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However, ileostomy patients reported needing less medication. Despite this, healthcare costs were three times higher for ileostomy patients than for IPAA patients. In
terms of quality of life, the study found no difference when using the overall IBDQ
score, but bowel symptoms-related IBDQ subscores were lower in IPAA patients.
Median QALY was higher for IPAA patients, as ileostomy patients reported more
frequent mobility-related problems.
According to a study by Hassab etal. [16] using data from the American College
of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP),
restorative procedures were found to have a higher rate of readmissions compared
to non-restorative procedures. However, the study found that there were no signicant differences in other 30-day complications, including mortality rates, between
the two groups.
R. Areán-Sanz and E. Messaris
Recommendations
Most patients diagnosed with ulcerative colitis who have failed medical therapy
should be offered total proctocolectomy with ileal pouch-anal anastomosis with the
aim of maintaining gastrointestinal tract continuity, taking into account the comparable rate of postoperative complications, similar quality of life parameters, and
potential lower care costs.
However, certain groups of patients such as the elderly, patients with obesity,
patients with multiple comorbidities, patients with a diagnosis of indeterminate
colitis or Crohn’s disease, and those with previous bowel or sphincter dysfunction
may not be suitable candidates for IPAA surgery due to an increased risk of complications and poorer quality of life outcomes. For these patients, a total proctocolectomy with end ileostomy is an alternative that has similar surgical and quality of life
outcomes. In patients in which IPAA surgery is contraindicated and an endileostomy is either refused or contraindicated, an ileo-rectal anastomosis (IRA) is
an alternative procedure.
It’s important to note that, despite a potentially higher incidence of surgical complications and inferior quality of life outcomes than primary pouch creation, a revisional procedure, or re-do IPAA, can still benet patients who failed primary IPAA
surgery.
Personal View
Total proctocolectomy with IPAA should be the procedure of choice in most cases;
however, it’s vital to keep complications and populations at risk in mind when
selecting candidates for this procedure. Multiple studies have been published that
evaluate the predictive factors for short- and long-term complications, poor quality
of life measures, and mortality for patients with UC who underwent IPAA as curative treatment.
5 Which Patients withUlcerative Colitis Benet fromIleal Pouch-Anal Anastomosis?
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In a retrospective review of 116 patients followed for 10 years, the authors
reported a 30-day complication rate of 16.4%. Fifty-seven percent of patients presented late adverse events —chronic pouchitis being the most frequent (23.3%),
followed by intestinal obstruction (17.2%) and perianal stula (13%)—. The study
also evaluated functional outcomes using the Öresland scale and the Cleveland
Global Quality of Life Scale. The results indicate that 75% of the study cohort
reported that their social life was not compromised by the procedure and 92.7% of
patients were satised with the results and would recommend the procedure to other
patients who might benet from it [17].
Male sex, older age, higher body-mass index, and extraintestinal manifestations
have been associated with failure of IPAA. (1,7) Moreover, the use of steroids before
colectomy may be a risk factor for anastomotic leak, stula formation, and pouch
failure [6].
Using the IBD-disability index, Kayal etal. [2] reported that 37.2% of patients
who underwent an IPAA creation for UC had moderate to severe disability. Certain
aspects, such as overall health, sleep, energy, regulating defecation, and pain were
found to be particularly affected when compared to patients receiving medical treatment alone. The study also found that certain patient groups were more likely to
experience higher levels of disability, such as women, patients with active symptoms, and those with public insurance.
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Patients withObesity
Up to 32% of patients diagnosed with UC have a BMI>30 and this population has
been traditionally considered at high risk for complications and failure of
IPAA. Although there is no consensus on whether functional outcomes such as
incontinence, frequency of bowel movement, pad usage, and pouchitis are signicantly different between patients with obesity and patients without, studies have
found that the former are more likely to undergo open IPAA surgery and have longer operative times, greater rates of complications (mainly surgical site and urinary
tract infections), as well as more blood transfusion requirements and longer length
of stay [18]. Furthermore, studies using the ACS-NSQIP database of patients who
underwent IPAA for UC have found that obesity is an independent factor associated
with higher rates of organ space sepsis and readmission for infectious complications
[19, 20]. Similar ndings were reported by Abd el Aziz etal. [21] which also found
higher rates of postoperative organ space infections in patients with obesity. In contrast, all the other complications included in their multivariate analysis showed no
difference when compared with patients with a BMI<30. The poor surgical outcomes in this population are mainly due to intraoperative technical difculties such
as a short mesentery length (due to adiposity or inammation, regarded as the most
common direct cause), as well as a limited working space in a narrow pelvis, which
can sometimes lead to deferring the surgery until after the patient has lost excess
weight [1, 21].
