Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1515_Библиотеки_им_академика_М_И_Перельмана
.pdf
390 G.G. Delaini, G. Colucci, F. Nifosì
sis in patients with familial adenomatous polyposis.
Dis Colon Rectum 42:1028–1033
22. Van DP, Slors JF, Taat CW et al (1999) Functional out-
come after colectomy and ileorectal anastomosis com-
pared with proctocolectomy and ileal pouch-anal
anastomosis in familial adenomatous polyposis. Ann
Surg 230:648–654
23. Gardner EJ (1962) Follow-up study of a family group
exhibiting dominant inheritance for a syndrome
including intestinal polyps, osteomas, fibromas and
epidermal cyst. Am J Hum Genet 14:390
24. Turcot J, Despres J, St. Pierre F (1959) Malignant
tumors of the central nervous system associated with
familial polyposis of the colon: report of two cases. Dis
Colon Rectum 2:468
25. Clark SK, Phillips RK (1996) Desmoids in familial ade-
nomatous polyposis. Br J Surg 83:1494–1504
26. Knudsen AL, Bulow S (2000) [Desmoid tumor in
familial adenomatous polyposis] Ugeskr Laeger.
162:5628–5631
27. Gonzalez CF, Herranz AF, Duran MR et al (1994)
[Obstructive uropathy in Gardner syndrome: a new
case and an alternative therapeutic option]. Actas Urol
Esp 18:128–132
28. Campos FG, Habr-Gama A, Kiss DR et al (2003)
[Extracolonic manifestations of familial adenomatous
polyposis: incidence and impact on the disease out-
come] Arq Gastroenterol 40:92–98
29. Shields C J, Winter D C, Kirwan WO, Redmond HP
(2001) Desmoid tumours. Eur J Surg Oncol 2:122–135
30. Klemmer S, Pascoe L, DeCosse J (1987) Occurrence of
desmoids in patients with familial adenomatous poly-
posis of the colon. Am J Med Genet 28:385–392
31. Bessler W, Egloff B, Sulser H (1984) Case report 253.
Gardner syndrome with aggressive fibromatosis.
Skeletal Radiol 11:56–59
32. Araki Y, Isomoto H, Shirouzu K et al (1991) Occur-
rence of desmoid tumors following surgery for famil-
ial adenomatosis coli – report of two cases. Kurume
Med J 38:9–14
33. Clark SK, Smith TG, Katz DE et al (1998) Identification
and progression of a desmoid precursor lesion in
patients with familial adenomatous polyposis. Br J
Surg 85:970–973
34. Hartley JE, Church JM, Gupta S et al (2004) Signifi-
cance of incidental desmoids identified during surgery
for familial adenomatous polyposis. Dis Colon Rec-
tum 47:334–338
35. Church J, Berk T, Boman BM et al (2005) Staging intra-
abdominal desmoid tumors in familial adenomatous
polyposis: a search for a uniform approach to a trou-
bling disease. Dis Colon Rectum 48:1528–1534
36. Jones IT, Jagelman DG, Fazio VW et al (1986) Desmoid
tumor in patients with familial polyposis coli. Ann
Surg 204:94–97
37. Tsukada K, Church JM, Jagelman DG et al (1991) Sys-
temic cytotoxic chemotherapy and radiation therapy
for desmoid in familial adenomatous polyposis. Dis
Colon Rectum 34:1090–1092
38. Poritz LS, Blackstein M, Berk T et al (2001) Extended
follow-up of patients treated with cytotoxic chemother-
apy for intra-abdominal desmoid tumors Dis Colon
Rectum 44:1268–1273
39. Patel SR, Benjamin RS (2006) Desmoid tumors
respond to chemotherapy: defying the dogma in
oncology. J Clin Oncol 24:11–12
40. Lynch HT, Fitzgibbons R Jr, Chong S et al (1994) Use
of doxorubicin and dacarbazine for the management
of unresectable intra-abdominal desmoid tumors in
Gardner’s syndrome. Dis Colon Rectum 37:260–267
41. Tsukada K, Church JM, Jagelman DG et al (1992) Non-
cytotoxic drug therapy for intra-abdominal desmoid
tumor in patients with familial adenomatous polypo-
sis. Dis Colon Rectum 35:29–33
42. Kulaylat MN, Karakousis CP, Keaney CM et al (1999)
Desmoid tumour: a pleomorphic lesion. Eur J Surg
Oncol 25:487–497
43. Tonelli F, Ficari F, Valanzano R, Brandi ML (2003)
Treatment of desmoids and mesenteric fibromatosis
in familial adenomatous polyposis with raloxifene.
