Improved Outcomes in Colon and Rectal Surgery part 34 ppsx

 Surgery for ulcerative colitis Patricia L Roberts CliniCal Vignette Challenging Case A 35-year-old male is undergoing an ileoanal pouch procedure for ulcerative colitis.. PROCtOCOleCt

 Surgery for ulcerative colitis

Patricia L Roberts

CliniCal Vignette

Challenging Case

A 35-year-old male is undergoing an ileoanal pouch procedure

for ulcerative colitis Following transection of the ileum flush

with the cecum, the surgeon notes that it will be difficult for the

pouch to reach the anus

Challenging Case Management

Difficulties with the ileoanal pouch reaching the anus occur for two

main reasons: failure to mobilize the small bowel, or patient-related

factors such as obesity or a long narrow anal canal Difficulty with

reach is more common if a mucosectomy is performed rather than

a double-stapled anastomosis An S pouch may reach the anus

eas-ier than a J pouch If the main reason for the pouch not reaching is

patient obesity and a thickened mesentery, an initial total

abdomi-nal colectomy, ileostomy, and Hartmann closure of the rectum may

be performed Following weight reduction, an ileoanal pouch

pro-cedure can be performed A series of technical maneuvers

includ-ing mobilization of the small bowel up to the duodenum, scorinclud-ing

the peritoneum over the superior mesenteric artery, and the

crea-tion of mesenteric windows can facilitate pouch reach If, despite

these maneuvers, the pouch does not reach, the pouch can be left

in the pelvis, a loop ileostomy created, and, after a period of

sev-eral months, the pouch can then be joined to the anus Additional

details of these technical maneuvers are described in the text

intRODUCtiOn

Ulcerative colitis is an inflammatory condition involving the colon

and rectum The incidence in the United States is 8.8 cases per

100,000 person years.(1) Thus, in this country, there are

approxi-mately 26,000 new cases of ulcerative colitis diagnosed annually and

730,000 people with ulcerative colitis.(1, 2) Although many patients

are treated effectively with medical therapy, approximately 23–45% of

patients require colectomy The risk of requiring colectomy is higher

in patients with pancolitis than patients with left sided disease.(3, 4)

This chapter concentrates on the indications for surgery, the

opera-tive options, and the outcome of surgery for ulceraopera-tive colitis

inDiCatiOnS fOR SURgeRy

Surgery for ulcerative colitis is divided into two categories: urgent

or emergency surgery, and elective surgery

Acute Colitis

Urgent or emergent surgery is indicated for patients with acute

unresolving colitis or life-threatening complications associated

with colitis, including fulminant or toxic colitis, hemorrhage,

colonic perforation, or obstruction Severe acute colitis may occur

in 5 to 15% of patients with ulcerative colitis The classification

system of Truelove and Witts is most commonly used and

iden-tifies clinical parameters by which colitis is categorized as mild,

moderate, and severe (5, 6) (Table 31.1) For patients with acute colitis, stool studies should be done to rule out superinfection with clostridium difficile, bacteria, or ova and other parasites

A flexible sigmoidoscopy without bowel preparation with mini-mal insufflation of air is helpful to biopsy the rectum to exclude cytomegalovirus (CMV) In one series of patients with steroid resistant acute ulcerative colitis, the incidence of associated cytomegalovirus was 36%.(7) The majority of patients diagnosed with CMV responded to administration of foscarnet or ganciclo-vir After exclusion of an infectious etiology, patients are treated with intravenous steroids for 5–7 days If there is no clinical response, cyclosporine or infliximab is considered Patients who are reluctant to use cyclosporine or infliximab, or patients who

do not respond, should undergo colectomy While administra-tion of steroids is associated with an increase in postoperative complications, immunosuppressives do not appear to increase the incidence of postoperative complications.(8)

A small subset of patients may develop fulminant colitis The classification system of Truelove and Witts does not define ful-minant colitis, but Hanauer (9) has modified the classification system to define patients with fulminant colitis In the classifica-tion system of Truelove and Witts, severe disease is defined as >6 stools per day, a temperature >37.5 degree Celsius, a pulse of >90 beats per minute, hemoglobin <75% of normal, an erythrocyte sedimentation rate of >30 mm/hr, the presence of air, edema-tous wall, or thumbprinting on x-ray and abdominal tenderness Fulminant colitis is defined as >10 stools per day, continuous

Table 31.1 Truelove and Witts Criteria for Evaluating the Severity

of Ulcerative Colitis

Variable Mild disease Severe Disease

fulminant Disease

Stools (Number/day) <4 >6 >10 Blood in stool Intermittent Frequent Continuous Temperature (ºC) Normal >37.5 >37.5 Pulse (beats/min) Normal >90 >90 Hemoglobin Normal <75% of

normal value

Transfusion required Erythrocyte

sedimentation rate

<30 >30 >30

Colonic features on x-ray

Air, edematous wall, thumb-printing

Dilatation

Clinical Signs Abdominal

tenderness

Abdominal distention and tenderness Source: After Truelove and Witts BMJ 1955; 2: 1041–45.

