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1
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Khan I, Holubar SD. Operative Management of Small and Large Bowel Crohn's Disease. Surg Clin North Am 2025; 105:247-276. [PMID: 40015815 DOI: 10.1016/j.suc.2024.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
The majority of patients with Crohn's disease, despite an ever-increasing number of advanced therapies, require abdominal surgery during their lifetime. In this review article, the authors provide a comprehensive overview of abdominal surgery for Crohn's disease, with an evidence-based focus on surgery for upper gastrointestinal Crohn's disease, bowel-preserving surgery with strictureplasties, selection of ileocolic anastomotic technique for terminal ileal Crohn's disease, extended resections and proctectomy for Crohn's proctocolitis, intentional ileoanal pouch for Crohn's disease, and several "hot topics" including early surgery for ileocolic Crohn's disease, and surgical approaches that target the mesentery including the Kono-S anastomosis and extended mesenteric excision.
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Affiliation(s)
- Imran Khan
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA.
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Ait Mohand J, Alves A, Brouquet A, Germain A, Bridoux V, Trilling B, Buscail E, Valibouze C, Leroy M, Desreumaux P, Zerbib P. Fate of ileorectal anastomosis for treating Crohn's disease in the era of biologics: Results from a French retrospective multicentre cohort study. Colorectal Dis 2024; 26:1941-1949. [PMID: 39317953 DOI: 10.1111/codi.17185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 08/03/2024] [Accepted: 08/31/2024] [Indexed: 09/26/2024]
Abstract
AIM The rate of surgical recurrence following ileorectal anastomosis (IRA) in patients with Crohn's disease (CD) remains poorly understood. Most studies were conducted before the advent of biologics. Our aim was to assess the fate of IRA in patients with CD during the biologics era and identify risk factors for endoscopic, clinical, and surgical recurrence. METHODS This retrospective multicentre cohort study included patients with CD who underwent IRA between 2006 and 2022. The association of patient characteristics and postoperative measures with each type of postoperative recurrence and need for a definitive stoma was investigated using the chi-square test or Fisher's exact test. RESULTS During a median follow-up period of 60 months, the rates of endoscopic, clinical, and surgical postoperative recurrence were 70%, 59%, and 35%, respectively. The rate of perianal lesions was higher in patients who underwent a definitive stoma (70% vs. 35%, p = 0.007) and with endoscopic (50% vs. 25%, p = 0.038), clinical (54% vs. 24%, p = 0.006), and surgical (63% vs. 34%, p = 0.015) recurrence. The incidence of residual microscopic disease at the rectal margin was higher in patients with endoscopic recurrence (p = 0.047). Biologics were identified as protective factors against the need for a definitive stoma (p = 0.044). CONCLUSION IRA is a good treatment option for extensive colitis in patients with CD. However, its consideration should be weighed in the presence of perianal lesions, which have been shown to be a risk factor for delayed proctectomy.
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Affiliation(s)
- Juba Ait Mohand
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
| | - Arnaud Alves
- Unité INSERM UMR 1086 ANTICIPE Registre spécialisé Des Tumeurs Digestives du Calvados-Service de Chirurgie Digestive, Université de Caen Normandie, Caen, France
| | - Antoine Brouquet
- Department of Digestive Surgery and Surgical Oncology, Bicêtre Hospital, Le Kremlin Bicêtre, France
| | | | - Valerie Bridoux
- Department of Digestive Surgery, University Hospital of Rouen, Rouen, France
| | - Bertrand Trilling
- TIMC, CHU Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, University of Grenoble Alpes, Grenoble, France
| | - Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, Toulouse, France
| | - Caroline Valibouze
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
| | - Maxime Leroy
- Department of Biostatistics, University Hospital of Lille Nord de France, Lille, France
| | - Pierre Desreumaux
- Inserm, U1286-INFINITE, Institute for Translational Research in Inflammation, University Hospital of Lille Nord de France, Lille, France
| | - Philippe Zerbib
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
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Georganta I, McIntosh S, Boldovjakova D, Parnaby CN, Watson AJM, Ramsay G. The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis. Tech Coloproctol 2023; 27:699-712. [PMID: 36906886 PMCID: PMC10404177 DOI: 10.1007/s10151-023-02762-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/25/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) who have had a total colectomy remain with their rectum in situ, and are therefore at risk of rectal carcinoma. It is not clear how high the incidence of rectal cancer is in this cohort. The primary objective of this meta-analysis was to estimate the incidence of rectal cancer in patients with ulcerative colitis or Crohn's disease who have undergone colectomy but have a residual rectum, and to identify the risk factors for its development. In doing so, we explore the current recommendations for screening processes for these patients. METHODS A systematic review of the literature was performed. Five databases (Medline, Embase, Pubmed, Cochrane Library and Scopus) were searched from inception to 29 October 2021, to identify studies adhering to the population, intervention, control and outcomes (PICO) criteria. The included studies were critically appraised, and the relevant data was extracted. Cancer incidence was estimated from the reported information. Risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines. RESULTS Data from 23 of the 24 identified studies was suitable for analysis. The pooled incidence of rectal carcinoma was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a de-functioned rectal stump and ileorectal anastomosis, respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2, 95% CI 2.4-21.1). Patients with previous colorectal dysplasia were also at higher risk (RR 5.1, 95% CI 3.1-8.2). No universal standardised guidance regarding screening for this cohort could be identified in the available literature. CONCLUSIONS The overall risk of malignancy was estimated to be 1.3%, which is lower than previously reported. There is a need for clear and standardised screening guidance for this group of patients.
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Affiliation(s)
- I Georganta
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - S McIntosh
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - D Boldovjakova
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - C N Parnaby
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - A J M Watson
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - G Ramsay
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK.
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Risto A, Nordenvall C, Deputy M, Hermanson M, Lindforss U, Block M, Faiz O, Myrelid P. Colectomy reconstruction for ulcerative colitis in Sweden and England: a multicenter prospective comparison between ileorectal anastomosis and ileal pouch-anal anastomosis after colectomy in patients with ulcerative colitis. (CRUISE-study). BMC Surg 2023; 23:96. [PMID: 37085812 PMCID: PMC10122388 DOI: 10.1186/s12893-023-01984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND There are no prospective trials comparing the two main reconstructive options after colectomy for Ulcerative colitis, ileal pouch anal anastomosis and ileorectal anastomosis. An attempt on a randomized controlled trial has been made but after receiving standardized information patients insisted on choosing operation themselves. METHODS Adult Ulcerative colitis patients subjected to colectomy eligible for both ileal pouch anastomosis and ileorectal anastomosis are asked to participate and after receiving standardized information the get to choose reconstructive method. Patients declining reconstruction or not considered eligible for both methods will be followed as controls. The CRUISE study is a prospective, non-randomized, multi-center, open-label, controlled trial on satisfaction, QoL, function, and complications between ileal pouch anal anastomosis and ileorectal anastomosis. DISCUSSION Reconstruction after colectomy is a morbidity-associated as well as a resource-intensive activity with the sole purpose of enhancing function, QoL and patient satisfaction. The aim of this study is to provide the best possible information on the risks and benefits of each reconstructive treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05628701.
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Affiliation(s)
- Anton Risto
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping, 581 85, Linköping, Sweden.
- Department of Surgery, County Council of Östergötland, Linköping, Sweden.
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Mohammed Deputy
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Maria Hermanson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Ulrik Lindforss
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Block
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Omar Faiz
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Pär Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping, 581 85, Linköping, Sweden
- Department of Surgery, County Council of Östergötland, Linköping, Sweden
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5
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Ocaña J, Pastor P, Timoteo A, Diez‐Alonso MM, de la Portilla F, Cagigas C, Labalde‐Martínez M, Espin E, Dujovne P, Nieto M, González M, Sanz R, Pascual M, Aguirre‐Allende I, Cervera J, Jiménez‐Carneros V, Guadalajara H, García‐Granero A, Fernández‐Cebrián JM, Die‐Trill J. Risk factors for anastomotic leakage and postoperative outcomes after total and subtotal colectomy: A nationwide retrospective cohort study (RIALTCOT Study Collaborative Group). Colorectal Dis 2023; 25:420-430. [DOI: 10.1111/codi.16384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/03/2022] [Indexed: 02/05/2025]
Abstract
AbstractAimAnastomotic leakage (AL) following ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with a high morbidity. The identification of potential risk factors for AL could change operative planning and reduce further complications. This study assesses the rate, potential risk factors and management of AL after total colectomy (TC) and subtotal colectomy (STC).MethodsA nationwide, multicentre, retrospective cohort study involved 26 Spanish referral centres. It included TC and STC with IRA or ISA patients between January 2013 and December 2020. Clinical data, primary surgery and complications were collected. Univariate and multivariate analysis to identify risk factors for AL were performed. Management of Grade B–C AL and permanent stoma rate was assessed according to revisional surgeries.ResultsThe study included 1074 patients, 433 ISA group (40.3%) and 641 IRA group (59.7%). The overall incidence of AL was 14.3% with no differences between IRA and ISA (14.2% and 14.5% respectively), P = 0.871. Male sex, ASA score and lower total preoperative proteins were identified as independent risk factors for global and Grade B–C AL. Diverting ileostomy did not protect against AL (P = 0.084). Clavien–Dindo ≥IIIA complication was found in 251 patients (23.3%). Stoma reversal was not possible in 85 patients (8.1%), being more frequent after anastomosis excision and terminal ileostomy in AL Grade C.ConclusionTotal colectomy and STC with IRA or ISA are high‐risk procedures with an increased AL rate. Male sex, ASA score and lower preoperative protein level were associated with global AL and AL Grade B and C. A lower permanent stoma rate could be obtained when diverting ileostomy is performed in revision surgery.
