Operative Therapy for UC

Maneuvers for Increasing Reach of the Ileal Pouch

In situations where the ileal J pouch does not reach the pelvic floor even after full mobilization, five maneuvers can be employed to gain extra length:

1. Ligation of the Ileocolic Pedicle:
   • If not previously divided during colectomy, ligate the ileocolic pedicle.
   • Excise a window of peritoneum to increase length.
2. Transverse Incision of Peritoneum Overlying Superior Mesenteric Vessels:
   • Incise anterior and posterior peritoneum transversely at multiple levels.
   • Risks:
     • Injury to blood supply of the pouch.
     • Potential for mesenteric hematoma.
     • Possibility of ileal pouch loss due to avulsion of denuded mesentery.
3. Selective Division of Secondary Arcade Mesenteric Vessels:
   • Transilluminate mesentery to identify vessels.
   • Divide secondary arcade vessels to the apex of the pouch while preserving the arcade to the distal ileum.
   • Benefit: Each centimeter of transverse incision yields an extra centimeter in length.
4. Creation of an S Pouch:
   • Offers extra reach due to near-normal mesenteric orientation and a 2-cm efferent limb.
5. Suspension of the Pouch as a Loop Ileostomy:
   • If tension-free anastomosis is not possible, suspend the pouch in the pelvis as a loop ileostomy.
   • Considerations:
     • Close the pouch outlet before placement.
     • Anchor the pouch to the pelvic floor.
     • Requires a subsequent operation for anastomosis.
     • Risks reperitonealization of the pelvic floor and rectal stump.

Construction of the Ileal Pouch

Various configurations exist for constructing the ileal pouch, mainly:

• J Pouch
• S Pouch
• W Pouch

Two-Limbed Pelvic Ileal Reservoir—J Pouch

• Most commonly used configuration.
• Created from two limbs of ileum, each 15–20 cm in length.
• Construction Steps:
  • Make an enterotomy at the terminal ileum portion that reaches below the pubis.
  • Use a linear stapler to align and join the antimesenteric borders of the afferent and efferent limbs.
  • Multiple firings may be needed to complete the pouch.
  • Place seromuscular sutures to prevent torque.
  • Fit the anvil of the circular stapler into the pouch apex for the ileal pouch-anal anastomosis (IPAA).

Alternative Pouch Configurations: The S Pouch and W Pouch

S Pouch

• Configuration: Three-limbed pouch with a 2-cm efferent limb.
• Indications: When a J pouch cannot reach the pelvis.
• Construction:
  • Fold 30–45 cm of ileum in an S shape.
  • Handsewn anastomoses are required for the three seams.
• Advantages:
  • Provides extra length for a tension-free anastomosis.
• Complications:
  • Outflow Obstruction:
    • Occurs if the efferent limb is too long (>2 cm) or if a long rectal cuff is retained.
    • May lead to stasis, bacterial overgrowth, distention, and atony of the pouch.
  • Need for Self-Catheterization:
    • Higher incidence compared to other pouch types.
    • Spontaneous lengthening of the efferent limb can exacerbate issues.

W Pouch

• Configuration: Four-limbed pouch created from four 12-cm lengths of ileum.
• Advantages:
  • Increased reservoir capacity similar to the native rectal ampulla.
  • No efferent limb, reducing risk of outflow obstruction.
• Considerations:
  • Can be bulky, which may be problematic in a narrow pelvis.
  • May require modification of limb lengths to accommodate pelvic space.

Comparative Studies of Pouch Design and Functional Outcome

• Short-Term Benefits:
  • W pouch associated with lower stool frequency and less antidiarrheal use compared to J pouch.
• Long-Term Outcomes:
  • No significant functional differences at 9-year follow-up.
• S Pouch Considerations:
  • Higher rates of evacuation difficulties and need for self-catheterization.
  • Outflow obstruction is a common issue.

Ileoanal Anastomosis: Handsewn vs. Stapled

Two techniques for IPAA:

1. Transanal Mucosectomy with Handsewn Anastomosis
2. Stapled Anastomosis

Handsewn Anastomosis

Operative Technique

• Procedure:
  • Evert the anus and make a circumferential incision at the dentate line.
  • Dissect the mucosa off the rectal wall up to above the anorectal ring.
  • Complete proctectomy and deliver the pouch to the sphincter level.
  • Secure the pouch with full-thickness sutures to complete the anastomosis.
• Advantages:
  • Removes all diseased mucosa.
• Disadvantages:
  • Time-consuming and technically challenging.
  • Risks anal trauma and potential incontinence.
  • Associated with higher rates of:
    • Anastomotic disruptions.
    • Peripouch abscesses.
    • Postoperative strictures.
    • Small bowel obstructions.

