Transcript Clinical Oncological Society of Australia

Q&A
Greetings from
New Orleans
&
The Ochsner Clinic
Restorative
Proctocolectomy
“The Pelvic
Pouch Procedure in 2004”
The Royal Infirmary Manchester U.K.
April 1, 2004
Terry C. Hicks, M.D.
GOALS:

Indications

Technique

Complications

Controversies
Know the Enemy!
Restorative Proctocolectomy
The Disease of Concern

Ulcerative Colitis

Familial adenomatous polyposis

Crohn’s disease

Indeterminate Colitis
Ulcerative Colitis

Ulcerative Colitis is an inflammatory
disorder. It affects the rectum and
extends proximally to affect a variable
extent of the colon.

The cause of the disease, and the
factors determining its chronic course
are unknown.
Etiology of Ulcerative Colitis

150 years after the discovery of this
disease by Samuel Wilkes, the etiology of
ulcerative colitis remains unknown.

The major hypotheses in 2003 include:
infection, allergy to dietary components,
immune responses to bacterial or selfantigens, and the psychosomatic theory.
Incidence of Ulcerative Colitis
USA
Minnesota
Baltimore
UK
Oxford
Wales
Aberdeen
Denmark
Copenhagen
Holland
Leiden
Sweden
Stockholm County
Israel
Tel-Aviv
Period of
INCIDENCE
Study
(Per 100,000)
1935-64
1960-63
7.2
4.6
1951-60
1968-77
1967-76
6.5
7.2
11.3
1962-78
1981-88
8.1
9.5
1979-83
6.8
1975-79
4.3
1961-70
3.6
Medical Management of
Ulcerative Colitis




Active disease
Mild-moderate disease
Distal colitis
Sulfasalazine or 5-ASA preparation
(oral or rectal)
Topical corticosteroid
Extensive colitis
Sulfasalazine or oral 5-ASA
preparation
Moderate-severe disease
Distal colitis
Topical corticosteroid
Prednisone
Extensive colitis
Prednisone
Severe-fulminant disease
Extensive colitis
Parenteral corticosteroid
Intravenous cyclosporine
Inactive disease
• Distal colitis
Sulfasalazine or 5-ASA
preparation (oral or rectal)
Azathioprine or 6-MP
• Extensive colitis
Sulfasalazine or oral 5-ASA
preparation
Azathioprine or 6-MP
Infliximab (Remicade) reports of small bowl tumors
“Familial Adenomatous Polyposis
Syndrome”
“Familial Adenomatous Polyposis
Syndrome”



Gastrointestinal polyposis refers to the presence
of numerous polyps throughout the GI tract. Most
of these syndromes are inherited, and most are
associated with an increased colon cancer risk.
FAP is the most common adenomatous polyposis
syndrome. Patients develop hundreds to
thousands of adenomas, and if the colon is not
removed, colon cancer is inevitable.
This disease is autosomal dominant with 80% to
100% penetrance and a prevalence of 1:7500.
“Familial Adenomatous Polyposis
Syndrome”




In 1987, a gene for FAP was isolated, and genetic
testing is now available to identify family members
that are carriers.
The average age of detectable polyps is 15 years.
Average age of cancer is 10-15 years after the
onset of the polyps.
Associated findings:





Gastric polyps – 30 to 100%
Duodenal polyps – 60 to 90%
Papilla Vater Adenomatous Changes – 50 to 85%
Duodenal Cancer Lifetime Risks – 4 to 12%
Desmoid Tumors – 4 to 32%
Familial Adenomatous Polyposis
Crohn’s
The “Crohn’s Disease” Trio in 1932
Crohn’s Morphology
Endoscopic Features of Ulcerative
Colitis and Crohn's Disease
Characteristics
Ulcerative
Colitis
Distribution
Rectal involvement
Skip lesions
Vascular pattern
Friability
Erythema
Aphthous ulcers
Linear ulcers
Serpiginous ulcers
Cobblestoning
Pseudo-polyps
Symmetric
Always
No
Blunted
Frequent
Frequent
No
Rare
Rare
No
Frequent
Crohn's
Disease
Asymmetric
Variable
Yes
Frequently normal
Infrequent
Less frequent
Yes
Frequent
Frequent
Yes
Frequent
The Case Against R.P. for Crohn’s
Disease
• High complication rate (vs UC)
• High pouch failure rate (vs UC)
• Pouch excision risky, complicated
• Small bowel loss is failure
• Salvage surgery…High failure rate
• Literature reports…Where
presumptive diagnosis was UC
or indeterminate
Final Thoughts on Crohn’s
• Rarely should restorative proctocolectomy be
•
•
•
advised if a diagnosis of Crohn’s is known prior
to surgery.
One stage restorative proctocolectomy should be
resisted in nearly all emergency situations.
At all times, it is the duty of the surgeon to inspect
the resected specimen before pouch construction.
If there are questions as to the diagnosis (even
after frozen sections) forego pouch formation.
If patients with a pouch later develop clear
evidence of Crohn’s, judge each case on its merits
(i.e. Function: Are complications amenable to
further surgical treatment?)
Forrest says, “Inflammatory Bowel
Disease is like a box of choc-lits”
“Indeterminate Colitis”
• Those five to ten percent of inflammatory
bowel disease patients that can not be
clearly diagnosed as either Crohn’s or
ulcerative colitis.
IPAA for Indeterminate Colitis at CCF
Indeterminate
Ulcerative
p
Stool frequency
6.0
6.0
0.99
Night frequency
2.0
1.0
0.001
Q. Of life
9
9
0.06
Q. Of health
8
9
0.07
L. Of energy
8
8
0.21
L. Of happiness
10
10
0.28
IPAA again? (%)
93.3
97.9
0.05
IPAA for others? (%)
97.9
98.2
0.99
Surveillance for Colorectal Cancer
in Ulcerative Colitis
Surveillance for Colorectal
Cancer in Ulcerative Colitis




Colorectal cancer occurs in approximately six
percent of patients with extensive disease and will
be the cause of death in about three percent.
The risk of developing colorectal cancer increases
over time, is greater in patients with extensive
disease, older age at the onset of symptoms, and
in those with cholestatic liver disease and
sclerosing cholangitis .
The frequency of surveillance colonoscopies is
contentious.
Goal of surveillance is to detect dysplasia.
Surveillance for Colorectal Cancer in
Ulcerative Colitis (cont’)
Low-grade dysplasia progresses or is
synchronous with cancer 18% to 30% of
patients.
 High-grade dysplasia is concurrent with
cancer or progresses to cancer in 40% of
patients.
 It is suggested that four biopsies be taken
at ten centimeter intervals throughout the
colon.

Colonoscopic View
Normal
UC
Normal
UC
UC
SURGICAL INDICATIONS FOR
ULCERATIVE COLITIS
Urgent
Non-urgent
Severe/fulminant colitis
Toxic megacolon
Perforation
Massive hemorrhage
Acute colonic obstruction
Colon cancer
Medically refractory disease
Unacceptable medication-related toxicity
Dysplasia, DALM, or suspected cancer
Selected extraintestinal manifestations
Growth failure in children
DALM = dysplasia-associated lesion or mass
Immediate surgery warranted
Prompt but not immediate surgery warranted
Refractory to medical therapy
Refractory to 5-aminosalicylic acid, corticosteroids, and immunomodulators
Contraindications to Restorative
Proctocolectomy Ulcerative Colitis
Absolute
• Acute, fulminant colitis, especially with clinical
•
•
•
toxicity, peritonitis, or perforation of the colon
Known Crohn’s disease at time of operation
Severe anal sphincter dysfunction
Carcinoma of the distal rectum
Relative contraindications
• Morbid obesity
• Severe malnutrition or debility
• Age > 65 years
• Psychologically impaired or patients at high risk for
non-compliance.
Age and IPAA
•
•
•
•
Early restrictions
Safety as experience increases
Expansion of age limits
Patient assessment of quality of life vs.
function
Under 60 years
61–70 years
70 years plus
Function
+++
++
+
Quality of Life
+++
+++
++
The Presence of Cancer…..Does it
Rule Out IPAA?
• The presence of colon cancer does not
preclude IPAA (adherence to traditional
standards of oncologic resection need to be
maintained).
• If advanced mid or low rectal cancer is
diagnosed, this may preclude IPAA.
Ulcerative Colitis
Surgical Options
• Proctocolectomy and Ileostomy
• Colectomy and Ileostomy
• Colectomy and Ileorectostomy
• Proctocolectomy and Continent Ileostomy
• Restorative Proctocolectomy
Continent Ileostomies
- Kock pouch (1969-1972)
Continent Ileostomies
• Stoma
 Smaller
& Flush
 Lower in Abdomen
Late Complications
• Valve Slippage: 3 - 25%
• Fistula : 3%
• Skin Level Stenosis : 8%
• Prolapse : 3%
• Pouchitis : 5 - 43%
Restorative Proctocolectomy
•
•
•
•
•
Major Operation
Cures Disease
Evacuation vs Normal Route
Bowel Function
Technical Variations or
Controversy
Restorative Proctocolectomy
Variations or Controversy
• Pouch Design
J,S,W,H
• Anastomosis
 Double-Stapled
 Mucosectomy
• Diversion
Pouch Design
• Original IPAA was hand sewn “S” configuration by Parks [BMJ 1978; 2:85-88].
• Ingenious thinking and the use of stapling techniques now provide multiple
options for constructing pouches J, W, K, H, B, & U.
• Initially the “S” pouch required pouch intubation in up to 50% of patients.
• Subsequent shortening of the efferent limbs to 2-3 cm, reduced this condition.
• Manovolumetic studies demonstrate that “S” pouches have a greater median
volume than “J” pouches 420 ml vs. 305 ml but without functional differences.
(Hallgren, INT J Col. Dis. 1989, 4:156;160)
• Major advantage of the “S” pouch is on extra couple of centimeters in length
than other pouches, helping form a tension free IPAA.
• The “W” pouch proposed by Nicholls in 1985 has the major problem of being
bulky and difficult to advance in the narrow pelvis.
“J” pouch vs. “W” pouch

