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4 Elective Surgical Management inPatients withUlcerative Colitis: How Many Stages?
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14% risk for anastomotic leak and pelvic sepsis in patients who had not been
diverted compared to 4% in the controls [8].
In 2008 Weston-Petrides, etal., published a meta-analysis for the data available
from 1978 through 2005 from all comparative studies looking at restorative proctocolectomy with or without covering ileostomy [11]. This analysis indicated that
restorative proctocolectomy without a diverting loop ileostomy resulted in similar
long-term functional results but was associated with an increased risk for anastomotic leak and pelvic sepsis. The conclusion of the authors was that the loop ileostomy should only be omitted in carefully selected patients.
The goal of avoiding an anastomotic leak is worthwhile as poor anastomotic
healing has major consequences both in the short and long term. Pelvic sepsis after
ileal pouch-anal anastomosis has signicant effects on long-term outcomes. For
instance, patients who experience pelvic sepsis are ve times more likely to require
excision of their pouches when compared to those patients who avoided anastomotic leaks and pelvic sepsis [1, 32, 33]. Those patients who have pelvic sepsis but
are able to retain their pouches were more likely to have anal incontinence [1].
While many of the studies looking at the value of fecal diversion focus on the
risk for anastomotic leak, there are other considerations that come into play when
deciding which operative strategy is best for the patient. Studies looking at the total
length of stay and total costs have favored the approach of performing the ileoanal
anastomosis without the loop ileostomy. While performing the operation in a single
step tends to lead to a longer initial hospitalization, when the length of hospital stay
for the reversal of the loop ileostomy is taken into account the total hospitalization
is shorter with the one step approach [9, 12, 14, 16–18, 20, 21, 26, 28]. Additionally
total costs have been shown to be lower in those patients undergoing the procedure
without a diverting loop ileostomy [28].
When considering a staged approach the morbidity associated with the loop ileostomy itself must also be considered [34]. Some have suggested that the overall
morbidity associated with loop ileostomy is substantial [35, 36], but others have
noted that severe complications are not frequent [37]. Additionally a large study
published in 2005 involving 1504 patients from the Cleveland Clinic demonstrated
that closure of the ileostomy can be accomplished with an overall complication rate
of 11.4% and a risk of intra-abdominal sepsis of only 1% [38]. Additionally an
aggressive and coordinated approach of managing stoma patients can greatly diminish the incidence of stoma related dehydration and need for readmission [39].
49
Initial Colectomy Prior toIPAA
The value of an initial total abdominal colectomy prior to ileal pouch-anal anastomosis in patients with intra-abdominal sepsis or severe co-morbid disease has not
been subject to comparative studies as the risks to these patients would be difcult
to justify. However, reports of patients who have undergone either a two or three
step approach have identied certain parameters under which a three stage approach
50
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would be prefered [40–42]. Traditionally these have included urgent surgery, sepsis,
fulminate disease, anemia, hypoalbuminemia, steroids, and uncertain diagnosis [3,
5, 42, 43].
A more recent and signicant controversy surrounds the risks for perioperative
complications for patients who are being treated with anti-TNF and other biologic
agents. In 2005 the anti-TNF antibody, iniximab, was approved for use in patients
with ulcerative colitis [44]. Shortly after the widespread use of iniximab for the
treatment of ulcerative colitis, the Mayo Clinic and the Cleveland Clinic both
reported a substantial increase in postoperative related infectious complications in
ulcerative colitis patients treated with iniximab [45, 46]. This nding is not entirely
consistent across all reports and is somewhat surprising given that prior to this infliximab had been used for many years in the treatment of Crohn’s disease and no
signicant increase in perioperative complications has been seen in these patients
[47–53]. This may be explained by the fact that the ileal pouch-anal anastomosis is
normally a high risk anastomosis even under ideal conditions. It may well be that
iniximab generates a relatively small effect on healing in general, but that this
effect is magnied with this very delicate anastomosis.
In response to the ndings suggesting that anti-TNF therapy increases risk for
anastomotic leaks, many surgeons have changed their approach to the surgical management by utilizing a three-step approach in patients treated with anti-TNF agents
[54, 55]. In a study from the Cleveland Clinic, Gu etal. looked at patients undergoing surgery for ulcerative colitis without an initial total abdominal colectomy [54].
They found that those patients on anti-TNF therapy had a signicantly greater risk
for pelvic sepsis (32% versus 16%; p=0.012) when the procedure is not staged with
an initial total abdominal colectomy. However, they reported no difference in outcomes between the patients who had been treated with anti-TNF therapy as compared to those who had never been treated with anti-TNF agents when patients
initially undergo a staged colectomy. These ndings not only indicate that the use of
anti-TNF therapy increases the risk for septic complications, they also indicate that
utilizing an initial total abdominal colectomy can mitigate the negative effects of the
anti-TNF agents.