Reprinted with permission from Clinics in Colon and Rectal Surgery Volume 17, Number 1, 2004, page 8.

bloody bowel movements, a temperature of >37.5 degree Celsius,

a pulse of >90 beats per minute, transfusion requirement, an

erythrocyte sedimentation rate of >30 mm/hr, dilatation of

the colon and abdominal distention and tenderness The term

toxic megacolon has been used when the colonic distention of

the transverse colon exceeds 6 cm, but relying on this finding to

diagnose toxic colitis is not necessary, as some patients will have

“toxicity” in the absence of colonic distention Prompt treatment

and diagnosis of toxic colitis is needed to avoid progression to

perforation Approximately 20–30% of patients with toxic colitis

require emergency surgery

Perforation in the setting of toxic or fulminant colitis

substan-tially increases the mortality rate Patients whose condition

wors-ens or who fail to make substantial improvement after a period

of 48–96 hours should be considered for surgery to avoid this

complication.(10) Massive hemorrhage in patients with

ulcera-tive colitis is uncommon, accounting for <10% of emergency

colectomies performed for ulcerative colitis, and raises the

pos-sibility of Crohn’s disease.(11)

Emergency vs Elective Procedures

The surgical options for patients who require emergency surgery

for acute colitis are aimed at restoring the patient back to a

gen-eral state of health and preserving reconstructive options for

sub-sequent surgery The most common operation performed is total

abdominal colectomy with ileostomy, and either Hartmann closure

of the rectum or creation of a mucous fistula Preoperative

coun-seling and marking by an enterostomal therapist is optimal This

procedure removes the majority of the diseased bowel, avoids an

intestinal anastomosis in an ill patient, and preserves the option for

an ileoanal pouch procedure in the future The colon is transected

at the level of the sacral promontory avoiding the need for a

pel-vic dissection If the severity of disease as demonstrated by severe

ulcerations and friability of the bowel precludes safe closure of the

stump, a variety of other options may be employed The stump may

be exteriorized as a mucous fistula This requires a longer segment

of bowel and is associated with bleeding and mucus from an

addi-tional stoma Alternatively, it has been suggested that extrafascial

placement compared with intraperitoneal closure of the Hartmann

stump may be associated with fewer infectious complications.(12)

Transanal drainage has also been suggested to decrease the

inci-dence of infectious complications associated with the Hartmann

stump.(13) Pelvic dissection and creation of a relatively short

Hartmann pouch should be avoided as this makes dissection and

subsequent ileoanal pouch creation more difficult A laparoscopic

or open approach may be used for performance of total abdominal

colectomy and ileostomy in patients with acute colitis.(14)

Elective Procedures

The most common indication for elective surgery is

intractabil-ity to medical management defined as failure of medical

ther-apy Intractability includes insufficient symptom control despite

intensive medical therapy Due to loss of time from work, school

or activities in general, the patient may not have an acceptable

quality of life The risks of medical therapy may be substantial

including potential complications from long-term steroid

ther-apy or complications of the side effects of medical therther-apy In

children, growth retardation can result from poorly controlled ulcerative colitis and is an indication for colectomy

Patients with longstanding ulcerative colitis are at an increased risk for the development of colorectal cancer The exact risk is dif-ficult to determine since many series have lacked longitudinal fol-low-up or have included patients seen at tertiary referral facilities Surveillance colonoscopy with biopsy has been recommended in patients with left-sided or pan colitis (defined as microscopic dis-ease proximal to the splenic flexure) after 8 years of disdis-ease symp-toms At least 33 biopsies are necessary to obtain a sensitivity of 90%, and four quadrant biopsies are recommended every 10 cm along the colon and in any abnormal appearing area A recent meta-analysis has estimated the risk of the development of color-ectal cancer in patients with long-standing ulcerative colitis to be 2% at 10 years, 8% at 20 years, and 18% after 30 years of disease (15) There is no evidence to show that surveillance prolongs sur-vival in such patients, although patients who develop cancers in a surveillance program tend to have earlier stage cancers.(16, 17) Proctocolectomy is indicated for patients with carcinoma, nonadenoma-like dysplasia associated lesion or mass (DALM), and patients with high grade dysplasia.(10) The presence of high grade dysplasia should ideally be confirmed by two independent expert pathologists For those patients who underwent immedi-ate colectomy, cancer was detected in 42% of patients with high-grade dysplasia and 19% with low-high-grade dysplasia.(18) Although patients with low-grade dysplasia should be offered colectomy, the natural history of low-grade dysplasia is not as well defined The interobserver variation between pathologists confounds the recommendations about low-grade dysplasia Studies are con-flicting, with one study of a surveillance program showing that in patients with low-grade dysplasia the 5-year predictive value for the development of cancer or high-grade dysplasia was 54%.(19) Another study showed that only 18% of patients with low-grade dysplasia progressed to high-grade dysplasia or a dysplasia associ-ated lesion/mass.(20)

Strictures may also develop in 10–25% of patients with ulcera-tive colitis, and while the majority are benign up to 25% are malignant Strictures which cause obstruction, develop in long-standing disease, and are found proximal to the splenic flexure, are most likely to be malignant and are another indication for colectomy.(21)

PROCtOCOleCtOMy WitH BROOKe ileOStOMy

Proctocolectomy with ileostomy has previously been the “gold stand-ard” operation for ulcerative colitis against which other operations have been compared This operation essentially cures the disease and restores patients back to health and to a relatively normal life It

is a one-stage procedure which removes the diseased mucosa and has fewer potential complications than the ileoanal pouch proce-dure The main drawback is the presence of a permanent ileostomy, something which most patients wish to avoid