Tumori 89:391–396
44. Bauernhofer T, Stoger H, Schmid M et al (1996)
Sequential treatment of recurrent mesenteric desmoid
tumor Cancer 77:1061–1065
45. Mace J, Sybil B , Sondak V et al (2002) Response of
extraabdominal desmoid tumors to therapy with ima-
tinib mesylate. Cancer 95:2373–2379
46. Berk T, Cohen Z, McLeod RS, Stern HS (1992) Man-
agement of mesenteric desmoid tumours in familial
adenomatous polyposis. Can J Surg 35:393–395
47. Clark SK, Neale KF, Landgrebe JC, Phillips RK (1999)
Desmoid tumours complicating familial adenomatous
polyposis. Br J Surg 86:1185–1189
48. Kadmon M, Moslein G, Buhr HJ, Herfarth C (1995)
[Desmoid tumors in patients with familial adenoma-
tous polyposis (FAP) Clinical and therapeutic obser-
vations from the Heidelberg polyposis register].
Chirurg 66:997–1005
49. Chatzipetrou MA, Tzakis AG, Pinna AD et al (2001)
Intestinal transplantation for the treatment of
desmoid tumors associated with familial adenomatous
polyposis. Surgery 129:277–281
50. Gajate ML, Elias ME, Martinez PA et al (2004) [Intesti-
nal transplantation in adults: present situation and
future prospects]. Rev Esp Anestesiol Reanim
51:537–548
51. Lattimer JK, Birkhoff J, Olsson CA (1987) The treat-
ment of ureteral obstruction in Gardner’s syndrome:
renal autotransplantation. J Urol 138:133–135
52. Soon JL, Lau WK, Seow-Choen F, Cheng CW (2005)
Unresectable desmoid tumours causing obstructive
uropathy in familial adenomatous polyposis. Asian J
Surg 28:233–237
53. Jovine E, Masetti M, Cautero N et al (2002) Modified
multivisceral transplantation without a liver graft for
Gardner/Desmoid syndrome and chronic intestinal
pseudo-obstruction. Transplant Proc 34:911–912
54. Misiakos EP, Pinna A, Kato T et al (1999) Recurrence
of desmoid tumor in a multivisceral transplant patient
with Gardner’s syndrome. Transplantation 67:1197–1199
Introduction
Surgery for Familial Adenomatous Polyposis
The surgical treatment of familial adenomatous poly-
posis (FAP) is aimed at minimising the risk of col-
orectal cancer whilst leaving the patient with a good
functional outcome and one that is socially accept-
able to them [1]. The ideal operation for FAP should
therefore be safe with regards to post-operative mor-
bidity and mortality, preserve faecal continence,
spare pelvic innervation to the sexual organs, and
eliminate cancer risk [2]. Because patients with FAP
are generally young and often asymptomatic at the
time of presentation for surgery, the prospect of
undergoing a “proctocolectomy and end ileostomy”
is one they understandably find difficult to accept,
making surgical options for FAP that remove the
need for a permanent stoma attractive. The two most
common options that offer this are the “colectomy
and ileo-rectal anastomosis” (IRA) and “procto-
colectomy with ileal pouch anal anastomosis”
(IPAA), with no clear consensus on which of these
two options is the best first-line treatment. This is
because surgery that preserves intestinal continuity
for FAP involves balancing certain risks and benefits,
all of which must be taken into account individually
before the final surgical option is decided. These are
considered in turn below.
