better results than two stage IPAA. The selection criteria
286 Table 4
A. Trigui et al. Meta-analysis comparing results in patients with or without ileostomy.
Results
Number of studies
Number of patients w/o S
S
OR (95% CI)
P
Operation Operative duration Hospital stay duration
6 10
320 507
315 496
−1.55 1.18
0.34 0.15
Short-term complications Anastomotic leak Sepsis Perineal sepsis
11 14 5
556 567 256
461 594 192
2.37 1.38 2.80
0.02 0.13 0.09
8 4
316 79
263 70
1.31 0.49
0.55 0.14
11 8 5 12
415 279 273 575
417 287 318 529
0.30 1.01 0.31 0.65
0.009 0.97 0.045 0.12
7 5 3
244 196 89
215 192 96
−0.42 0.56 1.27
0.14 0.43 0.49
Re-operation Laparotomy Others Long-term complications IAA failure Pouchitis Anastomotic stricture Intestinal obstruction Functional outcome Frequency bowel movements Incontinence Anti-diarrheal drugs
[49]. CI: confidence interval; OR: odds ratio; w/o S: without stoma; S: with stoma; IAA: ileo-anal anastomosis. Odds ratio: value < 1 are in favor of no stoma, values > 1 in favor of stoma. Bold values are significantly different.
for IPAA without ileostomy were stapled anastomosis, absence of tension, adequate hemostasis, air-tightness leak test, absence of malnutrition (albumin < 3.5 mg/dL), of anemia (Hb < 13.5 mg/dL) and of prolonged consumption of high doses of steroid (≥ 20 mg prednisone for more than 3 months) [50]. In conclusion: these studies confirmed that IPAA is feasible without a protective ileostomy with no increase in morbidity, particularly in patients with FAP and selected cases of UC.
Table 5
Impact of vaginal delivery on functional outcome The complications of C-section are those of any abdominal surgery including adhesions and prolonged hospital stay while vaginal delivery can result in pudendal nerve and anal sphincter damage, increasing the risk of fecal incontinence. The possibility of deterioration of functional outcome after vaginal delivery in women with IPAA has been debated in the literature.
Meta-analysis of outcome in patients with or without ileostomy.
Results
With ileostomy (n = 1725)
Sepsis
113 (6.5)
Anastomotic leak Fistula Pouch-vaginal fistula
Without ileostomy (n = 277) 15 (5.4)
P 0.51
94 (5.5)
12 (4.3)
0.57
139 (8.1)
18 (6.5)
0.36
52/712 (7.3)
4/154 (2.6)
0.049
Postoperative ileus
195 (11.3)
56 (20.3)
< 0.001
Postoperative fever
194 (11.3)
56 (20.3)
< 0.001
63 (3.7)
3 (1.1)
< 0.001
352 (20.4)
26 (9.4)
< 0.001
77 (4.5)
5 (1.8)
Bleeding Anastomotic stricture IAA failure [47]. IAA: ileo-anal anastomosis. Bold values are significantly different.
0.022
Ileal pouch-anal anastomosis: Points of controversy In a meta-analysis by Seligman et al. [51], including 283 pregnancies after IPAA, neither the frequency of bowel movements nor incontinence were statistically significantly affected by pregnancy or the route of delivery. The authors concluded that vaginal delivery seemed as safe as C-section. Along the same lines, Pemberton et al. published a prospective study including 135 pregnant women with IPAA [52]; they did not find any statistically significant difference in functional outcome between women who had delivered vaginally at least once compared with those who had undergone delivery by C-section. Because of this, they concluded the IPAA should not impact the choice of route of delivery, but that further studies are required to correctly evaluate the long-term functional outcome of IPAA after vaginal delivery. Conversely, Remzi et al. [53] reported a higher incidence of sphincter damage after vaginal delivery (50% vs. 13%, P = 0.012). These sphincter lesions did not seem to influence functional outcome but long-term evaluation remains to be performed. The authors therefore recommended C-section delivery in women with IPAA. In conclusion: even if functional outcome does not seem to be altered at medium term after vaginal delivery, there is no consensus as to which delivery route is best after IPAA because of the absence of studies evaluating the long-term outcome. Caution is therefore warranted. Of note, the 2009 INCA recommendations stated that it seemed ‘‘reasonable to propose a C-section in the light of the risk that vaginal delivery might alter sphincter function and pelvic floor status’’.
