The Ileoanal Pouch 30 Years On

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The Ileoanal Pouch30 Years On

• Alastair CJ Windsor MD FRCS

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Management Of IBDTraditional Care
Management Of IBD
Surgery
Medicine
Failed Medical Management
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Surgical Decision Making !!More important than
the surgery itself

• Right operation
• Right patient
• Right time

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Management Of IBDModern Paradigm Of Care
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Colectomy in UC Patients Following
Corticosteroids
100

• Contributing factors
• Disease activity
• Extent of disease at diagnosis
• Disease duration

80
60
Cumulative Probability ()
40
20
0
0 30 60
90 182 365
Days
Faubion WA. Gastroenterology. 2001121255-260.
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Medical SalvageLong-Term Experience of CsA
65
58
90
65 relapse within 12 months 58 have a colectomy
within 7yr
Campbell S, et al. Eur J Gastroenterol Hepatol.
20051779.
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Infliximab and UC (ACT I)Remission Without
Corticosteroids
P 0.022
Proportion of Patients,
Subjects receiving corticosteroids at baseline,
n222.
A greater proportion of infliximab-treated
subjects were in clinical remission and not
receiving corticosteroids at wk 54 (21.0)
compared with the placebo-treated group (8.9
P0.022).
ACT 1 54-Week Data
Rutgeerts P, et al. N Engl J Med.
20053532462-2476
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Biological TherapyMalignancy
Mackey AC, Green L, Liang LC, Dinndorf P, Avigan
M. J Pediatr Gastroenterol Nutr 2007 44 265267.
Rosh JR, Oliva-Hemker M. J Pediatr Gastroenterol
Nutr 2007 44 165167.
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J Am Coll Surg 2003
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Reconstruction After ColectomyThe Ileoanal Pouch

• Gold Standard
• Ulcerative colitis, FAP
• Parks AG Nicholls RJ
• BMJ 1978 2 65-8
• Benefits
• Normal route of defecation
• Good functional outcomes

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Restorative Proctocolectomy Issues
Technique
Complications
Learning Curve Stapled vs. Sewn Stoma Laparoscopy
Pouchitis Dysplasia Carcinoma Sepsis Failure
Restorative Proctocolectomy
Outcome
Indications
Fecundity Crohns
Functional Morbidity Children Elderly
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Restorative ProctocolectomyComplications

• Sepsis
• 5 - 27
• Obstruction
• 9 - 22
• Anast Stricture
• 5 significant
• Pouchitis
• 5 - 50
• Failure
• 2 - 10

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Restorative ProctocolectomyThe Learning Curve
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Restorative ProctocolectomyThe Learning Curve
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National IBD Audit
Average of 4 IAPP per year per Colorectal Unit in
UK
2 Surgeons per unit 2 IAPP per Surgeon per
year Career IAPPs 40 !!
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Restorative Proctocolectomy Pouch Configuration

• Volume may reduce frequency
• No difference in controlled trials

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Restorative Proctocolectomy Stapled versus
handsewn anastomosis
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Restorative ProctocolectomyDefunctioning Stoma

• Theory
• Mitigates effects of pelvic sepsis
• Recovery without functional probs
• However
• Controlled trials no difference
• Compromise
• Morbidity of ileostomy 10 -20
• Emergency stoma 10 -20
• ? Not a operation for the juniors

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Restorative Proctocolectomy Influence Of
Ileostomy

• 634 Patients (1976-1997)
• Mean f/u 85 58 mnths
• Failure in 61 (9.7)
• Early 15 (25)
• Late 46 (75)

