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Restorative Proctocolectomy / Ileal Pouch-Anal Anastomosis Jenny Zhang, MD UW General Surgery Seattle Children’s Hospital 2.20.14 JK 11M with UC diagnosed July 2011 Treated with Remicade, Humira, and prednisone with minimal benefit Planned 3-stage procedure 11/23/2013: Elective total abdominal colectomy with ileostomy 02/05/2014: Partial proctectomy, rectal mucosectomy, handsewn ileoanal J-pouch pull-through Uncomplicated hospital course post-operatively Tolerating low residue diet with benefiber and immodium supplementation by time of discharge DC’d home on POD 8 DB 18M with refractory UC Failed medical management including Remicade, azathioprine, and steroids Planned 3-stage procedure 12/06/2013: laparoscopic total abominal colectomy with ileostomy 02/07/2014: Proctectomy with stapled ileoanal J-pouch pullthrough Uncomplicated hospital course post-operatively Tolerating low-residue diet by time of discharge with immodium PRN DC’d home on POD 6 Background Since the 1980s, RP with IPAA has become procedure of choice for patients with UC requiring surgery Originally described to be performed in association with full mucosectomy, however subsequently modified to allow retention of short cuff of anorectum Two types of IPAA: Mucosectomy with Hand-sewn anastomosis Stapled anastomosis without mucosectomy Hand-sewn with mucosectomy Anal Transition Zone Kirat et al, 2010 Holder-Murray et al, 2009 Background Debate persists about preservation of the Anal Transition Zone (ATZ) What is the anal transition zone? “Zone interposed between uninterrupted crypt bearing colorectal type mucosa above and uninterrupted squamous epithelium below” Thought to play a role in continence in differentiating gas from liquid from solid Considered at risk for dysplasia and persistent or recurrent disease RP/IPAA: Stapled vs. Hand-Sewn? Technique used still largely based on institution, surgeon preference, and skills RP/IPAA: Stapled vs. Hand-Sewn? Mucosectomy with Hand-sewn Anastomosis Pros: [Ideally] removing all diseased bowel mucosa thereby eliminating disease and risk of malignancy Cons: Requires greater manipulation of anal canal with increased risk of damage to sphincter mechanism Disrupt anorectal inhibitory reflex (flatus vs. stool) RP/IPAA: Stapled vs. Hand-Sewn? Stapled Anastomosis without Mucosectomy Pros: Quicker operation requiring less manipulation of anal canal -> theoretically less post-operative incontinence Maintains ATZ thereby preserving anorectal inhibitory reflex Cons: Leaves potentially diseased and possibly inflamed rectal mucosa within region of anastomosis Requires regular follow-up of ATZ for risk of dysplasia/cancer Lovegrove et al, Annals of Surgery, 2006 A Comparison of Hand-Sewn Versus Stapled Ileal Pouch Anal Anastomosis (IPAA) Following Proctocolectomy- A Meta-Analysis of 4183 Patients Lovegrove et al, Annals of Surgery, 2006 Difference in post-operative complications between 2 anastomotic techniques Functional outcomes Anorectal physiology Quality of Life Neoplastic transformation Lovegrove et al, Annals of Surgery, 2006 Adverse outcomes: Anastomotic leak Pouch failure Wound infection 30 day mortality Anastomotic stricture Pouch-related fistulas Pelvic sepsis Pouchitis SBO Neoplastic transformation Lovegrove et al, Annals of Surgery, 2006 Functional outcomes Frequency of defecation per 24 hours and at night Incontinence Stool seepage Pad use during daytime and nighttime Use of antidiarrheal medication Lovegrove et al, Annals of Surgery, 2006 Results 21 studies, 4183 patients total between 1983-2000 2699 (64.5%) hand-sewn anastomosis with mucosectomy 1484 (35.5%) stapled pouch anastomosis 80% with J-pouch (65% hand-sewn, 35% stapled) 80% with proximal diversion at time of ileal pouch surgery Mean age Hand sewn- 32.5 years Stapled- 34.1 years Follow up ranged 3-155 months Mean 26.8 months hand-sewn Mean 19.6 months stapled Lovegrove et al, Annals of Surgery, 2006 Results: Perioperative complications Post-op adverse events in ~20% pts undergoing RP/IPAA No significant difference in rates of post-op adverse events between hand-sewn and stapled groups Lovegrove et al, Annals of Surgery, 2006 Results: Functional Outcomes No difference between stool frequency over 24 hours, nighttime defecation, or use of antidiarrrheal medication However, increased frequency of incontinence to liquid stool in HS 29.4% vs. 22.1% (OR 2.32, P = 0.009) Also increased seepage at night in HS 29.8% vs 16.8% (OR = 2.78, P < 0.001) Increased nighttime pad usage in HS 26.