Rectal Cancer Risk
IRA carries a definite cancer risk in FAP due to the
remaining rectal stump [3, 4], with a long-term rectal
cancer risk reported to increase from 4% at 5 years to
25% at 20 years post-operatively [5]. More recently it
has been suggested that absolute patient age is the
determinant factor for cancer development rather
than the length of post-operative follow-up [6]. This
has led some to suggest that IRA should be convert-
ed to IPAA before the age of 50 [7]. Several factors are
thought to increase the rectal cancer risk with IRA,
namely colorectal polyp density, and presence of col-
orectal cancer at presentation, both of which are
associated with higher proctectomy rates [8, 9]. Sup-
porting this is the finding that having greater than
1000 adenomas in the colon is associated with double
the risk of developing colorectal cancer [10]. Other
factors thought to increase colorectal cancer risk in
the retained rectum include length of rectal stump
[11], age of patient at surgery [8], site of the APC
mutation [8, 9] and adequacy of rectal surveillance
[12]. Despite this, recent evidence does suggest a role
for performing IRA in selected patients with FAP,
namely those with relative rectal sparing (<10 adeno-
mas), attenuated adenomatous polyposis coli or in
adolescents and teenagers with mild polyposis coli
[13, 14]. A study by Church et al. found IRA per-
formed since 1983 (termed the “IPAA era”) to carry a
significantly lower rate of proctectomy for rectal can-
cer than those performed before 1983 (termed the
“pre-IPAA era”) [15]. The authors attributed this to a
greater number of patients in the IPAA era having
undergone the procedure despite severe polyposis in
order to avoid a permanent ileostomy in an other-
wise young and asymptomatic patient. Although they
demonstrated that careful selection of patients for
IRA can result in a successful outcome, a limitation
of the study was the significantly shorter length of
follow-up in the IPAA era group. With restorative
proctocolectomy and IPAA, although the incidence
of adenomatous polyps in the ileal reservoir and the
risk of malignant transformation is reduced, this
cannot be eliminated [7, 16]. This is particularly the
case with IPAA using stapled anastomosis where
mucosectomy (as in the case of hand-sewn anasto-
mosis) is not possible, and results in retained rectal
mucosa with a potential to undergo adenomatous
change [17-19]. Although both IPAA and IRA reduce
the risk of colorectal cancer in FAP, neither com-
pletely remove this risk, resulting in a requirement
for endoscopic surveillance.
Ileo-Rectal Anastomosis vs. Ileo-Anal Pouch as the
Surgical Treatment for Familial Adenomatous Polyposis
Omer Aziz, Paris Tekkis
392 O. Aziz, P. Tekkis
Functional Outcome
Bowel habit and other functional outcomes are
thought by many to be better preserved and more
physiological with IRA as compared to IPAA [20, 21].
Restorative proctocolectomy with mucosectomy and
hand-sewn IPAA is thought to carry a relatively high-
er risk of postoperative functional impairment and
incontinence due to increased manipulation of the
anal canal [22]. Stapled IPAA, on the other hand,
results in preservation of the anal transition zone
mucosa 1–2 cm above the dentate line, which is
thought to be important in the control of continence.
This has been shown by many to result in better func-
tional outcome and quality of life after IPAA [13, 19,
22]. In the case of IPAA, it has been suggested that
functional outcome is poorer in patients with ulcera-
tive colitis (UC) than those with FAP [23]. It has also
been suggested that secondary IPAA, often per-
formed following failed IRA (due to rectal cancer or
poor functional outcome), is associated with poorer
bowel function than a primary IPAA procedure [24].
Post-operative Morbidity
Although both IPAA and IRA procedures qualify as
major abdominal operations, performing an IRA is
perceived as being an easier and less complicated
procedure, associated with less post-operative mor-
bidity [15]. Factors that are thought to play a part in
this include increased operative time, hospital stay
and blood loss, all of which have been suggested as
being greater with IPAA [13]. This procedure may
also involve the formation of a temporary defunc-
tioning ileostomy in order to minimise the risk of
anastomotic leakage and pelvis sepsis [25]. There are
however complications and disadvantages related to
this additional procedure, which requires closure
under general anaesthetic at a later date [26, 27]. This
has led to several groups avoiding defunctioning
ileostomy with IPAA altogether, with encouraging
results [27, 28]. The question of whether IRA is suit-
able for young patients, who are more likely to
require a later rectal excision due to polyp recurrence
or rectal cancer, or whether these patients are better
served with a one-stage restorative proctocolectomy,
mucosectomy, and IPAA, particularly in those with
severe FAP phenotype, has been considered and
remains to be answered [13]. Secondary IPAA is a
procedure in which technical difficulties are more
common than primary IPAA for both UC and FAP
[29, 30], with some suggesting significantly higher
complication rates due to technical difficulties and
increased age at presentation [31], and others sug-
gesting that it can be performed safely [20].
