Development of the Endoscopic Pouch Score for Assessment of Inflammatory Conditions of the Pouch.

Pouchoscopy provides a critical objective measure in the evaluation of patients with suspected inflammatory conditions of the pouch; however, there remain significant gaps in the reliability of the endoscopic scales used in the assessment of these conditions.1,2 Reliability and reproducibility in the assessment of patients after ileal pouch-anal anastomosis (IPAA) are critical, as evidenced by recent efforts to improve standardization in the evaluation of patients with pouch-related disorders.3.

Patients With Pouchitis Demonstrate a Significant Cost Burden in the First Two Years After Ileal Pouch-Anal Anastomosis.

Pouchitis, the most common long-term complication after colectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), can lead to increased health care costs and diminished quality of life.1 In this study, we aimed to compare the total costs among patients diagnosed with pouchitis in the first 2 years after an IPAA with those among patients who were not diagnosed with pouchitis, using a large administrative claims database. Additionally, we aimed to investigate the specific drivers of cost among patients with an IPAA during the 2-year study period, including inpatient hospitalizations, emergency department visits, and pharmacy-related costs.

Ileal Pouch Excision can Be Performed With Similar Outcomes in Obese Patients Compared to Nonobese Counterparts: An Assessment From American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. METHODS: The patients who underwent pouch excision between 2005 and 2017 were included using ACS-NSQIP participant user files. The operative outcomes were compared between obese (BMI ≥30 kg/m2) and nonobese (BMI<30 kg/m2) groups. RESULTS: There were 507 pouch excision patients included of which eighty (15.7%) of them were obese. Physical status of the obese patients tended to be worse (ASA>3, 56.3 vs 42.9%, P = .027). There were more patients who had diabetes mellitus (DM) and hypertension (HT) in the obese group (26.3% vs. 11.2%, P = .015; 11.3 vs. 4.4%, P < .001, respectively). Operative time was similar between 2 groups (mean ± SD, 275 ± 111 vs. 252±111 minutes, P = .084). Deep incisional SSI was more commonly observed in the obese group (7.5 vs 2.8%, P = .038). In multivariate analysis, only deep incisional SSI was found to be independently associated with obesity (OR: 2.79, 95% CI: 1.02-7.67). Obese patients were readmitted more frequently than nonobese counterparts (28.3 vs 16%, P = .035). The length of hospital stay was comparable [median (IQR), 7 (4-13.5) vs. 7 (5-11) days, P = .942]. CONCLUSION: Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

Pouchitis after ileal pouch-anal anastomosis in ulcerative colitis: Diagnosis, management, risk factors, and incidence.

Restorative proctocolectomy with ileal pouch-anal anastomosis has been the surgical treatment of choice for patients with ulcerative colitis who require surgery. Quality of life after this procedure is satisfactory in most cases; however, pouchitis is a troublesome condition involving inflammation of the ileal pouch. When a patient presents with symptoms of pouchitis, such as increased bowel movements, mucous and/or bloody exudates, abdominal cramps, and fever, endoscopy is essential for a precise diagnosis. The proximal ileum and rectal cuff, as well as the ileal pouch, should be endoscopically observed. The reported incidence of pouchitis ranges from 14% to 59%, and antibiotic therapy is the primary treatment for acute pouchitis. Chronic pouchitis includes antibiotic-dependent and refractory pouchitis. Intensive therapy including antitumor necrosis factor antibodies and steroids may be necessary for antibiotic-refractory pouchitis, and pouch failure may occur despite such intensive treatment. Reported risk factors for the development of pouchitis include presence of extraintestinal manifestations, primary sclerosing cholangitis, non-smoking, and postoperative non-steroidal anti-inflammatory drug usage. In the present review, we focus on the diagnosis, endoscopic features, management, incidence, and risk factors of pouchitis in patients with ulcerative colitis who underwent ileal pouch-anal anastomosis.

Endoluminal calprotectin measurement in assessment of pouchitis and a new index of disease activity: a pilot study.

