Keynote Lecture - Pouch Surgery 2004

Terry Hicks

Powerpoint File

BACKGROUND

In appropriately selected patients, ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for the treatment of ulcerative colitis and familial polyposis. IPAA was first described in 1978, and with its continued evolution can now be performed with good long-term outcomes with low morbidity. IPAA removes the diseased large bowel, eliminates the need for a permanent stoma, while providing a good functional outcome and increased quality of life when compared to those patients undergoing Brooke ileostomy or continent Koch ileostomy.

INDICATIONS

IPAA is performed as an elective procedure. In familial polyposis, it prevents the patient from developing an inevitable carcinoma of the colon. Approximately 50% of FAP gene carriers will have polyps at sigmoidoscopy by age 15 with carcinomas appearing 10 to 15 years after the onset of the polyposis. The timing of surgery for FAP patients should be individualized with regard to the patient’s clinical condition with most patients undergoing surgery at the time of polyposis discovery. Patients with ulcerative colitis become surgical candidates when they have failed medical therapy or complications of non-surgical therapy outweigh the anticipated benefits. Patients suffering from ulcerative colitis may also be candidates for IPAA when they are diagnosed with dysplasia, a dysplasia associated lesion or mass, or frank malignancy. Carefully selected patients with ulcerative colitis and an associated carcinoma of the rectum can still be candidates for surgical resection. However for those patients with mid or lower rectal cancers, IPAA may be contraindicated when the oncologic surgery could potentially damage the anal sphincter mechanism or when the potential utilization of adjuvant therapy could lead to complications of sphincter or pouch function. Increasing age is not an absolute contraindication to IPAA, but patients should be warned of potential frequent nocturnal pouch evacuations and occasional episodes of incontinence.

SURGICAL CONSIDERATIONS

Parks and Nichols initial report of IPAA in 1978 2 described a hand-sewn pouch with an “S” configuration. With the ongoing evolution of this technique, potential pouch configurations now include J;5 W;6 K;7 H; 8B; 9U.10 Each of these pouch configurations has its own unique positives and negatives. The “S” pouch is noted to have a greater average volume than a “J” pouch, however the “S” pouch in its early configuration lead to the need for pouch intubation in up to 50% of patients.6 It was discovered that the efferent limb was often made too long. Subsequently surgeons restricted the efferent limb to two to three centimeters in length to avoid this complication. One of the major advantages of the “S” pouch is the extra length provided by the efferent limb versus a “J” pouch configuration. This extra length may make an anastomosis possible for a patient who otherwise would have excessive tension if a “J” configuration were utilized. In 1985, Nichols described the “W” pouch.6 This pouch required 50 centimeters of ileum to construct, which was comparable to the “S” pouch, while the “J” pouch requires only 30 to 40 centimeters of ileum. Some surgeons noted that the bulkier nature of the “W” pouch lead to difficulties in anastomosing the pouch in a patient whose pelvis is somewhat narrow. When the “W” pouch is compared to the “S” pouch, it is noted to have greater maximum tolerated volumes, greater compliance, and greater efficiency of evacuation.

The most commonly used pouch in the United States now is the “J” pouch. Recent trials by Johnston11 and Keighley12 have shown no functional difference between “J” and “W” pouches when followed up to 12 months. Other studies have shown the “W” pouch to have less nighttime defecation when compared to the “J” pouch, and a daily stool frequency of five versus six to seven with the “J” pouch.13

THE NEED FOR DIVERTING ILEOSTOMY

One of the significant complications associated with IPAA is that of intra-abdominal or pelvic sepsis. The Mayo clinic reported a pelvic sepsis rate of 4.8% in patients undergoing IPAA and 26% of these patients encountered a pouch failure (i.e. permanent diversion or pouch excision).14 This was compared to 5.9% failure rate in patients who did not have this complication. The concept of utilizing a defunctioning ileostomy is to help lower the incidence of pelvic sepsis. Some pundits would point out that omitting a diverting ileostomy has multiple advantages including: requiring only one hospital admission, avoiding the complication of an ileostomy closure, and the financial savings it provides to the healthcare system. Sagar reported in the “Diseases of the Colon and Rectum,” equivalent outcomes with or without the use of temporary diversion.15 Several other series have reported equivalent findings. The authors do point out that patient selection is imperative when contemplating a single stage procedure. It appears to be a reasonable option in those patients who have generalized good health, have no history of chronic steroid therapy, and have a technically flawless operation with a tension free anastomosis. It is also important to remember that mechanical and functional complications may follow construction and closure of the stoma.