Indications

This operation is indicated in those patients who require surgery for ulcerative colitis, but are not candidates for the ileoanal pouch procedure These patients include those who are elderly, have fecal incontinence or an inadequate sphincter, patients with low rectal

cancers in association with ulcerative colitis who require

proc-tectomy and possibly pelvic radiation, and those patients who

opt for a permanent Brook ileostomy for personal preferences

Furthermore, patients who develop pouch failure and require

pouch excision essentially have a completion proctectomy

Operative technique

The preoperative period includes patient education about the

procedure and the effects of an ileostomy Preoperative

consulta-tion with an enterostomal nurse is helpful The stoma site selected

should be a flat area, away from bony prominences and creases

Proctocolectomy is performed through either an open or

laparoscopic approach Following mechanical bowel preparation

the day before surgery, the patient is administered preoperative

intravenous antibiotics and positioned in lithotomy position

After performance of a standard colectomy, pelvic dissection is

performed The retrorectal space is entered sharply and the pelvic

dissection is undertaken with careful attention to the ureters and

identification of the hypogastric nerves The dissection is carried

out to the pelvic floor A pack is placed posterior to the rectum

and the perineal dissection is performed An intersphincteric

dis-section allows for a smaller wound, a relatively bloodless

dissec-tion, and presumably better healing The perineal dissection is

carried out to the level of the pelvic dissection After excision of

the colon and rectum, the wound is closed in layers and a Brooke

ileostomy constructed A foley catheter is left for several days in

addition to a closed suction drain

Outcome

Proctocolectomy with ileostomy is associated with fewer

poten-tial complications than ileoanal pouch procedure In one series,

the long-term complication rate in patients undergoing

procto-colectomy with ileostomy compared to ileoanal pouch procedure

was 26% vs 52%.(22) The most common long-term

complica-tions include stoma related complicacomplica-tions From a physiologic

standpoint, patients with an ileostomy are more prone to

dehy-dration, electrolyte abnormalities, and kidney stone formation

Patients should be counseled to be aware of signs and symptoms

of dehydration Although problems have decreased substantially

with modern pouching systems, preoperative stoma marking,

and the expertise of enterostomal nurses, patients may experience

peristomal skin irritation, parastomal hernia formation, stomal

retraction, fistula, and stomal stenosis In the long-term, up to

one third of patients require operative revision.(23)

Slow or delayed perineal wound healing occurs in up to 25%

of patients after proctocolectomy with ileostomy An

intersphinc-teric dissection may decrease the size of the perineal wound and

improve wound-related complications.(24) If infection or delayed

wound healing occurs, local wound care with examination under

anesthesia, debridement, and curettage is performed The vacuum

assisted closure device has been helpful to treat persistent perineal

wounds.(25) In some cases, muscle transposition, such as gracilis

muscle transposition is necessary to heal persistent wounds

As with any operation involving a pelvic dissection, sexual and

uri-nary dysfunction may occur from injury to the sympathetic and

para-sympathetic nerves The incidence of sexual dysfunction is felt to be

less than that occurring in those patients who undergo proctectomy

for malignant disease However, this may reflect the younger age of patients undergoing proctocolectomy for ulcerative colitis Impotence occurs in 1–2% of patients and retrograde ejaculation may occur in

up to 5% of patients.(26) Dysparuenia and increase in vaginal dis-charge occur in up to 30% of women from scarring and change in the in-axis of the vagina.(27) Women must also be counseled about the potential for infertility because of scarring pelvic adhesions

Despite the fact that patients have undergone a major surgical procedure, the quality of life remains high after proctocolectomy with ileostomy Overall 90–93% of patients are satisfied with their quality of life.(28, 29) Despite the satisfaction, a number of difficul-ties exist, including restriction of social and recreational actividifficul-ties in

up to 25%, and dietary restrictions in almost 30%

PROCtOCOleCtOMy WitH COntinent ileOStOMy

Another option for patients who require surgery for ulcerative colitis is a continent ileostomy, introduced by Nils Kock in 1969 (30) Despite initial enthusiasm, this operation is infrequently performed today because of the appreciable number of complica-tions associated with the procedure, in addition to the fact that it has been largely supplanted by the ileal pouch anal anastomosis Indications for a continent ileostomy include those patients who have undergone prior proctocolectomy with ileostomy and desire

a continent stoma, selected patients who have a failed ileoanal pouch procedure, patients with ulcerative colitis and rectal cancer who could not undergo an ileal pouch anal anastomosis (IPAA) and patients with poor sphincter tone in whom the functional results would be quite poor

Advanced age and obesity are relative contraindications to per-formance of the procedure As with the ileoanal pouch procedure, Crohn’s disease is a general contraindication to the procedure because of the risk of recurrent disease which could necessitate resection of the continent ileostomy

Operative technique

The operative technique involves initial performance of a proctocolec-tomy The continent ileostomy is then constructed using the terminal 40–60 cm of the ileum A three limb pouch with an intussuscepted nipple valve is used (Figure 31.1) The valve is created by intussuscept-ing the efferent loop After beintussuscept-ing tested for integrity and continence, the exit conduit is brought through the abdominal wall The site of continent ileostomy is generally determined preoperatively with an enterostomal therapist and is lower in the abdomen than a standard ileostomy Catheter drainage is maintained for approximately 4 weeks

to allow complete healing of the pouch.(31, 32) Guidelines for catheter management have been outlined by Beck.(33)

A number of technical modifications have been made over the years to prevent nipple valve complications Mesh was initially used to stabilize the valve, but the technique was abandoned because of a high incidence (42.5%) of fistula formation.(31) A recently described modification to avoid slippage of the nipple valve is the “T-pouch” in which a portion of the ileum is folded into the side of the pouch.(33, 34)