Conclusion TCP with ileal pouch anal anastomosis has become the operation of choice for patients with UC and FAP. Progress in surgical technique has led to low mortality and morbidity rates while ensuring increasing satisfactory functional outcome. Through this update, we hope to have highlighted the main points of controversy concerning the indications, the technique as well as the results of TCP with IPAA. Once again, advanced age and CD are not absolute contra-indications and laparoscopy seems to be preferable in women of reproductive age.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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288 [26] Regimbeau JM, Panis Y, Pocard M, et al. Long-term results of ileal pouch-anal anastomosis for colorectal Crohn’s disease. Dis Colon Rectum 2001;44:769—78. [27] Fazio VW, Ziv Y, Church JM, Oakley JR, Lavery IC, Milson JW. Ileal pouch-anal anastomoses. Complications and function in 1005 patients. Ann Surg 1995;222:120—7. [28] Reese GE, Lovegrove RE, Tilney HS, et al. The effect of Crohn’s disease on outcomes after restorative proctocolectomy. Dis Colon Rectum 2007;50:239—50. [29] Dowson HM, Bong JJ, Lovell DP, Worthington TR, Karanjia ND, Rockall TA. Reduced adhesion formation following laparoscopic versus open colorectal surgery. Br J Surg 2008;95: 909—14. [30] Polymeneas G, Theodosopoulos T, Stamatiadis A, et al. A comparative study of postoperative adhesion formation after laparoscopic vs open cholecystectomy. Surg Endosc 2001;15:41—3. [31] Larson DW, Pemberton JH. Current concepts and controversies in surgery for IBD. Gastroenterology 2004;126:1611—9. [32] Taylor GW, Jayne DG, Brown SR, et al. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg 2010;97:70—8. [33] Schölin J, Buunen M, Hop W, et al. Bowel obstruction after laparoscopic and open colon resection for cancer: results of 5 years of follow-up in a randomized trial. Surg Endosc 2011;25:3755—60. [34] Beyer-Berjot L, Maggiori L, Birnbaum D, Lefevre JH, Berdah S, Panis Y. A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-Center Study. Ann Surg 2013;258:275—82. [35] Maartense S, Dunker MS, Slors JF, et al. Hand-assisted laparoscopic versus open restorative proctocolectomy with ileal pouch-anal anastomosis: a randomized trial. Ann Surg 2004;240:984—91. [36] Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, et al. A Comparison of hand-sewn versus stapled ileal pouch-anal anastomosis following proctocolectomy: a metaanalysis of 4183 patients. Ann Surg 2006;244:18—26. [37] Kirat HT, Remzi FH, Kiran RP, Fazio VW. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3109 patients. Surgery 2009;146:723—9. [38] Schluender SJ, Mei L, Yang H, Fleshner PR. Can a metaanalysis answer the question: is mucosectomy and hand-sewn or double-stapled anastomosis better in ileal pouch-anal anastomosis? Am Surg 2006;72:912—6. [39] O Connel PR, Strucker SJ, Metcalf AM, Pemberton JH, Kelly KA. Anal canal pressure and motility after ileo-anal anastomosis. Surg Gynecol Obst 1988;166:47—54.