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More recently, a retrospective multivariable analysis of 2202 patients found
that patients with obesity had longer surgical times, lower pouch survival and,
most importantly, they found that obesity was the strongest independent predictor of pouch failure (HR 4.24). Global quality-of-life scores were also lower than
in patients without. The authors did not, however, nd an independent association between obesity and postoperative complications (dened as a composite
outcome of any complication), in-hospital length of stay or anastomotic leak. [22]
Taking the aforementioned reports into account, patients with a BMI<30 should
be offered IPAA surgery, whereas caution should be taken when deciding whether
or not this procedure is recommended for patients with a BMI between 30 and 35.
For patients with a BMI over 35, other than carefully selected exceptions, pouch
surgery should not be offered given the higher risk of complications and negative
quality of life impact. On the other hand, weight loss management can convert these
high-risk patients to low-risk when BMI becomes <30 or<35in some cases.
R. Areán-Sanz and E. Messaris
Elderly Patients
There is still no consensus in terms of an age cut-off at which IPAA should not be
recommended, given that there are multiple factors associated with complications
and/or failure, and age alone does not seem to impact as much as previously thought.
Nonetheless, there still seems to be a tendency to recommend end ileostomy procedure to elderly patients. When comparing rates of procedure choice (IPAA vs ileostomy), Cohan etal. [23] found that older age patients received ileostomy more often
than IPAA, given the notion that the risks of the latter are higher; however, more
elderly patients have been undergoing IPAA over time.
In 2016, Bollegala etal. [24] published a comparative analysis of postoperative
outcomes in patients diagnosed with IBD and found that 30-day mortality among
elderly patients was almost 10 times higher than in non-elderly patients (5.3% vs
0.5%); in-hospital mortality was also found to be signicantly higher for this group
of patients (3.3% vs 0.4%). The authors reported higher rates of postoperative complications in elderly IBD patients. Emergent surgery in elderly patients diagnosed
UC presented ve-fold risk mortality rates in comparison to the non-elderly group.
Still, this study’s ndings are limited given a lack of information regarding disease
severity and previous medical treatments; moreover, as mentioned by Piper etal.
[25], it is unclear whether the ndings of Bollegala etal’s study correspond to specic risks posed by the surgical treatment of IBD, or if they are those inherent to
abdominal surgical procedure in the elderly population. This study’s results are not
consistent with previous and more recent reports. For instance, Cohan etal. [26]
published an ACS-NSQIP analysis comparing patients aged 50 or younger against
patients aged 51–60 and>60, as well as based on frailty trait count. They found no
signicant differences in terms of complication rate other than a 0.8-day longer
length-of-stay at the hospital for the >60 group, which, although statistically signicant, is not clinically relevant. Frailty trait count showed no association with either
complication rates or length of stay.
5 Which Patients withUlcerative Colitis Benet fromIleal Pouch-Anal Anastomosis?
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More recently, Lightner etal. [27] published an analysis of 1875 patients with a
median follow-up of 16.1years after IPAA.For patients aged 65 or older who had
undergone IPAA surgery, 47% reported complete lack of incontinence, 36% presented occasional incontinence, and only 17% reported frequent incontinence
throughout the day. At night, rates of no, occasional, and frequent incontinence
episodes were 25%, 43%, and 33%, respectively.
When it comes to differences among elderly subgroups, Minagawa etal. [28]
compared functional outcomes in patients aged 65–69 vs aged 70 and older and
found no signicant difference regarding stool frequency, and daytime/nighttime
soiling.
