Transcript Chronic Ulcerative Colitis Assessment and Surgical Management

Patient Selection for IAP
Nigel A. Scott MD FRCS
Manchester UK
Patient Selection for IAP
Why a Pouch ?
Fulminant Colitis
• 5-15% of colitics
• one third - first attack
• 37% will require colectomy
Chronic ill Health CUC
….. “ know every toilet between home and the supermarket”
Cancer Risk in CUC
• 3% (95% CI 2.2-3.8) at 10 years
• 5.9% (95% CI 4.3-7.4) at 20 years
• 8.7% (95% CI 6.4-10.9) at 30 years.
The risk of colorectal cancer in ulcerative colitis:
a meta-analysis Gut 2001;48:526-535
Patient Selection for IAP
Indication for colectomy and IAP (n=105)
Cancer
4%
Urgent
64%
Ill health
32%
Patient Selection for IAP
Who ?
IBD Diagnosis
Patient Selection for IAP
IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
Patient Selection for IAP
IBD Diagnosis
– or who said Crohns disease was OK anyway ?
Patient Selection for IAP
IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
• 41 patients 1985 - 1998
• no past or present history of
anal manifestations
• no evidence of small bowel
involvement
• 27 % Crohn’s related
complications in pouch
• of 20 patients followed for
more than 10 years – 7 (35%)
excised
Long-term results of Ileal Pouch-Anal anastomosis for Colorectal Crohns disease DCR
2001;44:769-778
IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
92 dysfunctional
24 excised
14 (59%) CROHNS DISEASE
IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
“ ……………. There is no obvious
explanation for the much better outcome
reported by Regimbeau et al ………….”
IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
CUC
n= 1135
CD
n= 36
Non-closure
0
1
Diversion
8
3
Excision
55 (5%)
16 (45%)
Failure
63 (6%)
20 (56%)
Patient Selection for IAP
IBD Diagnosis
– or who said Crohns disease was OK anyway ?
However when faced with the prospect of definitive
ileostomy in young patients, the possibility to keep even
for a few years before the disease recurs, acceptable
continence and defaecation should be stressed.
Patient Selection for IAP
IBD Diagnosis
– or who said Crohns disease was OK anyway ?
…. but Pouch Crohns is associated
with prolonged septic complications
and then a difficult excision, non
healing perineal sinus
Patient Selection for IAP
Who ?
IBD Diagnosis
Not CROHN’S
Informed
Patient
Patient Selection for IAP
Satisfaction = Result / Expectation
Patient Selection and the Ileoanal Pouch
Patient Selection – information
•www.ileostomypouch.co.uk
•www.nacc.org.uk (National Association for Colitis and Crohns)
•www.j-pouch.org (J Pouch Group)
Use and influence of the internet on patients undergoing ileoanal pouch surgeryJ. Torkington,
L. S. Bevan, A. R. Morgan, J. Beynon and N. D. Carr
Colorectal Disease Volume 5 Issue 2 Page 193 - March 2003
The Effect of Ageing on Function and Quality of Life in Ileal Pouch
Patients: A Single Cohort Experience of 409 Patients With Chronic
Ulcerative Colitis – Ann Surg 2004:240(4);615-623
10 % excised at 10 years
permanent ileostomy
Patient Selection for IAP
• not normality BO 5 D/ 1N
• 40 % medication
• pads
• excision
• pelvic autonomics –
impotence/ bladder dysfunction
•bleeding, infection, DVT/ PE
death
• fertility
Chronic Ulcerative Colitis
Assessment and Surgical Management
Long Term Outcomes – male fertility unaffected
• 34 of 40 consecutive patients made use of preoperative semen
preservation – all normal sperm concentrations, motility, and
morphology were found
• 23 patients returned for postoperative analysis - semen
characteristics not different from preoperative values
• None of the preserved semen samples was used, - semen
cryopreservation benefited none of these patients.
van Duijvendijk P, Slors JF, Taat CW, van Lochem LT, Bonsel GJ, de Vries JW, Obertop H. What is the
benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for
benign diseases? Dis Colon Rectum. 2000 Jun;43(6):838-42.