Stapled Anastomosis

Operative Technique

• Procedure:
  • Transect the rectum with a linear stapler within 1.5 cm above the dentate line.
  • Insert the circular stapling device into the anorectal stump.
  • Attach the anvil secured in the pouch apex to the stapler spike.
  • Close the stapler under direct visualization and fire to complete the anastomosis.
• Advantages:
  • Quicker and easier with minimal anal trauma.
  • Preserves the anal transitional zone (ATZ), enhancing continence.
• Disadvantages:
  • Retains some mucosa, which may risk dysplasia or cuffitis.
  • Regular endoscopic surveillance is recommended.

Comparative Outcomes

• Functional Results:
  • Stapled anastomosis generally associated with better continence.
  • Handsewn anastomosis linked to worse incontinence and quality of life metrics.
• Risk of Dysplasia:
  • Low in stapled technique but necessitates surveillance.
  • Residual mucosa can still be present after mucosectomy.

Complications and Considerations

Pelvic Sepsis and Pouch Failure

• Pelvic Sepsis:
  • Leads to a pouch failure rate of approximately 20%.
  • Lower rates observed with a three-stage surgical approach.
• Risk Factors:
  • High-dose corticosteroid use (≥40 mg prednisone daily).
  • Immunocompromised state.
• Staging Considerations:
  • Three-stage procedure recommended for high-risk patients.
  • Two-stage or single-stage procedures may be suitable for well-selected patients without risk factors.

Small Bowel Obstruction and Stoma Complications

• Small Bowel Obstruction:
  • Occurs in about 11.4% of patients with diverting ileostomies.
  • Higher rates compared to non-diverted patients.
• High Stoma Output:
  • Can cause dehydration and require readmission.
• Local Stoma Issues:
  • Skin breakdown, prolapse, retraction, stenosis.

Functional Outcomes and Patient Selection

• Evacuation Efficiency:
  • Generally good across different pouch configurations.
  • Most patients achieve 4–7 bowel movements per 24 hours.
• Continence:
  • Majority experience normal urge and can defer defecation.
  • Ability to discriminate between flatus and feces is typically preserved.
• Patient Factors:
  • Body habitus and pelvic dimensions influence pouch design choice.
  • Surgeon experience also plays a significant role.

Conclusion

The construction and anastomosis techniques of the ileal pouch are crucial for optimal functional outcomes. Selection of the appropriate pouch configuration and anastomosis method should be individualized based on patient factors and surgical expertise. Awareness of potential complications, such as pelvic sepsis, outflow obstruction, and stoma-related issues, is essential for postoperative management and patient counseling.

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Management of Pouch-Specific Postoperative Complications

Introduction

• Early postoperative complications following restorative proctocolectomy occur in 19%–33% of cases.
• Mortality rate is low at 0.1%.
• Prompt diagnosis and intervention are essential.

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Pelvic Sepsis

Incidence and Causes

• Occurs in 5%–19% of patients after ileal pouch–anal anastomosis (IPAA).
• Common sources:
  • Anastomotic leak (most common).
  • Pouch ischemia.
  • Inflammation or infection.

Presentation

• Acute:
  • Abdominal pain.
  • Fever.
  • General or local peritonitis.
• Subacute:
  • Indolent pelvic pain.
  • Pouch dysfunction.
  • May be asymptomatic.

Diagnosis

• CT Imaging:
  • Best tool for identifying pelvic collections or inflammation.
• Contrast Pouchogram:
  • Identifies site of disruption.
• Examination Under Anesthesia:
  • Assesses anastomotic integrity.
• Fistulogram:
  • Evaluates fistula formation.

Intervention

• Nonoperative Management:
  • Antibiotics alone may resolve abscesses in some cases.
  • CT-Guided Drainage:
    • Transabdominal or transgluteal approach.
    • Risk of creating an extrasphincteric fistula if anastomotic leak is present.
• Transanal Drainage:
  • Preferred if an anastomotic leak is suspected.
  • Placement of a small mushroom-tipped catheter through the defect.
• Surgical Intervention:
  • Required for uncontrolled sepsis or failure of nonoperative methods.
  • Abdominal Exploration:
    • Pelvic washout.
    • Repair of perforation if possible.
    • Creation of a diverting loop ileostomy to salvage the pouch.
  • Pouch Excision:
    • Necessary in cases of pouch ischemia.

Risk Factors

• High-dose corticosteroids (≥40 mg prednisone daily).
• Biologic agents (e.g., infliximab).
• Obesity (BMI >30 kg/m²).
• Intraoperative blood transfusion.
• Technical Factors:
  • Mesenteric manipulation leading to ischemia.
  • Tension on the anastomosis.