Age should not be the sole factor in determining whether a patient is suitable for
ileal pouch-anal anastomosis (IPAA) surgery, as multiple studies and a systematic
review published in 2021 have found. The review, conducted by Pedersen in 2021
[29], analyzed 13 studies and found no statistically signicant difference between
elderly (65 and older) and non-elderly patients in terms of short-term and long-term
complications after IPAA surgery. Instead, other factors such as comorbidities,
functional status, pre-operative bowel function, and patient preference should be
considered when making the decision to proceed with IPAA surgery.
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Sphincter Abnormalities
The restorative nature of IPAA surgery poses the benet of preserving sphincter
function; still, up to 30% of patients report some degree of fecal incontinence.
Certain patient populations, such as the elderly and those with a history of obstetric
complications, may be at higher risk for continence issues following the surgery.
This is likely due to potential preoperative sphincter abnormalities in these groups
[7]. A retrospective study that included patients who had had pouch surgery for over
30years found that patients older than 80years of age did not have higher rates of
fecal incontinence but did report increased episodes of seepage and more frequent
use of pads during both day and night [30].
An anorectal manometry is not always required, but a digital rectal examination
should be performed to evaluate sphincter tone before determining suitability for an
IPAA procedure. Patients with preoperative altered sphincter tone may be better
suited for a non-restorative procedure; however, this decision should be made after
a thorough discussion of postoperative expectations with the patient [7]. If a permanent stoma is not accepted by the patient, an IRA is a viable option in this group of
patients.
Primary Sclerosing Cholangitis
The outcomes of IPAA for patients with both ulcerative colitis (UC) and primary
sclerosing cholangitis (PSC) are not well understood. While these patients may
have a higher rate of pouch dysfunction and pouchitis, there does not appear to
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be a signicant difference in surgical complications when compared to other
groups. However, a study by Pavlides etal. [31] found that patients with UC and
PSC reported signicantly higher rates of nighttime bowel movements. On the
other hand, a large cohort study comparing restorative procedures for patients
with UC and PSC found no statistically signicant difference in terms of pouch
failure, with failure rates of 4%, 11%, and 18% at 1, 3, and 5years, respectively
[32]. Patients with UC and PSC should be treated as patients with UC and
without PSC.
R. Areán-Sanz and E. Messaris
Patients withIndeterminate Colitis or Crohn’s Disease
Patients who underwent pouch surgery can develop postoperative inammation of
the pouch with features similar to Crohn’s disease (CD), a complication controversially referred to as “CD of the pouch” [33, 34]. However, it is important to distinguish between actual CD of the pouch (i.e., a patient with preoperative diagnosis of
CD or a patient with a preoperative diagnosis of UC or indeterminate colitis (IC)
whose colectomy specimen was diagnosed as CD) versus a pouch with CD-like
features. Suggestive features for the former include pre-pouch ileitis; development
of stulas and abscesses 6–12months after ileostomy takedown; strictures, segmental or skip lesions affecting the pouch or small intestine; and non-caseating granulomas in the pouch or cuff [34, 35]. Postoperative (de novo) CD has been reported in
up to 15.9% of patients who undergo IPAA for UC, and their outcomes differ from
those patients where CD diagnosis was already established [36, 37].
Patients with a preoperative diagnosis of CD who undergo pouch creation have a
risk of complications such as stulas, strictures, and abscesses, and end-ileostomy
is the preferred procedure in most cases where colectomy is needed. However, certain patients may benet from IPAA surgery, mainly those without perianal or small
bowel involvement (occurring in up to 20% of cases) [35, 38]. Information on
patients preoperatively diagnosed with CD who have undergone IPAA is limited
and most studies report results of patients with original diagnosis of UC or indeterminate colitis (IC) [36]. The risk of pouch failure is higher in patients with CD and
has been reported in up to 15% of patients, a rate signicantly higher than that of
patients with UC.Due to this, some experts prefer IRA over IPAA in patients with
indeterminate colitis without rectal involvement to avoid the potential pouch failure
if the patient is postoperatively diagnosed with CD.However, other complications
and long-term functional outcomes appear to be similar to those reported for patients
with UC [37]. Therefore, patients with a preoperative CD diagnosis with no perianal
or small bowel disease who undergo IPAA should be closely monitored for adverse
events and complications. Specically, for patients with CD in which the pouch did
not fail, complication rates and functional outcomes are comparable to those in
patients with UC [38]. Biologic medications can be used to maintain the disease in
remission and increase IPAA retention.
