Download - Patient Selection for IAP
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Patient Selection for IAP
Nigel A. Scott MD FRCS
Manchester UK
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Patient Selection for IAP
Why a Pouch ?
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Fulminant Colitis
• 5-15% of colitics
• one third - first attack
• 37% will require colectomy
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Chronic ill Health CUC
….. “ know every toilet between home and the supermarket”
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Cancer Risk in CUC
• 3% (95% CI 2.2-3.8) at 10 years
• 5.9% (95% CI 4.3-7.4) at 20 years
• 8.7% (95% CI 6.4-10.9) at 30 years.
The risk of colorectal cancer in ulcerative colitis: a meta-analysis Gut 2001;48:526-535
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Ill health32%
Urgent64%
Cancer4%
Indication for colectomy and IAP (n=105)
Patient Selection for IAP
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Who ?
Patient Selection for IAP
IBD Diagnosis
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IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
Patient Selection for IAP
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IBD Diagnosis
– or who said Crohns disease was OK anyway ?
Patient Selection for IAP
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IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
• no past or present history of anal manifestations
• no evidence of small bowel involvement
Long-term results of Ileal Pouch-Anal anastomosis for Colorectal Crohns disease DCR 2001;44:769-778
Patient Selection for IAP
• 41 patients 1985 - 1998
• 27 % Crohn’s related complications in pouch
• of 20 patients followed for more than 10 years – 7 (35%) excised
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IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
92 dysfunctional
24 excised
14 (59%) CROHNS DISEASE
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IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
“ ……………. There is no obvious explanation for the much better outcome reported by Regimbeau et al ………….”
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CUC n= 1135
CDn= 36
Non-closure 0 1
Diversion 8 3
Excision 55 (5%) 16 (45%)
Failure 63 (6%) 20 (56%)
IBD Diagnosis
– or who said Crohn’s disease was OK anyway ?
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IBD Diagnosis
– or who said Crohns disease was OK anyway ?
Patient Selection for IAP
However when faced with the prospect of definitive ileostomy in young patients, the possibility to keep even for a few years before the disease recurs, acceptable continence and defaecation should be stressed.
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IBD Diagnosis
– or who said Crohns disease was OK anyway ?
Patient Selection for IAP
…. but Pouch Crohns is associated with prolonged septic complications and then a difficult excision, non healing perineal sinus
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Who ?
Patient Selection for IAP
IBD Diagnosis
Not CROHN’S
Informed Patient
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Satisfaction = Result / Expectation
Patient Selection for IAP
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•www.ileostomypouch.co.uk•www.nacc.org.uk (National Association for Colitis and Crohns)•www.j-pouch.org (J Pouch Group)
Use and influence of the internet on patients undergoing ileoanal pouch surgeryJ. Torkington, L. S. Bevan, A. R. Morgan, J. Beynon and N. D. CarrColorectal Disease Volume 5 Issue 2 Page 193 - March 2003
Patient Selection and the Ileoanal Pouch
Patient Selection – information
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The Effect of Ageing on Function and Quality of Life in Ileal Pouch Patients: A Single Cohort Experience of 409 Patients With Chronic Ulcerative Colitis – Ann Surg 2004:240(4);615-623
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10 % excised at 10 years
permanent ileostomy
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Patient Selection for IAP
• not normality BO 5 D/ 1N
• 40 % medication
• pads
• excision
• pelvic autonomics – impotence/ bladder dysfunction
•bleeding, infection, DVT/ PE death
• fertility
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• 34 of 40 consecutive patients made use of preoperative semen preservation – all normal sperm concentrations, motility, and morphology were found
• 23 patients returned for postoperative analysis - semen characteristics not different from preoperative values
• None of the preserved semen samples was used, - semen cryopreservation benefited none of these patients.
van Duijvendijk P, Slors JF, Taat CW, van Lochem LT, Bonsel GJ, de Vries JW, Obertop H. What is the benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for benign diseases? Dis Colon Rectum. 2000 Jun;43(6):838-42.