A. Trigui et al. [40] Remzi FH, Fazio VW, Delaney CP, et al. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum 2003;46:6—13. [41] Branco BC, Sachar DB, Heimann TM, Sarpel U, Harpaz N, Greenstein AJ. Adenocarcinoma following ileal pouch-anal anastomosis for ulcerative colitis: review of 26 cases. Inflamm Bowel Dis 2009;15:295—9. [42] Scarpa M, van Koperen PJ, Ubbink DT, Hommes DW, Ten Kate FJW, Bemelman WA. Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis. Br J Surg 2007;94:534—45. [43] Borjesson L, Willen R, Haboubi N, Duff SE, Hulten L. The risk of dysplasia and cancer in the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low: a long-term term follow-up study. Colorectal Dis 2004;6:494—8. [44] Dignass A, Lindsay JO, Sturm A, Windsor A, Colombel J-F. Second European evidence-based Consensus on the diagnosis and management of ulcerative colitis: current management. J Crohns Colitis 2012;6:991—1030. [45] Galandiuk S, Wolff BG, Dozois RR, Beart RW. Ileal pouchanal anastomosis without ileostomy. Dis Colon Rectum 1991;34:870—3. [46] Tjandra JJ, Fazio VW, Milsom JW, Lavery IC, Oakley JR, Fabre JM. Omission of temporary diversion in restorative proctocolectomy — is it safe? Dis Colon Rectum 1993;36:1007—14. [47] Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, et al. The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum 2006;49:470—7. [48] Grobler SP, Hosie KB, Keighley MR. Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992;79:903—6. [49] Weston-Petrides GK, Lovegrove RE, Tilney HS, et al. Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg 2008;143:406—12. [50] Hor T, Zalinski S, Lefevre JH, et al. Feasibility of laparoscopic restorative proctocolectomy without diverting stoma. Dig Liver Dis 2012;44:118—22. [51] Seligman NS, Sbar W, Berghella V. Pouch function and gastrointestinal complications during pregnancy after ileal pouch-anal anastomosis. J Matern Fetal Neonatal Med 2011;24:525—30. [52] Hahnloser D, Pemberton JH, Wolff BG, Larson D, Harrington J, et al. Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease. Dis Colon Rectum 2004;47:1127—35. [53] Remzi FH, Gorgun E, Bast J, et al. Vaginal delivery after ileal pouch-anal anastomosis: a word of caution. Dis Colon Rectum 2005;48:1691—9.
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REVIEW
Ileal pouch-anal anastomosis: Points of controversy A. Trigui ∗, F. Frikha , H. Rejab , H. Ben Ameur , H. Triki , M. Ben Amar , R. Mzali Department of general and digestive surgery, Habib Bourguiba Teaching Hospital, 3029 Sfax, Tunisia Available online 3 July 2014
KEYWORDS Ileal pouch anal anastomosis; Ulcerative colitis; Familial adenomatous polyposis; Indeterminate colitis; Crohn’s disease
Summary Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current ‘‘hot topics’’ for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn’s disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues. © 2014 Published by Elsevier Masson SAS.
Introduction Ileal pouch-anal anastomosis (IPAA) is currently a well-codified surgical procedure, and can be proposed for treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The theoretical value of IPAA in these settings is to achieve definitive cure the disease, prevent the risk of malignant degeneration and ensure adequate continence with defecation while avoiding a permanent stoma. Progressive improvements in surgical technique have led to satisfactory functional outcomes with low associated mortality and morbidity. The goal of this update is to identify the points of controversy arising in the management of patients requiring an IPAA.
∗
Corresponding author. E-mail address: [email protected] (A. Trigui).
http://dx.doi.org/10.1016/j.jviscsurg.2014.05.004 1878-7886/© 2014 Published by Elsevier Masson SAS.
282
Indications for IPAA Total coloproctectomy (TCP) with IPAA is the reference treatment for UC and FAP. Although generally contraindicated in colonic Crohn’s disease (CD), IPAA can also be proposed in some highly selected patients.
Ulcerative colitis (UC) Subtotal colectomy with ileo-rectal anastomosis (IRA) allows preservation of postoperative fertility in the female similar to that of the overall population. Functional results are better than with ileo-anal anastomosis (IAA) (frequency of bowel movements, nighttime and daytime seepage, anal incontinence), but the quality of life is not necessarily improved [1]. IRA can also be proposed in case of technical difficulties, when doubt persists between the diagnosis of UC and CD or in patients with altered sphincter function, in particular, patients older than 70. IRA is also indicated in the young female with hopes of procreation since fertility is better preserved [2]. IRA can only be performed when the rectum is not fibrotic and when there are no extra-intestinal manifestations, dysplasia or colorectal malignancy or when the duration of disease is less than 10 years. The patient must adhere to a strict surveillance program for the remnant rectum (level of evidence 3). At 10 years, the risk of secondary proctectomy is estimated to be around 20% [3].