R. D. Hurst
Recommendations Based ontheData
1. A diverting loop ileostomy may be omitted in highly selected patients undergo-
ing ileal pouch-anal anastomosis. (Weak Recommendation based upon lowquality of evidence)
From the current available data it is difcult to give strong recommendations
as to appropriateness of omitting a diverting loop ileostomy with restorative
proctocolectomy. Even investigators intimately involved in the subject have had
difculties with this. For instance in 1992 Sagar, etal. initially reported a comparison of one stage versus two-stage ileoanal procedures and found no signicant difference in the risk for anastomotic leaks or other complications and
concluded that omission of the loop ileostomy may be a reasonable option in
4 Elective Surgical Management inPatients withUlcerative Colitis: How Many Stages?
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51
selected patients [17]. The same group later reported in 1997 that with further
experience they found that patients undergoing a one stage restorative proctocolectomy had signicantly higher risk for severe septic complications and
cautioned against the routine use of a one stage proctocolectomy [9]. Additionally
Tjandra etal. initially reported 1994 a matched control study and found that in
equally favorable cases restorative proctocolectomy without diversion was not
as safe as with diversion [8]. The same institution later reported a retrospective
study indicating no difference in septic complications [27]. The senior author on
both of these studies subsequently co-authored a meta-analysis indicating that
restorative proctocolectomy without a diverting ileostomy was associated with
an increased risk for anastomotic leak [11].
Even with these difculties, there is general consensus among experts that the
diverting loop ileostomy can be omitted in highly selected patients. And this has
been the recommendation from expert panels from both Europe and North
America [56, 57]. Patient selected for omission of loop ileostomy are best not to
have any of the risk factors listed in Table 4.5. Despite the recommendations
from expert panels that omission of the loop ileostomy is reasonable in selected
patients, many practicing surgeons appear to adopt a very conservative approach
to this issue. A 2009 survey of colorectal surgeons in North America indicated
that 73% would perform a diverting loop ileostomy even in low risk patients. [58]
2. Ulcerative colitis patients with sepsis, severe comorbid factors, or who have
been treated with anti-TNF therapy should undergo an initial total abdominal
colectomy prior to ileal pouch-anal anastomosis. (Weak recommendation based
upon low-quality of evidence)
There is little controversy that the sickest of patients should undergo a three
stage approach. At the same time, there is insufcient evidence to accurately
delineate the circumstances in which the three stage approach is the best option.
Table 4.5 Factors that may
increase risk for poor
anastomoic healing
Factors that may increase risk for poor anastomotic
healing
1. Severe or fulminate colitis
2. Sepsis
3. Malnutrition
4. Hypoalbuminemia
5. Obesity
6. Technical difculties
7. Steroid use
8. Use of immunosuppressants
9. Technical concerns
10. Tension on anastomosis
11. Fecal contamination
12. Anemia
13. Anti-TNF therapy
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R. D. Hurst
Early evidence suggests that the use of anti-TNF therapy poses a risk for increase
in anastomotic leaks and pelvic sepsis and that these risks can be diminished by
utilizing a three-stage approach [54]. Further study however is required to
conrm the advantage of this approach. Even less is known about the effects on
healing with other biologics such as anti-integrins and JAK inhibitors.
A Personal View oftheData
Unfortunately the data on the value of staging the surgeries for the ileoanal procedure are conicting. Thus, it is truly a difcult decision as to whether to omit the
diverting loop ileostomy. Likewise it is also a difcult decision as when to perform
an initial total abdominal colectomy prior to the ileoanal procedure. Ultimately it is
up to the discretion of the experienced surgeon working in concert with the patient’s
wishes to determine the best approach for each individual case.
In the past as many as one third of this author’s patients underwent an ileoanal
procedure in a single step. With the advent of anti-TNF therapy this however has
changed and now most patients in my practice undergo surgery with a staged
approach. The reports of poor anastomotic healing with anti-TNF therapy are concerning. This combined with my personal, albeit antidotal, experience with anastomotic problems in patients receiving anti-TNF therapy has made staging in my
practice much more common. Additionally, the decision to stage the operations has
become somewhat more attractive with the advent of laparoscopic surgery. The
decrease morbidity and enhanced recovery after laparoscopic total abdominal colectomy makes the decision for staging easier to accept as it is much better tolerated
than an open procedure [59].
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4 Elective Surgical Management inPatients withUlcerative Colitis: How Many Stages?
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20. Hainsworth PJ, Bartolo DC.Selective omission of loop ileostomy in restorative proctocolectomy. Int J Color Dis. 1998;13:119–23.