Johnston [Gut 1996] 60 pts.  no difference

Keighley [BR J Surg 1988] 33 pts.  no difference

Salvaggi [DC&R 2000] 24 pts.  daily defecation
frequency of three in “W” pouches and five in “J”
pouches (at 12 months). The “W” also had less night
time defecation and less anti-diarrheal usage.

Farock [Ann Surg 2000]  “J” pouch stool frequency
per day :
six in males
seven in females
Comparing Pouch Design &
Function
What is missing in the analysis?
 Sphincter function
 Stool consistency
 Patterns of motility
 Capacity of the pelvis to
accommodate the pouch
Pouches – My Choice

All use 30-40 cm of terminal ileum

Small differences in function and design

The “J” is easy to construct and
conserves operative time and provides
equivalent function
Restorative Proctocolectomy
J - Pouch
Preoperative Preparation
• Confer with patient and family so they
•
•
•
•
understand the nature of the operation,
the necessity for surgery, alternative
therapies, operative hazards, possible
complications, and potential benefits.
Understanding of the nature of an
ileostomy.
Possibility of awareness of possible
function impairment.
Offer male patients cryopreservation of
sperm prior to operation.
Selection of ileostomy site.
Preoperative Preparation (cont’)
• Correct specific medical problems
(anemia, hyperglycemia, electrolyte
abnormalities)
• Bowel preparation
• Stress steroid therapy
• Antibiotic prophylaxis
Pitfalls and Danger Points
• Injury to pelvic autonomic nerves with
•
•
•
resultant sexual and urinary dysfunction.
Ureteral injuries.
Fecal contamination with risk of intraabdominal sepsis and wound infections.
Presacral venous bleeding.
• Improper ileostomy placement and
•
construction.
Splenic injury.
Operative Strategies
• Wide surgical dissection with radical
mesentery resection is unnecessary
and meddlesome (unless invasive
carcinoma is suspected).
• Close adherence to rectal wall during
lateral and posterior dissection to
avoid injury to pelvic nerves.
Exploration
• Look for manifestations of possible
Crohn’s disease.
• If diagnosis is unclear, need for
total proctocolectomy needs
reassessment.
Proctectomy
a. Avoid injury to the pelvic autonomic nerves.
b. We use mesorectal dissection; bloodless plane .
Impotence: injury during antero-lateral dissection of
the rectum (necessary with both close or mesorectal
resection) Injury at upper rectum: hurts the
hypogastric nerves = retrograde ejaculation
c. At S3; the anterior ® angle turn of the rectum occurs,
so don’t dig deep into the presacral fascia.
d. Continue posterior dissection to a palpable coccyx.
e. Circumferential mobilization of rectum @ levators.
f. Pressing in on perineum may give better exposure.
Achieving Length