Chronic Ulcerative ColitisAssessment and Surgical Management
Long Term Outcomes – male fertility unaffected
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Female Infertility After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Toronto – Dis Colon Rectum 2004;47(7):1119 - 1126
Chronic Ulcerative ColitisAssessment and Surgical Management
Long Term Outcomes – female fertility reduced
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Who ?
Patient Selection for IAP
IBD Diagnosis
Not CROHN’S
Informed Patient
Sphincter
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Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;
Patient Selection – the sphincter
• preoperative anal manometry before IAP formation
• questionaire
• faecal seepage
• incontinence
• quality of life
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2 year outcomes <40mmHg >=40mmHg
P value
Incontinence 35.5% 30.2% 0.007
Day Seepage 34.5% 19.3% 0.001
Night Seepage 44.8% 35.3% 0.012
Social Restrictions 11.5% 12.3% 0.07
Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;
Patient Selection – the sphincter
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Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;
• resting anal sphincter pressures > 40 mm Hg are associated with significantly better function after IAP
• However low preoperative resting pressures do not preclude successful outcome after IPAA.
Patient Selection – the sphincter
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DefectmmHg
No defectmmHg
P value
MRP upper 28 51 0.005
MRP mid 56 89 0.002
MRP low 63 82 0.015
Wexner Incontinence Score
11.5% 12.3% 0.5
Gearhart et al Sphincter defects are not associated with long term incontinence following ileal pouch anal anastomosis. DCR 2005;48:1410-1415
Patient Selection – obstetric sphincter defects on EAUS
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Who ?
Patient Selection for IAP
IBD Diagnosis
Not CROHN’S
Informed Patient
Sphincter ?counselling
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Patient Selection for IAP
age ????????
Kok Sun Ho, C. C. Chang, M. K. Baig, L. Börjesson, J. J. Nogueras, J. Efron, E. G. Weiss, D. Sands, A. M. Vernava III and S. D. Wexner Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians Colorectal Disease Volume 8 Page 235 - March 2006
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Patient Selection – age
< 70yrsn=313
> 70 yrsn=17
p
los 5.8d 6.0d ns
Postop complications
40% 39% ns
Failure 2% 11% ns
IAP is a safe and feasible option in Ulcerative Colitis patients over the age of 70 years – with similar functional results to younger patients
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Who ?
Patient Selection for IAP
IBD Diagnosis
Not CROHN’S
Informed Patient
Sphincter ?counselling
age ?
Optimisation
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Optimisation – No steroids
From: Heuschen: Ann Surg, Volume 235(2).February 2002.207-216
PRSC - the presence of fistulas or abscesses near the pouch (in the small pelvis), in the upper, middle, or lower part of the pouch, in the area of the rectal cuff, in the area of the IPAA, or in the area of the anal sphincter
Preoperative Steroid Use (mg/d)
PRSC
0 mg/d (n=51) 6.2%
<40 mg/d (n=193) 16.2%
>40 mg/d (n=80) 23.1%
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Obesity and Ileoanal Pouch Construction
Efron JE, Uriburu JP, Wexner SD, Pikarsky A, Hamel C, Weiss EG, Nogueras JJRestorative proctocolectomy with ileal pouch anal anastomosis in obese patients.Obes Surg. 2001 Jun;11(3):246-51
Obese Non-obese pOperative time mins 229 196 0.02LOS (d) 9.7 7.7 nsStomal complications 10% 0% ns
Postop morbidity 32% 9.6% 0.058Pelvic septic
complications16% 0% 0.05
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2 x 20cm lengths of terminal ileum
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Who ?
Patient Selection for IAP
IBD Diagnosis
Not CROHN’S
Informed Patient
Sphincter ?counselling
age ?
Optimisation
no steroids
BMI <30
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Never, Never, Never, Never, Never, Never, Never,
Never,
Never,
ever...
Patient Selection for IAP - one other thing
- make sure that they
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Never eat beans in a Wet Suit