&% vs. 8.1% (OR = 4.12, P = 0.007) Lovegrove et al, Annals of Surgery, 2006 Results: Anorectal Physiology Significant reduction in resting and squeeze pressure in HS by 13.4 and 14.4 mmHg, respectively (P < 0.018) No difference in neorectal volume nor length of high-pressure zone Results: QOL No significant differences in reported QOL or reported sexual dysfunction Results: ATZ Pathology No significant differences regarding dysplasia, inflammation, or neoplasia Lovegrove et al, Annals of Surgery, 2006 Conclusion Stapled IPAA allows better functional outcomes and less disruption of anal sphincter mechanism Need studies with longer follow-up time and larger sample size to adequately quantify risk of dysplasia/cancer. Kirat et al, Surgery, 2009 Comparison of outcomes after hand-sewn versus stapled ileal pouch anastomosis in 3,109 patients Single institution, 1983-2007 Group A: Hand-sewn Group B: Stapled Compared short-term and long-term outcomes Kirat et al, Surgery, 2009 Results 474 (15%) HS, 2635 (85%) Stapled Similar age at operation, sex, albumin level, rate of prior colectomy, use of steroids Mean age 37.9 ± 13.2 years BMI for Group B higher Group A more FAP patients, Group B more indeterminate colitis Hospital LOS significantly longer for Group A 10 ± 5 days for Group A 7.5 ± 4 days for Group B Group A longer follow up (10 ± 7 yrs vs 6 ± 5 yrs) Kirat et al, Surgery, 2009 Postoperative complications Group A > Group B: Anastomotic stricture (p = 0.02) Septic complications (p = 0.019) SBO (p <0.027) Pouch failure (p <0.001) No significant difference in pouchitis Kirat et al, Surgery, 2009 Functional results Group A > Group B Incontinence (p < 0.001) Seepage (p < .001) Pad usage (p < .001) Dietary restrictions (p < .001) Social restrictions (p < .001) Work restrictions (p < .025) Group B > Group A QOL (p < 0.001) Happiness with operation ( p = 0.001) Health (p = 0.019) Kirat et al, Surgery, 2009 Conclusions: In closely matched groups of patients with FAP and UC, pts in UC group had higher overall complication rate, more pouch-related septic complications, and pouchitis Stapled IPAA seems to be safer in terms of complications and provides better long-term functional outcomes and QOL than hand-sewn IPAA RP/IPAA: Stapled vs. Hand-Sewn? So, what about the risk of dysplasia? Remzi et al, Dis Colon Rectum, 2003 Dysplasia of the Anal Transition Zone After Ileal Pouch-Anal Anastomosis: Results of Prospective Evaluation After a Minimum of Ten Years Goal: Establish risk of dysplasia in the ATZ and outcome of a conservative management policy for ATZ dysplasia with minimum of 10 years’ f/u after IPAA 289 pts 1986-1990 underwent stapled IPAA for IBD Followed with serial ATZ biopsies for at least 10 years post-op (n = 178) Median f/u 130 months (range 120-157 months) Remzi et al, Dis Colon Rectum, 2003 Results ATZ dysplasia in 8 patients occurring 4-123 months after surgery High grade: 2 patients Low grade: 6 patients 2 of 6 with LGD underwent completion mucosectomy 1 of 2 with HGD underwent partial mucosectomy (2/2 technical difficulty) No association with gender, age, preoperative disease duration, or extent of colitis Significant association with cancer/dysplasia as preop diagnosis or in proctocolectomy specimen Remzi et al, Dis Colon Rectum, 2003 Conclusions ATZ dysplasia after stapled IPAA is infrequent and usually selflimiting ATZ preservation did not lead to development of cancer with minimum follow up of 10 years Recommend long-term surveillance If repeat biopsy confirms dysplasia, recommend completion mucosectomy with advancement and neo IPAA Fichera et al, J Gastrointest Surg, 2007 Preservation of the Anal Transition Zone in Ulcerative Colitis. Long-Term Effects on Defecatory Function. Select patients offered stapled IPAA, primarily based on presence of dysplasia on multiple pre-operative colonoscopic biopsies, regardless of location or degree Goal: to determine oncologic risk of retained ATZ in stapled IPAA over time, assess the inflammatory changes during follow up, and evaluate impact on long-term functional outcome measures Fichera et al, J Gastrointest Surg, 2007 Methods Consecutive UC patients with stapled IPAA 1992-2006 