2-Stage and 3-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis show comparable short- and long-term outcomes.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) represents the standard treatment for therapy-refractory, malignant or complicated ulcerative colitis (UC) and can be performed as a 2-stage or 3-stage procedure. This study aimed to compare the short- and long-term outcomes after 2- and 3-stage IPAA in patients with UC in our department. A retrospective analysis of 176 patients with UC who received 2- or 3-stage restorative proctocolectomy with IPAA at our institution from 2001 to 2021 was performed. Outcomes for short-term (morbidity, longer hospital stay, readmission) and long-term (pouch failure and quality of life) parameters were compared between the 2- and 3-stage procedure. Regarding short-term outcomes for all patients, in-hospital morbidity and readmission rates after any surgical stage were observed in 69% and 24%, respectively. Morbidity and readmission did not differ significantly between the 2- and 3-stage procedure in uni- and multivariate analysis. Median length of hospital stay for all stages was 17 days. The 3-stage procedure was identified as an independent factor for longer hospital stay (OR 3.8 (CI 1.3-10.8), p = 0.014). Pouch failure and failure of improved quality of life during long-term follow-up occurred both in 10% of patients, with no significant differences between the 2- and 3-stage procedure in uni- and multivariate analysis. Our data suggest that both the 2- and 3-stage proctocolectomy with IPAA demonstrate favourable and comparable postoperative short- and long-term outcomes, with a high rate of improved quality of life in patients with UC.

Complications and failure after Kock continent ileostomy: A systematic review and meta-analysis.

BACKGROUND: A significant number of patients experience complications of the Kock pouch (KP) warranting revision or excision. This systematic review aimed to assess the pooled prevalence and risk factors for complications and failure of the KP. METHODS: This Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant systematic review (CRD42023416961) searched PubMed, Scopus, and Web of Science for studies on adult patients with Kock continent ileostomy published after the year 2000. The main outcome measures were revision, complications, and failure of the KP. Risk factors for complications and failure were assessed using a meta-regression analysis. Risk of bias was assessed using the ROBINS-1 tool. A proportional meta-analysis of the main outcomes was performed. RESULTS: A total of 19 studies (2042 patients) were included. The weighted mean prevalence of complications was 60.4% [95% confidence interval (CI): 46.1-74.7%], of pouch revision was 46.6% (95% CI: 38.5-54.7%), and of pouch failure was 12.9% (95% CI: 9.3-16.4%). Studies conducted in the USA had a mean failure prevalence of 12.6% (95% CI: 6.2-18.9%) comparable to studies conducted in Europe (11.1%; 95% CI: 7.5-14.7%). Factors associated with higher complications were increased body mass index (BMI) and previous ileoanal pouch anastomosis (IPAA); however, these factors were not associated with increased pouch failure. CONCLUSIONS: The KP is a highly complex operation as shown by a pooled complication prevalence of 60%, and thus, it should be only performed by experienced surgeons. Despite the high prevalence of complications and need for revisional surgery, patients are keen to preserve their KP. Increased BMI and a previous failed IPAA are risk factors for pouch complications, but not failure.

Functional and postoperative outcomes in ideal pouch-anal anastomosis in patients with parkinson disease and multiple sclerosis.

INTRODUCTION: Patients with multiple sclerosis and Parkinson's disease may experience pelvic floor dysfunction and constipation which can affect ileoanal pouch emptying. This can lead to complications such as pouchitis, pouch dysfunction, and failure. We hypothesized that patients with neurological diseases have a higher rate of pouch failure and complications than healthy controls. METHODS: Data were sourced from the institutional ileoanal pouch database. Patients with multiple sclerosis or Parkinson's disease, diagnosed before or after pouch construction, were matched to a control group of patients without neurological disease using propensity score-optimal matching. Demographics, postoperative and functional outcomes, and quality of life were analyzed. RESULTS: Twenty-six patients (38%) with multiple sclerosis and 16 (62%) with Parkinson's disease were matched with 42 healthy controls. The overall median age was 39 years, median BMI was 25.3 kg/m2, and most patients were female (61.9%). Preoperative colorectal diagnoses included ulcerative colitis (83.3%), indeterminate colitis (9.5%), and Crohn's disease (7.1%). Patients with neurological diseases had higher ASA scores (class III, 57.1% vs. 21.4%; p < 0.01), fewer nocturnal bowel movements (median 0 vs. 2; p < 0.001), fewer bowel movements over 24 h (median 6 vs. 8; p = 0.01), and were less likely to recommend IPAA construction (72.7% vs. 97%; p = 0.01) than the controls. Other surgical, functional, and quality-of-life outcomes were similar. CONCLUSION: Patients with multiple sclerosis or Parkinson's disease might differ in pouch function compared with healthy controls. These neurological diseases might affect pouch function. The rate of pouch failure was similar, showing its feasibility despite multiple sclerosis and Parkinson's disease.