Familial adenomatous polyposis (FAP) The choice of anastomotic technique (ileo-anal vs. ileorectal) is based on several criteria: • age; • sphincter function; • possibility of regular surveillance; • degree of dysplasia and the severity of colonic and rectal involvement: ◦ in case of severe polyposis (> 1000 colonic adenomas and/or > 20 rectal adenomas), first-line IRA is recommended (grade of recommendation C) [4], ◦ in case of non-severe polyposis (< 1000 colonic polyps and < 5 rectal polyps), subtotal colectomy with IRA is recommended, particularly in young patients wanting pregnancy after the operation (grade C) [5], ◦ for patients with 6—19 rectal polyps, irrespective of the number of polyps elsewhere in the colon, the indication must be discussed case by case (grade C) [5]. However, whenever maintenance of a program of rigorous rectal surveillance seems impossible, an IAA is recommended, irrespective of the degree of colorectal involvement (grade C) [5].
Is there an age limit to performance of IAA? Because of the complexity of the operation and the absence of prospective studies with long-term results, IAA has long been reserved for young patients capable of tolerating the consequences of altered intestinal and sphincter function inherent in such a procedure. On one side, ageing with consequent muscular atrophy, fibrosis and neurologic disorders have a deleterious effect on pelvic floor and anal sphincter function [6,7], leading to decreased anal pressure and rectal compliance. On
A. Trigui et al. the other, aged patients are more vulnerable to sphincter traumatism during IAA because of slower recuperation of muscular elasticity [7]. Consequently, the functional outcome of IAA is less satisfactory in the elderly with more seepage than in younger patients [8,9]. One prospective study from the Mayo Clinic including 2002 patients with an average follow-up of 10 years, divided patients into three age-defined groups [< 45-yearsold (n = 1688), between 46 and 55-years-old (n = 249), and > 55-years-old (n = 65)]. The authors concluded that the postoperative complication rate was similar among the three groups. The functional outcomes as well as the quality of life were evaluated by a yearly questionnaire. The reservoir failure rate for patients older than 55 was 1.6% at 10 years, without any statistically significant difference compared to the other age categories. The quality of life as evaluated by social, professional, sexual and sports activities was also similar among the three age categories. Quality of life was thought to be satisfactory for most patients. Daytime and nighttime seepage nevertheless occurred more frequently for patients > 55-years-old: 5.6% and 13.3%, respectively (P = 0.002) [10]. Nine studies, five of which were prospective (Table 1), evaluated the impact of age on morbidity, quality of life and functional outcome. The authors concluded that the rate of readmission for dehydration was statistically significantly higher in older patients. The daytime and nighttime rates of seepage were higher for the older patients, but the differences were not statistically significant [10,11]. Digital anorectal examination is the investigation of choice to evaluate preoperative sphincter function. Anorectal manometry should be proposed in case of sphincter disorders and should be considered in patients over 70 [7]. Evaluation of sphincter function should take into account anal incontinence secondary to rectal fibrosis, which does not contra-indicate TCP with IAA. In conclusion: IAA can be proposed to elderly patients who want to avoid a definitive ileostomy, as long as preoperative sphincter function is preserved.
Initial disease Studies comparing IAA for UC vs. indeterminate colitis (IC) One prospective study reported by Murrell et al. compared 334 patients undergoing IAA, 236 for UC and 98 for IC. The authors concluded that there was no statistically significant difference in the incidence of acute or chronic pouchitis between the two groups [18]. Dayton et al. prospectively evaluated postoperative morbidity in 723 patients undergoing IAA of whom 79 had IC and 565 had UC. No statistically significant difference could be found between the two groups for anastomotic leak (5.1% vs. 2.3%, P = 0.15), intra-abdominal abscess (0 vs. 1.1%, P = 0.36) or anastomotic stricture (7.6% vs. 4.8%, P = 0.29) [19]. Revision of diagnosis from indeterminate colitis to CD seems to be a risk factor for IAA failure, as the reservoir failure rate increases from 4 to 28% [19]. Patients with IC without any clinical signs of CD preoperatively seem to have similar functional outcomes and failure rates after IAA compared to patients with UC [20,21]. In conclusion: patients with IC have functional results and failure rates similar to those patients with UC.