Outcomes

• Pouch Failure Rate: Approximately 20% in patients with pelvic sepsis.
• Functional Impact:
  • Increased stool frequency.
  • Incontinence.
  • Decreased stool/gas discrimination.
  • Sexual dysfunction.

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Postoperative Hemorrhage

Incidence and Sites

• Occurs in 1.5%–3.5% of patients.
• Intraluminal:
  • Along staple lines.
  • At the ileostomy site.
• Extraluminal:
  • Pelvic or peritoneal cavity bleeding.

Management

• Minor Bleeding:
  • Often self-limited.
  • Endoscopic interventions:
    • Clipping or cautery.
    • Irrigation with dilute epinephrine solution.
• Severe Bleeding:
  • May require surgical exploration.
  • Pelvic packing.
  • Inspection and control of mesenteric bleeding.

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Stricture at the Ileal Pouch–Anal Anastomosis

Incidence and Symptoms

• More common after handsewn anastomosis.
• Symptoms:
  • Incomplete evacuation.
  • Straining.
  • Defecatory urgency.
  • Frequent watery stools.
• Onset: Typically 6–9 months post-surgery.

Management

• Digital Examination:
  • Assess anastomotic patency before ileostomy closure.
• Dilation Techniques:
  • Digital Dilation:
    • Gentle, radial pressure.
  • Hegar Dilators:
    • Sequential dilation in clinic or under anesthesia.
  • Self-Dilation:
    • For maintenance in recurrent cases.
• Surgical Options:
  • Excision of stricture with mucosal advancement.
  • Redo of the pouch.
  • Pouch excision in severe cases.

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Pouch-Vaginal Fistulas

Incidence and Presentation

• Occur in 2.9% of patients post-IPAA.
• Symptoms:
  • Feculent vaginal discharge.
  • Passage of gas via the vagina.
• Average Onset: 21 months postoperatively.

Diagnosis

• Contrast Studies:
  • Water-soluble enema.
  • Methylene blue test with vaginal tampon.
• Endoscopic Examination:
  • Pouchoscopy and speculum exam to localize fistula.
• Biopsy:
  • If Crohn's disease is suspected.

Management

• Initial Measures:
  • Placement of a noncutting seton.
• Surgical Repair:
  • Local Procedures:
    • For fistulas at or below the anastomosis.
  • Transabdominal Approach:
    • For fistulas above the anastomosis.
• Outcomes:
  • Healing rates vary (40%–66%).
  • Pouch Failure Rate: 33% at median follow-up.
• Considerations:
  • Diverting ileostomy may not reduce fistula risk but aids in symptom relief.
  • Transvaginal repairs limit anal sphincter trauma.

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Small Bowel Obstruction

Incidence and Causes

• Occurs in 20%–40% of patients.
• Causes:
  • Adhesive disease (most common).
  • Obstruction at ileostomy takedown site.
  • Afferent limb angulation due to adhesions.

Management

• Conservative Treatment:
  • Successful in most cases.
• Surgical Intervention:
  • Required in approximately 7% of cases.
  • Pouchopexy:
    • Fixation of the pouch to prevent angulation.
  • Enteroenteral Bypass:
    • In cases where adhesions cannot be safely released.

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Long-Term Complications

Cuffitis

• Incidence: Up to 15% in stapled IPAA patients.
• Symptoms:
  • Increased stool frequency.
  • Outlet bleeding.
  • Pelvic pain.
• Diagnosis:
  • Endoscopy: Normal pouch, inflamed rectal cuff.
  • Histology: Ulceration and inflammatory infiltration.

Management

• Topical Therapy:
  • Corticosteroid suppositories.
  • 5-Aminosalicylic Acid enemas or suppositories.
• Systemic Therapy:
  • For refractory cases.
• Surgical Intervention:
  • Mucosectomy and Pouch Advancement:
    • For persistent or severe cuffitis.

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Risk for Neoplasia

• Concern: Dysplasia or cancer in retained rectal mucosa.
• Incidence: Low; dysplasia in 2.8% of patients over long-term follow-up.

Surveillance Recommendations

• Without Preexisting Dysplasia:
  • Pouchoscopy at 1 year post-surgery.
  • Every 2–3 years thereafter.
• With Preexisting Dysplasia:
  • Annual surveillance.
• Management:
  • Persistent or high-grade dysplasia warrants mucosectomy and pouch advancement.