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Affiliation(s)
- Juan Ocaña
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
| | - Paula Pastor
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
| | - Ander Timoteo
- Division of Coloproctology Hospital Universitario Doctor Josep Trueta Gerona Spain
| | | | | | - Carmen Cagigas
- Division of Coloproctology Hospital Universitario Marqués de Valdecilla Santander Spain
| | | | - Eloy Espin
- Department of Colorectal Surgery, Hospital Universitari Vall d'Hebron Universitat Autonoma de Barcelona Barcelona Spain
| | - Paula Dujovne
- Division of Coloproctology Hospital Universitario Gregorio Marañón Madrid Spain
| | - Marta Nieto
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario La Fe Valencia Spain
| | - Manuel González
- Division of Coloproctology Complejo Hospitalario Universitario A Coruña A Coruña Spain
| | - Rodrigo Sanz
- Division of Coloproctology Hospital Universitario Clínico San Carlos Madrid Spain
| | - Marta Pascual
- Division of Coloproctology Hospital Del Mar Barcelona Spain
| | | | - Jorge Cervera
- Division of Coloproctology Hospital Universitario de Cruces Barakaldo Spain
| | | | - Hector Guadalajara
- Division of Coloproctology Hospital Universitario Fundación Jiménez Díaz Madrid Spain
| | | | - José María Fernández‐Cebrián
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
| | - Javier Die‐Trill
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
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A systematic review of outcomes and quality of life after ileorectal anastomosis for ulcerative colitis. Arab J Gastroenterol 2023:S1687-1979(23)00008-4. [PMID: 36813579 DOI: 10.1016/j.ajg.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/14/2022] [Accepted: 01/15/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND STUDY AIMS Ileorectal anastomosis (IRA) is one option for restoring bowel continuity in patients who have undergone subtotal colectomy for ulcerative colitis (UC). This systematic review aims to assess short- and long-term outcomes after IRA for UC, including anastomotic leak rates, IRA failure (as defined by conversion to pouch or end stoma), cancer risk in the rectal remnant, and quality of life (QoL) post-IRA surgery. MATERIALS & METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist was used to demonstrate the search strategy. A systematic review of PubMed, Embase, Cochrane library, and Google Scholar from 1946 to August 2022 was undertaken. RESULTS This systematic review included 20 studies, representing 2538 patients who underwent IRA for UC. The mean age ranged from 25 to 36 years and the mean postoperative follow-up ranged between 7 and 22 years. The overall leak rate reported across 15 studies was 3.9 % (n = 35/907) ranging from 0 % to 16.7 %. The failure of IRA (requiring conversion to pouch or end stoma) as reported across 18 of the studies was 20.4 % (n = 498/2447). The risk of developing cancer in the remaining rectal stump following IRA was reported by 14 studies and was accumulatively 2.4 % (n = 30/1245). Five studies reported on patient QoL using a variety of different instruments and 66.0 % of patients (n = 235/356) reported a "high" QoL score. CONCLUSION IRA was associated with a relatively low leak rate and a low risk of colorectal cancer in the rectal remnant. However, it does carry a significant failure rate which invariably requires conversion to an end stoma or the formation of an ileoanal pouch. IRA provided a QoL to most of the patients.
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Berghog J, Hermanson M, de la Croix H, Bengtson J, Block M. Ileo-rectal anastomosis in ulcerative colitis-Long-term outcome, failure and risk of cancer at a tertiary centre. Colorectal Dis 2022; 24:1535-1542. [PMID: 35768885 PMCID: PMC10084240 DOI: 10.1111/codi.16237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 01/07/2023]
Abstract
AIM Ileo-rectal anastomosis (IRA) is an option to restore bowel continuity after colectomy in patients with ulcerative colitis (UC). Concerns that the remaining rectum may serve as a site for continuing proctitis with subsequent poor function and IRA failure and the fear of development of dysplasia and cancer have led to the abandonment of IRA in large parts of the world. This study investigated the outcome of IRA in a large patient cohort with UC and IRA with regard to failure of IRA and development of dysplasia and cancer. METHODS This was a retrospective data gathering of patients with UC and IRA enrolled at the Department of Colorectal Surgery, Surgical Clinic, Sahlgrenska University Hospital/Östra, Gothenburg, 1972-2019. End-points were IRA failure, rectal dysplasia and cancer. IRA survival analysis and the cumulative probability of rectal cancer were calculated. RESULTS In total, 183 patients (121 men) were included in the study. The IRA failure rate was 34% and the estimated cumulative IRA failure rates were 25% and 35% at 5 and 10 years respectively. Four patients developed rectal cancer and the estimated cumulative probability of rectal cancer was 3% and 6% at 10 and 15 years respectively. CONCLUSION Ileo-rectal anastomosis remains a restorative option after colectomy for UC, even if the failure rate raises some concern. Further knowledge is needed for optimal patient selection to avoid early IRA failures. With increasing probability of rectal cancer over time a vigilant surveillance protocol is mandatory.
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Affiliation(s)
- John Berghog
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Maria Hermanson
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Hanna de la Croix
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Jonas Bengtson
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Mattias Block
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
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Ocaña J, Pastor-Peinado P, Abadía P, Ballestero A, Ramos D, García-Pérez JC, Fernández-Cebrián JM, Die J. Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0041-1740207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Introduction A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. The main aim of the present study was to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity.
Methods We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity.
Results Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of AL was 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p = 0.038), in the elective-laparoscopic approach subgroup (p = 0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p = 0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA.
Discussion A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgery may improve short-term outcomes.
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Affiliation(s)
- J. Ocaña
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - P. Pastor-Peinado
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - P. Abadía
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - A. Ballestero
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - D. Ramos
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - JC. García-Pérez
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - JM. Fernández-Cebrián
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - J. Die
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
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9
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Ashburn JH. Operative indications and options in ulcerative colitis. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Baelum JK, Qvist N, Ellebaek MB. Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review. Colorectal Dis 2021; 23:2501-2514. [PMID: 34309170 DOI: 10.1111/codi.15839] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/27/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
AIM The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome. METHODS Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction. RESULTS The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found. CONCLUSIONS Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up.
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Affiliation(s)
| | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark
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11
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Salice M, Rizzello F, Sgambato D, Calabrese C, Manguso F, Laureti S, Rottoli M, Poggioli G, Gionchetti P. Long term remission after ileorectal anastomosis in Crohn's colitis. Dig Liver Dis 2021; 53:592-597. [PMID: 32616463 DOI: 10.1016/j.dld.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease represents a heterogeneous entity, but its location tends to be relatively stable overtime. For extensive refractory Crohn's colitis, ileorectal anastomosis after colectomy is an engaging option, since the necessity of a permanent ileostomy is avoided. AIMS In our study, the long-term outcome of two groups of patients with Crohn's colitis who underwent colectomy and ileorectal anastomosis was compared. The first group had isolated colonic Crohn's disease without rectal involvement and perianal disease, while the second group included patients who had rectal and/or ileal involvement, with or without perianal disease. METHODS Between 1996 and 2016, in a single IBD tertiary center, 80 patients with a history of colectomy and ileorectal anastomosis for refractory Crohn's colitis were retrospectively identified. RESULTS Recurrence of disease was diagnosed in 57/64 of patients with Crohn's colitis with rectal and/or ileal and/or perianal involvement compared with 1/16 of patients with isolated Crohn's colitis without rectal and perianal disease in a median time of recurrence of 2 years (IQR 1-6 years, minimum to maximum, 1-18 years, p < 0.001). Only 6 patients (7,5%) underwent definitive end ileostomy without proctectomy (1 in the noIRP group and 5 in the IRP group). CONCLUSION Our data suggest that colectomy with ileorectal anastomosis may represent a curative option in patients with refractory isolated colitis without rectal and perianal involvement.