Ileal pouch-anal anastomosis: Points of controversy Table 1
283
Comparative studies in patients older than 50 years. Number of patients > 50years-old
Number of patients > 60years-old
Conclusions
100
18
NS
Age is not a contra-indication to IAA
1996 (Prospective)
455
32 (> 55)
NS
Functional outcome ± safe Preferable to ileostomy
Bauer et al. [14]
1997
392
66
NS
Functional outcome and morbidity are similar. The incidence of dysplasia and cancer is higher in the elderly
Tan et al. [15]
1997
227
28
15
Functional outcome similar for patients older than 50 years Caution warranted in patients > 70-years-old
Takao et al. [7]
1998 (Prospective)
122
17
No significant differences in manometric parameters in relation to younger patients Slower return of intestinal function
Delaney et al. [16]
2003 (Prospective)
1895
327
91
Age is not a contra-indication to IAA
Chapman et al. [10]
2005 (Prospective)
2000
65 (> 55)
NS
Satisfactory postoperative functional outcome and quality of life at all ages Deterioration of continence after 55 years of age
Ho et al. [17]
2005 (Retrospective)
330
103
17 (> 70)
Postoperative morbidity and functional outcome similar in patients > 70 years of age
Pinto et al. [11]
2009 (Prospective)
401
NS
33 (> 65)
Increased co-morbidities, dysplasia and malignancy Similar morbidity for patients > 65-years-old, except for re-admissions for dehydration
Authors and references
Years (Studies)
Lewis et al. [12]
1993
Dayton and Larsen [13]
n
IAA: ileo-anal anastomosis; NS: non significant.
Studies comparing IAA for UC vs. CD For certain selected Crohn’s patients without anoperineal or small bowel involvement, IAA can be proposed as an alternative to definitive ileostomy when rectal resection is indispensable [22]. Fazio et al. studied the functional outcome and quality of life in 150 patients undergoing IAA for CD. Functional outcome and quality of life were good or excellent in 95% of patients, irrespective of whether their underlying disease was CD, UC, FAP or IC [23]. In the Mayo Clinic series [24], considering 37 patients with CD who underwent IAA with at least 10 years of follow-up, the incidence of immediate postoperative complications was similar to the outcome when IAA was performed for other indications. Eleven patients (30%) developed complex perineal fistulas after an average follow-up of 29 months. Seven patients were able to retain their reservoir bypassed by ileostomy. Reservoir ablation was performed in 10 patients, leading to an overall failure rate of 45%. In the 55% of patients who retained their reservoir, functional outcome was satisfactory (mean 7 bowel movements per day). The conclusions of this series were similar to those of Fazio et al. demonstrating that IAA for CD was associated with acceptable long-term functional outcome when the reservoir was retained in situ, i.e. in one out of two patients. Likewise, similar results were found in the study by Mylonakis et al. [25], comparing the outcome of 23 patients who underwent
IAA to that of 35 patients who underwent IRA for colonic CD. After an average follow-up of 10 years, the rate of reservoir takedown was 48% and among the patients undergoing reoperation, 73% had persistent perineal sinus. Satisfactory functional outcome was found in patients whose reservoir could be preserved (Table 2). An update by Reese et al. included 3103 patients with IAA, 225 of whom underwent operation for CD (four prospective and six retrospective studies). The authors concluded that the reservoir failure rate IPAA was higher when the procedure was performed for CD than for UC (32% vs. 4%; P < 0.001) [28]. In conclusion: IPAA for CD can be envisioned in wellselected patients with acceptable long-term functional outcome when the reservoir can be left in situ.
Surgical approach Laparoscopy offers the advantages of a mini-invasive approach with less blood loss during dissection. Moreover, laparoscopy is associated with earlier return of intestinal transit, less postoperative pain, shorter hospital stay, earlier return to normal activities and, in the long-term, fewer adhesions and fertility disorders in women [29—31]. The correlation between fewer postoperative adhesions and a lower incidence of small bowel obstruction, however, remains to be shown in colorectal surgery [32,33].
284 Table 2
A. Trigui et al. Long-term recurrence in Crohn’s disease after IAA.
Authors, years and references
Number of patients
Mean follow-up (years)
Clinical recurrences (%)
Definitive ileostomy rate (%)
Mylonakis et al. 2001 [25]
23
10
30
48
Regimbeau et al. 2001 [26]
41
10
35
10
Fazio et al. [27]
67
3
—
25
Sagar et al. [24]
37
10
54
45
IAA: ileo-anal anastomosis.