Magnitude of the problem  of 74 pouches that could not be
constructed in the Mayo series, 32 were due to length problems.
[Browning A, J.AM.Col. Surg. 1998 ) of the pouch should reach
the inferior border of the pubic symphysis.
Maneuvers to obtain extra length
a. Division of terminal ileum should be done within tow to three
cm. of the cecum.
b. Divide adhesions; mobilize the terminal ileal mesentery to the
level of the duodenum
c. Mesenteric peritoneum division in stair step technique
d. Retest length before pouch formation
e. Division of the terminal divisions of the SMA or the ileal-colic
artery (IC); confirming adequate vascularity of the ileum.
f. Clamp the vessels for at least 15 minutes prior to ligation
g. “S” pouch is always an alternative
Controversies
in IPAA
Mucosectomy vs. Double Staple
Technique
• The aim of IPAA is to remove all of the diseased
•
•
•
•
•
colonic and rectal mucosa.
The double stapled technique leaves a cuff of anal
transitional zone (ATZ).
The ATZ contains residual columnar mucosa.
Anastomosis at this point gives better function than
anastomosis at the dentate line.
Inherent risks of leaving the ATZ are malignancy and
recurrent inflammation (cuffitis).
The theories for poorer function with mucosectomy
include trauma to anal sphincter during dissection
and removal of the anal transition zone.
Type of Anastomosis (handsewn vs. stapled)
and The Rate of Sepsis

ZIV et al report stapled IPAA are safer than handsewn (fewer
septic complications).

ZIV found the rate of anastomosis disruption and parapouch
abscess were higher in the handsewn group.

Gecim (Mayo Clinic) stated the rate of abscess or fistula may
be influenced by the surgeons experience.

Gecim pointed to long term steroids and other
immunomodulants as contributors to fistula formations.

Gecim found no difference in perianal abscess rate or fistula
rate in stapled vs. handsewn pouches.
1) ZIV Y, AM J Surg 1996; 172(3): 320-3
2) Gecim IE, Dis Colon Rectum 2000; 43(9): 1241-5
Function Following Mucosectomy and
Double Staple Technique
DOUBLE STAPLED
Reilly [Ann Surg 1997] Notes
occ. episodes of incontinence
is 38% in stapled group and
64% in mucosectomy group.
Anal canal resting pressures
stapled 78.3 mm Hg
mucosectomy 49.4 mm Hg
Squeeze pressures
stapled 195 mm Hg
mucosectomy 144 mm HG
Hallgren EUR, J Surg 1995, 161,
95 pg 21, found similar results
MUCOSECTOMY
Sew-Chen BR J. Surg 1991
Luukkeon Arch Surg 1993
Both randomized trials found no
difference in function between
the two techniques.
The Factors in Choosing Mucosectomy vs.
Double Stapled

What is safest and best for patient.

In the presence of mucosal neoplastic change
perform mucosectomy.

If double-stapled technique is used, you must:
Do yearly follow-up of the anal transition zone
with digital examination and endoscopy with
biopsy.
What is The Role of a Defunctioning
Ileostomy?

Pelvic sepsis occurs in 4.8% of
patients undergoing IPAA [Farouk
etal, Dis Colon Rectum 1998].

In patients with pelvic sepsis, the
pouch failure rate (permanent
diversion or excision) was 26%
compared to 5.9% in patient without
pelvic sepsis.

Patients with pelvic sepsis who
retained their pouch had similar
evacuation rates as non- pelvic
sepsis patients but retained their
protective pad use, incontinence
rates, and medication rates were all
increased.

Pelvic sepsis can be life threatening.
The Role of Ileostomy in IPAA
• Sugerman reported an abscess or enteric leak rate of 12% in
•
•
•
•
patients who underwent one stage procedures without ileostomy.
Tjandra et al reported a higher rate of septic complications in
patients without an ileostomy.
ZIV at the same institution reported that as the number of
IPAA without ileostomy cases have increased the two
groups of patients are showing a nonstatistical difference in
complication rate.
Remzi reported on 1,725 patients with ileostomy vs. 277
patients without ileostomy.
Remzi found no differences between the groups in respect to:
sepsis, leaks, or fistula occurrence.
1) Sugerman H J et al. Ann Surg 2000;232(4):530-41.
2) Tjandra et al. Dis Colon Rectum 1993; 36(11):1007-14.
3) ZIV Y et al. AM J Surg 1996; 171(3):320-3.
4) Remzi FH, et al. Dis Colon Rectum 2003.
Ileostomy Avoidance in 277 Patients *
Ileostomy
No
n = 1725
6.5%
5.5%
18.8%
NA
n = 277
5.4%
4.3%
10.1%
4.0%
4.5%
1.8%
ileostomy
Pelvic sepsis
Leak
SBO
Need for
ileostomy
Pouch failure
Comparable functional results
Remzi et all 2002
OUTCOMES
Temporary Diversion vs. Single Stage Procedures