Outcome

In a large series of patients undergoing continent ileostomy with

a median follow-up of 11 years, 16.6% of patients required Kock

Figure 31.1 Continent ileostomy (A) Three limbs of small bowel are measured and the bowel wall is sutured together (B) After opening the bowel along the dotted

lines in (A), the edges are sewn together to form a two-layered closure (C) A valve is created intussuscepting the efferent limb into the pouch and fixing it in place with

a linear noncutting stapler (Inset: staples in place on valve.) (D) The valve is attached to the pouch side-wall with the linear noncutting stapler A cross-section of the finished pouch is shown (E) After closure of the last suture line, the pouch is attached to the abdominal wall and a catheter is inserted to keep the pouch decompressed during healing (Reprinted with permission).

pouch excision.(31) The number of complications associated

with the procedure was high with an average of 3.7 (range 1–28)

complications per patient

Some of the most significant complications are associated with

nipple valve slippage which occurs because of the tendency of the

intussuscepted segment to slide and evert on the mesenteric aspect

Manifestations of nipple valve slippage include difficult

catheteriza-tion, incontinence, and obstructive symptoms from obstruction of

the outflow tract The incidence of nipple valve slippage is

approxi-mately 30% A variety of technical modifications have been devised

to reduce the incidence of this complication Use of prosthetic

mate-rials to wrap the valve reduces the incidence of nipple valve slippage

but is associated with abscess and fistula formation.(35) The T-pouch

modification (34) has been advocated to avoid this complication, but

there is currently no controlled data available

Pouchitis is a well recognized complication of the Kock pouch

occurring in up to 25% of patients It is manifested by increased

bowel frequency, often associated with blood and mucus and at

times, incontinence The etiology of pouchitis is unknown, but

the majority of patients are treated effectively with antibiotics

and continuous pouch drainage

Other complications associated with the procedure include

the development of fistula, parastomal hernia, and small bowel

obstruction

Long-term results of patients with continent ilesotomies reveal

a cumulative success rate of 71% at 29 years in 96 patients followed

from 1972 to 2000.(36) The success rate with continent ileostomy

is appreciably less than with the ileoanal pouch procedure

tOtal aBDOMinal COleCtOMy WitH

ileOReCtal anaStOMOSiS

Although the majority of patients with ulcerative colitis have rectal

involvement, a small number of patients with rectal sparing may

be treated with total abdominal colectomy and ileorectal

anasto-mosis Such patients may subsequently require rectal excision for

diarrhea and poor functional results, ongoing proctitis, and

malig-nant transformation Surveillance for the development of dysplasia

is recommended Recent series have shown an average number of

bowel movements of 3–6/day after the procedure with a failure rate

of 11–57% (37, 38, 39) The incidence of developing cancer with

long-term follow-up ranges from 0–6% (40, 41, 42)

ReStORatiVe PROCtOCOleCtOMy

WitH ileOanal POUCH

Since its introduction in 1978, the ileoanal pouch procedure has

become the procedure of choice for patients who require surgery

for ulcerative colitis and familial adenomatous polyposis Over

the years, the operation has undergone a series of technical

modi-fications and it can be performed with essentially no mortality

and good long-term outcomes The procedure avoids the need

for a permanent stoma and removes the diseased bowel

Indications

The most common indication for the ileoanal pouch procedure is

failure of medical therapy for ulcerative colitis or development of

complications from medical therapy which outweigh the benefit

Additional indications include the development of dysplasia and

certain extraintestinal manifestations Colon cancer is not a con-traindication to the procedure, but performance of an ileoanal pouch must not compromise the oncologic resection IPAA is usually not advisable in a low- or mid-rectal cancer because of the need for chemoradiation therapy and the potential effects on the pouch and the anal sphincter Although the majority of patients who undergo pouch surgery are young, age is not a contraindica-tion to the performance of the procedure We advise patients on a case by case basis over the age of 65 Nocturnal leakage and incon-tinence is more common in older patients who undergo pouch surgery and preoperative assessment should include assessment

of anal sphincter function and extensive discussion about the potential functional outcome

Operative technique

Preoperatively, the risks and benefits of the procedure are dis-cussed with the patient, and consultation with an enterostomal therapist is beneficial An appropriate site for the intended stoma

is marked in the right lower quadrant The procedure is perform-ance after mechanical and antibiotic bowel preparation Although the procedure may be performed with an open or laparoscopic approach, pouch surgery is increasingly being performed by a laparoscopic approach Retrospective case-matched comparative studies have shown a longer operative time (median 330 min vs

230 min), but a quicker return of bowel function (2 days vs 4 days) and a shorter hospital stay (7 days vs 8 days) with laparo-scopic pouch procedures (43) A recent meta- analysis of 10 stud-ies with 329 patients confirmed that despite a longer operative time, patients had a lower blood loss, shorter hospital stay, and smoother recovery compared to open surgery.(44) In a review

of 100 laparoscopic and 189 open ileoanal pouch procedures for ulcerative colitis, patients reported excellent body image and quality of life scores regardless of open or laparoscopic approach (45) In the past 5 years, the majority of the ileoanal pouch proce-dures have been performed at our institution with a laparoscopic hand-assisted approach

The technical details of the procedure are outlined in videos (CineMed-American College of Surgeons)

One of the critical maneuvers during the performance of ile-oanal pouch surgery is the creation of a tension-free anastomosis between the pouch and the anus Undue tension on the anasto-mosis leads to stricture formation, anastomotic leakage, potential pelvic sepsis, and poor function To perform a tension-free anas-tomosis, the apex of the pouch should reach the inferior border

of the symphysis pubis Assessment of potential pouch reach to the anus is performed before pouch creation In obese patients,

it may be necessary to perform an initial total abdominal colec-tomy, ileostomy and Hartman closure of the rectum in anticipa-tion of significant weight reducanticipa-tion and then pouch creaanticipa-tion.(46)