MUCOSECTOMY AND ILEOANAL POUCH

The controversy surrounding mucosectomy in hand-sewn IPAA versus double-stapled IPAA has revolved around the following issues: technical feasibility; risk of inflammation, dysplasia or carcinoma developing in the residual rectal mucosa; septic complications; and functional results. Many experienced surgeons feel that the double-stapled IPAA has been shown to be technically easier, have fewer complications, and have better functional results than mucosectomy and hand-sewn technique. Proponents of the double-stapled technique point out that they are able to avoid prolonged retraction of the anal canal and are also able to preserve the distal internal anal sphincter muscle and anal transition zone, both of which may contribute to improve continence. Those surgeons who are proponents of the mucosal stripping technique point out that patients undergoing a double-stapled technique are at risk for the development of severe inflammation, dysplasia, or even malignancy in the retained rectum.

Data from the Cleveland Clinic has shown that dysplasia in the anal transitional zone is extremely rare when there is no evidence of dysplasia or carcinoma in the colon and rectum, and it develops in very few patients postoperatively. The Cleveland Clinic group found low-grade dysplasia in 3% of 254 patients who underwent double-stapled IPAA that were followed up with postoperative biopsies of the anal transitional zone. They advocated completion mucosectomy when dysplasia persisted on follow-up biopsy. In regard to development of carcinoma, there had been at least seven reports of patients developing rectal carcinoma after mucosectomy.16,17,18 There have been at least three reported cases of rectal adenocarcinoma developing in the anal transitional zone or distal rectum following the double-stapled technique.

In regard to septic complications, the Cleveland Clinic reported on 692 patients of which 238 had hand-sewn IPAA and 454 had double-stapled IPAA. Although this study was not randomized, the two groups were similar in sex, ration of disease, and age at surgery. In the hand-sewn IPAA group, 10.5% of patients had a septic complication, and 4.6% of the double-stapled group had a septic complication. Proponents of the double-stapled technique find that the major functional advantages of the double-stapled technique are the preservation of the anal transitional zone, obviating sphincter stretch, and damage for those patients who undergo mucosectomy. The majority of investigations concerning functional results have indicated and reported functional advantages of the double-stapled technique including increased anal resting pressure, preservation of the anorectal inhibitory reflex, and improved continence.

COMPLICATIONS

IPAA is a complex procedure with complications being reported on a frequent basis. Mortality rate after IPAA is less than 1%,19 however the overall morbidity for these patients still ranges between 19-30%.20,21 These complications can be categorized into early (within 30 days after surgery) and late (after ileostomy closure). Pelvic sepsis, anastomotic leaks, small bowel obstructions, and pouch bleeding represent the most common early complications. Pelvic sepsis as described earlier in this abstract is the most serious early complication of IPAA. The overall leak rate after IPAA ranges between 5-18%.20,21 Some reports have noted that pouch anal anastomotic leakage occurs more frequently in patients undergoing the procedure without a diverting ileostomy. Sugarman22 however reported a lower anastomotic leak rate utilizing the one stage stapled ileoanal pouch procedure. For symptomatic leak patients who are stable and have no acute peritonitis, initial therapy is conservative with intravenous antibiotic during intravenous antibiotic therapy bowel rest and potential drainage (CT). Patients undergoing pouchography prior to the closure of the ostomy often show asymptomatic sinuses and delaying the closure will often allow these sites to close spontaneously. The overall frequency of small bowel obstruction with IPAA range from 15-44%.23 The incidence of obstruction requiring operative intervention ranges from 5-20%. Remzi24 reported on 1,725 pouch patients who had a diverting ileostomy and 277 that did not. He noted that patients without an ileostomy had a small bowel obstruction rate of 18%; and those with a diverting ileostomy had a rate of 10%. MacLean25 reported the results of their series of 1,178 patients who underwent IPAA and noted that in those patients who develop a bowel obstruction, most commonly they are due to pelvic adhesions (32%) followed by adhesions at the ileostomy closure site of 21%. Fazio etal reported bleeding from the pouch in 38 (3.8%) of 1,005 patients.20 Of this group, 30 of the patients were treated with local irrigation of .9% of saline and adrenaline 1:200000, and 8 had transanal suturing.