Grobler [BR. J Surg 1992;79:903-906]
23 patients with IPA and loop ileostomy
22 patients with IPAA without loop ileostomy
No patients taking steroids
All operations without intra-op complications
All were double stapled “J” pouches
No statistically significant differences in
postoperative complication rates or pouch
function
OUTCOMES
Temporary Diversion vs. Single Stage Procedures
Galandiuk [Dis Colon Rectum 1991;34:870-873]
37 pts with diversion
37 pts without diversion
Complication rate
NSD
NSD
Reoperation
NSD
NSD
Functional outcomes
NSD
NSD
Potential Complications Associated
with Defunctioning Ileostomy




Defunctioning ileostomy may help reduce the incidence of pelvic
sepsis, but is not a risk free procedure.
Mechanical and functional complications may follow construction
and closure of the stoma.
[Metcalf Dis Colon Rectum 1986]
157 temporary loop ileostomies
39 patients had mechanical complications





Retraction 15.9%
Prolapse 1.3%
Fistula .6%
Abscess .6%
Bowel obstruction (stoma related)
Potential Complications Associated
with Defunctioning Ileostomy (con’t)
111 patients had functional complications
Peristomal irritation 53.5%
 Leakage 7.6%
 High output 3.8%
 Incomplete diversion 5.7%
 After closure: Bowel obstruction 14.7%
Peritonitis 7.4%
Wound infections 1.6%

Advantages of omitting a loop ileostomy



Required one hospital admission
Avoid potential complications of ileostomy closure
Financial advantage
Which Patients are Candidates for Single Stage
Procedure?

Generalized good health

No chronic steroid therapy

Tension free anastomosis

No intraoperative complications
Laparoscopic IPAA vs. Open IPAA


Young – Faddock [Gastroenterology 2001 I A-452-2302
Seven laparoscopic IPAA vs. seven open IPAA
(matched controls)
Laparoscopic IPAA
I.V. narcotic use
Resumption of diet
Hospital stay
Complication rate
Operation Time
2 days
4
NSD
340 min.
OPEN IPAA
7 days p=0.010
9
NSD
237 min.
Other Considerations With Laparoscopic IPAA




Schmitt suggested no reduction in ileus or
postoperative length of stay with laparoscopic
vs. open [Int J Colorectal0 Dis 1994;9:134-137
Dunker [DC&R 2001, 44, 1800-1807] Reports
functional outcomes and quality of life are no
different in open vs. laparoscopic IPAA
Patient satisfaction with the cosmetic result is
higher with laparoscopic IPAA
Laparoscopic IPAA may reduce adhesion
formation
Complications
Mortality After IPAA

The mortality rate after IPAA is less than 1%

Patients are typically young

Patients usually do not have co-morbid
disease

Operations are generally performed in tertiary
centers on selected patients
Blumberg , Opelka, Hicks
South Med J 2001;94(5):467-71
Morbidity After IPAA

In early studies major complications were reported
to be as high as 54%

With increased experience the rated has dropped
to approximately 19%

Complications after IPAA may be categorized as
early [within 30 days after surgery and late (after
ileostomy closure)]

For one stage procedures early (within 30 days
after surgery) and late (after 30 days post surgery)
Marcello PW et al
Arch Surg 1993;128(5) 500-3;
Meagher AP et al BR J Surg 1998; 85(6): 800-3
Early Complications

The most common early complications
are pelvic sepsis, anastomosis leaks,
small bowel obstruction, and pouch
bleeding
Sepsis

Pelvic sepsis is the most serious early IPAA complication,
and it one of the main causes of pouch failure.

The rate of sepsis after IPAA ranges from 5% to 24%.
The etiology may be suture line leaks, or bacterial
contamination of the surgical space during the operation.
Risks factors for pelvic sepsis: malnutrition, prolonged
steroid use, hypoalbuminemia, anemia, and hypoxemia.
The most common presenting signs are: fever, perineal
pain, purulent discharge, and leukocytosis.