An S-pouch may afford an additional 2 cm of length compared

to a J-pouch but it is more difficult to construct and has potential efferent limb problems.(47) A tension-free anastomosis is more difficult to achieve in male patients with a narrow pelvis, patients with a long anal canal, obese patients, and patients who undergo mucosectomy with handsewn anastomosis To achieve adequate length on the mesentery, a series of technical maneuvers is performed, including mobilization of the posterior attachment

of the small bowel mesentery, exposing the inferior portion of

the head of the pancreas, and scoring the peritoneum of the small

bowel mesentery serially on the anterior and posterior surfaces

(48) Each of these relaxing incisions confers an additional 1 cm

of distal reach At least two relaxing incisions are made along the

course of the superior mesenteric artery If additional length is

required, the mesentery of the small bowel is transilluminated to

delineate the loop formed by the ileocolic artery and the terminal

ileal branch of the superior mesenteric artery Traction is placed

on the small bowel by grasping the intended apex of the pouch,

and vessels between the primary and secondary arcades that are

under tension are identified and ligated This maneuver adds 2–5

cm of additional length The terminal branches of the superior

mesenteric artery of the ileocolic artery can be divided for

addi-tional length These vessels are clamped for 10–15 minutes before

ligation to confirm adequate vascularity of the ileum before

divi-sion In selected cases, interposition vein grafts have been used

to obtain adequate mesenteric length.(49) If there is inadequate

length despite these maneuvers, the pouch may be left in the

pel-vis, and not anastomosed to the anal canal with plans to return at

a subsequent date for anastomosis The weight of the pouch and

the dependent portion of it with the aid of gravity may facilitate

reach to the anus at a later date

Outcome

The mortality after ileoanal pouch surgery is <1% The

major-ity of the patients undergoing the procedure are young and

oth-erwise in good health, with the exception of ulcerative colitis or

familial adenomatous polyposis Despite refinements in

surgi-cal technique, the operation is associated with an appreciable

number of complications

A recent meta-analysis with a review of 5,215 patients who

underwent ileoanal pouch surgery between 1988 through 2000

revealed a preoperative diagnosis of ulcerative colitis in 87.5%,

indeterminate colitis in 2%, Crohn’s disease in 0.8%, familial

ade-nomatous polyposis in 8.9%, and other diagnoses in 0.7%.(50)

A diverting ileostomy was performed in 81.6%

fUnCtiOnal ReSUltS (BOWel, URinaRy,

gyneCOlOgiC anD SexUal fUnCtiOn)

At a median follow-up of 37.2 mos after ileoanal pouch surgery

and ileostomy reversal, the mean defecation frequency was 5.2

during the day with a mean night-time frequency of 1.0.(50) Mild

fecal incontinence during the day occurred in 17%, while 3.7%

had severe fecal incontinence during the day and 7.3% had urge

incontinence Bowel function deteriorates with advancing age

(51) Prospective evaluation of long-term function reveals that

especially 12 years or more after surgery, major and minor

incon-tinence are worse Twelve years following surgery, 27% of patients

vs 9% (<12 years) had major daytime incontinence and 33% vs

10% reported more major night time incontinence Furthermore,

minor incontinence was seen in 48% of patients after 12 years vs

16% of patients followed for under 12 years.(51)

The reported incidence of sexual dysfunction in a meta-analysis

of 21 studies including 5,112 patients was 3.6%.(50) The authors

point out the risk of underestimating complications due to a

posi-tive publication bias, and thus studies with negaposi-tive results may be

less likely to be submitted and published Indeed, a more recent review has further quantified the impact of the ileoanal pouch procedure on sexual and gynecologic function in women A sys-tematic review of 22 in 1,852 women who underwent restorative proctocolectomy from 1980 to 2005 revealed a much more sig-nificant impact on function.(52) The incidence of infertility was

12% before restorative proctocolectomy and 26% after (n = 945

women, 7 studies) Sexual dysfunction occurred in 8%

preopera-tively and 25% postoperapreopera-tively (n = 419 women, 7 studies) More

Cesarean sections were performed after restorative proctocolec-tomy, although no significant differences in pouch function and

no significant perineal trauma was seen after vaginal delivery, thus suggesting that the mode of delivery should be based on obstet-ric considerations An increase in bowel actions was noted during the third trimester but bowel activity returned to normal within 6 months of delivery Peritoneal inclusion cysts which are associated with pelvic sepsis and adhesions are an additional underreported consequence of the ileoanal pouch procedure.(53, 54)

COMPliCatiOnS

Despite refinements in surgical technique, restorative proctocolec-tomy is associated with an appreciable number of complications including pelvic sepsis, fistulas, strictures, fecal incontinence, pouch failure, and sexual dysfunction A recent meta-analysis on pooled data of observational studies has been performed on 43 studies com-prising 9,317 patients detailing the results and complications.(50)

Small Bowel Obstruction

Small bowel obstruction is a common complication after restora-tive proctocolectomy ranging from 15–44% of patients, with approximately half of patients requiring operation for treatment of obstruction.(55) Small bowel obstruction occurs more commonly after restorative proctocolectomy than after Brook ileostomy, pre-sumably because of the cumulative increase in obstruction after multiple procedures Patients who develop early postoperative small bowel obstruction are more likely to resolve with conserva-tive measures than those patients diagnosed in later follow-up.(56)