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Affiliation(s)
- Marco Salice
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Fernando Rizzello
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Dolores Sgambato
- Division of Hepato-Gastroenterology, Department of Clinical and Experimental Medicine, Second University of Naples, Via Pansini 5, 80131 Naples, Italy
| | - Carlo Calabrese
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Francesco Manguso
- Complex Operating Unit of Gastroenterology, AORN 'A. Cardarelli', Naples, Italy
| | - Silvio Laureti
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Matteo Rottoli
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Gilberto Poggioli
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy.
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Hennessy O, Egan L, Joyce M. Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump. World J Gastrointest Surg 2021; 13:198-209. [PMID: 33643539 PMCID: PMC7898189 DOI: 10.4240/wjgs.v13.i2.198] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.
AIM To review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.
METHODS A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.
RESULTS For rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.
CONCLUSION The retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.
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Affiliation(s)
- Orla Hennessy
- Department of Colorectal Surgery, Galway University Hospital, Galway H91RR2N, Ireland
| | - Laurence Egan
- Department of Gastroenterology, Galway University Hospital, Galway H91RR2N, Ireland
| | - Myles Joyce
- Department of Gastroenterology, Galway University Hospital, Galway H91RR2N, Ireland
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Ileorectal Anastomosis Versus IPAA for the Surgical Treatment of Ulcerative Colitis: A Markov Decision Analysis. Dis Colon Rectum 2020; 63:1276-1284. [PMID: 32472777 DOI: 10.1097/dcr.0000000000001686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ileorectal anastomosis in patients with ulcerative colitis results in decreased postoperative morbidity and better functional outcome but leads to increased risk for rectal cancer compared with IPAA. OBJECTIVE This study aims to compare ileorectal anastomosis with IPAA in ulcerative colitis by using a decision model. DESIGN A Markov simulation model was designed to simulate clinical events of ileorectal anastomosis and IPAA over a time horizon of 40 years with time cycles of 1 year. All probabilities and utilities were derived from observational studies, identified after a systematic literature search using MEDLINE. Primary outcomes were life-years and quality-adjusted life-years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS A decision model using Markov simulation was designed. PATIENTS The base case was a 35-year-old patient with ulcerative colitis and a relatively preserved rectum. MAIN OUTCOMES MEASURES The primary outcome measures were (quality-adjusted) life-years. RESULTS The model resulted in lower life-years (36.22 vs 37.02) and higher quality-adjusted life-years (33.42 vs 31.57) for ileorectal anastomosis. This was confirmed after probabilistic sensitivity analysis. The model was sensitive to the utility of ileorectal anastomosis, IPAA, and end-ileostomy. A higher proportion of patients with ileorectal anastomosis will develop rectal cancer (7.6% vs 3.2%) and 43.5% of all patients with ileorectal anastomosis will end with an ileostomy as opposed to 23.0% of all patients with IPAA. LIMITATIONS The study was limited by characteristics inherent to modeling studies, including assumptions necessary to build the model, data input based on best available but often limited evidence, and unavoidable extra- and interpolation of data. CONCLUSIONS Ileorectal anastomosis was the preferred treatment option when quality-adjusted life-years were the outcome, with higher life-years for IPAA. This model highlights that both surgical strategies are useful in patients who have ulcerative colitis with a relatively spared rectum. See Video Abstract at http://links.lww.com/DCR/B249. ANASTOMOSIS ILEORRECTAL VERSUS ANASTOMOSIS ANAL CON RESERVORIO ILEAL EN EL TRATAMIENTO QUIRÚRGICO DE LA COLITIS ULCEROSA: ANÁLISIS DE DECISIÓN DE MARKOV: Las anastomosis ileorrectales en pacientes con colitis ulcerosa se encuentran asociadas con la disminución de la morbilidad postoperatoria y un mejor resultado funcional, pero conducen a un mayor riesgo de cáncer de recto cuando se las compara con casos de confección de un reservorio íleo-anal.Comparar las anastomosis ileorrectales con la anastomosis de un reservorio íleo-anal en casos de colitis ulcerosa, utilizando un modelo de procesos de decisión.Se diseñó un modelo de proceso de Markov para simular eventos clínicos en casos de anastomosis ileorrectales y anastomosis de reservorios íleo-anales en un horizonte temporal de 40 años comprendiendo ciclos temporales de 1 año. Todas las probabilidades y utilidades se derivaron de estudios observacionales, identificados después de una búsqueda sistemática de literatura usando MEDLINE. Los resultados primarios fueron años de vida y los años ajustados a la calidad de vida. Se realizaron los análisis de sensibilidad determinada y de probabilística.Se diseñó un modelo de decisión utilizando el proceso de simulación de Markov.El caso base fue el de un paciente de 35 años con colitis ulcerosa y con un recto relativamente sano.El resultado principal fué la medida de los años de vida (con ajuste en la calidad de vida).El modelo resultó en menos años de vida (36.22 frente a 37.02) y años de vida de menor calidad (33.42 frente a 31.57) para los casos de anastomosis ileorrectales. Esto se confirmó después del análisis de sensibilidad probabilística. El modelo era sensible a la utilidad de la anastomosis ileorrectal, la anastomosis del reservorio íleo-anal y la ileostomía terminal. Una mayor proporción de pacientes con anastomosis ileorectales desarrollarán cáncer de recto (7,6% frente a 3,2%) y el 43,5% de todos los pacientes con anastomosis ileorrectales terminarán con una ileostomía en comparación con el 23,0% de todos los pacientes con un reservorio íleo-anal.El analisis estuvo limitado por las características inherentes a los estudios de modelado, incluidas las suposiciones necesarias para construir el modelo, la entrada de datos basada en la mejor evidencia disponible pero a menudo limitada y la extrapolación e interpolación inevitable de datos.Las anastomosis ileorrectales fueron la opción de tratamiento preferida cuando el resultado fue ajustado en años con calidad de vida, con años de vida más larga para la anastomosis de reservorios íleo-anales. Este modelo destaca que ambas estrategias quirúrgicas son útiles en pacientes con colitis ulcerosa con rectos relativamente sanos. Consulte Video Resumen en http://links.lww.com/DCR/B249.
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McKenna NP, Bews KA, Habermann EB, Dozois EJ, Lightner AL, Mathis KL. What Factors Are Associated With the Eventual Need for an Ileostomy After Total Abdominal Colectomy and Ileosigmoid or Ileorectal Anastomosis for Crohn's Colitis in the Biologic Era? Dis Colon Rectum 2020; 63:504-513. [PMID: 32015288 DOI: 10.1097/dcr.0000000000001556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Outcomes after total abdominal colectomy with ileosigmoid or ileorectal anastomosis for Crohn's colitis and risk factors for requirement of a permanent ileostomy remain poorly understood, particularly in the biologic era. OBJECTIVE This study aimed to determine long-term ostomy-free survival after ileosigmoid or ileorectal anastomosis for Crohn's colitis and potential risk factors for requirement of an ileostomy. DESIGN This is a retrospective cohort study. SETTING This study was conducted at a single-institution IBD tertiary referral center. PATIENTS Patients diagnosed with Crohn's disease and undergoing ileosigmoid or ileorectal anastomosis between 2006 and 2018 were selected. MAIN OUTCOME MEASURE Long-term ostomy-free survival and hazard ratios of potential predictors of ileostomy requirement were the primary outcomes measured. RESULTS One hundred nine patients (56% female) underwent ileosigmoid or ileorectal anastomosis for Crohn's disease. The majority of surgical procedures were completed in 2 or 3 stages (53%). The indication for total abdominal colectomy was predominantly medically refractory disease (77%), with dysplasia the second leading indication (13%). At an overall mean follow-up of 3 years, 16 patients had undergone either proctectomy or diversion with the rectum in situ. This resulted in ostomy-free survival estimates at 5 and 10 years of 78% (95% CI, 68-90) and 58% (95% CI, 35-94). A positive distal microscopic margin was the only risk factor for later requirement of a permanent ileostomy (HR, 5.4; 95% CI, 1.7-17.2). LIMITATIONS This study is limited because it is a retrospective study at a tertiary referral center. CONCLUSIONS Long-term ostomy-free survival can be achieved in the majority of patients who undergo restoration of intestinal continuity after total abdominal colectomy for Crohn's colitis. A positive distal microscopic margin was independently associated with long-term anastomotic failure, and it should be accounted for when risk stratifying patients for postoperative prophylactic medical therapy. See Video Abstract at http://links.lww.com/DCR/B111. ¿QUÉ FACTORES ESTÁN ASOCIADOS CON LA EVENTUAL NECESIDAD DE UNA ILEOSTOMÍA DESPUÉS DE UNA COLECTOMÍA ABDOMINAL TOTAL Y UNA ANASTOMOSIS ILEOSIGMOIDEA O ILEORRECTAL PARA LA COLITIS DE CROHN EN LA ERA BIOLÓGICA?: Los resultados después de la colectomía abdominal total con anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo para el requerimiento de una ileostomía permanente siguen siendo poco conocidos, particularmente