Pouchitis is the most common complication following proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis (UC). To provide a standardized definition of pouchitis clinical, endoscopic and histological markers were grouped and weighted in the pouch disease activity index (PDAI). However, the delay in the assessment of the final score due to the time requested for histological analysis remains the main obstacle to the index implementation in clinical practice so that the use of modified-PDAI (mPDAI) with exclusion of histologic subscore has been proposed. We tested the ability of calprotectin measurement in the pouch endoluminal content to mimic the histologic score as defined in the PDAI, the index that we adopted as gold standard for pouchitis diagnosis. Calprotectin was measured by ELISA in the pouch endoluminal content collected during endoscopy in 40 consecutive patients with J-pouch. In each patient PDAI and mPDAI were calculated and 15% of patients were erroneously classified by mPDAI. ROC analysis of calprotectin values vs. acute histological subscore ≥ 3 identified different calprotectin cut-off values with corresponding sensitivity and specificity allowing the definition and scoring of different range of calprotectin subscores. We incorporated the calprotectin score in the mPDAI obtaining a new score that shows the same specificity as PDAI for diagnosis of pouchitis and higher sensitivity when compared with mPDAI. The use of the proposed new score, once validated in a larger series of patients, might be useful in the early management of patients with symptoms of pouchitis.

Long-term functional outcome after ileal pouch anal anastomosis in 191 patients with ulcerative colitis.

BACKGROUND: A long-lasting good functional outcome of the pelvic pouch and a subsequent satisfying quality of life (QoL) are mandatory. Long-term functional outcome and QoL in a single-center cohort were assessed. PATIENTS AND METHODS: A questionnaire was sent to all patients with an IPAA for UC, operated between 1990 and 2010 in our department. Pouch function was assessed using the Öresland Score (OS) and the 'Pouch Functional Score' (PFS). QoL was assessed using a Visual Analogue Score (VAS). RESULTS: 250 patients (42% females) with a median age at surgery of 38 years (interquartile range (IQR): 29-48 years) underwent restorative proctocolectomy. Median follow-up was 11 years (IQR: 6-17 years). Response rate was 81% (n=191). Overall pouch function was satisfactory with a median OS of 6/15 (IQR: 4-8) and a median PFS of 6/30 (IQR: 3-11). 24-hour bowel movement is limited to 8 times in 68% of patients (n=129), while 55 patients (29%) had less than 6 bowel movements. 12 patients (6.5%) were regularly incontinent for stools, while 154 patients (82%) reported a good fecal continence. Fecal incontinence during nighttime was more common (n=72, 39%). Pouch function had little impact on social activity (4/10; IQR: 2-6) and on professional activity (3/10; IQR: 1-6). 172 patients (90%) reported to experience an overall better health condition since their operation. The OS and the PFS correlated well (Pearson's correlation coefficient=0.83). Overall pouch function was stable over time. CONCLUSION: Majority of patients report a good pouch function on the long-term with limited impact on QoL.

Quality of life following reversal of temporary stoma after rectal cancer treatment.

PURPOSE: An examination of quality of life outcomes following reversal of a temporary stoma after rectal cancer treatment. METHOD: An extensive search of the literature was conducted. Studies selected examine the consequences of stoma reversal on individual's lives. Methodological issues and implications for nursing practice are also considered. RESULTS: It is clear that after stoma reversal, there is often a temporary alteration in bowel function, impacting on individuals' physical, social and psychological health for several months. There is possibility of permanent difficulties for some, significantly affecting their quality of life if left untreated. These effects can lead to more negative post-operative experiences than expected. CONCLUSION: This review prompts discussion about how to provide appropriate support for patients following stoma reversal but also optimal pre-operative preparation, to foster realistic expectations and subsequent adaptation. It is suggested that nursing support should be targeted to the first few months post-reversal when bowel symptoms tend to be most troublesome.

Ileal pouch prolapse: prevalence, management, and outcomes.

AIM: The study aim is to review the prevalence, management, and outcomes for patients diagnosed with ileal pouch prolapse after restorative proctocolectomy. MATERIALS AND METHODS: Patients were identified retrospectively from a prospectively maintained pouch database. Parameters analyzed included presenting symptoms, indications for pouch surgery, type of ileal pouch-anal anastomosis, treatment modalities, and outcomes. RESULTS: Of 3,176 patients who underwent ileal pouch surgery, 11 were diagnosed with pouch prolapse (0.3%). Seven had full-thickness prolapse and four mucosal prolapse. Six were male, and five were female. Indication for index surgery was ulcerative colitis (nine patients), familial adenomatous polyposis (one patient), and colonic inertia (one patient). Median age at pouch prolapse was 34 years. Median time from index surgery to prolapse diagnosis was 2 years. Two patients with mucosal prolapse responded to conservative management; two required mucosal excisions. An abdominal approach was successful in four out of seven patients with full thickness prolapse. The three failures subsequently underwent continent ileostomy formation and prompted us to add biological mesh to future pouchpexy repairs. CONCLUSIONS: Pouch prolapse is rare, and there are no obvious predisposing factors. Mucosal prolapse may be treated by stool bulking or a local perineal procedure. Full thickness prolapse requires definitive surgery and is associated with risk of pouch loss.

Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas.

BACKGROUND: The treatment of rectovaginal and ileal pouch-vaginal fistulas remains a challenging problem for the colorectal surgeon. The aim of this study was to assess the short-term efficacy of the new Surgisis Biodesign rectovaginal button fistula plug in patients with such fistulas. METHODS: Between May 2008 and September 2008, patients with confirmed rectovaginal and ileal pouch-vaginal fistulas with backgrounds of inflammatory bowel disease were treated with the button fistula plug. The fistulas were assessed by magnetic resonance imaging and/or examination under anesthesia before the procedure. RESULTS: Twelve patients with a median age of 36 (range, 29-42) years underwent a total of 20 plug insertions. Five patients had confirmed rectovaginal fistulas and seven patients had ileal pouch-vaginal fistulas. At a median follow-up of 15 (interquartile range, 10-21) weeks, 7 of 12 patients (58%) had been treated successfully. Seven of the 20 plugs that were inserted (35%) were successful. This equates to the successful treatment of three of five (60%) of the rectovaginal fistulas, and four of seven (57%) of the ileal pouch-vaginal fistulas. Of the six patients who initially failed, a repeat procedure was performed of which one was successful. Two patients underwent a third repeat procedure, which was again unsuccessful in both cases. The success rate of these eight repeat plug insertions was therefore 12.5%. All plug failures were the result of dislodgement of the plug. There was no morbidity in our series. CONCLUSIONS: The new button fistula plug successfully treated 7 of 12 (58%) rectovaginal and ileal pouch-vaginal fistulas.

An assessment of bacterial dysbiosis in pouchitis using terminal restriction fragment length polymorphisms of 16S ribosomal DNA from pouch effluent microbiota.

PURPOSE: Previous studies on dysbiosis and pouchitis using conventional culture techniques have been disappointing because of inherent limitations associated with the technique. This study was designed to use terminal restriction fragment length polymorphism to evaluate patients with and without pouchitis. METHODS: Bacterial microbiota in 20 pouch patients (15 healthy and 5 with inflamed) were studied. DNA was extracted from feces, and polymerase chain reaction was performed using primers (V6-V8 region) that were modified at the 5' end with cyanine dyes. Amplicons were digested with merozoite surface protein-1 enzyme. The restricted fragments were analyzed by capillary electrophoresis, and the electrophenograms were studied. Electrophenograms provide information about operational taxonomic units, which correspond to specific organisms. Principal component analysis was performed to identify dominant and important operational taxonomic units in the 20 patients. Bacterial diversity and counts of these operational taxonomic units were compared in the two groups of patients. RESULTS: Total bacterial diversity in patients with pouchitis was similar to that in patients with healthy pouches (16 (11-20) vs. 12 (9-13), P = 0.279). Using principal component analysis, 29 operational taxonomic units were found to be important. Bacterial counts of seven dominant organisms (operational taxonomic unit 79 (enterococci), 85 (Pantoea), 88 (Enterobacteriaceae), 90 (eubacteria), 91 (Pseudomonas), 146 (clostridia), and 148 (bacilli)) were similar in patients with pouchitis and those with a healthy pouch (P > 0.05). Seventeen (operational taxonomic unit 73 (Leptospira), 93 (Pseudoalteromonas), 96, 100 (Desulfosporosinus), 114, 121, 134, 137, 141 (Microcystis), 159, 174 (Methylobacter), 193 (uncultured proteobacteria), 232, 376, 381, 414, and 465) of the remaining 22 nondominant organisms were seen exclusively in patients with pouchitis. The majority of these organisms were novel. CONCLUSION: Terminal restriction fragment length polymorphism can be used to identify candidate organisms that may be associated with pouchitis.