Open vs. laparoscopic vs. robotic pouch excision: unveiling the best approach for optimal outcomes.

INTRODUCTION: Despite advantages for patients with ulcerative colitis, Crohn's disease, and familial adenomatous polyposis, restorative proctocolectomy with ileal pouch-anal anastomosis carries a risk of pouch failure, necessitating pouch excision. The traditional open approach is associated with potential complications. Robotic and laparoscopic techniques are emerging, but comparative outcome data are limited. METHODS: We conducted a retrospective study of consecutive adult patients undergoing robotic, laparoscopic, and open ileal pouch excision at Mayo Clinic, Rochester, MN, between January 2015 and December 2023. We analyzed data on patient characteristics, perioperative variables, and postoperative outcomes, focusing on short-term complications. Statistical analysis included appropriate tests. RESULTS: The study included 123 patients: 23 underwent robotic-assisted pouch excision, 12 laparoscopic, and 82 open. The robotic approach had the longest median operative time (334 ± 170 min, p = 0.03). However, it demonstrated significantly lower estimated blood loss than open (150 ± 200 ml vs. 350 ± 300 ml, p = 0.002) and laparoscopic surgery (250 ± 250 ml, p = 0.005). Robotic and laparoscopic groups required fewer preoperative ureteral stents than the open group (p = 0.001). Additionally, the robotic approach utilized fewer pelvic drainages (p < 0.0001) and had a lower rate of lysis of adhesions > 60 min compared to open surgery (p = 0.003). Robotic procedures had significantly lower 30-day postoperative complications than the open approach (30.4% vs. 65.9%, p = 0.002) while also demonstrating fewer 30-day reoperations than the laparoscopic group (p = 0.04). CONCLUSIONS: Robotic-assisted pouch excision offered significant benefits, including decreased EBL, reduced need for preoperative ureteral stents, and significantly fewer 30-day postoperative complications compared to open surgery.

Clinical and histological impact of diffuse inflammation at pouchoscopy.

PURPOSE: The anatomical location of inflammation in and around the ileal pouch affects the pouch survival rate, and diffuse inflammation has poor pouch survival rates. We aimed to clarify the symptoms and histological findings of diffuse inflammation of the pouch. METHODS: We evaluated the symptoms, treatment, and histological findings according to the endoscopic phenotypes of diffuse inflammation, focal inflammation, and normal as the pouch body phenotype and afferent limb involvement, inlet involvement, cuffitis, and fistula as the peripheral findings. RESULTS: Of the 318 pouchoscopies, 47 had diffuse inflammation, 201 had focal inflammation, and 70 were normal. Symptomatic patients had diffuse inflammation more frequently (46.8%) than focal inflammation (13.4%) and normal (14.2%), with no difference between focal inflammation and normal. Antibiotics and steroids were higher rate administered in cases of diffuse inflammation, but not in cases of focal inflammation or in normal cases. Histological inflammation, inflammatory bowel disease (IBD)-specific finding, and colonic metaplasia showed severity in the order of diffuse inflammation > focal inflammation > normal. The number of peripheral inflammatory findings overlapped in the following order: diffuse inflammation > focal inflammation > normal. The number of symptomatic patients increased as the number of peripheral inflammatory findings increased. CONCLUSION: Pouches with diffuse inflammation are more symptomatic, have a higher use of therapeutic agents, and have more severe histological inflammation, IBD-specific finding, and colonic metaplasia accompanying peripheral inflammatory findings than the other groups. The higher the overlap of inflammatory findings in the surrounding tissues, the more symptomatic the patients will appear.

End-to-end anastomosis provides similar quality-of-life, compared with other reconstructive techniques six months following total mesorectal excision: Systematic review and meta-analysis.