In a series of 1,178 patients who underwent IPAA, the cumulative risk of small bowel obstruction was 9% at 30 days, 18% at 1 year, 27% at 5 years and 31% at 10 years.(57) The most common site of adhesions were pelvic adhesions (32%) and adhesions at the ileos-tomy closure site (21%) Recent strategies to decrease the risk of adhesions have focused on the use of a bioresorbable membrane which has reduced the incidence, extent, and severity of adhesions (58), as well as the use of laparoscopic surgery (which results in less adhesions)

Postoperative Hemorrhage

Intraabdominal hemorrhage may occur from failure to secure the vascular pedicles and from pelvic bleeding, in addition to bleed-ing of the pouch suture or staple line Pouch ischemia may also be associated with bleeding Pouch bleeding noted intraoperatively

is best treated by eversion of the pouch to expose the mucosa and cauterization or suture ligation as needed Postoperative bleeding may require examination under anesthesia and/or pouch endos-copy with suture or endoscopic clipping of the bleeding point Bleeding, especially 5–7 days after operation, may be associated

with anastomotic dehiscence In a series of 1,005 patients, pouch

bleeding occurred in 38 patients (3.8%) and was treated with local

irrigation with saline and adrenaline in 30 patients and transanal

suture ligation in 8.(59)

Pelvic sepsis

Pelvic sepsis is defined as pelvic abscess, anastomotic leakage or

dehiscence, or any pelvic or perineal infection Some series

distin-guish between pelvic sepsis and anastomotic leak; pelvic sepsis

gen-erally results from a defect in the ileoanal anastomosis, anastomotic

leak, or defect of the other staple or suture lines A meta-analysis

noted the incidence of pelvic sepsis to be 9.8%.(50) Manifestations

of pelvic sepsis include fever, leukocytosis, perineal pain, purulent

drain output, and prolonged ileus As pelvic sepsis is a significant

cause of pouch failure and since those patients with sepsis are

more likely to have compromise of pouch function, any patient

suspected of having pelvic sepsis, should be evaluated and treated

expeditiously CT scan confirms the diagnosis of pelvic sepsis, and

contrast in the pouch (either by instilling rectal contrast or contrast

through the efferent limb of the ileostomy) is useful in assessing

the integrity of the anastomosis Alternatively, a pouchogram and

examination under anesthesia may be necessary Intraabdominal

or pelvic abscess requires percutaneous or operative drainage in

addition to broad spectrum antibiotics (Figure 31.2) For patients

with leakage from the anastomotic suture or staple line the abscess

can be drained into the pouch This potentially avoids the

develop-ment of a complex fistula Untreated pelvic sepsis results in fibrosis,

a stiff, non-compliant reservoir, and a higher incidence of ultimate

pouch failure.(60)

Anastomotic leak or dehiscence

Anastomotic leak after the ileoanal pouch procedure occurs

between 5–18% of patients In a recent meta-analysis, the

incidence of anastomotic leakage from either the pouch-anal anastomosis or the pouch itself was 7.1%.(61) The incidence

of anastomotic leakage was more common in patients who did not have a stoma at the time of pouch surgery The presence of

a stoma may help to ameliorate the clinical manifestations of a leak A leak may occur at the pouch anal anastomosis or along any

Figure 31.2 Retrograde pouch study shows a presacral collection (A) confirmed on CT scan (B) Collections arising from the anastomosis are preferably drained into

the pouch to avoid a complex fistula.

Figure 31.3 Asymptomatic anastomotic sinus in patient before ileostomy closure

often requires no further treatment Delay in ileostomy closure and repeat pouch study generally shows healing.

of the staple or suture lines including the top of the J-pouch, the

ileoanal anastomosis, or the pouch itself Manifestations of a leak

include the development of an abscess, fistula, or symptoms of

pelvic pain, diarrhea, and fever Risk factors associated with leak

include tension on the anastomosis and ischemia resulting from

tension on the anastomosis One study suggested a lower

inci-dence of pelvic sepsis associated with a double-stapled

anastomo-sis compared with a mucosectomy and hand sewn anastomoanastomo-sis

(62) Management of anastomotic leak is individualized; patients

who have an asymptomatic sinus before ileostomy closure

with-out associated sepsis can be treated by delay in ileostomy closure

and in most cases, ultimate healing of the tract.(Figure 31.3)

Patients with peritonitis who have undergone restorative

proc-tocolectomy without diverting ileostomy require diversion and

drainage Leaks from the tip of the J pouch are challenging both

to diagnose and treat and developed in 14 out of 1,309 patients;

all required surgical repair and none healed with conservative

treatment (63) (Figure 31.4) With expertise and

individual-ized management, pouch salvage can be was achieved in 88% of

patients who developed anastomotic leak.(64)

Stricture at the ileal pouch anal anastomosis

Strictures at the ileal pouch anal anastomosis occur in

approxi-mately 10% of patients, and are more common after

mucosec-tomy and handsewn anastomosis than after double-stapled

anastomosis.(65, 66) Tension on the anastomosis and ischemia

are associated with stricture formation A lumen which admits

the DIP joint of the index finger is generally satisfactory for good

bowel function Soft strictures are treated with gentle finger

dila-tion or with balloon dilators Long fibrotic strictures are more

challenging to treat and pouch advancement and neoileoanal anastomosis may be necessary to treat such patients.(67)

Pouch vaginal fistula

The incidence of pouch-vaginal fistulas ranges from 3–16%.(68) Pouch-vaginal fistulas are a major potential cause of pouch fail-ure Fistulas which occur in the early postoperative period are most commonly a manifestation of sepsis, and can occur from anasto-motic leak and necessitation through the vaginal wall, or may result from technical factors including entrapment of the perivaginal tis-sue in the staple line (Figure 31.5) An important part of the ileoanal pouch procedure is to ensure that the vagina is not incorporated within the stapler Late pouch-vaginal fistulas are more commonly associated with unsuspected Crohn’s disease.(69)