en la era biológica.Determinar la supervivencia a largo plazo sin ostomía después de una anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo potenciales para la necesidad de una ileostomía.Estudio de cohorte retrospectivo.Centro de referencia de tercel nivel para enfermedad inflamatoria intestinal de una sola institución.Pacientes diagnosticados con enfermedad de Crohn y sometidos a anastomosis ileosigmoidea o ileorrectal entre 2006 y 2018Supervivencia a largo plazo sin ostomías y cocientes de riesgo de predictores potenciales de requerimiento de ileostomía109 pacientes (56% mujeres) se sometieron a anastomosis ileosigmoidea o ileorrectal por enfermedad de Crohn. La mayoría de los procedimientos quirúrgicos se completaron en 2 o 3 etapas (53%). La indicación de colectomía abdominal total fue predominantemente enfermedad médicamente refractaria (77%), con displasia la segunda indicación principal (13%). En un seguimiento medio general de 3 años, 16 pacientes se habían sometido a una proctectomía o a una derivación con el recto in situ. Esto dio como resultado estimaciones de supervivencia sin ostomía a los 5 y 10 años de 78% (intervalo de confianza del 95%: 68-90) y 58% (intervalo de confianza del 95%: 35-94), respectivamente. Un margen microscópico distal positivo fue el único factor de riesgo para el requerimiento posterior de una ileostomía permanente (razón de riesgo: 5.4; intervalo de confianza del 95%, 1.7-17.2).Estudio retrospectivo en un centro de referencia de tercer nivel.La supervivencia a largo plazo sin ostomía se puede lograr en la mayoría de los pacientes que se someten a la restauración de la continuidad intestinal después de la colectomía abdominal total por colitis de Crohn. Un margen microscópico distal positivo se asoció de forma independiente con la insuficiencia anastomótica a largo plazo, y debe tenerse en cuenta cuando se trata de pacientes con estratificación de riesgo para el tratamiento médico profiláctico postoperatorio. Consulte Video Resumen en http://links.lww.com/DCR/B111.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Katherine A Bews
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Yamamoto-Furusho J, Gutiérrez-Grobe Y, López-Gómez J, Bosques-Padilla F, Rocha-Ramírez J. The Mexican consensus on the diagnosis and treatment of ulcerative colitis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018. [DOI: 10.1016/j.rgmxen.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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18
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Consenso mexicano para el diagnóstico y tratamiento de la colitis ulcerosa crónica idiopática. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:144-167. [DOI: 10.1016/j.rgmx.2017.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/15/2017] [Accepted: 08/29/2017] [Indexed: 12/15/2022]
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Lightner AL. Segmental Resection versus Total Proctocolectomy for Crohn's Colitis: What is the Best Operation in the Setting of Medically Refractory Disease or Dysplasia? Inflamm Bowel Dis 2018; 24:532-538. [PMID: 29462390 DOI: 10.1093/ibd/izx064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Indexed: 12/16/2022]
Abstract
Crohn's disease (CD) may affect any part of the gastrointestinal tract. When isolated to the colon, and patients become medically refractory, there are several surgical options - segmental resection, subtotal colectomy with ileorectal anastomosis, or a total proctocolectomy and end ileostomy. Unfortunately, surgery does not cure CD, and, regardless of the extent of bowel removed, recurrence may be seen in the small bowel. This may lead to need for further immunosuppression or surgery. Therefore, when appropriate, a segmental colectomy or subtotal colectomy may prevent a permanent ostomy required with a total proctocolectomy. In the setting of dysplasia identified on colonoscopy, low quality evidence guides our treatment paradigms. Even though identification of dysplasia has greatly improved with chromoendoscopy, rates of synchronous or metachronous neoplasm remain high. Thus, a total proctocolectomy and end ileostomy, whereas a larger operation, may be best for the patient to remove all at risk tissue. Further research with prospective or randomized control trials is needed to improve our practice guidelines of both scenarios.
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Affiliation(s)
- Amy L Lightner
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester MN
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20
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Gallo G, Kotze PG, Spinelli A. Surgery in ulcerative colitis: When? How? Best Pract Res Clin Gastroenterol 2018; 32-33:71-78. [PMID: 30060941 DOI: 10.1016/j.bpg.2018.05.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/25/2018] [Indexed: 02/07/2023]
Abstract
Ulcerative Colitis (UC) is an idiopathic chronically-remitting inflammatory bowel disorder characterized by a contiguous inflammation of the colonic mucosa affecting the rectum that generally extends proximally in a continuous manner through the entire colon. Patients typically experience intermittent exacerbations, with symptoms characterized by bloody diarrhea associated with urgency and tenesmus. The anatomical extent of mucosal involvement is the most important factor determining disease course and is an important predictor of colectomy. The precise etiology of UC is unknown. However, a combination of genetic predisposition and environmental factors seems to have a key role in the development of the disease. UC usually is mildly active but it can be a life-threatening condition because of colonic and systemic complications, and later in the disease course due to the development of colorectal cancer. Interestingly, even if pathogenetic features detected in patients with sporadic CRC can be also found in UC-related colorectal cancer (UC-CRC), this latter is, usually, driven by an inflammation-driven pathway rising from a non-neoplastic inflammatory epithelium to dysplasia to cancer. Thus, a long-term follow-up with colonoscopy surveillance has been recommended. Approximately 15% of UC patients develop an acute attack of severe colitis, and 30% of these patients require colectomy. The initial treatment strategy in UC typically follows the traditional step-up approach. One third of the patients will not respond to steroid therapy and cyclosporine and infliximab are the most common salvage agents employed in these cases in order to avoid emergent surgery. Unfortunately, although a significant short-term benefit have been observed after infliximab treatment, the colectomy rate have remained stable. Surgery in UC depends on the stage of the disease as well as patient's status and is divided into the following settings: urgent, emergent and elective. Despite many efforts the surgical management of UC remains a significant challenge. A multidisciplinary management of UC is key in order to define the best timing and the best procedure for each patient in an individualized basis.
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Affiliation(s)
- Gaetano Gallo
- Department of Medical and Surgical Sciences, O.U. of General Surgery, University of Catanzaro, Catanzaro, Italy; Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, IBD Outpatient Clinics, Catholic University of Paranà, Curitiba, Brazil
| | - Antonino Spinelli
- Humanitas University, Department of Biomedical Sciences, Via Manzoni 113, 20089, Rozzano, Milano, Italy; Humanitas Clinical and Research Center, Colon and Rectal Surgery Unit, Via Manzoni 113, 20089, Rozzano, Milano, Italy.
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21
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Khan M, Jayne D, Saunders R. Comparison of defecatory function after laparoscopic total colectomy and ileorectal anastomosis versus a traditional open approach. Ann R Coll Surg Engl 2018; 100:235-239. [PMID: 29364015 DOI: 10.1308/rcsann.2017.0219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction Total colectomy and ileorectal anastomosis can result in significant defecatory frequency and poor bowel function. The aim of this study was to assess whether a laparoscopic approach is associated with any improvement in this regard. Methods A single institution retrospective review was undertaken of patients undergoing elective total colectomy and ileorectal anastomosis between 2000 and 2011. Those undergoing emergency surgery and paediatric surgery were excluded. The primary outcome measure was satisfactory defecatory function after surgery. Results Forty-nine patients (24 male, 25 female) were included in the study. The median age was 48 years (range: 20-83 years). Laparoscopic total colectomy (LTC) was performed in 20 patients and open total colectomy (OTC) in 29 patients. Indications for surgery were slow colonic transit (n=17), colorectal cancer (CRC) (n=17), CRC with hereditary colorectal cancer syndrome (n=8), inflammatory bowel disease (n=4) and diverticular disease (n=3). In the LTC group, 85% had a satisfactory defecatory frequency of 1-6 motions per day compared with 45% in the OTC cohort (p=0.006). There was no statistically significant difference in bowel frequency related to primary pathology (benign vs cancer surgery, p=1.0). Postoperative complications for both groups included relaparotomy (n=3), anastomotic leak (n=2), small bowel obstruction (n=2), postoperative bleeding (n=1) and pneumonia (n=1). Conclusions This study indicates that long-term defecatory function is better following LTC than following OTC and ileorectal anastomosis. The mechanism for this improvement is unclear but it may relate to the underlying reason for surgery or possibly to reduced small bowel handling leading to fewer adhesions after laparoscopic surgery.