Anastomotic sinuses after ileoanal pouch construction: incidence, management, and outcome.

PURPOSE: This study was designed to analyze the incidence, management, and outcome of pouch sinuses after ileal pouch-anal anastomosis at one institution. METHODS: We identified 282 ileal pouch-anal anastomosis patients between 1992 and 2002 who had a pouchogram before planned ileostomy closure. The management and outcome of patients with pouchograms revealing pouch sinuses were reviewed. RESULTS: Twenty-two patients (7.8 percent) had a pouch sinus at pouchogram. Nineteen patients were observed and underwent repeat pouchogram. Of these, ten had sinus resolution (mean, 3.6 months) and underwent successful ileostomy closure. Eight patients underwent examination under anesthesia +/- sinus debridement. Six of these patients had subsequent pouchograms with five showing sinus resolution. The patient without resolution was not reversed. Of the eight patients who underwent examination under anesthesia +/- debridement, seven underwent ileostomy closure (mean, 4.9 months), with healing in six and pelvic sepsis in one. Four patients underwent successful ileostomy takedown despite persistent sinus. Overall, 21 of the 22 pouch sinus patients underwent ileostomy closure and only 1 had postoperative pelvic sepsis. CONCLUSIONS: Pouch sinuses after ileal pouch-anal anastomosis with ileostomy are uncommon. Most heal within six months. The majority of patients with sinuses eventually undergo successful ileostomy closure. Pelvic septic complications are rare but can occur despite sinus healing on pouchogram.

Cost-effectiveness of quantitative fecal lactoferrin assay for diagnosis of symptomatic patients with ileal pouch-anal anastomosis.

BACKGROUND AND AIMS: To assess cost-effectiveness of fecal lactoferrin (FL) as the initial diagnostic approach to symptomatic patients with ileal pouch-anal anastomosis (IPAA). METHODS: Four competing strategies [empiric metronidazole therapy (txMTZ), initial pouch endoscopy with biopsy (testBiop), initial FL assay followed by metronidazole therapy (testFL+MTZ), and initial FL assay followed by pouch endoscopy and biopsy (testFL+Biop)] were modeled in a decision tree. RESULTS: In the base-case, the average cost per patient was $241 for testFL+MTZ, $251 for txMTZ, $405 for testFL+Biop, and $431 for testBiop. The testBiop strategy had greater effectiveness compared with txMTZ but at an incremental cost of $158 per day. The txMTZ strategy was slightly more costly and minimally more effective than testFL+MTZ with an incremental cost effectiveness of just over $12 per day. However, the testFL+MTZ strategy was associated with a 31% absolute reduction in antibiotic exposure compared with the txMTZ strategy. CONCLUSIONS: Compared with empiric metronidazole therapy, FL before treatment with metronidazole is less costly with less exposure to antibiotics and less need for endoscopy, with only marginal decrease in effectiveness.

Prevalence and management of prolapse of the ileoanal pouch.

PURPOSE: Known late complications of ileal pouch-anal anastomoses include chronic pouchitis, poor pouch function, or stricture. These may jeopardize the pouch and may require pouch salvage procedures. Prolapse of the ileoanal pouch is a little-known complication infrequently noted in the literature. The objective of this study was to determine the prevalence of this problem and identify approaches used to correct it and salvage the pouch. METHODS: The literature was reviewed for publications describing the diagnosis and treatment of patients with ileoanal pouch prolapse. A survey inquiring about experience with ileoanal pouch prolapse was sent to all North American members and fellows of The American Society of Colon and Rectal Surgeons. The survey assessed the number of years that the respondent had been performing ileal pouch-anal anastomoses and the number and type of pouches constructed. The respondents indicated the prevalence of patients with ileoanal pouch prolapse in their practices and length of time from pouch creation to onset of prolapse. They also were asked to indicate presenting symptoms, need for and method of surgical repair, and outcome. RESULTS: Two hundred and sixty-nine responses were received (response rate, 19.5 percent). Thirty-five respondents indicated that they had assisted in the care of a total of 83 patients with prolapse of the ileoanal pouch. Prolapse symptoms included external prolapse of tissue, sense of obstructed defecation, seepage, and pain. Patients with pouch prolapse most commonly presented within two years of pouch construction. Fifty-two patients required surgery and were managed by a combination of transanal repair, abdominal pouchpexy, and transabdominal revision or removal. The ileoanal pouch was salvaged in all but one case. CONCLUSIONS: Although the incidence of pouch prolapse is relatively low in this survey, the number of cases reported far exceeds the previous known experience. The possibility of this clinical entity should be considered in the differential diagnosis of ileoanal pouch dysfunction. Such recognition should lead to correction of prolapse and pouch salvage in the great majority of patients.