Pouch-vaginal fistulas may manifest as pelvic pain, fever, a

“Bartholin’s abscess” which when drained has fecalent mate-rial, or passage of gas Fistulas which occur before ileostomy takedown are treated by management of infection, delayed ile-ostomy closure, and local repair A number of procedures have been described for treatment of pouch vaginal fistulas Ultimate success may be achieved in over 50% (70) but often requires mul-tiple procedures For patients with Crohn’s disease, the use of infliximab and other biologics may be helpful

Pouch anal fistulas

Early fistulas are generally a manifestation of sepsis and leakage

at the ileoanal anastomosis Late fistulas may be crytoglandular

in origin and may also be a manifestation of Crohn’s disease Our preference is for liberal use of draining setons and avoidance of fistulotomy

Figure 31.4 A leak from the efferent limb of the pouch may be difficult to diagnose

Such patients rarely heal with antibiotics and drainage alone and often require

exploration and repair.

Figure 31.5 A pouch vaginal fistula is seen on retrograde study Early fistulas

are due to infection and leak at the anastomosis while late fistulas often herald unsuspected Crohn’s disease.

Pouchitis

The most frequent long-term complication of the ileoanal pouch

procedure is the development of pouchitis, a nonspecific

inflam-mation of the ileal pouch mucosa The precise etiology of

pouchi-tis has not been elucidated but it is believed to potentially result

from an overgrowth of anaerobic bacteria It is disease specific and

more commonly seen in patients with ulcerative colitis; it is rarely

encountered in patients with familial adenomatous polyposis

Patients with ulcerative colitis associated with extraintestinal

man-ifestations and patients with sclerosing cholangitis have a higher

incidence of pouchitis.(71, 72) Presenting signs and symptoms of

pouchitis include abdominal cramps, abdominal tenderness, fever,

and increase in stool frequency, often associated with blood or

mucus The diagnosis may be made clinically, on the basis of

endo-scopic examination in addition to clinical findings, or on the basis

of histologic examination of the pouch mucosa; the lack of

uni-form criteria to make such a diagnosis accounts for the variation in

the incidence of pouchitis in many series A pouchitis disease

activ-ity index has been devised which includes clinical, endoscopic, and

histologic features.(73) Pouchitis is generally treated with antibiotic

therapy and the most commonly used agents include

metronida-zole or ciprofloxacin Some patients with pouchitis develop

ongo-ing symptoms, and for patients with refractory pouchitis or rapidly

relapsing symptoms, the use of probiotics appears to be helpful

Probiotics may suppress the resident pathogenic bacteria,

stimu-late mucin glyocoprotein, prevent adhesion of pathogenic strains

to epithelial cells, and reduce host immune responses Probiotics

may also be helpful in preventing recurrent pouchitis A diagnosis

of Crohn’s disease should be considered in patients with chronic

pouchitis In some cases, pouchitis is a cause of pouch failure

Pouchitis has been termed by some as “the Achilles heel” of the

ileoanal pouch procedure It is a cause of significant long-term

morbidity; elucidation of the cause of pouchitis would likely

ben-efit a large number of patients

Dysplasia and Malignancy

Following construction, the ileoanal pouch undergoes a number

of histologic changes, and with time, the metaplastic changes result

in the ileal mucosa resembling colonic mucosa These changes may

also occur because of inflammation in the pouch and raise concerns

of malignant transformation and the development of dysplasia

Neoplastic changes appear to be extremely rare The majority of

ile-oanal pouch patients who develop cancer had a prior cancer at the

time of pouch construction The recent ASCRS guidelines do not

endorse routine surveillance of ileal pouches for dysplasia.(10)

Pouch Failure

Pouch failure defined as pouch excision or a nonfunctioning pouch

at 12 months after the ileoanal pouch procedure occurs in 5 to 15%

While the majority of pouch failures occur within 2 years of pouch

construction, late pouch failures also occur The common cause of

pouch failure include unsuspected Crohn’s disease, chronic pouchitis,

poor function with incontinence, persistent fistula, and other pouch

related complications such as stenosis with outlet obstruction

Reoperative pouch surgery with an attempt to salvage the

pouch is challenging; pouch salvage is higher in patients with

ulcerative colitis than Crohn’s disease.(74)

COntROVeRSieS Reservoir Design

While the original report by Parks used an S-pouch configu-ration, a number of other pouch configurations have been described, including J-pouch, lateral isoperistaltic H-pouch, and quadruple-loop W pouch S pouches were initially asso-ciated with an increased need for catheterization because of a long distal ileal conduit Shortening of the ileal conduit helps

to initially avoid this complication, however, with time, the exit conduit of the S-pouch seems to elongate and obstructive defecation can occur An S pouch may confer additional length compared to a J-pouch and may be the preferred configuration

if achieving adequate length to performed a tension-free anas-tomosis in selected cases The long outlet tract associated with

an H pouch has been associated with stasis, pouch distention, and pouchitis

There have been no significant differences in pouch func-tion based on the configurafunc-tion of the pouch Due to the ease of construction and the lack of compelling data favoring a specific pouch design, J pouches are most frequently performed Use of

an S or W pouch adds about 45 minutes to the time of the opera-tive procedure

A recent meta-analysis examined the short and long-term out-come of J-, S- and W- reservoirs in patients undergoing restora-tive proctocolectomy.(75) A total of 18 studies of 1,519 patients (689 J, 306 W, and 524 S pouches) were reviewed There was no difference in the incidence of early complications among the

