Patient Selection

Nigel Scott, Hope Hospital, Salford

Powerpoint File

The ileoanal pouch has become the restorative procedure of choice in patients requiring colectomy for chronic ulcerative colitis. In order to maximise the outcome of this technique it is important to select those patients that are most suitable. Relevant considerations include:

Histopathology – CUC not Crohns disease (1)

Amongst 1,270 patients undergoing ileoanal pouch, complications were significantly more common in patients with Crohn’s disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn’s disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01).

An Informed Patient

An ileoanal pouch does not restore bowel function to normal. On average patients have 6 stools during the day and one at night. There is a risk of pelvic autonomic injury from the proctectomy and at least one third of patients will require long term constipating medication. Overall 10% of pouches will be excised for a poor result.

Useful internet sources of advice include:

• www.ileostomypouch.co.uk

• www.nacc.org.uk (National Association for Colitis and Crohns)

• www.j-pouch.org (J Pouch Group)

The possible association of reduced fertility with an ileoanal pouch must be discussed with prospective female patients of child bearing age.

Good resting pressures ?

The Cleveland Clinic group prospectively collected perioperative anal manometry data from 1439 patients and compared the manometric findings to postoperative functional status at various time intervals from 6 months to 8 years after IPAA. Low (<40 mm Hg) pre- and postoperative resting pressures were associated with increased seepage, pad use, and incontinence. Patients with low resting pressures also reported diminished quality of life, health, energy level, and satisfaction with surgery. There was a significant association (P < 0.001) between seepage and degree of incontinence and quality of health, quality of life, energy level, and level of satisfaction with surgery..

However, for individual patients, low preoperative resting pressures did not preclude successful outcome after IPAA.

Off Corticosteroids

Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P <.001)

Preoperative Steroid Use (mg/d) Pouch related septic complications

0 (n=51) 6.2%

<40 (n=193) 16.2%

>40 (n=80) 23.1%

On the skinny side

Obese patients have a higher rate of pelvic sepsis and peri-operative morbidity when compared to a matched non-obese cohort of patients.

REFERENCES

Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum. 2005 Aug;48(8):1542-9.

Use and influence of the internet on patients undergoing ileoanal pouch surgery. Colorectal Disease Volume 5 Issue 2 Page 193 - March 2003

Female Infertility After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Toronto – Dis Colon Rectum 2004;47(7):1119 - 1126

Karoui M, Cohen R, Nicholls J. Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum. 2004 Jun;47(6):869-75

Richards DM, Hughes SA, Irving MH, Scott NA. Patient quality of life after successful restorative proctocolectomy is normal. Colorectal Dis. 2001 Jul;3(4):223-6.

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

Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20; discussion 320-1.

Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg. 2002 Feb;235(2):207-16.

Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients.

Obes Surg. 2001 Jun;11(3):246-51