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24. Heuschen UA, Hinz U, Allemeyer EH, Lucas M, Heuschen G, Herfarth C.One- or two-stage
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27. Remzi FH, Fazio VW, Gorgun E, etal. The outcome after restorative proctocolectomy with or
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28. Joyce MR, Kiran RP, Remzi FH, Church J, Fazio VW.In a select group of patients meeting
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29. Gray BW, Drongowski RA, Hirschl RB, Geiger JD. Restorative proctocolectomy without
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31. Olecki EJ, Kroni AP, Stahl KA, King S, Razavi NC, Koltun WA.Stoma-less IPAA is not
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32. Heuschen UA, Allemeyer EH, Hinz U, Lucas M, Herfarth C, Heuschen G.Outcome after
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33. Gorne SR, Fichera A, Harris MT, Bauer JJ.Long-term results of salvage surgery for septic
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34. Kaidar-Person O, Person B, Wexner SD.Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg. 2005;201:759–73.
35. Metcalf AM, Dozois RR, Beart RW, Kelly KA, Wolff BG. Temporary ileostomy for ileal
pouch-anal anastomosis. Function and complications. Dis Colon Rectum. 1986;29:300–3.
36. Park J, Gessler B, Block M, Angenete E.Complications and morbidity associated with loop
ileostomies in patients with ulcerative colitis. Scand J Surg. 2018;107:38–42.
37. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT.Techniques and complications
of ileostomy takedown. Am J Surg. 1999;177:463–6.
38. Wong KS, Remzi FH, Gorgun E, etal. Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum. 2005;48:243–50.
39. Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V.Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55:1266–72.
40. Nicholls RJ, Holt SD, Lubowski DZ. Restorative proctocolectomy with ileal reservoir.
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41. Bikhchandani J, Polites SF, Wagie AE, Habermann EB, Cima RR.National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis. Dis Colon Rectum.
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43. Hyman NH, Cataldo P, Osler T.Urgent subtotal colectomy for severe inammatory bowel
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45. Selvasekar CR, Cima RR, Larson DW, etal. Effect of iniximab on short-term complications in
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47. Marchal L, D’Haens G, Van Assche G, etal. The risk of post-operative complications associated with iniximab therapy for Crohn’s disease: a controlled cohort study. Aliment Pharmacol
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4 Elective Surgical Management inPatients withUlcerative Colitis: How Many Stages?
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54. Gu J, Remzi FH, Shen B, Vogel JD, Kiran RP. Operative strategy modies risk of pouchrelated outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α
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Which Patients withUlcerative Colitis
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Benefit fromIleal Pouch-Anal
Anastomosis?
RodrigoAreán-Sanz andEvangelosMessaris
Given the long-term bowel function and patient satisfaction rates, proctocolectomy
with ileal pouch-anal anastomosis (IPAA) is considered the standard procedure for
the surgical treatment of ulcerative colitis (UC), with 10-20% of patients undergoing IPAA due to failure of medical treatment or dysplasia. [1–3] However, shortand long-term complications (e.g. pouchitis, pouch failure, increased stool
frequency, anal stenosis, and incontinence) are reported in up to 50% of patients
[4–6], making it essential to determine which patients are at higher risk and could
benet from an alternative, non-restorative procedure (i.e. proctocolectomy with
end ileostomy). The most vulnerable groups are patients with obesity and those with
increased risk of incontinence, mainly elderly patients and individuals with a history of sphincter abnormalities [7].
5
PICO Table:
Population:
Patients with ulcerative
colitis treated with total
proctocolectomy and ileal
pouch-anal anastomosis
R. Areán-Sanz (*) · E. Messaris
Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, MA, USA
e-mail: rareansa@bidmc.harvard.edu; emessari@bidmc.harvard.edu
© 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_5
Intervention: Comparator:
Ileal pouch-
anal
anastomosis
Patients with ulcerative
colitis treated with total
proctocolectomy and end
ileostomy
Outcome:
Mortality,
complications,
quality of life,
costs.
57
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R. Areán-Sanz and E. Messaris
Search Strategy
Referenced publications were identied through a comprehensive search of Pubmed,
Medline, and Cochrane using the following search terms: “ulcerative colitis”,
“restorative surgery”, “ileal pouch-anal anastomosis”, “ileostomy”, “pouch”, and
“proctocolectomy”. Articles published from 1985 to 2022 were reviewed for the
present book chapter. Studies comparing IPAA to ileostomy for UC as well as publications on factors associated with poor short- and long-term outcomes were synthesized and compared. Papers that analyzed patients diagnosed with Crohn’s
disease or any other colorectal condition were only included if a subgroup analysis
of patients diagnosed with UC was performed. Additional studies deemed relevant
for inclusion in this chapter were identied via review of the included publications’
references.