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Affiliation(s)
- Mas Khan
- Leeds Teaching Hospitals NHS Trust , UK
| | - D Jayne
- Leeds Teaching Hospitals NHS Trust , UK
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Abdalla M, Landerholm K, Andersson P, Andersson RE, Myrelid P. Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study. Clin Gastroenterol Hepatol 2017; 15:1055-1060.e2. [PMID: 28013111 DOI: 10.1016/j.cgh.2016.11.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/19/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Patients with ulcerative colitis (UC) have an increased risk of rectal cancer, therefore reconstruction with an ileal pouch-anal anastomosis (IPAA) generally is preferred to an ileorectal anastomosis (IRA) after subtotal colectomy. Similarly, completion proctectomy is recommended for patients with ileostomy and a diverted rectum, although this approach has been questioned because anti-inflammatory agents might reduce cancer risk. We performed a national cohort study in Sweden to assess the risk of rectal cancer in patients with UC who have an IRA, IPAA, or diverted rectum after subtotal colectomy. METHODS We collected data from the Swedish National Patient Register for a cohort of 5886 patients with UC who underwent subtotal colectomy with an IRA, IPAA, or diverted rectum from 1964 through 2010. Patients who developed rectal cancer were identified from the Swedish National Cancer Register. The risk of rectal cancer was compared between this cohort and the general population by standardized incidence ratio analysis. RESULTS Rectal cancer occurred in 20 of 1112 patients (1.8%) who received IRA, 1 of 1796 patients (0.06%) who received an IPAA, and 25 of 4358 patients (0.6%) with a diverted rectum. Standardized incidence ratios for rectal cancer were 8.7 in patients with an IRA, 0.4 in patients with an IPAA, and 3.8 in patients with a diverted rectum. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio, 6.12), and colonic severe dysplasia or cancer before subtotal colectomy in patients with a diverted rectum (hazard ratio, 3.67). CONCLUSIONS In an analysis of the Swedish National Patient Register, we found that the risk for rectal cancer after colectomy in patients with UC is low, in relative and absolute terms, after reconstruction with an IPAA. An IRA and diverted rectum are associated with an increased risk of rectal cancer, compared with the general population, but the absolute risk is low. Patients and their health care providers should consider these findings in making decisions to leave the rectum intact, perform completion proctectomy, or reconstruct the colon with an IRA or IPAA.
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Affiliation(s)
- Maie Abdalla
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Peter Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Roland E Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Ryhov County Hospital, Jönköping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Linköping University Hospital, Linköping, Sweden.
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Abstract
The use of temporary fecal diversion is of great importance to tenuous anastomosis, immunosuppressed patient, or actively infected patient. Its use protects newly constructed intestinal anastomoses from being the culprit of pelvic sepsis or systemic illness. Thus, potential morbidity and mortality can be averted. However, its appropriate or optimal use is often debated. We herein discuss the evidence for when to best use a diverting stoma for colorectal, coloanal, and ileoanal anastomoses. We also discuss the importance of considering a temporary diverting stoma in the setting of high-dose immunosuppression (e.g., transplant patients or inflammatory bowel disease), active infection, or upon creation of ileal pouch-anal anastomosis. Lastly, we discuss the advantages and disadvantages of a loop ileostomy versus colostomy for temporary diversion of fecal contents.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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Abstract
BACKGROUND Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease. OBJECTIVE The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. DESIGN Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. SETTINGS The study was conducted at a tertiary care research center. PATIENTS Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. MAIN OUTCOME MEASURES Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy. RESULTS Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis. LIMITATIONS The study was limited by its retrospective nature and small sample size. CONCLUSIONS Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.
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Onder A, Benlice C, Church J, Kessler H, Gorgun E. Short-term outcomes of laparoscopic versus open total colectomy with ileorectal anastomosis: a case-matched analysis from a nationwide database. Tech Coloproctol 2016; 20:767-773. [PMID: 27783175 DOI: 10.1007/s10151-016-1539-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the current study, we aimed to compare peri- and postoperative 30-day outcomes of patients undergoing laparoscopic versus open total colectomy with ileorectal anastomosis in a case-matched design using data procedure-targeted database. METHODS Patients who underwent elective total colectomy with ileorectal anastomosis in 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into two groups according to the type of surgical approach (laparoscopic and open). Laparoscopic and open groups were matched (1:1) based on age, gender, diagnosis, body mass index, and American Society of Anesthesiologists classification. Comorbidities, perioperative, and short-term (30-day) postoperative outcomes were compared between the matched groups. RESULTS We identified 1442 patients-549 in the laparoscopic group and 893 patients in the open group. After case matching, there were 326 patients in each group. There were 48 (14.7%) patients who had conversion in the laparoscopic group. The open group had a higher proportion of patients with ascites [0 (0%) vs. 7 (2.1%) p = 0.015], preoperative weight loss [26 (8.0%) vs. 45 (13.8%) p = 0.018], and contaminated wound classifications [Clean/Contaminated 261 (80%) vs. 240 (74%), Contaminated 55 (16.9%) vs. 54 (16.6%), and Dirty/Infected 8 (2.5%) vs. 28 (8.6%), (p = 0.003)]. The laparoscopic group had a significantly longer operative time (242 ± 98 vs. 202 ± 116 min, p < 0.001), shorter hospital stay (9.4 ± 8.5 vs. 13.3 ± 10.7 days, p < 0.001), and lower ileus rate (23.9 vs. 31.0%, p = 0.045) than the open group. After adjusting for covariates, the differences in terms of operative time and hospital stay remained significant [odds ratio (OR): 0.79, confidence interval (CI) 0.74-0.85 and OR 1.36, CI 1.21-1.52, p < 0.001, respectively]. CONCLUSIONS Laparoscopic approach for total colectomy with ileorectal anastomosis is associated with a shorter hospital stay but longer operative time compared with an open approach.
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Affiliation(s)
- A Onder
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - C Benlice
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - J Church
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA.
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Nordenvall C, Olén O, Nilsson PJ, Ekbom A, Bottai M, Myrelid P. The Fate of Reconstructive Surgery Following Colectomy for Inflammatory Bowel Disease in Sweden: A Population-based Cohort Study. J Crohns Colitis 2016; 10:1165-71. [PMID: 26975385 DOI: 10.1093/ecco-jcc/jjw073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Previous studies describing the cumulative failure rate after reconstructive surgery in patients with inflammatory bowel disease have been restricted to specific hospitals, and the generalizability of these results in a population-based setting is unknown. The aim of this study was to investigate the cumulative failure rate and risk factors for failure after reconstructive surgery in patients with inflammatory bowel disease. METHODS The study cohort includes all patients with inflammatory bowel disease in Sweden who underwent colectomy in 2000 through 2013 who were later treated with reconstructive surgery with ileal pouch-anal anastomosis or ileorectal anastomosis. Each patient was followed from admission for reconstructive surgery until admission for failure (a diverting stoma or permanent stoma), date of death, migration or December 31, 2013. Cumulative failure distributions were obtained with the Kaplan-Meier method, and multivariable Cox regression models were used to calculate the risk of failure. RESULTS Of the 1809 patients with inflammatory bowel disease treated with colectomy and reconstructive surgery, 83% had ulcerative colitis. During follow-up, 270 patients failed, and the cumulative failure rate was 4.1%, 13.2%, and 15.3% after 1, 3, and 5 years, respectively. The risk of failure was lower after treatment with ileal pouch-anal anastomosis than with ileorectal anastomosis [hazard ratio (95% confidence interval): 0.72 (0.56-0.93)]. Gender, hospital volume, and timing of reconstruction were not significantly associated with the risk of failure. CONCLUSIONS The 5-year cumulative failure rate in a nationwide setting was 15.3%, and hospital volume was not associated with the risk of failure.
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Affiliation(s)
- Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Ola Olén
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden Department of Pediatric Gastroenterology and Nutrition, Sachs' Children's Hospital, Stockholm, Sweden
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Pär Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden Department of Surgery, County Council of Östergötland, Linköping, Sweden
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Lepistö A, Järvinen HJ. Fate of the Rectum after Colectomy with Ileorectal Anastomosis in Ulcerative Colitis. Scand J Surg 2016; 94:40-2. [PMID: 15865115 DOI: 10.1177/145749690509400110] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Aim of the study was to evaluate the cumulative success of colectomy and ileorectal anastomosis in 20 patients with ulcerative colitis. Patients and Methods: Data were collected from patient histories and cumulative success was calculated by the Kaplan-Meier method. Results: Seven of 20 (35 %) ileorectal anastomoses were lost. Cumulative success rate was 84 % at 5 years, 69 % at 10 years and 56 % at 20 years. Most common indication for proctectomy was disabling proctitis. Other reasons for failure were postoperative ileal necrosis and persisting presacral infection. Patients with advanced colonic cancer managed relatively well with ileorectal anastomosis until death. No cases of rectal cancer were detected during postoperative follow-up but one moderate dysplasia was treated locally. Conclusion: Ileorectal anastomosis can be chosen for patients who are not suitable for ileoanal operation. Rectal endoscopies are mandatory postoperatively.
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Affiliation(s)
- A Lepistö
- Helsinki University Central Hospital, Department of Surgery, Helsinki, Finland.