Chronic Ulcerative Colitis
Assessment and Surgical Management
Long Term Outcomes – female fertility reduced
Female Infertility After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Toronto – Dis Colon Rectum 2004;47(7):1119 - 1126
Patient Selection for IAP
Who ?
IBD Diagnosis
Not CROHN’S
Sphincter
Informed
Patient
Patient Selection – the sphincter
• preoperative anal manometry before IAP formation
• questionaire
• faecal seepage
• incontinence
• quality of life
Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.
Perioperative resting pressure predicts long-term postoperative function after ileal
pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;
Patient Selection – the sphincter
2 year outcomes
<40mmHg
>=40mm
Hg
P value
Incontinence
35.5%
30.2%
0.007
Day Seepage
34.5%
19.3%
0.001
Night Seepage
44.8%
35.3%
0.012
Social
Restrictions
11.5%
12.3%
0.07
Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.
Perioperative resting pressure predicts long-term postoperative function after ileal
pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;
Patient Selection – the sphincter
• resting anal sphincter pressures > 40 mm Hg are
associated with significantly better function after IAP
• However low preoperative resting pressures do not
preclude successful outcome after IPAA.
Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.
Perioperative resting pressure predicts long-term postoperative function after ileal
pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;
Patient Selection – obstetric sphincter defects on EAUS
Defect
mmHg
No defect
mmHg
P value
MRP upper
28
51
0.005
MRP mid
56
89
0.002
MRP low
63
82
0.015
11.5%
12.3%
0.5
Wexner
Incontinence
Score
Gearhart et al Sphincter defects are not associated with long
term incontinence following ileal pouch anal anastomosis.
DCR 2005;48:1410-1415
Patient Selection for IAP
Who ?
Informed
Patient
IBD Diagnosis
Not CROHN’S
Sphincter ?counselling
Patient Selection for IAP
age ????????
Kok Sun Ho, C. C. Chang, M. K. Baig, L. Börjesson, J. J. Nogueras, J. Efron, E. G. Weiss, D. Sands,
A. M. Vernava III and S. D. Wexner Ileal pouch anal anastomosis for ulcerative colitis is feasible for
septuagenarians Colorectal Disease Volume 8 Page 235 - March 2006
Patient Selection – age
los
Postop
complications
Failure
< 70yrs
n=313
5.8d
> 70 yrs
n=17
6.0d
p
ns
40%
39%
ns
2%
11%
ns
IAP is a safe and feasible option in Ulcerative Colitis
patients over the age of 70 years – with similar functional
results to younger patients
Patient Selection for IAP
Who ?
IBD Diagnosis
Informed
Patient
age ?
Not CROHN’S
Optimisation
Sphincter ?counselling
Optimisation – No steroids
Preoperative Steroid Use
(mg/d)
0 mg/d (n=51)
PRSC
6.2%
<40 mg/d (n=193)
16.2%
>40 mg/d (n=80)
23.1%
PRSC - the presence of fistulas or abscesses near the pouch (in the small pelvis), in the
upper, middle, or lower part of the pouch, in the area of the rectal cuff, in the area of the
IPAA, or in the area of the anal sphincter
From: Heuschen: Ann Surg, Volume 235(2).February 2002.207-216
Obesity and Ileoanal Pouch Construction
Operative time mins
Obese
229
Non-obese
196
p
0.02
LOS (d)
Stomal complications
9.7
10%
7.7
0%
ns
ns
Postop morbidity
Pelvic septic
complications
32%
16%
9.6%
0%
0.058
0.05
Efron JE, Uriburu JP, Wexner SD, Pikarsky A, Hamel C, Weiss EG, Nogueras JJ
Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients.
Obes Surg. 2001 Jun;11(3):246-51
2 x 20cm lengths
of terminal ileum
Patient Selection for IAP
Who ?
IBD Diagnosis
Informed
Patient
age ?
Not CROHN’S
Optimisation
no steroids
BMI <30
Sphincter ?counselling
Never,
Never,
Never,
Never,
Never,
Never,
Never,
Never,
Never,
ever...
Patient Selection for IAP
- one other thing
- make sure that they
Never eat beans in a Wet Suit