Re-doing IPAA after a failed primary restorative procedure in patients with preoperative CD may be a viable option for specic patients given acceptable quality
5 Which Patients withUlcerative Colitis Benet fromIleal Pouch-Anal Anastomosis?
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of life outcomes, although complication rates are higher for this group compared to
re-doing IPAA in patients with UC [39].
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Patients ofChildbearing Age
There have been reports of higher infertility rates after IPAA surgery in patients of
childbearing age, although the evidence behind this has been inconclusive. Some
surgeons offer these patients an IRA as an alternative to IPAA with the same purpose of restoring the GI tract while lowering the risk of postoperative infertility
[40]. However, the proposed advantage in fertility supporting IRA is debatable, with
some studies showing no difference between the two procedures. For instance, a
recent large observational study compared the impact of IPAA and IRA in pregnancy rates, and also compared them with a control group of people who had undergone appendectomy. After adjusted analysis, they found that both procedures for
UC increased the rate of infertility versus the control population, yet reported no
difference between IPAA and IRA [41]. It’s important to note that any restorative
procedure for UC can decrease fertility. Patients may choose to delay restoration
with IPAA or IRA until after they no longer wish to have more children.
Redo IPAA
There is limited information available on the effectiveness of re-doing an IPAA procedure for patients who have previously failed primary IPAA surgery. The main indication for this is patients with failed IPAA with a signicant aversion to living with a
permanent stoma. Moreover, if re-do IPAA surgery is unsuccessful, another attempt at
a restorative procedure may be considered. The long-term outcomes in patients who
have undergone an IPAA revision after failed re-do IPAA appear to be similar to re-do
IPAA procedures in terms of pouch survival rate and patient quality of life, making
revision after a failed re-do IPAA a safe and viable option for this patient population
[42]. It’s worth noting that pouch excision after a failed IPAA creation is also linked
with increased morbidity and reduced quality of life. [43] For selected patients, re-do
of the IPAA is the best option in order to preserve the gastrointestinal continuity.
Conclusion
In conclusion, total proctocolectomy with ileal pouch-anal anastomosis offers comparable postoperative complications, quality of life, and potentially lower care cost
to patients in need of surgery for ulcerative colitis as measured against total proctocolectomy and end ileostomy and should be offered to most patients with an indication for surgical treatment of ulcerative colitis. The decision-making process should
take into account several patient characteristics which could affect the surgical morbidity and overall quality of life of patients undergoing restorative proctocolectomy.
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R. Areán-Sanz and E. Messaris
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R. Areán-Sanz and E. Messaris
Persistent Posterior Sinus After Ileal
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Pouch-Anal Anastomosis
KathrynE.Chuquin andBrianL.Bello
Introduction
Ileal pouch-anal anastomosis (IPAA) is the preferred reconstructive option to maintain continence after proctocolectomy for inammatory bowel disease or familial
adenomatous polyposis syndrome. IPAA has many documented complications, one
of which is formation of a posterior sinus tract. This is a blind-ending tract usually
in the presacral space originating from the pouch-anal anastomosis that most frequently forms as a sequela of a contained anastomotic leak. Incidence of posterior
sinus after IPAA has been reported to range from 2–8% [1–3], with persisting sinus
a signicant predictor of pouch failure [2]. Pouch sinus is routinely diagnosed when
performing a Gastrogran enema (or pouchoscopy) prior to consideration of diverting loop ileostomy closure. Management of a posterior sinus can be difcult and
ranges from observation to pouch excision depending on the size and complexity of
the sinus, patient symptoms, and surgeon expertise.
6
Search Strategy
A comprehensive search of PubMed, EMBASE, MEDLINE and Cochrane Database
was performed to include the last 25years (1997–2022). Results were limited to
English language and peer-reviewed publications. Additional studies were identied using the references sections from the initially identied papers. Search terms
K. E. Chuquin
Washington, DC, USA
B. L. Bello (*)
Medstar Medical Center, Washington, DC, USA
e-mail: brian.l.bello@medstar.net
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_6
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