Surveillance of ATZ Rigid anoscopy with 4-quadrant biopsies of ATZ performed annually to evaluate for new-onset dysplasia Inflammatory component graded as acute, chronic, or absent by expert GI pathologist Bx’s excluded if contained small intestinal mucosa or squamous epithelium Bx’s with concurrent detailed survey analysis were included in analysis of defecatory function and QOL Two-part Questionnaire mailed at 3, 6, 9, 12, 18, and 24 months post-op and then yearly thereafter Fichera et al, J Gastrointest Surg, 2007 Results 225 consecutive UC patients with no pre-operative cancer or dysplasia nor unexpected cancer or dysplasia on final pathology review of surgical specimen Mean age 34.7 ±11.5 years (range 13-66) Median follow up 36 months (range 3-132 months) 238 successful biopsies of ATZ during study period No dysplasia or cancer in any biopsies No patients developed cancer in pouch, retained ATZ, or pelvic floor Fichera et al, J Gastrointest Surg, 2007 Results cont’d 238 successful biopsies of ATZ during study period No patients developed cancer in pouch, retained ATZ, or pelvic floor 11 biopsies (4.6%) with acute inflammation 9 asymptomatic, 2 with cuffitis (resolved with medical treatment) 202 biopsies (84.9%) with chronic inflammation 25 (10.5%) with normal biopsies Fichera et al, J Gastrointest Surg, 2007 Results cont’d 72 successful biopsies with concurrent questionnaires 5 biopsies with acute inflammation (7%) 59 biospies with chronic inflammation (82%) 8 biopsies normal (11%) No significant difference in any of the measures surveyed for defecatory function No patients with major incontinence episodes CI group: 96% reported perfect continence, 93% able to defer BM if needed, and 5% use protective pads Fichera et al, J Gastrointest Surg, 2007 Conclusions Retained ATZ after stapled IPAA predominantly demonstrated persistence of chronic inflammation CI shown to have minimal impact on both stooling function and QOL Patients free of dysplasia or cancer in median follow-up of 36 months Majority of reports of cancer in retained ATZ have been in patients with preop evidence of cancer or dysplasia Alessandroni et al, Updates in Surgery, 2012 Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis Case report and literature review Alessandroni et al, Updates in Surgery, 2012 39M with 20 year h/o UC s/p RP/ stapled IPAA, negative pathology 1984-2001: serial endoscopy with negative exams and biopsies Sept 2001, increase in stool frequency. Endoscopy with acute pouchitis. Partial resolution with topical steroids and systemic abx Then began having BRBPR. Pouch endoscopy with nodular adenocarcinoma (CEA WNL) Aug 2002 underwent pouch excision & permanent ileostomy with pathology revealing Stage III adenoCA by AJCC 2002 classification Underwent post-op chemoradiation however died 24 months after operation 2/2 cancer progression Alessandroni et al, Updates in Surgery, 2012 On literature review, there are 50 reported cases of carcinoma following IPAA for UC 25 (50%) after HS with mucosectomy 25 (50%) after stapled 48% of patients had pre-operative dysplasia or cancer at time of colectomy Conclusion: Routine long-term endoscopic surveillance is needed in patients with long-standing ileal pouches Summary Stapled IPAA is associated with better functional outcomes Stapled IPAA does not appear to be associated with increased risk of dysplasia/cancer Current studies limited by small sample-size and short follow-up time Long-term surveillance of ATZ recommended References Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, et al. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg 2006;244:18-26. Remzi FH, Fazio VW, Delaney CP, Preen M, Ormsby A, Bast J, et al. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation af- ter a minimum of ten years. Dis Colon Rectum 2003;46:6- 13. Kirat H T, Remzi F H, Kiran R P, Fazio V W. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009;146(4):723–729. discussion 729–730. Fichera A, Ragauskaite L, Silvestri MT, Elisseou NM, Rubin MA, Hurst RD, Michelassi F. Preservation of the anal transition zone in ulcerative colitis. Long-term effects on defecatory function. J Gastrointest Surg. 2007;11:1647–1652; discussion 1652-1653. L. Alessandroni, A. Kohn, M. Capaldi, I. Guadagni, A. Scotti, R. Tersigni. Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis. Updates Surg, 64 (2012), pp. 149–152