Early sepsis after IPAA usually presents between the third
and sixth postoperative day.
1) McMullen K, Hicks TC, World J Surg 1991; 15(6):763-6
2) Hyman et al, Dis Colon Rectum 1991;34(8):653-7
Leaks After IPAA
• Overall leak rate after IPAA ranges between 5 % and 18%.
• Leaks may develop from pouch-anal anastomosis, pouch
itself, or from the tip of the “J” pouch.
• The two major factors associated with leaks are
anastomotic tension and bowel ischemia.
• Elderly patients, males, and those patients on
corticosteroids are also at greater risk for leak
development.
Matty P et al. Ann Chir 1993; 47 (10) 1020-5
Fazio V et al. Ann Surg 1995; 222 (2):120-7
Small Bowel Obstruction After IPAA
•
•
•
•
•
•
•
•
The overall incidence of small bowel obstruction after IPAA
ranges from 15% to 44%.
The incidence of obstruction requiring operative intervention
ranges from 5% to 20%.
Remzi reported on 2002 IPAA patients:
1725 had a diverting ileostomy with an 18% SBO rate
 277 had no diverting ileostomy with a 10% SB0 rate
Remzi also noted that the ileostomy group required more
laparotomies for SBO than the non-diverted group.
MacLean reported on 1,178 IPAA patients
The cumulative risk of small bowel obstruction was
9% at 30 days; 18% at one year; 27% at five years;
and 31% at ten years.
MacLean noted that 32%of the obstructions were due to the pelvic
adhesions and the ileostomy closure site.
The surgical window = 2nd to 6th week is the most dangerous time
Francois Y et al. Ann Surg 19889; 209(1):46-50
Pouch Bleeding
• Postoperative bleeding from the pouch may arise from
the suture line or because of pouch ischemia.
• Fazio reported bleeding from the pouch in 38 (3.8%) of 1
005 patients.
• Thirty patients were treated with local irrigation of .9%
saline and adrenaline 1:200,000
• Eight patients were treated with trans-anal suturing
• Significant bleeding occurring five to seven days post
surgery may suggest a partial dehiscence.
Chalikonda S, Podium Presentation ASCRS 2003 New Orleans, La.
Fazio VW, Ann Surg 1995; 222(2):120-7
Pouchitis
•
The most common complication following IPAA.
• Symptoms: Increased frequency, urgency, cramping pain, bright
red bleeding, incontinence, diarrhea, and fever.
• Extraintestinal manifestations: Arthritis, iritis, and Pyoderma
Gangrenosum.
• Histology: Acute granulocyte infiltration.
• Prevalence: Varies from 15% to 50%.
• Etiology: Unknown. Theories include genetic, immune, microbial, and
toxic mediators.
• Most popular theory: Fecal stasis with an increased anaerobe/aerobe
bacterial ratio.
• Rarely seen with FAP.
• Male predominance.
Nicholls RJ, World J Surg 1998;22(4):347-51
Subraman:K Gut; 1993, 34(11):1539-42
Diagnosis of Pouchitis
•
Diagnosis should be made on the basis of clinical, endoscopic, and
histologic features.
• Pouch disease activity index (PDAI) is the most commonly used
diagnostic instrument.
• The PDAI has three separate scales: clinical symptoms,
endoscopic findings, and histologic changes.
• Total score of seven or higher is defined as Pouchitis.
• Because the PDAI is costly, a modified scale was introduced in
which the histology is omitted.
• This modified scale offers similar sensitivity, decreases cost, and
avoids delay in diagnosis awaiting histology report.
Shen B, Drs Colon Rectum 2003, 46(6):748-53
Sandborn, Mayo Clinic Proc 1994; 69(5):409-15
Pouchitis Disease Activity Index
• Stool frequency
• Rectal Bleeding
• Fecal urgency or abdominal cramps
• Fever (temperature>37.8° C)
• Endoscopic inflammation
• Acute histological inflammation
• Ulceration per low-power field (mean)
Treatment for Pouchitis
• Includes antibiotic therapy and symptomatic relief with
anti-diarrheal agents.
• Most effective agents are metronidazole and
ciprofloxacin.
• 80% of pouchitis patients are successfully treated with
metronidazole alone.
• Steroids, 5 – aminosalicylates, azathioprine, and sixmercaptopurine compromise the other major category
of treatment.
• Surgery?
Bertoni: G, Dis Colon Rectum 2003;46(6):748-53
Refractory or Prolapsing Pouchitis
• 5% to 10% of pouchitis patients will develop refractory or