Colorectal malignancy ranked third globally in cancer incidence with 1.9 million cases and nearly 1 million deaths in 2020. Rectal cancer is primarily treated with total mesorectal excision (TME). This study examines surgical, functional, and quality-of-life (QoL) outcomes for different anastomosis types. Pre-registered on PROSPERO (CRD42022368907), the systematic search on November 8, 2022, covered three databases: MEDLINE (via PubMed), Embase, and Cochrane Central. Randomized controlled trials (RCT) assessing adults post-TME, comparing end-to-end anastomosis (EEA) to colonic J-pouch (CJP) and/or side-to-end anastomosis (SEA) were eligible. 29 studies out of 4459 were included. EEA vs. CJP showed no significant differences in anastomotic leakage (AL) (RR: 1.03; CI: [0.84-1.26]) or mortality (RR: 0.77; CI: [0.30-1.98]). At 12 months, the mean bowel movement difference was 1.59/day (CI: [(-)0.66-3.84]). QoL at six and 12 months was similar (SMD: -0.22; CI: [(-)0.82-0.37]). Compared with SEA, EEA had similar AL ratios (RR: 1.59; CI: [0.54-4.72]) and QoL at six months (SMD: -0.04; CI: [(-)0.66-0.58]). EEA demonstrates surgical efficacy comparable to other techniques. Six months postoperatively, EEA's impact on QoL appears similar to CJP or SEA, irrespective of daily stool frequency.

Pelvic Radiation Therapy Increases Risk of Pouch Failure in Patients with Inflammatory Bowel Disease and Ileal Pouch.

BACKGROUND: The effect of radiation on the ileal pouch is less well studied in patients with inflammatory bowel disease (IBD) and ileal pouch-anal anastomosis. AIMS: This retrospective study investigates the impact of external radiation therapy on the outcomes of ileal pouches. METHODS: The study included 82 patients with IBD and ileal pouches, of whom 12 received pelvic radiation, 16 abdominal radiation, 14 radiation in other fields, and 40 served as controls with no radiation. Pouch-related outcomes, including pouch failure, worsening of symptoms, pouchitis, and development of strictures, along with changes in Pouch Disease Activity Index (PDAI) scores pre- and post-radiation were assessed. RESULTS: The pelvic radiation group exhibited a significantly higher rate of pouch failure (25%, p < 0.004) and worsening pouch-related symptoms (75%, p = 0.012) compared to other groups. Although not statistically significant, a higher incidence of pouchitis was observed in the pelvic radiation group (45.5%, p = 0.071). Strictures were more common in the pelvic radiation group (25%, p = 0.043). Logistic regression analysis revealed that pelvic radiation significantly increased the odds of pouch-related adverse outcomes (OR 5.66; 95% confidence interval: 1.61-21.5). CONCLUSION: Pelvic radiation significantly impacts the outcomes of ileal pouches in patients with IBD, increasing the risk of pouch failure, symptom exacerbation, and structural complications. These findings underscore the need for careful consideration of radiation therapy in this patient population and highlight the importance of closely monitoring and managing radiation-induced pouch dysfunction.

Ileal pouch-anal anastomosis and end ileostomy result in equivalent graft survival following liver transplantation for inflammatory bowel disease-primary sclerosing cholangitis.

INTRODUCTION: Patients with inflammatory bowel disease and primary sclerosing cholangitis may require both liver transplantation and colectomy. There are concerns about increased rates of hepatic artery thrombosis, biliary strictures, and hepatic graft loss in patients with ileal pouch-anal anastomosis compared to those with end ileostomy. We hypothesized that graft survival was not negatively affected by ileal pouch-anal anastomosis compared to end ileostomy. MATERIALS AND METHODS: A tertiary center's database was searched for patients meeting the criteria of liver transplantation because of primary sclerosing cholangitis and total proctocolectomy with ileal pouch-anal anastomosis or end ileostomy because of ulcerative colitis. Primary endpoints were hepatic graft survival and post-transplant complications. RESULTS: Fifty-five patients met the inclusion criteria between January 1990 and December 2022. Of these, 46 (84%) underwent ileal pouch-anal anastomosis, and 9 (16%) underwent end ileostomy. The average age at total proctocolectomy (41.5 vs. 49.1 years; p = 0.12) and sex distribution (female: 26.1% vs. 22.2%; p = 0.99) were comparable. The rates of re-transplantation (21.7% vs. 22.2%; p = 0.99), hepatic artery thrombosis (10.8% vs. 0; p = 0.58), acute rejection (32.6% vs. 44.4%; p = 0.7), chronic rejection (4.3% vs. 11.1%; p = 0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p = 0.99), and biliary strictures (19.6% vs. 33.3%; p = 0.36) were similar between the ileal pouch-anal anastomosis and end ileostomy groups, respectively. None of the end ileostomy patients developed parastomal varices. The log-rank tests for graft (p = 0.97), recipient (p = 0.3), and combined graft/recipient survival (p = 0.73) were similar. CONCLUSION: Ileal pouch-anal anastomosis did not negatively affect graft, recipient, and combined graft/recipient survival, or the long-term complications, compared to end ileostomy.

Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae.

BACKGROUND: Ileal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180-360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure. METHODS: Patients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%). RESULTS: Over a 12-year period, nine patients were identified; the median age at CPA was 41 (36-44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1-2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn's disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6-24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up. CONCLUSIONS: Transanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.

Acute Pouchitis is Common in Pregnant and Postpartum Women.

INTRODUCTION: The impact of pregnancy on the development of pouchitis in women who have undergone total proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis is poorly understood. METHODS: This was a retrospective study of women with ulcerative colitis who underwent total proctocolectomy with ileal pouch anal anastomosis and subsequently became pregnant at Mount Sinai Hospital. The primary outcome was acute pouchitis during pregnancy or the postpartum period defined as symptoms of increased stool frequency and urgency treated with antibiotics. RESULTS: A total of 44 women with 63 pregnancies and complete data were identified. Acute pouchitis occurred in 14 pregnancies (22.2%) in 12 women and in the postpartum period of 10 pregnancies (15.9%) in 9 women. Acute pouchitis occurred more frequently in women with a history of acute pouchitis immediately before, during, or after pregnancy. DISCUSSION: Acute pouchitis was common during pregnancy and the postpartum period, likely due to microbial shifts. Although not statistically significant, these results provide insight into the impact of pregnancy on the risk of pouchitis and establish the framework for preconception counseling that focuses on prevention and management of pouchitis during pregnancy.

Pouch abandonment is extremely rare even in the reoperative setting: A high-volume referral center experience.

BACKGROUND: Ileal pouch anal anastomosis is the preferred method for restoration of intestinal continuity after proctocolectomy. Successful ileal pouch anal anastomosis requires adequate reach of the ileal mesentery to the pelvis. Reach issues are a common cause for intraoperative pouch abandonment; however, data regarding contemporary abandonment rates are rare and nonexistent in the revisional setting. METHODS: A retrospective review was conducted of consecutive ileal pouch anal anastomosis surgery at a single referral center. Both initial or "primary" pouches and revisional pouch surgery were included. RESULTS: In total, 447 attempts at pouch anal anastomosis were made, with an 1.6% overall rate of intraoperative abandonment. Pouch abandonment was attributed to inadequate mesenteric reach during 3 surgeries, desmoid tumors in 2 surgeries, and insufficient remaining small bowel in 2 surgeries. Twelve patients required lengthening maneuvers including 6 S pouches (1%) and 6 H pouches (1%). One half (49%) of operations were revisional ileal pouch anal anastomosis surgery. Overall, reach issues led to intraoperative abandonment in only 0.4% of attempted primary pouches and 1.0% of revisional surgeries. A preoperative diagnosis of familial adenomatous polyposis was associated with pouch abandonment (P < .001). CONCLUSION: Extremely low pouch abandonment rates as a result of mesenteric reach can be achieved even in the revisional setting at a high-volume center with institutional expertise. In the revisional setting, intra-abdominal desmoids or the potential for short gut affects pouch abandonment rates as much as reach issues.

Long-term ileoanal pouch survival after pouch urinary tract fistulae.

BACKGROUND: Ileoanal pouch is a demanding procedure with many potential technical complications including bladder or ureteral injury, while inflammation or stricture of the anastomosis or anal transition zone may lead to the formation of strictures and fistulae, including to the adjacent urethra. Pouch urinary tract fistulae are rare. We aimed to describe the presentation, diagnostic workup, and management of patients with pouch urinary at our center. METHODS: Our prospectively maintained pouch registry was queried using diagnostic codes and natural language processing free-text searches to identify ileoanal pouch patients diagnosed with any pouch-urinary tract fistula from 1997 to 2022. Descriptive statistics and pouch survival using Kaplan-Meier curves are presented. Numbers represent frequency (proportion) or median (range). RESULTS: Over 25 years, urinary fistulae were observed 27 pouch patients; of these, 16 of the index pouches were performed at our institution [rate 0.3% (16/5236)]. Overall median age was 42 (27-62) years, and 92.3% of the patients were male. Fistula locations included pouch-urethra in 13 patients (48.1%), pouch-bladder in 12 patients (44.4%), and anal-urethra in 2 (7.4%). The median time from pouch to fistula was 7.0 (0.3-38) years. Pouch excision and end ileostomy were performed in 12 patients (bladder fistula, n = 3; urethral fistula, n = 9), while redo ileal pouch-anal anastomosis (IPAA) was performed in 5 patients (bladder fistula, n = 3; urethral fistula, n = 2). The 5-year overall pouch survival after fistula to the bladder was 58.3% vs. 33.3% with urethral fistulae (p = 0.25). CONCLUSION: Pouch-urinary tract fistulae are a rare, morbid, and difficult to treat complication of ileoanal pouch that requires a multidisciplinary, often staged, surgical approach. In the long term, pouches with bladder fistulae were more likely to be salvaged than pouches with urethral fistulae.