Beyer-Berjot et al. [34] studied the impact of laparoscopy on infertility in 56 women undergoing IPAA. The average age of patients was 31 ± 9-years-old. The average followup after IPAA was 68 ± 33 months. Twenty-eight patients had at least one full-term delivery before undergoing IPAA. Fifteen patients wanted another pregnancy after their IPAA. Eleven out the 15 became pregnant, leading to ten successful deliveries and one miscarriage. No statistically significant difference in fertility was found compared with 14 controls (laparoscopic appendectomy) or during the same period (90% vs. 86% at 36 months, P = 0.397). The authors concluded that the infertility rate was lower after laparoscopy than after traditional surgery. One prospective randomized study [35] compared the postoperative course and quality of life (SF-36 and GIQLI scores) in 60 patients after laparoscopy and laparotomy. No significant differences were found in terms of postoperative complications (20% vs. 17%, P = 0.74), or medium term quality of life. However, duration of operation was longer in the laparoscopic group (210 min vs. 133 min; P < 0.001). In conclusion: the laparoscopic approach seems to have value in fertile woman. Postoperative morbidity and quality of life seem to be equivalent to those observed after laparotomy with, however, earlier return of transit, less postoperative pain and shorter hospital stay [5].
Type of anastomosis There are two anastomotic techniques for IPAA, manual and mechanical, reported in the literature: • manual anastomosis consists of construction of a J-pouch with anastomosis to the dentate line after endoanal mucosectomy [5]. This procedure has the advantage of removing all diseased or potentially diseased mucosal tissues; • the stapled ileo-anal anastomosis is performed 1 to 2 centimeters above the dentate line respecting the transitional mucosa [5]; • this technique has the theoretical advantage of lessening the risk of anal sphincter damage, and consequently, decreasing the rate of postoperative anal incontinence. Moreover, the transitional mucosa has a rich sensory innervation, which is implicated in the discrimination between feces and gas, and consequently inhibits the anorectal reflex. Moreover, it results in less tension on the mesentery and this could be important in patients with short mesenteries. Six controlled studies and two meta-analyses have compared these two techniques of IPAA. In the meta-analysis reported by Lovegrove et al. [36] (21 studies, 4183 patients
with FAP and UC), the authors compared the outcome of 2699 patients with hand-sewn IPAA to 1484 patients undergoing stapled anastomosis; they concluded that more patients with hand-sewn anastomosis had nighttime incontinence and seepage, and used protective pads. The risk of malignant degeneration of the transitional mucosa was not statistically significantly higher in the stapled anastomosis arm (odds ratio = 0.42, P = 0.08), but follow-up was variable, ranging from four to 155 months in the studies (Table 3). In their prospective study, Kirat et al. [37] divided 3109 patients into two comparable groups: group A (hand-sewn anastomosis; n = 474) and group B (stapled anastomosis; n = 2635). The median follow-up was 7.1 years. In group A, more ileostomies were performed (P = 0.001) and hospital stay was longer (P < 0.001). Postoperatively, anastomotic stricture, septic complications, intestinal obstruction and reservoir failure occurred more frequently in group A (P = 0.002, 0.019, 0.027 and < 0.001, respectively). However, the rates of abdominal wall infection and pouchitis were similar (P = 0.42 and 0.59, respectively). Concerning the functional outcome, incontinence, spotting, protective pad use, alimentary problems in professional activity were more prevalent in group A (P < 0.001, P < 0.001, < 0.001, < 0.001, and = 0.025, respectively). Consequently, the Cleveland Clinic overall quality of life score was higher in group B (P = 0.018). However, in the meta-analysis by Schuendler et al. [38] including four prospective randomized studies (86 patients in the hand-sewn group vs. 98 patients in the stapled anastomosis group), no statistically significant differences were found in terms of functional outcome or manometric sphincter continence (resting and contraction pressures). This meta-analysis concluded that stapled anastomosis provided similar results to hand-sewn anastomosis in terms of functional outcome and manometric findings. Connel et al. [39] reported a histologic study of 25 operative specimens of total coloproctectomy with mucosectomy; they found that mucosectomy was incomplete in 14% of patients. Moreover, after stapled anastomosis, the anal transitional area can easily be seen and biopsied during follow-up to detect dysplasia [40,41]. Additionally, the incidence of cancer was similar between patients with stapled or hand-sewn anastomoses. Of note, the incidence of cancer noted after stapled anastomosis is very limited (< 30 cases out of tens of thousands of IPAA performed worldwide) [42,43]. In conclusion: according to the 2012 ECCO recommendations, it is preferable to perform a stapled anastomosis but the surgeon should have mastery of both anastomotic techniques (grade D) [44].