A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch-anal anastomosis.

OBJECTIVE: Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics (treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy (test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis. METHODS: Pouchitis was defined as pouchitis disease activity index scores > or =7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data. RESULTS: Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses. CONCLUSIONS: Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.

Factors affecting cost and length of stay associated with the ileal pouch-anal anastomosis.

PURPOSE: The purpose of this study was to evaluate the costs associated with the ileal pouch-anal anastomosis procedure and identify those factors that most affected or determined such costs. Specifically evaluated were the costs, complication rates, and length of stay associated with the ileal pouch-anal anastomosis done as a one-stage, two-stage, two-stage modified, or three-stage procedure. METHODS: Costs from the hospital accounting database and clinical data from retrospective chart review of 135 ileal pouch-anal anastomosis patients from a ten-year period were compiled. Overall costs and length of stay (the sum of all hospitalizations for all surgeries and any related complications) for each group were compared by analysis of variance. Linear regression was used to compute net costs and length of stay excluding contributions from other relevant factors such as number of operative stages, complications, demographics, and nonelective operations. RESULTS: The average overall cost and length of stay of the ileal pouch-anal anastomosis ranged from a low of $12,738 and 13.5 days for the one-stage procedure to a high of $32,758 and 23.9 days for the three-stage pathway. Overall costs, length of stay, and incidence of complications increased with the number of operations necessary to complete the ileal pouch-anal anastomosis. This pattern of increased costs and length of stay with the greater number of stages persisted even after demographic and preoperative characteristics were controlled for in the analyses. The occurrence of a complication added an average of $9,304 (P < 0.0001) and 7.4 days to the procedure (P = 0.0002), whereas an urgent presentation added an average of $5,258 (P = 0.15) and 6.1 days (P = 0.04). CONCLUSIONS: The two most definitive determinants of cost and length of stay after ileal pouch-anal anastomosis are complications and number of operative stages used to complete the operation. Elective ileal pouch-anal anastomosis operations done in the fewest stages with the least complications provide the least costly result and the shortest hospital stay. For patients with severe disease, the two-stage modified pathway (total abdominal colectomy followed by pouch creation without a protecting ileostomy) appears to have fewer complications, lower costs, and a shorter length of stay than the traditional three-stage pathway.

Hospital costs and risk factors associated with complications of the ileal pouch anal anastomosis.

BACKGROUND: The purpose of this study was to estimate the costs associated with the most common complications of the ileal pouch anal anastomosis (IPAA) and identify factors that predispose to them. METHODS: Hospital costs of 135 patients undergoing the IPAA were combined with information abstracted from charts. Logistic and linear regression modeling were used to estimate the marginal costs for the most common IPAA complications and determine factors predisposing to their occurrence. RESULTS: The average overall cost for the IPAA was $20,865. Just more than half (53%) of patients experienced complications, the 3 most common being small-bowel obstruction (24.4%), pelvic/abdominal sepsis (6.7%), and dehydration (5.9%). The average cost to treat an episode of small-bowel obstruction was $6709. Treatment of pelvic/abdominal sepsis averaged $9268 per occurrence, whereas dehydration averaged $4860. Steroid use > 3 months before colectomy significantly increased the risk for any complication (P =.02). No factors were found to be good predictors of bowel obstruction. However, age > 42 years and low patient hematocrit were significant predictors of dehydration as a complication (P <.05). Trending toward significance were urgent operation and weight loss greater than 5%. CONCLUSIONS: The most common complications of the IPAA are small-bowel obstruction, pelvic/abdominal sepsis, and dehydration. Complications were responsible for approximately 44% of the overall cost of an IPAA. Factors that increase risk of IPAA complications are steroid use, low hematocrit, age > 42 years, nonelective procedures, and preoperative weight loss.