LATE COMPLICATIONS

Late complications include pouch fistula, pouchitis, pouch stricture, and rarely a pouch failure. Pouchitis remains the most common complications following IPAA. Most patients with apparent pouchitis have intermittent symptoms that respond well to therapy. This inflammation in the ileal reservoir causes symptomatology such as increased stool frequency, cramping abdominal pain, urgency, bright red bleeding, incontinence, diarrhea, or fever. The prevalence of pouchitis varies from 15-50% with an incidence of 15-18% during their first postoperative year.26 Pouchitis is seen more commonly in ulcerative colitis patients, and its etiology is poorly understood. Presently, there is a pouchitis disease activity index (PDAI) developed at the Mayo clinic, which allows a scoring system to define pouchitis. The therapy for pouchitis includes antibiotic therapy and symptomatic relief with anti-diarrheal agents. Presently, ciprofloxacin and metronidazole seem to be the most affective agents. Bertoni reported that 80% of the patients in his series were treated successfully with metronidazole. Probiotics appear to be affective in preventing flare-ups of acute relapsing pouchitis. Recent studies with VSL #3 (probiotic) was successful in reducing the recurrence rate for pouchitis in the nine month follow-up period to only 15%, whereas 100% of the placebo group developed a relapse.27 Fistula and anastomotic stricture also are significant as postoperative complications.

POUCH FAILURE

Presently, less than 6% of the patients require pouch excision or construction of a permanent ileostomy, secondary to failure of ileoanal pouch. Most frequent causes of failure are pelvic sepsis, high stool volume, Crohn’s disease, and uncontrollable fecal incontinence.

DYPLASIA AND MALIGNANCY

As noted earlier in this abstract, dysplasia and malignancies represent a potential risk for pouch patients. These findings suggest careful follow-up for pouch patients, which would include periodic digital and endoscopic examination of the ileal pouch, and for those who are double-stapled, an evaluation of anal transitional zone.

FEMALE FERTILITY

Olsen has reported that IPAA perform for ulcerative colitis reduces female fertility.28 Though many possible etiological factors exists most scholars feel pelvic adhesions represent the greatest risk. Recent reports indicate that vaginal deliveries in patients with IPAA are at no greater risk for anal sphincter trauma than the general population.

CONCLUSIONS

Since Ileal-anal pouch anastomosis was first described in 1978, it is now considered the procedure of choice for those patients with chronic ulcerative colitis and FAP that require proctocolectomy. New reports of excellent long-term functional outcomes provides patients an alternative to permanent ileostomy. With the evolution of new techniques for IPAA many controversies have arisen. At present these controversies remain a contentious issue among colon and rectal surgeons. With continued advances and refinements in the IPAA procedure hopefully these issues will be resolved.

REFERENCES

1. Farouk R, Pemberton JH, Wolff BG, Dozois RR, Browning S, Larson D. Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg 2000;231;919-926

2. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. BMJ 1978;2:85-88

3. Pemberton JH, Phillips SF, Ready RR, Zinmeister AR, Beahrs OH. Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis. Comparison of performance status, Ann Surg;209:620-628

4. Delaney CP, Dadvand B, Remzi FH, Church JM, Fazio VW. Functional outcome, quality of life, and complications after ileal pouch-anal anastomosis in selected septuagenarians. Dis Colon Rectum 2002;45:890-894