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29
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Derikx LAAP, Nissen LHC, Smits LJT, Shen B, Hoentjen F. Risk of Neoplasia After Colectomy in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:798-806.e20. [PMID: 26407752 DOI: 10.1016/j.cgh.2015.08.042] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/31/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal neoplasia can still develop after colectomy for inflammatory bowel disease. However, data on this risk are scare, and there have been few conclusive findings, so no evidence-based recommendations have been made for postoperative surveillance. We conducted a systematic review and meta-analysis to determine the prevalence and incidence of and risk factors for neoplasia in patients with inflammatory bowel disease who have undergone colectomy, including the permanent-end ileostomy and rectal stump, ileorectal anastomosis (IRA), and ileal pouch-anal anastomosis (IPAA) procedures. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library through May 2014 to identify studies that reported prevalence or incidence of colorectal neoplasia after colectomy or specifically assessed risk factors for neoplasia development. Studies were selected, quality was assessed, and data were extracted by 2 independent researchers. RESULTS We calculated colorectal cancer (CRC) prevalence values from 13 studies of patients who underwent rectal stump surgery, 35 studies of IRA, and 33 studies of IPAA. Significantly higher proportions of patients in the rectal stump group (2.1%; 95% confidence interval [CI], 1.3%-3.0%) and in the IRA group (2.4%; 95% CI, 1.7%-3.0%) developed CRC than in the IPAA group (0.5%; 95% CI, 0.3%-0.6%); the odds ratio (OR) for CRC in the rectal stump or IRA groups compared with the IPAA group was 6.4 (95% CI, 4.3-9.5). A history of CRC was the most important risk factor for development of CRC after colectomy (OR for patients receiving IRA, 12.8; 95% CI, 3.31-49.2 and OR for patients receiving IPAA, 15.0; 95% CI, 6.6-34.5). CONCLUSIONS In a meta-analysis of published studies, we found the prevalence and incidence of CRC after colectomy to be less than 3%; in patients receiving IPAA it was less than 1%. Factors that increased risk of cancer development after colectomy included the presence of a residual rectum and a history of CRC. These findings could aid in development of individualized strategies for post-surgery surveillance.
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Affiliation(s)
- Lauranne A A P Derikx
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Loes H C Nissen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lisa J T Smits
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Departments of Gastroenterology/Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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Ishii H, Hata K, Kishikawa J, Anzai H, Otani K, Yasuda K, Nishikawa T, Tanaka T, Tanaka J, Kiyomatsu T, Kawai K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Kitayama J, Watanabe T. Incidence of neoplasias and effectiveness of postoperative surveillance endoscopy for patients with ulcerative colitis: comparison of ileorectal anastomosis and ileal pouch-anal anastomosis. World J Surg Oncol 2016; 14:75. [PMID: 26960982 PMCID: PMC4784460 DOI: 10.1186/s12957-016-0833-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 03/01/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The incidence of neoplasia after surgery has not been sufficiently evaluated in patients with ulcerative colitis (UC), particularly in the Japanese population, and it is not clear whether surveillance endoscopy is effective in detecting dysplasia/cancer in the remnant rectum or pouch. The aims of this study were to assess and compare postoperative development of dysplasia/cancer in patients with UC who underwent ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) and to evaluate the effectiveness of postoperative surveillance endoscopy. METHODS One hundred twenty patients who received postoperative surveillance endoscopy were retrospectively reviewed for development of dysplasia/cancer in the remnant rectal mucosa or pouch. RESULTS Three hundred seventy-nine endoscopy sessions were conducted for 30 patients after IRA, while 548 pouch endoscopy sessions were conducted for 90 patients after IPAA. In the IRA group, 5 patients developed dysplasia/cancer during postoperative surveillance and in all cases, neoplasia was detected at an early stage. In the IRA group, no patient developed neoplasia within 10 years of diagnosis; the cumulative incidence of neoplasia after disease onset was 7.2, 12.0, and 23.9% at 15, 20, and 25 years, respectively. In one case after stapled IPAA, dysplasia was found at the ileal pouch; a subsequent 9 endoscopy sessions in 8 years did not detect any dysplasia. Neoplasia was found more frequently during postoperative surveillance in the IRA group than in the IPAA group (p = .0028). The cumulative incidence of neoplasia after IRA was 3.8, 8.7, and 21.7% at 10, 15, and 20 years, respectively, and that after IPAA was 1.6% at 20 years. CONCLUSIONS The cumulative incidence of neoplasia after IPAA was minimal. Those who underwent IRA had a greater risk of developing neoplasia than those who underwent IPAA, although postoperative surveillance endoscopy was able to detect dysplasia/cancer at an early stage. IRA can be the surgical procedure of choice only in selected cases in which it would be of benefit to the patient, with more careful surveillance.
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Affiliation(s)
- Hiroaki Ishii
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan.
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Junko Kishikawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Koji Yasuda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Junichiro Tanaka
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Shinsuke Kazama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Hironori Yamaguchi
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Eiji Sunami
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Joji Kitayama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
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Myrelid P, Øresland T. A reappraisal of the ileo-rectal anastomosis in ulcerative colitis. J Crohns Colitis 2015; 9:433-8. [PMID: 25863275 DOI: 10.1093/ecco-jcc/jjv060] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 04/07/2015] [Indexed: 02/04/2023]
Abstract
Colectomy is still frequently required in the care of ulcerative colitis. The most common indications are either non-responding colitis in the emergency setting, chronic active disease, steroid-dependent disease or neoplastic change like dysplasia or cancer. The use of the ileal pouch anal anastomosis has internationally been the gold standard, substituting the rectum with a pouch. Recently the use of the ileorectal anastomosis has increased in frequency as reconstructive method after subtotal colectomy. Data from centres using ileorectal anastomosis have shown the method to be safe, with functionality and risk of failure comparable to the ileal pouch anal anastomosis. The methods have different advantages as well as disadvantages, depending on a number of patient factors and where in life the patient is at time of reconstruction. The ileorectal anastomosis could, together with the Kock continent ileostomy, in selected cases be a complement to the ileal pouch anal anastomosis in ulcerative colitis and should be discussed with the patient before deciding on reconstructive method.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery, County Council of Östergötland, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Tom Øresland
- Faculty of Medicine, University of Oslo, and Department of GI Surgery, Akershus University Hospital, Oslo, Norway
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Franck D, Chung YG, Coburn J, Kaplan DL, Estrada CR, Mauney JR. In vitro evaluation of bi-layer silk fibroin scaffolds for gastrointestinal tissue engineering. J Tissue Eng 2014; 5:2041731414556849. [PMID: 25396043 PMCID: PMC4228923 DOI: 10.1177/2041731414556849] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/25/2014] [Indexed: 01/01/2023] Open
Abstract
Silk fibroin scaffolds were investigated for their ability to support attachment, proliferation, and differentiation of human gastrointestinal epithelial and smooth muscle cell lines in order to ascertain their potential for tissue engineering. A bi-layer silk fibroin matrix composed of a porous silk fibroin foam annealed to a homogeneous silk fibroin film was evaluated in parallel with small intestinal submucosa scaffolds. AlamarBlue analysis revealed that silk fibroin scaffolds supported significantly higher levels of small intestinal smooth muscle cell, colon smooth muscle cell, and esophageal smooth muscle cell attachment in comparison to small intestinal submucosa. Following 7 days of culture, relative numbers of each smooth muscle cell population maintained on both scaffold groups were significantly elevated over respective 1-day levels—indicative of cell proliferation. Real-time reverse transcription polymerase chain reaction and immunohistochemical analyses demonstrated that both silk fibroin and small intestinal submucosa scaffolds were permissive for contractile differentiation of small intestinal smooth muscle cell, colon smooth muscle cell, esophageal smooth muscle cell as determined by significant upregulation of α-smooth muscle actin and SM22α messenger RNA and protein expression levels following transforming growth factor-β1 stimulation. AlamarBlue analysis demonstrated that both matrix groups supported similar degrees of attachment and proliferation of gastrointestinal epithelial cell lines including colonic T84 cells and esophageal epithelial cells. Following 14 days of culture on both matrices, spontaneous differentiation of T84 cells toward an enterocyte lineage was confirmed by expression of brush border enzymes, lactase, and maltase, as determined by real-time reverse transcription polymerase chain reaction and immunohistochemical analyses. In contrast to small intestinal submucosa scaffolds, silk fibroin scaffolds supported spontaneous differentiation of esophageal epithelial cells toward a suprabasal cell lineage as indicated by significant upregulation of cytokeratin 4 and cytokeratin 13 messenger RNA transcript levels. In addition, esophageal epithelial cells maintained on silk fibroin scaffolds also produced significantly higher involucrin messenger RNA transcript levels in comparison to small intestinal submucosa counterparts, indicating an increased propensity for superficial, squamous cell specification. Collectively, these data provide evidence for the potential of silk fibroin scaffolds for gastrointestinal tissue engineering applications.