Ileal pouch-anal anastomosis: Points of controversy Table 3
285
Comparison between mechanical and manual anastomoses.
Results
Number of patients
Number of studies
P value
Anastomotic leak
1774
10
0.96
Sepsis
1941
12
0.21
637
10
0.20
2842
11
0.31
Intestinal obstruction Medical treatment Surgical treatment
318 362
5 4
0.75 0.85
Pouchitis
525
9
0.81
Reservoir failure
1737
9
0.06
Overall morbidity
207
3
0.81
Bowel movement frequency Per 24 h Nighttime
909 344
11 6
0.44 0.62
Spotting Daytime Nighttime
288 465
4 9
0.12 < 0.001
Use of protective pads Daytime Nighttime
298 225
6 3
0.59 0.007
Incontinence
285
5
0.009
Anti-diarrheal drugs
215
6
0.61
Anorectal physiology Resting pressure Threshold volume Length of high pressure zone
341 168 197
7 2 4
< 0.001 0.98 0.10
Dysplasia
202
2
0.08
Inflammation
183
2
0.16
Neoplasm
118
1
0.75
Quality of life
151
2
0.50
Anastomotic stricture Fistula
[36]. Bold values are significantly different.
Protective ileostomy No impact on septic complications or mortality related to the absence of protective ileostomy in selected patients has been reported in the literature [45,46]. Moreover, neither the functional outcome nor the quality of life seems to be modified [47]. A protective stoma was performed routinely after IPAA throughout the early 1980’s. The Mayo Clinic published one of the first series available on IPAA without a protective stoma in 1986 [48]. Since then, several studies have confirmed that IPAA without a protective stoma was feasible. One metaanalysis including 17 studies (one randomized, and 11 non-randomized prospective studies) compared the results of 721 patients with ileostomy vs. 765 patients without [49]. The anastomotic fistula rate was significantly higher in the group without ileostomy (odds ratio: 2.37; P = 0.002) while anastomotic strictures were significantly more frequent in the group with stoma (odds ratio: 0.31; P = 0.045). Intestinal obstruction occurred more
frequently in the stoma group, but the difference did not reach statistical significance. The rates of pouchitis and pelvic sepsis and the functional outcomes were similar (Table 4). A second meta-analysis by Remzi et al. compared the results of IPAA with ileostomy (n = 1725 patients; group A) and without ileostomy (n = 277; group B) ileostomy [47]. Patients in group A were older (38 ± 13 vs. 34.3 ± 12.7, P < 0.001), more often male (59 vs. 44%, P < 0.001), had higher doses of steroids (≥ 20 mg) (22 vs. 5%, P = 0.007), had greater corporeal surfaces (1.87 m2 vs. 1.8 m2 , P < 0.001), required more blood transfusions during surgery (20% vs. 11%, P < 0.001) and were more often afflicted with FAP (18 vs. 6%, P < 0.05). The rates of anastomotic fistula and pelvic sepsis were similar between the two groups. However, the rates of pouch-vaginal fistula, intestinal obstruction, bleeding, anastomotic stricture and IPAA failure were higher in group A, while postoperative ileus was higher in group B (Table 5). The authors concluded that single stage IPAA had similar or better results than two stage IPAA. The selection criteria