5. Utsunomiya J, Iwama T, Imajo M, et al. Total colectomy, mucosal proctectomy and ileoanal anastomosis. Dis Colon Rectum 1980;23:459-466

6. Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three-reservoir design. BR J surg 1985;72:470-474

7. Hallgren T, Fasth S, Nordgren S, Oresland T, Hallsberg L, Hulten L. Manovolumetric characteristics and functional results in three different pelvic pouch designs. Int J Colorectal Dis 1989;4:156-160

8. Fonkalsrud EW. Update on clinical experiences with different surgical techniques of the endorectal pull-through operation for colitis and polyps. Gurg Gynecol Obstet 1987;165:309-316

9. Slors JFM, Taat CW, Brummelkamp WH. Ileal pouch-anal anastomosis without rectal muscular cuff. Int J Colorectal Dis 1989:4:178-181

10. Nelson RL, Leela Prasad M, Pearl RK, Abcarian H. Inverted U-pouch construction for restoration of function in patients with failed straight ileoanal pull-throughs. Dis Colon Rectum 1991;34:1040-1042

11. Johnston D, Williamson MER, Lewis WG, Miller AS, Sagar PM, Holdsworth PJ. Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis. Gut 1996;39:242-247

12. Keighley MRB. Yoshioka K, Kmiot W. Prospective randomized trail to compare the stapled double lumen and the suture quadruple pouch for restorative proctocolectomy. Br J Surg 1988;75:1008-1011

13. Lumley J, Stevenson A, Stitz R. Prospective randomized study of J vs. W pouches in ulcerative colitis. Dis Colon Rectum 2002;45:A5

14. Farouk R, Dozois RR, Pemberton JH, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 1998;41:1239-1243

15. Sagar PM, Lewis W, Holdsworth PJ, Johnston D. One-stage restorative proctocolectomy without temporary defunctioning ileostomy. Dis Colon Rectum:35:582-588

16. Stern H, Walfisch S, Mullen B, McLeod R, Cohen Z. Cancer in an ileoanal reservoir: a new lat complication. Gut 1990;31:473-5

17. Rodriguez-Sanjuan JC, Polavieja MG, Naranjo A, Castillo J. Adenocarcinoma in an ileal pouch for ulcerative colitis. Dis Colon Rectum 1995;38:779-80

18. Laureti S. Ugolini F. D’Errico A et al. Adenocarcinoma below ileoanal anastomosis for ulcerative colitis: report of a case and review of the literature. Dis Colon Rectum 2002; 45:418-21

19. Blumberg D, Opelka FG, Hicks TC, et al. Restorative proctocolectomy: Ochsner Clinic experience. South Med J 2001;94(5):467-71.

20. Fazio VW, Ziv Y, Church JM, et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222(2):120-7.

21. McMullen K, Hicks TC, Ray JE, et al. Complications associated with ileal pouch-anal anastomosis. World J Surg 1991;15(6):763-6;discussion 766-7

22. Sugerman HJ, Sugerman EL, Meador JG, et al. Ileal pouch anal anastomosis without ileal diversion. Ann Surg 2000;232(4):530-41.

23. Francois Y, Dozois RR, Kelly KA, et al. Small intestinal obstruction complicating ileal pouch-anal anastomosis. Ann Surg 1989;209(1):46-50.

24. Remzi FH, Fazio V, M.P., et al. Omission of Temporary Diversion after Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis: Surgical Complications, Functional Outcome and Quality of Life Analysis. Dis Colon Rectum 2003.

25. MacLean AR, Cohen Z, MacRae HM, et al. Risk of small bowel obstruction after the ileal pouch-anal anastomosis. Ann Surg 2002: 235(2):200-6.

26. Gray M. Colwell JC. Pouchitis: Part 1: Etiologies and risk factors. J Wound Ostomy Continence Nurs 2002;29(2):68-73.

27. Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000;119(2):305-9.

28. Olsen KO, Joelsson M, Laurberg S, Oresland T. Fertility after ileal pouch-anal anastomosis in women with ulcerative colitis. Br J Surg 1999;86:493-495.