relapsing symptoms.
• Probiotics are effective in these clinical situations
• A recent trial using VSL #3 (probiotic) was shown to be
therapeutic for patients with acute relapsing pouchitis.
• These patients were induced into remission using
ciprofloxacin and rifaximin.
• In follow-up only 15% in the probiotic group relapsed within
nine months, whereas 100% of the placebo group
developed a relapse.
1) Shen B, Inflamm Bowel Dis 2001, 7 (4) 301-5
2) Sarton RB, Gastroenterology 200; 119(2):584-7
Mechanism of Action of Probiotics
• Suppression of resident pathogenic bacteria.
• Stimulation of mucin glycoprotein by intestinal
epithelial cells.
• Prevention of adhesion of pathogenic strains to
epithelial cells.
• Induction of host immune responses.
Sartor R.B. Gastroenterology 2000; 119(2):584-7
Irritable Pouch Syndrome (IPS)
• Patients with IPAA who have Pouchitis symptoms but
normal endoscopic and histologic findings.
• They have a PDAI of < 7 and the absence of cuffitis.
• The etiology of IPS is unclear, and there is no algorithm for
its management.
• 50% of IPS patients respond to irritable bowel treatments.
• This includes reassurance, diet modification, fiber
supplements, anti-diarrheal, antispasmodics, and
antidepressants.
Giochetti P, Gastroenterology 2000; 119(2):305-9
Shen B, AM J Gastroenterol 2002; 97(4):972-7
Cuffitis
• The 1 to 2 cm. of anal canal mucosa retained after IPAA
(without mucosectomy) can become inflamed.
• Cuffitis has endoscopic and histologic inflammation of
the pouch.
• 4% of patients with preserved anal mucosa after IPAA
develop cuffitis.
• Most patients respond to local therapy with
hydrocortisone suppositories or enemas.
Lavery IC, Dis Colon Rectum 1995;38(8):803-6
FISTULA
• Usually a late complication
• 6% of IPAA patients develop a fistula
• Most common sites: vaginal, perineal, cutaneous, and
presacral
• Options for therapy: fistulotomy, seton, advancement
flap, prolonged ileal diversion, antibiotics, and fibrin
glue.
• Fistula may represent undiagnosed Crohn’s.
• Postoperative pathologic diagnosis of Crohn’s leads to
a pouch failure rate of 25%.
1) Fazio VW, Ann Surg 1995; 222(2):125-7
2) Ozuner G, Dis Colon Rectum 1997; 40(5) 543-7
Pouch – Vaginal Fistula (PVF)
• Leads to poor functional results and is a major cause of
•
•
•
•
•
•
•
•
•
•
•
pouch failure.
Etiology: Sepsis, leaks, and “technical error”.
Most patients can be managed by local procedures.
The trans-anal ileal advancement flap is often successful.
SHAH reported on 60 patients with PVF.
65% of the SHAH group had a diverting ileostomy.
44% had a primary healing.
4 patients had repeat flap advancement and closed the
fistula.
Recurrence and pouch failure rates are high.
Patients with fistula formation diagnosed within six months
of surgery have better outcomes.
Those with > six month PVF presentation may be related to
Crohn’s.
When local therapy fails, pouch reconstruction is an option.
1) SHAH NS, Dis Colon Rectum 2003
Anastomotic Strictures
•
•
•
•
•
•
•
Anastomosis is considered strictured if it will not
allow the admission of an index finger DIP joint or is
less than 1 cm. in diameter.
If stricture is severe, it can lead to outlet obstruction,
pouch dilatation, and bacterial overgrowth.
The rate of stricture ranges from 7.8% to 14%
St. Marks reported a 14% rate in handsewn and 40%
with stapled anastomosis.
Mayo reported a 12% rate with handsewn group
having the greatest problems.
Treatment options : Hegar dilators (office) #13 to #18
vs. surgical incision. (OR)
For complex stricture pouch advancement and neoileal anastomosis. (good for strictures < 5 cm in length)
Fazio BR J Surg 1992; 27(7):694-6
Senapati A. INT J Colorectal Dis 1996, (2):57-59
Impotence, Retrograde Ejaculation, and
Dyspareunia
• 1.5% of men will develop impotence.
• 4% of men will develop retrograde
ejaculation.
• 7% of women develop dyspareunia.
• 49% of women note sexual
dysfunction preoperatively. Their
sexual activity increases dramatically
after surgery.
IPAA for Ulcerative Colitis
Does it Affect Female Fertility?