Managing prostate cancer after proctocolectomy and ileal pouch-anal anastomosis: feasibility and outcomes of single-port transvesical robot-assisted radical prostatectomy.

INTRODUCTION: Patients with proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA) face unique challenges in managing prostate cancer due to their hostile abdomens and heightened small bowel mucosa radiosensitivity. In such cases, external beam radiation therapy (EBRT) is contraindicated, and while brachytherapy provides a safer option, its oncologic effectiveness is limited. The Single-Port Transvesical Robot-Assisted Radical Prostatectomy (SP TV-RARP) offers promise by avoiding the peritoneal cavity. Our study aims to evaluate its feasibility and outcomes in patients with PC-IPAA. METHODS: A retrospective evaluation was done on patients with PC-IPAA who had undergone SP TV-RARP from June 2020 to June 2023 at a high-volume center. Outcomes and clinicopathologic variables were analyzed. RESULTS: Eighteen patients underwent SP TV-RARP without experiencing any complications. The median hospital stay was 5.7 h, with 89% of cases discharged without opioids. Foley catheters were removed in an average of 5.5 days. Immediate urinary continence was seen in 39% of the patients, rising to 76 and 86% at 6- and 12-month follow-ups. Half of the cohort had non-organ confined disease on final pathology. Two patients with ISUP GG3 and GG4 exhibited detectable PSA post-surgery and required systemic therapy; both had SVI, multifocal ECE, and large cribriform pattern. Positive surgical margins were found in 44% of cases, mostly Gleason pattern 3, unifocal, and limited. After 11.1 months of follow-up, no pouch failure or additional BCR cases were found. CONCLUSION: Patients with PC-IPAA often exhibit aggressive prostate cancer features and may derive the greatest benefit from surgical interventions, particularly given that radiation therapy is contraindicated. SP TV-RARP is a safe option for this group, reducing the risk of bowel complications and promoting faster recovery.

A Rat Model of Pouchitis Following Proctocolectomy and Ileal Pouch-Anal Anastomosis Using Dextran Sulfate Sodium.

Ulcerative colitis (UC) is a chronic immune-mediated disease that affects the entire colon and rectum with a relapsing and remitting course, causing lifelong morbidity. When medical treatment is ineffective, especially in cases of massive gastrointestinal bleeding, perforation, toxic megacolon, or carcinogenesis, surgery becomes the last line of defense to cure UC. Total colorectal resection and ileal pouch-anal anastomosis (IPAA) offer the best chance for long-term treatment. Pouchitis is the most common and troublesome postoperative complication. In this investigation, microsurgery is employed to create an ileal pouch model in experimental rats via IPAA surgery. Subsequently, a sustained rat model of pouchitis is established by inducing inflammation of the ileal pouch with dextran sulfate sodium (DSS). The successful establishment of rat pouchitis is validated through analysis of postoperative general status, weight, food and water intake, fecal data, as well as pouch tissue pathology, immunohistochemistry, and inflammatory factor analysis. This experimental animal model of pouchitis provides a foundation for studying the pathogenesis and treatment of the condition.

The Pouch Corner: A Review of Functional Pouch Disorders.

Functional pouch disorders such as dyssynergic defecation, fecal incontinence, and irritable pouch syndrome are common and manifest with symptoms that overlap with those of pouchitis. The appropriate recognition of these disorders is imperative to guide necessary management and reduce unnecessary antibiotic exposure.

Influence of hospital-level and surgeon factors on the outcomes after ileo-anal pouch surgery for inflammatory bowel disease: systematic review.

BACKGROUND: Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease. METHODS: A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851). RESULTS: A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience. CONCLUSION: This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.