Results
IPAA has been the preferred procedure for surgical management of UC for many
years as it allows for restoration of gastrointestinal continuity with outcomes that
are comparable or superior to total proctocolectomy with end ileostomy. As a result,
there have not been many recent studies that directly compare the outcomes of
IPAA versus those with end ileostomy in terms of morbidity and quality of life.
(Table5.1).
Most studies that have used validated quality of life scales have found that there
are no major differences between IPAA and total proctocolectomy with end ileostomy in terms of patient quality of life. [8–16] However, a study by Emblem etal.
[8] found that patients who underwent ileostomy for UC had higher rates of urinary
and sexual dysfunction, whereas patients who underwent IPAA used antidiarrheal
agents more frequently. O’Birchere etal. [11] found that diet changes and altered
bowel habits were the only outcomes that were superior for ileostomy patients. On
the other hand, social functioning and emotional functioning, as measured by the
SF-36 and IBDQ questionnaires respectively, were signicantly better in patients
who underwent IPAA [12].
Similarly, Kuruvilla etal. [14] conducted a cross-sectional study comparing 35
IPAA patients and 24 ileostomy patients, and found no signicant difference in
disease-specic and health-related quality of life at 1year, as measured by ve validated scores: EQ-5D-3L, Short Quality of Life in Inammatory Bowel Disease
Questionnaire, Cleveland Global Quality of Life, Fecal Incontinence Quality of
Life Scale, and Stoma Quality of Life Scale.
In line with the superior quality of life reported for restorative procedures, medical care costs that take surgical and long-term management into account are higher
for patients who undergo ileostomy. A study by Van der Valk etal. [15] compared
care costs and quality of life between the two surgical options during a follow-up of
2years and found that ileostomy patients needed to visit a specialized nurse and
surgeon more frequently and required more hospitalizations than IPAA patients.
5 Which Patients withUlcerative Colitis Benet fromIleal Pouch-Anal Anastomosis?
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59
Table 5.1 Included publications and main ndings
No. of patients
Study
Emblem etal.
(1988) [8]
(IPAA v
Ileostomy) Outcome evaluated Results
14 v 22 Dietary restrictions
Use of antidiarrheal
Urinary dysfunction
Sexual dysfunction
No difference
79% v 9%
(p<0.01)
0% v 32%
Quality of
evidence
Low
(p<0.05)
0% v 36%
(p<0.05)
McLeod etal.
(1991) [9]
Liddell etal.
(1995) [10]
37 v 28 TTOT
DQO
25 v 10 Overall satisfaction
(subdivided by specic
No difference
Moderate
No difference
No difference Low
activity satisfaction)
O’Birchere
(2000) [11]
Nordin etal.
(2002) [12]
30 v 30 SF-36
Body image (VAS)
Altered bowel emptying (VAS)
Odor (VAS)
Noise (VAS)
Sexual relationship
Clothes
Diet
57 v 42 SF-36
– Social functioning
– Rest of components
IBDQ
– Emotional
functioning
No difference
No difference
8.0 vs 5.0
No difference
No difference
No difference
No difference
5.5 vs 2.0
70.2 v 89.3
(p<0.05)
No difference
64.8 v 72.2
(p<0.01)
No difference
Moderate
Moderate
– Rest of components
CamilleriBrennan etal.
19 v 19 IBDQ
SF-36
No difference
No difference
High
(2003) [13]
Kuruvilla etal.
(2012) [14]
van der Valk
etal. (2015) [15]
35 v 24 EQ-5D-3L
SIBDQ scores
CGQL score (Fazio
score)
FIQL scale
SQOL scale
81 v 48 Costs
IBDQ
No difference
No difference
0.9 v 0.8
(p<0.05)
No difference
IPAA >
Ileostomy
a
3-fold higher
costs for
Moderate
Moderate
ileostomy
No difference
Hassab etal.
(2022) [16]
95 v 297 30-day readmission
Other 30-day
complications
29.5 v 16.8
(p<0.05)
No difference
Moderate
SIBDQ Short Quality of Life in Inammatory Bowel Disease Questionnaire, CGQL Cleveland
Global Quality of Life, FIQL Fecal Incontinence Quality of Life Scale, SQOL Stoma Quality of
Life Scale, TTOT Time Trade-Off Technique, DQO Direct Questioning of Objections, SF36 ShortForm 36, VAS Visual analogue scale, IBDQ Inammatory Bowel Disease Questionnaire
a
IPAA was superior than ileostomy in: sexuality/body, work/social function, and skin irritation
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