Long-term Complications
Desmoid tumours are known to occur in 5–15% of
patients with FAP and known to cluster in families
[32]. The conversion of IRA to IPAA may not be pos-
sible due to the presence of low rectal cancer or an
abdominal desmoid tumour [24]. The question of
whether an IPAA or IRA affects the development
of intra-abdominal desmoid tumour is also unclear
[33, 34], with some suggesting that this may be
greater in IPAA due to increased handling and
mobilisation of the small bowel mesentery [14].
Other long-term adverse events include perianal irri-
tation and anastomotic stricture formation [35].
Quality of Life
The risk of sexual dysfunction is also thought to be
greater with IPAA as compared to IRA, mainly due to
the increased handling of the pelvic floor and there-
fore risk of nerve damage [2]. Other factors that
affect a patient’s the quality life are restrictions to
their social activities (including occupation), and
changes to their diet in order to maintain manage-
able bowel function [35]. Scoring systems such as the
“Short Form-36 Health Survey questionnaire” and
“European Organisation for Research and Treatment
of Cancer QoL questionnaire” have been used to
compare IPAA and IRA for FAP, with inconclusive
results [36], whilst other systems have suggested bet-
ter results following IPAA for FAP [
37].
Current Evidence
Whilst it is clear that the ideal surgical intervention
for FAP would involve minimal colorectal malignan-
cy risk, whilst obtaining a good functional outcome,
quality of life, and low post-operative morbidity; it is
unclear from the literature as to which of the IPAA
and IRA techniques best offer this, and in which
patients. This chapter aims to systematically review
and present the existing comparative literature on
IPAA as compared to IRA for the primary treatment
of FAP, using meta-analytic techniques where appro-
priate. The specific questions that we aim to answer
are:
• does one technique carry significantly less early
post-operative morbidity (bowel obstruction,
haemorrhage, intra-abdominal sepsis, anastomot-
ic separation, wound infection and need for re-
operation within 30 days) than the other?
• How does the functional outcome compare
between the two techniques with regards to stool
frequency, urgency, night defecation, inconti-
Ileo-Rectal Anastomosis vs. Ileo-Anal Pouch as the Surgical Treatment for Familial Adenomatous Polyposis 393
nence, pad requirement and need for anti-diar-
rhoeal medication?
• Is there a significant difference in the dietary
restrictions and social dysfunction between IRA
and IPAA techniques?
• How does male and female sexual dysfunction
compare between the two techniques?
• What are differences between IPAA and IRA in the
incidence of long-term complications (anastomotic
stricture, perianal irritation, intra-abdominal
desmoid formation and cancer in the pouch/rectum)?
Please note that where appropriate meta-analysis
of these outcomes has been performed in line with
recommendations from the Cochrane Collaboration
and the Quality of Reporting of Meta-analyses (QUO-
RUM) guidelines [38, 39]. Statistical analysis for cat-
egorical variables has been carried out using the odds
ratio as the summary statistic. This ratio represents
the odds of an adverse event occurring in the IPAA
group compared with the IRA group. An odds ratio
of less than one favours the IPAA group, and the
point estimate of the odds ratio is considered statis-
tically significant at the p<0.05 level if the 95% confi-
dence interval does not include the value one. For
continuous variables such as bowel frequency per 24-
h period, statistical analysis has been carried out
using the weighted mean difference (WMD) as the
summary statistic [40]. For studies that presented
continuous data as means and range values, the stan-
dard deviations (SD) have been calculated using sta-
tistical algorithms and checked using “bootstrap” re-
sampling techniques. Thus all continuous data have
been standardised for analysis.