286 Table 4
A. Trigui et al. Meta-analysis comparing results in patients with or without ileostomy.
Results
Number of studies
Number of patients w/o S
S
OR (95% CI)
P
Operation Operative duration Hospital stay duration
6 10
320 507
315 496
−1.55 1.18
0.34 0.15
Short-term complications Anastomotic leak Sepsis Perineal sepsis
11 14 5
556 567 256
461 594 192
2.37 1.38 2.80
0.02 0.13 0.09
8 4
316 79
263 70
1.31 0.49
0.55 0.14
11 8 5 12
415 279 273 575
417 287 318 529
0.30 1.01 0.31 0.65
0.009 0.97 0.045 0.12
7 5 3
244 196 89
215 192 96
−0.42 0.56 1.27
0.14 0.43 0.49
Re-operation Laparotomy Others Long-term complications IAA failure Pouchitis Anastomotic stricture Intestinal obstruction Functional outcome Frequency bowel movements Incontinence Anti-diarrheal drugs
[49]. CI: confidence interval; OR: odds ratio; w/o S: without stoma; S: with stoma; IAA: ileo-anal anastomosis. Odds ratio: value < 1 are in favor of no stoma, values > 1 in favor of stoma. Bold values are significantly different.
for IPAA without ileostomy were stapled anastomosis, absence of tension, adequate hemostasis, air-tightness leak test, absence of malnutrition (albumin < 3.5 mg/dL), of anemia (Hb < 13.5 mg/dL) and of prolonged consumption of high doses of steroid (≥ 20 mg prednisone for more than 3 months) [50]. In conclusion: these studies confirmed that IPAA is feasible without a protective ileostomy with no increase in morbidity, particularly in patients with FAP and selected cases of UC.
Table 5
Impact of vaginal delivery on functional outcome The complications of C-section are those of any abdominal surgery including adhesions and prolonged hospital stay while vaginal delivery can result in pudendal nerve and anal sphincter damage, increasing the risk of fecal incontinence. The possibility of deterioration of functional outcome after vaginal delivery in women with IPAA has been debated in the literature.
Meta-analysis of outcome in patients with or without ileostomy.
Results
With ileostomy (n = 1725)
Sepsis
113 (6.5)
Anastomotic leak Fistula Pouch-vaginal fistula
Without ileostomy (n = 277) 15 (5.4)
P 0.51
94 (5.5)
12 (4.3)
0.57
139 (8.1)
18 (6.5)
0.36
52/712 (7.3)
4/154 (2.6)
0.049
Postoperative ileus
195 (11.3)
56 (20.3)
< 0.001
Postoperative fever
194 (11.3)
56 (20.3)
< 0.001
63 (3.7)
3 (1.1)
< 0.001
352 (20.4)
26 (9.4)
< 0.001
77 (4.5)
5 (1.8)
Bleeding Anastomotic stricture IAA failure [47]. IAA: ileo-anal anastomosis. Bold values are significantly different.
0.022
Ileal pouch-anal anastomosis: Points of controversy In a meta-analysis by Seligman et al. [51], including 283 pregnancies after IPAA, neither the frequency of bowel movements nor incontinence were statistically significantly affected by pregnancy or the route of delivery. The authors concluded that vaginal delivery seemed as safe as C-section. Along the same lines, Pemberton et al. published a prospective study including 135 pregnant women with IPAA [52]; they did not find any statistically significant difference in functional outcome between women who had delivered vaginally at least once compared with those who had undergone delivery by C-section. Because of this, they concluded the IPAA should not impact the choice of route of delivery, but that further studies are required to correctly evaluate the long-term functional outcome of IPAA after vaginal delivery. Conversely, Remzi et al. [53] reported a higher incidence of sphincter damage after vaginal delivery (50% vs. 13%, P = 0.012). These sphincter lesions did not seem to influence functional outcome but long-term evaluation remains to be performed. The authors therefore recommended C-section delivery in women with IPAA. In conclusion: even if functional outcome does not seem to be altered at medium term after vaginal delivery, there is no consensus as to which delivery route is best after IPAA because of the absence of studies evaluating the long-term outcome. Caution is therefore warranted. Of note, the 2009 INCA recommendations stated that it seemed ‘‘reasonable to propose a C-section in the light of the risk that vaginal delivery might alter sphincter function and pelvic floor status’’.
Conclusion TCP with ileal pouch anal anastomosis has become the operation of choice for patients with UC and FAP. Progress in surgical technique has led to low mortality and morbidity rates while ensuring increasing satisfactory functional outcome. Through this update, we hope to have highlighted the main points of controversy concerning the indications, the technique as well as the results of TCP with IPAA. Once again, advanced age and CD are not absolute contra-indications and laparoscopy seems to be preferable in women of reproductive age.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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