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Affiliation(s)
- Debra Franck
- Urological Diseases Research Center, Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Yeun Goo Chung
- Urological Diseases Research Center, Department of Urology, Boston Children's Hospital, Boston, MA, USA ; Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Jeannine Coburn
- Department of Biomedical Engineering, Tufts University, Medford, MA, USA
| | - David L Kaplan
- Department of Biomedical Engineering, Tufts University, Medford, MA, USA
| | - Carlos R Estrada
- Urological Diseases Research Center, Department of Urology, Boston Children's Hospital, Boston, MA, USA ; Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Joshua R Mauney
- Urological Diseases Research Center, Department of Urology, Boston Children's Hospital, Boston, MA, USA ; Department of Surgery, Harvard Medical School, Boston, MA, USA
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Scoglio D, Ahmed Ali U, Fichera A. Surgical treatment of ulcerative colitis: Ileorectal vs ileal pouch-anal anastomosis. World J Gastroenterol 2014; 20:13211-13218. [PMID: 25309058 PMCID: PMC4188879 DOI: 10.3748/wjg.v20.i37.13211] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/19/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the current gold standard in the surgical treatment of ulcerative colitis (UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis (IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.
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Duclos J, Lefevre JH, Lefrançois M, Lupinacci R, Shields C, Chafai N, Tiret E, Parc Y. Immediate outcome, long-term function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014; 16:O288-96. [PMID: 24428330 DOI: 10.1111/codi.12558] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/29/2013] [Indexed: 02/08/2023]
Abstract
AIM Total/subtotal colectomy with ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with various reported rates of morbidity, function and quality of life. Our object was to determine these end-points in a series of patients undergoing these operations in our institution. METHOD All patients who underwent IRA or ISA between 1994 and 2009 were retrospectively reviewed. RESULTS A total of 320 patients (female 49%) with a median age of 54.2 (16.8-90.6) years underwent 338 IRA or ISA (in 18 patients the anastomosis was done twice) for inflammatory bowel disease (n = 96), polyposis (n = 95) and colorectal cancer (n = 97). Mortality and morbidity rates were 1.2% (n = 4) and 19.5% (n = 66) and 47 surgical complications (13.9%) occurred, including 26 (7.7%) cases of anastomotic leakage, leading to 23 re-operations. After a median follow-up of 49 (0-196) months, 262 patients still had a functioning anastomosis; 45 patients had died and 13 had a proctectomy. Information on function was obtained in 51.4% (133/259) of the cohort after a median follow-up of 77 (10-196) months. The mean (± standard deviation) rates of 24 h and nocturnal defaecation were 3.6 ± 2.4 and 0.5 ± 0.9. A disturbance of faecal or flatus continence occurred in 20% and 21% of patients. There was no case of faecal incontinence to solid stool. The mean SF-36 Physical and Mental Health Summary Scales were 46.3 ± 9.3 and 51.9 ± 9.3. Multivariate analysis showed that IRA and inflammatory bowel disease were both independently associated with poorer long-term function. CONCLUSION Colectomy with IRA or ISA is safe with low postoperative morbidity and mortality. The employment of IRA and inflammatory bowel disease appear to be independent negative factors on function in multivariate analysis.
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Affiliation(s)
- J Duclos
- Department of Digestive Surgery, Saint-Antoine Hospital, University Pierre and Marie Curie, Paris VI, Paris, France
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Coviello LC, Stein SL. Surgical management of nonpolypoid colorectal lesions and strictures in colonic inflammatory bowel disease. Gastrointest Endosc Clin N Am 2014; 24:447-54. [PMID: 24975535 DOI: 10.1016/j.giec.2014.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with inflammatory bowel disease (IBD) and dysplasia have pathologic characteristics and risks different from those of patients with sporadic carcinomas. Therefore, surgical interventions need to be more aggressive than in sporadic cases. This article reviews the surgical management of nonpolypoid lesions, dysplasia, and strictures found in patients with IBD.
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Affiliation(s)
- Lisa C Coviello
- Colorectal Surgery and Endoscopy, Department of Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79920, USA.
| | - Sharon L Stein
- Section of Colon and Rectal Surgery, Department of Surgery, University Hospitals/Case Medical Center, 11100 Euclid Avenue, LKS 5047, Cleveland, OH 44106, USA
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Andersson P, Norblad R, Söderholm JD, Myrelid P. Ileorectal anastomosis in comparison with ileal pouch anal anastomosis in reconstructive surgery for ulcerative colitis--a single institution experience. J Crohns Colitis 2014; 8:582-9. [PMID: 24315777 DOI: 10.1016/j.crohns.2013.11.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/12/2013] [Accepted: 11/13/2013] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Ileal pouch anal anastomosis (IPAA) is the standard procedure for reconstruction after colectomy for ulcerative colitis (UC). However, ileorectal anastomosis (IRA) as an alternative has, recently experienced a revival. This study from a single center compares the clinical outcomes of these procedures. METHODS From 1992 to 2006, 253 patients consecutively underwent either IRA (n=105) or IPAA (n=148). Selection to either procedure was determined on the basis of rectal inflammation, presence of dysplasia/cancer or patient preferences. Patient-records were retrospectively evaluated. Mean follow-up time was 5.4 and 6.3 years respectively. RESULTS Major postoperative complications occurred in 12.4% of patients after IRA and in 12.8% after IPAA (ns). Complications of any kind after IRA or IPAA, even including subsequent stoma-closure, occurred in 23.8% and 39.9% respectively (p<0.01). Estimated cumulative failure rates after 5 and 10 years were 10.1% and 24.1% for IRA and 6.1% and 18.6% for IPAA respectively (ns). The most common cause for failure was intractable proctitis (4.8%) and unspecified dysfunction (4.8%) respectively. At follow-up 76.9% of patients with IRA had proctitis and 34.1% with IPAA had pouchitis. Estimated cumulative cancer-risk after 10, 20 and 25 year duration of disease was 0.0%, 2.1% and 8.7% for IRA. Figures for IPAA were 0.7%, 1.8% and 1.8% (ns). CONCLUSION Failure-rates did not significantly differ between patients operated with IRA or IPAA. Patients operated with IPAA had a higher cumulative number of postoperative complications. The high long-term cancer-risk after IRA indicates that this procedure should be an interim solution in younger patients.
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Affiliation(s)
- Peter Andersson
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden.
| | - Rickard Norblad
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
| | - Johan D Söderholm
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
| | - Pär Myrelid
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
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Jones DW, Garrett KA. Anastomotic technique—Does it make a difference? SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
Many patients with Crohn’s disease (CD) require surgery. Indications for surgery include failure of medical treatment, bowel obstruction, fistula or abscess formation. The most common surgical procedure is resection. In jejunoileal CD, strictureplasty is an accepted surgical technique that relieves the obstructive symptoms, while preserving intestinal length and avoiding the development of short bowel syndrome. However, the role of strictureplasty in duodenal and colonic diseases remains controversial. In extensive colitis, after total colectomy with ileorectal anastomosis (IRA), the recurrence rates and functional outcomes are reasonable. For patients with extensive colitis and rectal involvement, total colectomy and end-ileostomy is safe and effective; however, a few patients can have subsequent IRA, and half of the patients will require proctectomy later. Proctocolectomy is associated with a high incidence of delayed perineal wound healing, but it carries a low recurrence rate. Patients undergoing proctocolectomy with ileal pouch-anal anastomosis had poor functional outcomes and high failure rates. Laparoscopic surgery has been introduced as a minimal invasive procedure. Patients who undergo laparoscopic surgery have a more rapid recovery of bowel function and a shorter hospital stay. The morbidity also is lower, and the rate of disease recurrence is similar compared with open procedures.
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Abstract
Surgical management for refractory Crohn colitis often involves creation of a temporary or permanent stoma. Traditionally, the procedure of choice has been a total proctocolectomy with permanent ileostomy. However, restorative procedures that help to avoid a permanent stoma are being used with more frequency. In this article, the authors will address these procedures, including colocolonic anastomosis, ileorectal anastomosis, ileal pouch rectal anastomosis, and ileal pouch anal anastomosis. Factors that may influence one's decision to perform these procedures, such as patient age and nutritional status, medical comorbidities, sphincter function, desire to avoid a permanent ostomy, and prior medical therapy, will be discussed. Functional outcomes regarding these procedures will also be described. One should keep in mind that surgery does not cure Crohn disease and that postoperative long-term management is essential in preventing progression or recurrence of disease.