Literature Review
Since 1991, seventeen studies comparing the results
from primary IRA and primary IPAA for FAP [2, 13,
14, 20, 25,29, 31, 35-37, 41-48] have been published in
the peer-reviewed literature (including all lan-
guages). One of these studies reported on a mixed
patient group of both FAP and UC patients [47],
making it difficult to draw conclusions from its
results. In addition to this, in four papers, the authors
reported on overlapping patient groups (these
patients had already been reported on in another
paper) [25, 36, 45, 46]. In this case the most informa-
tive and highest quality paper was selected to repre-
sent this patient group. The results from the remain-
ing twelve studies (containing 1002 subjects) pub-
lished between 1991 and 2003 comparing primary
IPAA to primary IRA for FAP and were therefore
included in this review [2, 13, 14, 20, 29, 31, 35, 37, 41-
44]. Table 1 shows the characteristics of these twelve
studies with 535 (53.3%) patients undergoing IPAA
Table 1. Characteristics of studies included in the systematic review
Author Institution Year Design IPAA IRA Group Male Follow-up
(%) (months)
Madden [35] St. Marks 1991 R 24 62 IPAA 42 62
IRA 53 78
Ambrose [2] Mayo Clinic, 1992 R 91 18 IPAA 55 48
Minnesota IRA 56 72
Rodriguez [42] Santander, 1992 R 11 8 IPAA 55 26
Spain IRA 25 3
Penna [29] St. Antoine, Paris 1993 R 120 23 IPAA N/A N/A
IRA
Ziv [13] Cleveland Clinic, 1995 R 717IPAA 57 36
Ohio RA 53 46
Rotondano [43] Napoli, Italy 1997 R 15 25 IPAA N/A 46
IRA 54
Tonelli [14] Florence, Italy 1997 Pr 24 14 IPAA 63 61
IRA 57 82
Soravia [20, 24] Mount Sinai, 1999 R 38 60 IPAA 48 72
Toronto IRA 42 92.4
Van Leiden, 1999 R 118 161 IPAA 57 79
Duijvendijk [44] Netherlands IRA 49 144
Ko [41] Lahey Clinic, 2000 R 30 14 IPAA N/A 120
Massatussets IRA 168
Bjork [31] Multicentre, 2001 R 20 43 IPAA 40 84
Sweden IRA 51 128
Gunther [37] Erlangen, 2003 R 37 22 IPAA 59 118
Germany IRA 50 180
R, retrospective patient identification, prospective data collection; Pr, prospective study
394 O. Aziz, P. Tekkis
and 467 (46.7%) undergoing IRA as the primary
treatment for FAP. Please note that the mean/median
length of follow-up for both IPAA and IRA groups
was at least 36 months in all but one study.
Early Post-Operative Morbidity
Early post-operative complications such as bowel
obstruction, haemorrhage, intra-abdominal sepsis,
anastomotic separation, wound infection, and the
need for 30-day re-operation were reported by the
ten studies shown in Table 2. The results from meta-
analysis of post-operative complications from these
studies are shown in the Forrest plot in Fig. 1. Please
note that squares indicate point estimates of treat-
ment effect (odds ratio), with the size of the square
representing the weight attributed to each study and
95% confidence intervals indicated by horizontal
bars. The diamond represents the summary odds
ratio from the pooled studies with 95% confidence
intervals. There was no significant difference
between IRA and IPAA groups in the incidence of
bowel obstruction, post-operative haemorrhage,
intra-abdominal sepsis, anastomotic separation, and
post-operative wound infection. There was however
a significantly reduced need for re-operation within
30 days of 11.6% with IRA vs. 23.4% with IPAA (OR
2.11, CI 1.21-3.70).
Long-Term Complications
Long-term adverse events such as perianal irritation,
anastomotic stricture, desmoid formation, cancer in
pouch/rectum, and need for further operation on the
pouch (IPAA) or rectum (IRA) were reported by the
ten studies shown in Table 3. It is important to note
that further operation on the rectum after IRA
involves excision of retained rectum and either proc-
tectomy or secondary IPAA, whereas in the case of
IPAA this involves either a redo IPAA or pouch exci-
sion and end ileostomy. The results from meta-
analysis of post-operative complications from these
studies are shown in the Forrest plot in Figure 2.
Results significantly favouring IRA over IPAA
included a reduced incidence of perianal irritation of
57.4% with IRA as compared to 62.7% with IPAA
(OR=2.48, CI 1.36–4.55), and reduced incidence of
anastomotic stricture formation of 2% with IRA vs.
8.1% following IPAA. Results significantly favouring
IPAA over IRA included a reduced incidence of can-
cer in the pouch or retained rectum at 0% (0/187) fol-
lowing IPAA vs. 5.5% after IRA group (OR=0.13, CI
0.03–0.61), and a reduced need for further surgery to
the pouch or rectum of 3.1% in the IPAA vs. 27.7% in
the IRA group. There was no significant difference
between IPAA and IRA groups in the incidence of
intra-abdominal desmoids.