Tulchinsky, Hawley,Nicholls Ann Surg
2003238229-234
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Restorative Proctocolectomy Laparoscopic Approach
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Restorative Proctocolectomy Laparoscopic Approach
Young-Fadok DCR 2005
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Restorative Proctocolectomy Issues
Technique
Complications
Learning Curve Stapled vs. Sewn Stoma Laparoscopy
Pouchitis Dysplasia Carcinoma Sepsis Failure
Restorative Proctocolectomy
Outcome
Indications
Crohns
Functional Morbidity QOL
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Restorative ProctocolectomyFunctional Outcome
Pouches convert a colitic with a colon to a
colitic with a pouch
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Restorative Proctocolectomy Functional outcomes
Frequency but not urgency
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Restorative ProctocolectomyQuality Of Life
Quality of life in patients undergoing pouch
surgery
Normal pouch function 4-8 bowel movements per day
(approx 700ml total)
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How Long Do They Last ?Deterioration With Time
Bullard KM, Dis Colon Rectum 45299304
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Restorative Proctocolectomy Patient Satisfaction
Postoperative Time Interval (yrs) 0
2 2- 5 5 6 gt8 Would recommend to
others 98 98.1 98.3 97.7 Would have
again 94.8 96.7 96.8 96 Happiness with
surgery 8.92 9.13 9.24 9.29 (VAS 0 10)
Fazio V et al. Ann Surg 201999
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Restorative Proctocolectomy Issues
Technique
Complications
Learning Curve Stapled vs. Sewn Stoma
Failure Sepsis Pouchitis Dysplasia Carcinoma
Restorative Proctocolectomy
Outcome
Indications
Fecundity Crohns
Functional Morbidity QOL
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Ileoanal PouchPouchitis
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EpidemiologyPouchitis

• Acute Pouchitis
• 20-59 develop acute pouchitis within 5 years
• 40 of these have single episode
• Clinical Course - Remaining 60
• Infrequent lt1 per year
• Relapsing 1-3 per year
• Chronic Pouchitis
• gt 4 months
• 5-10 with pouchitis

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Presentation and DiagnosisPouchitis

• Symptoms
• Frequency
• Urgency
• Incontinence
• Anorexia / fever
• Extra-IM
• Diagnosis
• Symptoms
• Endoscopic Findings
• Histopathology

Differential Diagnosis

• Secondary pouchitis
• Sepsis pelvic
• pouch-anal fistula
• anastomotic stricture
• Cuffitis
• Functional disorders
• Evacuation problems
• Irritable pouch syndrome
• Enteric Infection
• Crohns disease (5)

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Pouchitis AetiologyDysbiosis
Lower concentrations of Bifidobacteria Lactobacil
li Lower diversity
Higher concentrations of Aerobes Bacteroides Cert
ain strains of E. coli Sulfate reducing
bacteria Unusual phylogenetic groups
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PouchitisTreatment Principles
Prebiotics
Dietary components
Microbiota
Mucosal immune system
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Antibiotics for acute pouchitis

• Metronidazole 400mg TDS
• DBPC crossover trial 73 improvement in
  diarrhoea Vs 9 placebo (n13/group)
• no endoscopic / histological improvement (Madden
  et al 1994)
• Ciprofloxacin 500md bd
• RCT vs metronidazole both reduce PDAI, but
  cipro has more benefit (6.9 /-1.2 vs. 3.8
  /-1.7, P .002)
• Less side effects (0 vs 33) (Shen et al, 2001)
• Combination
• Open label data shows 73 patients failing first
  line antibiotic therapy may respond to
  combination treatment (Hurst et al, 1998).

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Probiotics in pouchitis VSL3 is an effective
maintenance strategy
40 patients in remission after 1 month antibiotic
therapy VSL3 6g / day vs placebo DBPCT for 9
months
All patients relapsed 3 months after trial
terminated
Gionchetti et al, Gastroenterology, 2000 119305
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Chronic Resistant Pouchitis

• Cyclical Antibiotics
• Corticosteroids
• Budesonide
• 5 ASA
• Immune suppression
• Infliximab
• Topical
• Bismuth
• Butyrate
• Glutamine

Little in the way of robust data to support any
of these
Surgical Excision
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Restorative Proctocolectomy Issues
Technique
Complications
Learning Curve Stapled vs. Sewn Stoma
Pouchitis Dysplasia Carcinoma Sepsis Failure
Restorative Proctocolectomy
Outcome
Indications
Fecundity Crohns
Functional Morbidity QOL
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Restorative Proctocolectomy Fecundity
FAP
Olsen et al.Br J Surg 2003
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Restorative Proctocolectomy Fecundity
UC
Ording et al Gastroenterology 2002
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Restorative Proctocolectomy Fecundity-
Implications

• Informed Consent
• Timing of Surgery
• Alternative therapy
• Cyclosporin , Infliximab
• Bridge to surgery
• Alternative procedures
• Subtotal or Ileorectal anastomosis
• Bridge to IAPP

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Summary

• IAPP Gold standard surgical treatment for UC
• Technically demanding Learning curve
• Done well Excellent functional results
• Despite 30yr history Evolving operation
• Keys to success
• Multidisciplinary care
• Right patient, right time
• High volume unit and surgeon