Ileal pouch for Crohn`s colitis - Advances in Inflammatory Bowel

Report
Crohn’s colitis patients can
be offerred an ileoanal pouch
Feza H. Remzi, MD, FACS,FASCRS, FTSS ( Hon)
Chairman
Department of Colorectal Surgery
Rupert B. Turnbull Jr., MD Chair
Professor of Surgery
Digestive Disease Institute
Cleveland Clinic
Cleveland, OH
Disclosures
None
“If one can accept and live happily with a
permanent ileostomy, trying to convince
him/her to have an ileoanal pouch is a great
disservice”
Surgical therapy for Crohn’s colitis
• Extent of disease is an important consideration in
determining the extent of bowel resection in Crohn’s
disease (CD)
• Based on the rectal involvement of Crohn’s colitis
(CC), following procedures can be performed after a
total procto /colectomy
– An end ileostomy
– A straight ileosigmoid or ileorectal anastomosis
– An ileal pouch- anal anastomosis (IPAA)
– An ileal pouch-rectal anastomosis (IPRA
Ileal pouch for Crohn’s colitis
– An ileal pouch-rectal anastomosis (IPRA)
Short rectal stump
• Extensive colonic involvement
• Distal rectal sparing
Near total proctocolectomy
(TAC + proximal proctectomy)
straight IRA
permanent end ileostomy
ileal pouch/rectal anastomosis
IPRA
Cleveland Clinic Experince
N=23 patients
• IPRA was associated with low perioperative
morbidity.
• Crohn’s disease recurred in most patients
after IPRA.
• Gastrointestinal continuity was established in
91% in 8 years follow-up.
• Functional outcome and quality of life scores
are good and comparable to straight
ileorectal and ileosigmoid anastomosis.
• IPRA is associated with high satisfaction
rates with surgery, similar to SIRA.
Kariv et al JACS 2003
Conclusions
When Crohn’s proctocolitis necessitates
total colectomy and the length of the rectal
stump precludes straight IRA, Ileal PouchRectal Anastomosis can be considered a
viable alternative to permanent diversion.
IPRA offers good long term functional
results and quality of life.
Ileal pouch for Crohn’s colitis
– An ileal pouch- anal anastomosis (IPAA)
Results over 4000 IPAA Patients
Cleveland Clinic Experience
• 97% patients said that they would
undergo surgery again
• 97.4% patients stated that they would
be willing to recommend surgery to
other patients
Ileal pouch for Crohn’s colitis
Ideal indication
• Limited CD in the colorectum
• Preoperative pathologic confirmation of
diagnosis
• No history of anoperineal CD
• No evidence of anoperineal CD involvement
• No evidence of small-bowel involvement by CD
Panis et al. Lancet 1996.
Ileal pouch for Crohn’s colitis
indication
• CD in the colorectum
• Preoperative pathologic confirmation of
diagnosis
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• Limited evidence of anoperineal CD
involvement; excluding rectovaginal fistula
• No gross evidence of small-bowel involvement
by CD
Ileal pouch for Crohn’s colitis
• Intentional IPAA creation, in patients who had prior
colectomy confirming the diagnosis = Preop
• Patients undergoing two stage IPAA with apparent
MUC or IndC and diagnosed with CD on the basis
of postoperative histopathology = Postop
• Diagnosed with CD months or years after their
surgery on the basis of subsequent clinical course
or histopathology = Delayed diagnosis
Melton et al. Ann Surg 2008
Predictors of pouch failure
Factor
Hazard ratio (95% CI)
P value
Age <30 yr
1.3 (0.8-3.1)
0.26
Delayed CD diagnosis
2.6 (1.1-6.5)
0.03
Mouth ulcer
1.9 (0.7-3.8)
0.17
3-stage IPAA
1.2 (0.8-1.8)
0.36
Prior anal fissure
1.5 (0.9-2.5)
0.13
Postoperative pouch-vaginal
fistula
2.8 (1.3-6.4)
0.01
Postoperative perianal fistula
1.3 (0.6-2.6)
0.56
Pelvic sepsis
9.7(3.4-27.3)
0.0001
Melton et al. Ann Surg 2008
Crohn’s and IPAA
Cleveland Clinic Experience
• 204 patients, with median F/U 7.4 years
– Preoperative diagnosis
– Postoperative diagnosis
– Delayed diagnosis
N=20 10%
N=97 47%
N=87 43%
• Pouch retention rate 71 % ( 10 years)
• Delayed diagnosis , pouchvaginal fistula and
postoperative sepsis were associated with
higher failure rates
Melton Ann Surg 2008
Cleveland Clinic Experience
10 years pouch survival rates
– Preoperative diagnosis N=20 10%
85 %
– Postoperative diagnosis N=97 47% 87 %
– Delayed diagnosis
N=87 43% 53 %
– Pouch retention rate 71 % ( 10 years)
Melton Ann Surg 2008
Survival of IPAA
in patients with CD
Melton et al. Ann Surg 2008
Survival of IPAA
in patients with CD
P= 0.0001)
Intentional CD (solid thin line), incidental CD pouch
(dotted line), delayed diagnosis (solid thick line)
Melton et al. Ann Surg 2008
Ileal pouch for Crohn’s colitis
• Carefully selected patients with CD undergoing
primary restorative proctocolectomy with ileal
pouch-anal anastomosis have low pouch loss
and favorable functional results
• Patients with presumed ulcerative colitis or
indeterminate colitis diagnosed with CD from
operative histopathology can expect similar
good results
• Outcomes in patients with delayed diagnosis are
worse but approximately half retain their pouch
at 10 years with good functional outcome
Ileal pouch for Crohn’s colitis
• For patients, with good anal sphincter function
and associated morbidity, facing definitive
end-ileostomy
• An ileal pouch can be a reasonable alternative
keeping continence and gastrointestioanal
tract continuity, even for a good period of time
None
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