Dietary Restriction, Social and Sexual Dysfunction
The studies reporting on dietary restriction, social
restriction, and sexual dysfunction are shown in
Table 4. The results from meta-analysis of these out-
comes are shown in the Forrest plot in Figs. 3 and 4.
The incidence of social restrictions following 58
IPAA and 85 IRA procedures (33, 35), was found to
be significantly lower at 3.5% following IRA as com-
pared to 13.8% following IPAA (OR=6.04, CI
1.53–23.78). There was no significant difference
between IPAA and IRA in terms of need for dietary
restriction and male and female sexual dysfunction.
Table 2. Studies reporting early post-operative complications
Author Early post-operative complications
Bowel Haemorrhage Abdominal Anastomotic Wound
30
-day
obstruction sepsis separation infection reoperation
Ambrose [2]* *
Bjork [31]******
Gunther [37]*** **
Madden [35]******
Penna [29]* *
Rodriguez [42]* ** *
Soravia [20, 24]* * * **
Tonelli [14]* * *
Van Duijvendijk [44]* * *
Ziv [13]* *
Ileo-Rectal Anastomosis vs. Ileo-Anal Pouch as the Surgical Treatment for Familial Adenomatous Polyposis 395
Fig. 1. Meta-analysis of post-operative complications
396 O. Aziz, P. Tekkis
Table 3. Studies reporting long-term complications
Author Long-term complications
Perianal Anastomotic Intra-abdominal Cancer in Reoperation
irritation stricture desmoids pouch/rectum on rectum
Ambrose [2]* ***
Bjork [31]* * * *
Ko [41]*
Madden [35]* *
Penna [29]*
Rodriguez [42]**
Soravia [20, 24]*****
Tonelli [14]* * *
Van Duijvendijk [44]*****
Ziv [13]**
Fig. 2. Meta-analysis of long-term complications
Ileo-Rectal Anastomosis vs. Ileo-Anal Pouch as the Surgical Treatment for Familial Adenomatous Polyposis 397
Functional Outcome
The studies reporting on functional outcome includ-
ing bowel frequency (number of motions during the
day, night, or over a 24-h period), need for night
defecation, incontinence (during day, night, or 24-h
period), faecal urgency (inability to hold stool for
more than 15 min), incontinence pad requirement,
and the need for anti-diarrhoeal medication
(Table 5). Figures 5 and 6 shows the results from
meta-analysis of these outcomes and are depicted as
a Forrest plot.
Results significantly favouring IRA over IPAA
included: reduced bowel frequency of 2–6.1 per 24 h
vs. 3.8–8 per 24 h (WMD=1.62, 95% CI 1.05–2.20),
reduced need for night defecation of 8.2 vs. 44.1%
(OR=6.64, CI 2.99–14.74), reduced incontinence dur-
ing the night of 3.8 vs. 21% (OR=8.03, CI 4.22–15.25),
reduced incontinence rate over a 24-h period 30 vs.
50.5
% (OR=2.71, 95% CI 1.81–4.07), and reduced
requirement for incontinence pad use during a 24-h
period of 5.4 vs. 14.5% (OR=2.72, CI 1.02–7.23). The
only functional outcome significantly favouring the
IPAA group was faecal urgency, which was 39.2%
with IRA vs. 14.2% following IPAA (OR=0.43, CI
0.23–0.80). There was no significant difference
between IPAA and IRA groups in bowel frequency at
night, daytime incontinence, and need for anti-diar-
rhoeal medication.