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Pouchitis

Incidence and Risk Factors

• Occurs in 16%–48% of patients.
• Risk Factors:
  • Ulcerative colitis diagnosis.
  • Primary sclerosing cholangitis.
  • Extraintestinal manifestations.
  • Postoperative septic complications.
  • Older age and nonsmoking status.
  • NSAID use.

Pathogenesis

• Infectious Theory:
  • Bacterial overgrowth and altered microbiota.
• Immune-Mediated Inflammation:
  • Similar to underlying IBD processes.
• Colonic Metaplasia:
  • Mucosal changes due to chronic inflammation.

Diagnosis

• Symptoms:
  • Increased bowel frequency.
  • Loose stools with blood or mucus.
  • Pelvic discomfort and low-grade fever.
• Endoscopy:
  • Inflamed, ulcerated pouch mucosa.
• Histology:
  • Acute inflammatory infiltrate.
  • Villous atrophy and crypt abscesses.
• Pouchitis Disease Activity Index (PDAI):
  • Score >7 indicates pouchitis.

Treatment of Acute Pouchitis

• Antibiotics:
  • Metronidazole: 750–1500 mg/day for 7–14 days.
  • Ciprofloxacin: May be more effective in some cases.
• Probiotics:
  • VSL#3 shown to prevent recurrence.
• Budesonide Suppositories:
  • 1.5 mg/day as an alternative.

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Chronic Antibiotic-Refractory Pouchitis (CARP)

Management

• Culture and Sensitivity:
  • Tailor antibiotics based on results.
• Evaluate for Infections:
  • Cytomegalovirus (CMV).
  • Clostridium difficile.
• Exclude Structural Issues:
  • Fistulas, ischemia, strictures.
• Immune-Mediated Therapy:
  • Corticosteroids.
  • Immunomodulators.
  • Anti-TNF-α Agents (e.g., infliximab).

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Crohn Disease

Impact on Pouch Function

• Independent predictor of pouch failure (~50%).
• Complications:
  • Anorectal abscess/fistula.
  • Refractory pouchitis.
  • Anal stricture.

Management

• Controversial use of IPAA in Crohn's patients.
• Careful Selection:
  • May be considered in isolated colonic disease without small bowel or perineal involvement.

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Other Complications

Polyps

• Inflammatory Polyps:
  • Occur in up to 20% of patients.
  • May cause bleeding or obstruction.

Alopecia

• Incidence: Reported up to 38% in some series.
• Course: Temporary; patient reassurance is important.

Ileal Pouch Prolapse

• Incidence: Rare.
• Management:
  • Mucosal Prolapse:
    • Stool bulking agents.
    • Local procedures.
  • Full-Thickness Prolapse:
    • Surgical intervention.
    • May result in pouch loss.

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Sexual and Reproductive Health

Male Sexual Function

• Incidence of Severe Dysfunction: 2%–4%.
• Postoperative Outcomes:
  • Improvement in erectile function and satisfaction.
  • Enhanced overall quality of life.
• Counseling:
  • Discuss potential risks.
  • Consider sperm banking if future fertility is a concern.

Female Sexual Function

• Positive Changes:
  • Improved sexual function in 35% of women.
  • Enhanced orgasm quality in 16%.
• Dyspareunia:
  • Increased incidence post-surgery.
  • May resolve over time or persist in some cases.

Female Reproductive Health

• Menstrual Irregularities:
  • Transient in a small percentage.
• Infertility Risk:
  • Increases to approximately 50% post-IPAA.
  • Due to pelvic adhesions affecting fallopian tubes.
• Laparoscopic Approach:
  • May reduce adhesion formation.
  • Associated with better fertility preservation.
• Pregnancy and Delivery:
  • Vaginal Delivery is generally safe.
  • Cesarean Section may be recommended to avoid sphincter injury.

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Age-Related Surgical Results and Functional Outcome

• Older Patients:
  • Slightly higher rates of incontinence and nighttime frequency.
  • High levels of postoperative satisfaction.
• Long-Term Function:
  • Daytime stool frequency remains stable.
  • Nighttime frequency and incontinence may increase over time.
• Quality of Life:
  • Remains high even after 15 years post-surgery.
  • Majority would undergo surgery again and recommend it to others.

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Conclusion

Understanding the management of pouch-specific postoperative complications is crucial for optimizing patient outcomes after restorative proctocolectomy. Early recognition and appropriate intervention for complications such as pelvic sepsis, pouchitis, anastomotic strictures, and fistulas can significantly improve patient quality of life. Long-term follow-up, patient education, and individualized care strategies are essential components in the successful management of these patients.