Olsen reported  fertility [B. J Surg
1999;PL:493-495

Theory of Etiology: Pelvic
Adhesions
Dysplasia and Malignancy
•
The ileal pouch undergoes a series of histologic changes.
• The changes include slight villous atrophy to colonic metaplasia.
• Colonic metaplasia may be a premalignant condition.
• In 1997 Cox et al. reports an invasive adenocarcinoma in a longstanding
Koch pouch.
• Heuschen et al. reported an IPAA pouch developed cancer.
• Baratris reported an adenocarcinoma in the anus after IPAA for U.C.
• Mucosectomy does not provide 100% removal of rectal mucosa.
• The anal transitional zone (ATZ) in the double stapled technique is at risk
for dysplasia or cancer.
• The risk of dysplasia was studied in 178 patients (double stapled IPAA)
over ten years.
• The risk of dysplasia was 4.5% without cancer being reported.
Baretsis et al. Dis Colon Rectum 2002 45(5):687-91
Remzi FH et al. Dis Colon Rectum 2503 :46(1):6-13
Dysplasia and Cancer Following IPAA
• O’Connell published data showing residual
rectal mucosa in 7% of their IPAA patients
with mucosectomy.
• Remzi reports ten year follow-up of the
double staple technique with dysplasia in
the residual anal transition zone to be 4.5%
DC&R 2003, 46:6-13
• Cancer has been reported after both
techniques.
Pouch Failure
•
6% of IPAA patients require either pouch excision or permanent
ileostomy.
• Most frequent causes of failure are pelvic sepsis, high stool volume,
Crohn’s disease, uncontrolled fecal incontinence.
• A scoring system for calculating the risk of pouch failure identified
eight risk factors: 1) Crohn’s 2) Patient co-morbidity
3) Prior anal pathology 4) Diminished sphincter manometry
measurements 5) Anastomotic separation 6) Anastomotic
stricture 7) Pelvic sepsis and 8) Perineal fistula formation.
• Overall salvage rates from pouches is 86%.
• 97% of patients who underwent pouch revision said they would
undergo it again if necessary.
Fazio BR J Surg 1992; 27(7):694-6
Senapati A. INT J Colorectal Dis 1996, (2):57-59
Incidence of Pouch Failure
CENTER
YEAR
Mayo
1998
Cleveland
1995
Toronto
1997
Lahey
1993
Oxford
1997
Buenos Aires 1998
Ochsner
1995
U of Minn
1998
# PATIENTS
1310
1005
551
460
200
178
145
505
% FAILURE
10.2
4.5
10.5
3.5
8.0
6.1
3.0
8.8
Repeat (IPAA) to Salvage Complication of Pelvic Pouches
Zmora 61
19911999
Dayton 52
1983-1999
Heuschen
48
1988-1999
Mc Lean 51
1982-2000
Fazio 50
1983-1998
Sagar
62
19811995
Baixauli 53
1985-2001
Institution
Florida
Salt Lake
Heidelberg
Toronto
Cleveland
Mayo
Cleveland
No. patients
411
650
706
1200
1680
1700
---
Reoperation
32
29
107
57
35
23
112
Repeat
IPAA
5
6
4
17
31
---
101
Septic
complicatio
ns
16
---
107
14
35
4
64
Fistula
3
3
87
23
25
4
47
Stricture
1
---
---
5
14
1
35
Abscess
---
1
8
---
25
4
46
Salvage
21(84%)
29 (100%)
99 (92%)
42 (77%)
80 (86%)
17
(74%)
70 (82%)
Pouch
failure
4
0
8
15
5
0
14
Complicatio
ns after
reop.
9
6
---
32
34
6
46
Rocket
Science?
CONCLUSION




Ileal pouch anal anastomosis has evolved over
the last 25 years
Now it is the procedure of choice for patients
requiring proctocolectomy for ulcerative colitis
and selected FAP patients
As technical developments have emerged
controversies have arisen
With continued commitment to research for
pouch surgery hopefully these dilemmas will
be resolved
“All at present
known in
medicine is
almost nothing
in comparison
with what
remains to be
discovered”
R. Descartes (1596-1650)