Table 4. Studies reporting dietary restriction, social restriction and sexual dysfunction
Author Quality of life
Dietary Social Male sexual Female sexual
restrictions restrictions dysfunction dysfunction
Ambrose [2]**
Bjork [31]****
Gunther [37]
Ko [41]**
Madden [35]* *
Penna [29]*
Rodriguez [42]**
Rotondano [43]**
Soravia [20, 24]*
Tonelli [14]**
Van Duijvendijk [44]*
Fig. 3. Meta-analysis of dietary and social restrictions
398 O. Aziz, P. Tekkis
Discussion
This systematic review has highlighted some very
important differences in outcome between restora-
tive proctocolectomy and IRA for the patient with
FAP. The results on functional outcome suggest a
favourable outcome towards the IRA procedure with
regards to stool frequency over a 24-h period, need
for defecation at night, incontinence (both over a 24-
h period and at night) and pad usage. These finding
are perhaps expected in a patient with a retained,
functioning rectum. Interestingly, IPAA was not sig-
nificantly different to IRA in stool frequency at night,
day incontinence, and need for anti-diarrhoeal med-
ication, all of which are outcomes that may make it
acceptable for many young patients. Another inter-
Fig. 4. Meta-analysis of sexual dysfunction
Table 5. Studies reporting functional outcome with IPAA vs. IRA
Author Functional outcome
Bowel Night Incontinence Faecal Pad Anti-diarrhoeal
frequency stools urgency use medication
Night
2 4
h Day Night
2 4
h
Ambrose [2]** ** *
Bjork [31]*****
Gunther [37]
Ko [41] *
Madden [35]** ****
Penna [35]**** * *
Rodriguez [42]** *
Rotondano [43]* *
Soravia [20, 24]*****
Tonelli [14]* *** ** *
Van
Duijvendijk [44]* * * * * *
Ziv [13]* *
Ileo-Rectal Anastomosis vs. Ileo-Anal Pouch as the Surgical Treatment for Familial Adenomatous Polyposis 399
esting finding was that faecal urgency (the ability to
defer defecation for at least 15 min) was significantly
better in the IPAA group. This finding is important,
as urgency can be a very detrimental outcome, par-
ticularly with regards to patient embarrassment,
social behaviour, and ultimately patient satisfaction
with the IRA procedure. A patient may therefore pre-
fer the IPAA and increased frequency of stools, or
even pad usage, for this outcome. Whether hand-
sewn or stapled IPAA offers the best functional
option for the patient undergoing surgery for FAP
remains to be seen.
There was no significant difference between IPAA
and IRA in the quality of life outcomes of dietary
restriction and male and female sexual dysfunction.
This is an important finding, particularly with
regards to sexual dysfunction, as the patient facing
FAP surgery is often young and likely to want to con-
ceive at a later point in their lives. Normal sexual
function is also an important outcome with regards
to patient satisfaction with the procedure. One out-
come that was significantly different between IPAA
and IRA groups, was social restriction as a result of
the procedure, which significantly favoured the IRA
group. These results should, however, be treated with
caution as there were only two studies reporting this
outcome, containing at total of 58 patients in the
IPAA and 85 patients in the IRA groups respectively.
As previously mentioned, restorative proctocolec-
tomy with IPAA is perceived to be a more complicat-
ed procedure than IRA because of the increased
pelvic dissection and potential for damage to the
internal anal sphincter. The result of this meta-analy-
sis showed that the incidence of all post-operative
complications was significantly higher with IPAA
(10%), as compared to IRA (6.8%). This was also
reflected in an increased rate of 30-day re-operation
with IPAA (23.4%) vs. IRA (11.6%). With regards to
the individual post-operative outcomes, there was no
significant difference between IPAA and IRA for
bowel obstruction, haemorrhage, intra-abdominal
sepsis, anastomotic separation and wound infection.
The findings of this paper support this, although the
magnitude of this overall increase (3.2%) is probably
smaller than expected. The use of temporary defunc-
tioning ileostomy adds another procedure to the pri-
mary IPAA where it is used, and although our study
did not mention the morbidity associated with its
reversal, there was little on this documented in the
papers included in our meta-analysis.
With regards to long-term adverse events, IRA
was associated with significantly less perianal irrita-
tion than IPAA (57.4 vs. 62.7%) as well as anastomot-
ic stricture formation (2 vs. 8.1%). There was, howev-
er, no significant difference between the groups for
the incidence of intra-abdominal desmoids, and no
evidence that this is higher for primary IPAA as com-
pared to IRA (5.4% with IPAA vs. 8.7% with IRA).
Although the choice of whether to perform IRA or
IPAA as the primary operation for young patients
with FAP relies on several factors as illustrated by our
paper, the risk of cancer recurrence plays a signifi-
cant part in this decision. Cancer recurrence was
5.5% following IRA as compared to 0% following
IPAA, which is not surprising as the retained rectum
(following IRA) has a higher chance of undergoing
polyposis than the stapled IPAA with 1–2 cm of
retained rectal mucosa, and the hand-sewn IPAA
Fig. 5. Meta-analysis of bowel frequency
Соседние файлы в папке Библиотека им академика М.И. Перельмана