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Alternatives to Ileal Pouch–Anal Anastomosis

Total Abdominal Colectomy with Ileorectal Anastomosis

• Definition: Surgical removal of the entire colon (colectomy) with preservation of the rectum, followed by connecting the ileum to the rectum (ileorectal anastomosis).

Advantages

• Avoids a stoma: Eliminates the need for an external ileostomy bag.
• Preserves pelvic nerves: Reduces the risk of nerve damage compared to proctectomy.
• Lower fecal frequency: Patients typically have 2–4 liquid daytime bowel movements and occasional nocturnal movements, less than with an IPAA.

Indications

• High-risk patients: Those unsuitable for IPAA but with reasonable rectal compliance.
• Young patients: As a temporary measure for those wishing to delay IPAA due to educational or work commitments.
• Women of childbearing age: Interested in preserving fertility, as IPAA can increase infertility risks.

Disadvantages

• Risk of rectal disease progression: Up to 40% may require later proctectomy.
• Rectal cancer risk: Approximately 15% after 30 years, necessitating regular endoscopic surveillance.

Contraindications

• Severe Proctitis: Inflammation of the rectal mucosa causing pain, bleeding, and urgency.
• Poor Rectal Compliance: Reduced ability of the rectum to stretch and accommodate stool.
• Fecal Incontinence: Inability to control bowel movements.
• Anoperineal Disease: Conditions affecting the anus and perineum, such as fistulas or abscesses.
• Dysplasia or Carcinoma: Presence of precancerous changes or cancer in the rectum.

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Total Proctocolectomy with End Ileostomy

• Definition: Complete removal of the colon and rectum (proctocolectomy) with the creation of a permanent end ileostomy.

Advantages

• Cures Ulcerative Colitis: Removes all diseased tissue.
• Lower Surgical Risk: Absence of anastomosis reduces complications like leaks.

Procedure Details

• Intersphincteric Dissection: Removal of the rectum through the space between the internal and external sphincter muscles.
• Perineal Closure: Layered closure of the pelvic floor muscles and sphincters.

Risks and Complications

• Pelvic Neuropathy: Nerve damage leading to urinary or sexual dysfunction.
• Stoma Complications: Skin irritation, stoma retraction, or prolapse.
• Perineal Wound Complications: Poor healing or infection at the site of rectal removal.

Considerations

• High-Risk Patients: For those at risk of perineal complications, the rectal stump may be left in place temporarily and removed later.

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Kock Continent Ileostomy

• Definition: An internal reservoir (Kock pouch) created from the ileum with a continent valve, allowing control over ileostomy output.

Components

1. Ileal Pouch: Acts as a storage reservoir.
2. Intussuscepted Valve: Prevents leakage by folding the ileum into itself to create a one-way valve.
3. Exit Spout: Allows for catheterization and emptying of the pouch.

Advantages

• No External Appliance: Eliminates the need for an ileostomy bag.
• Controlled Drainage: Patients can decide when to empty the pouch.

Complications

• High Reoperation Rate: Due to valve slippage or prolapse.
  • Valve Prolapse: The intussuscepted valve slips out of place, causing incontinence.
  • Structural Failures: Leading to leakage or difficulty in catheterization.

Indications

• Patients with Failed IPAA: Those who cannot have an ileal pouch–anal anastomosis due to structural issues.
• Desire for Continence: Patients seeking control over ileostomy output without an external bag.

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Conclusion

• IPAA Advancements: The ileal pouch–anal anastomosis has revolutionized surgical treatment for ulcerative colitis, offering a balance between disease eradication and quality of life.
• Preferred Technique: The J pouch with double-stapled IPAA is widely favored due to its simplicity and good functional outcomes.
• Minimally Invasive Approaches: Laparoscopic IPAA is becoming standard, reducing recovery time and complications.
• Patient Selection: Tailoring the surgical approach based on patient factors, disease severity, and surgeon expertise is crucial.
• Managing Complications: Aggressive management of both short- and long-term complications is essential to preserve pouch function and prevent loss.
• Quality of Life: With appropriate surgical techniques and postoperative care, patients can achieve good long-term function and an improved quality of life.

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Key Takeaways

• Alternatives to IPAA are important for patients unsuitable for standard restorative procedures.
• Total Abdominal Colectomy with Ileorectal Anastomosis preserves rectal function but requires vigilant cancer surveillance.
• Total Proctocolectomy with End Ileostomy offers a definitive cure but results in a permanent stoma.
• Kock Continent Ileostomy provides stoma control but has a high complication rate.
• Patient-Centered Approach: Surgical decisions should consider individual patient needs, risks, and lifestyle preferences.

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By understanding these alternatives and their implications, healthcare professionals can better guide patients in making informed decisions about their surgical options for ulcerative colitis.