3 types of pouch design The frequency of defecation favored an S- or W- pouch design over a J pouch, although in practical terms the difference of 1–1.5 stools in a 24 hour period is unlikely to

be of clinical significance to the patient Night evacuation was significantly lower for a W than a J pouch S pouches were associ-ated with a greater need for pouch intubation due to a long distal conduit; W pouches also required intubation more often than

J pouches

Mucosectomy vs Double-Stapled technique

The ileoanal anastomosis may be performed with a handsewn technique after mucosal stripping (mucosectomy) or with a dou-ble-stapled technique

The initial technique reported by Parks was mucosal strip-ping commencing at the dentate line and removing all diseased mucosa, thus eliminating the risk of recurrent proctitis or neo-plastic transformation A potential advantage of the double-stapled technique is greater technical ease, and potentially less tension on the anastomosis Preservation of the anal transitional zone may minimize sphincter damage and improve functional results Three prospective randomized trials have not shown

an advantage for the double-stapled technique vs the muco-sectomy technique.(76, 77, 78) These trials have all been small and are underpowered to demonstrate a difference A meta-analysis of 4,183 patients (2,699 hand-sewn vs 1,488 stapled IPAA) found similar early postoperative outcomes; however, stapled IPAA patients had improved nocturnal continence and had higher resting and squeeze pressures on anorectal physi-ologic testing.(79)

Preservation of the anal transitional zone and performance

of a double-stapled technique leaves a residual 1–2 cm of

dis-eased rectal mucosa, which may be at risk for the development of

dysplasia and subsequent malignant transformation It has been

suggested that patients who have had a double-stapled

tech-nique be followed in a surveillance program, with biopsies of the

retained columnar mucosa at least every 2 years beginning 8 to 10

years after the onset of symptoms of disease.(80) The

recommen-dations for biopsy are controversial and is an area where further

study is needed to define the natural history of the retained 1–2

cm of columnar mucosa Other authors have not found the

devel-opment of dysplasia with long-term follow-up.(81)

Omission of ileostomy

Restorative proctocolectomy is most commonly performed in

two stages with an initial proctocolectomy, pouch construction,

and diverting ileostomy, followed by ileostomy takedown after

demonstration of satisfactory pouch healing However,

construc-tion of a loop ileostomy may be associated with excessive stoma

output, dehydration, hernia, bowel obstruction, and subsequent

anastomotic complications associated with ileostomy takedown;

these have been cited as a reason to potentially avoid diverting

ileostomy in selected patients after ileoanal pouch construction

Conversely, many feel that loop ileostomy construction will

mini-mize the potential consequences of pelvic sepsis (and potentially

reduce the chance of pouch failure)

This issue has been characterized by a great deal of passion and

no randomized controlled studies A one stage procedure without

loop ileostomy is associated with a more difficult initial recovery

and most likely a slight increased rate of anastomotic disruption

and pelvic sepsis An alternate view of this is that with fecal

diver-sion, some patients with minor leaks and sepsis may not be

clini-cally detected

Loop ileostomy avoids some of the consequences of pelvic

sep-sis, which is a major cause of pouch failure Despite aggressive

treatment the risk of pouch failure after pelvic sepsis is 20%, 31%

and 35% at 3, 5 and 10 years respectively.(61) A single stage IPAA

without loop ileostomy decreases the risk of ileostomy related

complications, and complications including small bowel

obstruc-tion associated with an addiobstruc-tional operative procedure

A recent review compared 17 studies with 1,486 patients (765

without ileostomy and 721 with ileostomy).(61) While there was

no significant difference in the functional outcome of the two

groups, those patients without an ileostomy had a higher

inci-dence of pouch related leak and stricture formation

Selective omission of an ileostomy may be considered when an

anastomosis is intact and under no tension, the procedure is not

complicated by excessive bleeding or other technical difficulties

and the patient is not on high dose steroids before the procedure

(10) The patient should be adequately counseled preoperatively

concerning the pros and cons of ileostomy omission

Crohn’s Disease and Indeterminate Colitis

Crohn’s disease has been considered to be a contraindication to

the performance of an ileoanal pouch procedure because of the

risks of recurrent disease and the potential need for pouch

exci-sion with subsequent loss of substantial amounts of bowel

However, there are some patients who undergo the procedure for ulcerative colitis and an ultimate diagnosis of Crohn’s disease

is made In general these patients are found to have a higher risk of pouch failure from 28–52% (82, 83, 84, 85) compared to patients with ulcerative colitis or familial adenomatous polyposis In a cohort

of 32 patients out of 790 patients with an ultimate diagnosis of Crohn’s disease, 93% had complications including perineal abscess/ fistula (63%), pouchitis (50%), and anal stricture (38%) (85) It is not known whether administration of agents such as infliximab to such patients will ultimately impact the incidence of pouch failure,

or whether it will delay the diagnosis or pouch failure All efforts should be made to confirm a diagnosis of ulcerative colitis and exclude a diagnosis of Crohn’s disease preoperatively In addition to

a thorough history and examination, a recent study suggested that

a family history of Crohn’s disease and serology positive for

anti-Saccharomyces cerevisiae immunoglobulin-A were more likely to be

diagnosed with Crohn’s s after IPAA (67%) than patients with either risk factor (18%) or neither risk factor (4%) (86)

While techniques of restorative surgery for ulcerative colitis have shown substantial advances over the past several decades, further study focusing on improvements in complications and functional outcomes will ultimately further improve a patient’s quality of life

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