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Affiliation(s)
- Sean T. Martin
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jon D. Vogel
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
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Reshef A, Gurland B, Zutshi M, Kiran RP, Hull T. Colectomy with ileorectal anastomosis has a worse 30-day outcome when performed for colonic inertia than for a neoplastic indication. Colorectal Dis 2013; 15:481-6. [PMID: 23061597 DOI: 10.1111/codi.12058] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/10/2012] [Indexed: 02/08/2023]
Abstract
AIM Whether bowel related dysfunction adversely affects postoperative recovery after total colectomy with ileorectal anastomosis (C + IRA) for colonic inertia (CI) has not been previously well evaluated. This study compared the early postoperative outcome of C + IRA for CI and for other noninflammatory indications. METHOD Patients undergoing elective C + IRA from 1999 to 2010 were identified from a prospectively maintained database. Since inflammation in the rectum or small bowel may influence the outcome, patients with inflammatory bowel disease were excluded. Patients undergoing surgery for CI (group A) were compared with patients having the operation for other benign noninflammatory diseases (group B). Demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), surgical procedure and 30-day complications were assessed. RESULTS The study population consisted of 333 patients undergoing elective C + IRA (99 men, mean age 39 ± 16 years). The procedure was laparoscopic in 163 (49%) patients. Groups A (n = 131) and B (n = 202) had similar age and ASA score (39 ± 11 vs 39 ± 19 years, P = 0.4; 2.2 ± 0.5 vs 2.4 ± 0.7). Group A patients had lower BMI (25 ± 5 vs 28 ± 8 kg/m(2) , P = 0.002), more women (99 vs 51%, P < 0.001) and fewer laparoscopic procedures (43 vs 53%, P = 0.04). Compared with group B, group A had a greater incidence of postoperative ileus (32 vs 19%, P = 0.009), higher overall morbidity (36 vs 15%, P < 0.001) and increased length of stay (8.4 ± 6 vs 7.2 ± 5 days, P < 0.006). These differences persisted when subgroups of patients who underwent laparoscopic or open surgery were compared. CONCLUSION Although CI is considered a 'benign' condition, patients undergoing C + IRA for this indication have significant morbidity compared with patients having the operation for other noninflammatory benign conditions.
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Affiliation(s)
- A Reshef
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Araki T, Uchida K, Okita Y, Fujikawa H, Inoue M, Ohi M, Tanaka K, Inoue Y, Mohri Y, Kusunoki M. Impact of postoperative infliximab maintenance therapy on preventing the surgical recurrence of Crohn's disease: a single-center paired case-control study. Surg Today 2013; 44:291-6. [PMID: 23463537 DOI: 10.1007/s00595-013-0538-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 12/17/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE Preventing a recurrence of Crohn's disease is a problem that remains to be solved. We evaluated the impact of using infliximab as a postoperative therapy on preventing the surgical recurrence of Crohn's disease. METHODS We performed a pair-matched study comparing 100 patients who had received postoperative infliximab maintenance therapy with those who had not between 1995 and 2010. The patients were matched by gender, Vienna classification and age at the time of the operation. Crohn's disease-related reoperation was evaluated as surgical recurrence. RESULTS In the postoperative infliximab maintenance therapy group, infliximab was administrated within 8 weeks after the operation. The median follow-up period was 36 months in the postoperative infliximab maintenance therapy group and 51 months in the control group. Surgical recurrences were recognized in 37 patients (three in the postoperative infliximab maintenance therapy group and 34 in the control group). A univariate analysis by the Kaplan-Meier method identified a body mass index >18 at the time of the operation (HR 0.19, p = 0.01) and postoperative infliximab maintenance therapy (HR 0.22, p = 0.0022) as factors related to the reduction of surgical recurrence. The multivariate analysis revealed that postoperative infliximab maintenance therapy was the only significant factor preventing surgical recurrence. CONCLUSION Postoperative infliximab maintenance therapy for Crohn's disease prevents surgical recurrence, at least within 3 years after the operation.
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Affiliation(s)
- Toshimitsu Araki
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan,
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da Luz Moreira A, Lavery IC. Ileorectal anastomosis and proctocolectomy with end ileostomy for ulcerative colitis. Clin Colon Rectal Surg 2012; 23:269-73. [PMID: 22131897 DOI: 10.1055/s-0030-1268253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Until the development of the ileal pouch-anal anastomosis in the early 1980s, proctocolectomy with end ileostomy was the only definitive surgery for ulcerative colitis and colectomy with ileorectal anastomosis was the procedure of choice for affected patients who were reluctant to have a permanent ileostomy. Currently, ileal pouch-anal anastomosis is the most common procedure for patients with ulcerative colitis requiring surgical treatment. However, there is still a role for ileorectal anastomosis and proctocolectomy with end ileostomy for a selected group of patients. In this review, the authors summarize the current indications for ileorectal anastomosis and proctocolectomy with end ileostomy in patients with ulcerative colitis.
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Affiliation(s)
- Andre da Luz Moreira
- Division of Colorectal Surgery, Rio de Janeiro State University Medical School, Rio de Janeiro, Brazil
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Biodistribution of technetium-99m pertechnetate after total colectomy in rats. Appl Radiat Isot 2010; 68:2169-73. [DOI: 10.1016/j.apradiso.2010.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Revised: 10/18/2009] [Accepted: 07/25/2010] [Indexed: 11/22/2022]
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Abstract
Ileal pouch-anal anastomosis has clearly diminished the role of colectomy and ileorectal anastomosis (IRA) in the management of patients with ulcerative colitis. Nonetheless, IRA probably still has an appropriate place in highly selected patients, and many others maintain an "out of circuit" rectal remnant after subtotal colectomy. Although symptomatic proctitis is the most common reason for completion proctectomy, these patients are also at a significant risk to develop rectal cancer. Routine surveillance appears to be warranted.
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Affiliation(s)
- Adam Juviler
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT 05401, USA
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Abstract
Toxic colitis, also known as fulminant colitis, or toxic megacolon when associated with bowel dilation, remains a significant emergent problem in patients with ulcerative colitis. The surgical options differ when compared with the patient undergoing elective resection for this disease and are influenced by the patients' overall medical status. Generally the options are total abdominal colectomy with ileostomy, and proctocolectomy with ileostomy or pouch reconstruction. In few circumstances, a decompressing colostomy and loop ileostomy may be performed. More recently, laparoscopy has been employed. The general surgical recommendations, indications, and techniques will be discussed.
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Affiliation(s)
- Tracey D Arnell
- Division of General Surgery, New York Presbyterian Hospital-Columbia Campus, New York, NY 10032, USA.
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47
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Averboukh F, Kariv Y. Ileal Pouch Rectal Anastomosis: Technique, Indications, and Outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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49
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Kariv Y, Remzi FH, Strong SA, Hammel JP, Preen M, Fazio VW. Ileal Pouch Rectal Anastomosis: A Viable Alternative to Permanent Ileostomy in Crohn's Proctocolitis Patients. J Am Coll Surg 2009; 208:390-9. [DOI: 10.1016/j.jamcollsurg.2008.10.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 10/02/2008] [Accepted: 10/02/2008] [Indexed: 12/14/2022]
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Segmental vs. extended colectomy: measurable differences in morbidity, function, and quality of life. Dis Colon Rectum 2008; 51:1036-43. [PMID: 18470560 DOI: 10.1007/s10350-008-9325-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Revised: 10/06/2007] [Accepted: 10/28/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE The colon coordinates fecal elimination while reabsorbing excess fluid. Extended colonic resection removes synchronous and prevents metachronous disease but may adversely alter bowel function and health-related quality of life to a greater degree than segmental resection. This study examined the short-term morbidity and long-term function and quality of life after colon resections of different extents. METHODS Patients undergoing extended resections (n = 201, subtotal colectomy with ileosigmoid or total abdominal colectomy with ileorectal anastomosis) and segmental colonic resections (n = 321) during 1991 to 2003 were reviewed for perioperative outcomes and surveyed for bowel function and quality of life using an institutional questionnaire and a validated quality of life instrument (response rate: 70 percent). RESULTS The most common indication for extended resections was multiple polyps, and for segmental resections, single malignancy. The complication-free rate was 75.4 percent after segmental resections, 42.8 percent after ileosigmoid anastomosis, and 60 percent after ileorectal anastomosis. Median daily stool frequency was two after segmental resections, four after ileosigmoid anastomosis, and five after ileorectal anastomosis, despite considerable dietary restrictions (55.6 percent) and medication use (19.6 percent daily) after ileorectal anastomosis. Significant proportions of patients felt restricted from preoperative social activity (31.5 percent), housework (20.4 percent), recreation (31.5 percent), and travel (42.6 percent) after ileorectal anastomosis. The overall quality of life after segmental resection, ileosigmoid anastomosis, and ileorectal anastomosis was 98.5, 94.9, and 91.2, respectively. CONCLUSIONS Measurable compromises in long-term bowel function and quality of life were observed after extended vs. segmental resections. The relative differences in patient-related outcomes should be deliberated against the clinical benefits of extended resection for the individual patient.
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