Patient Selection for IAP

Nigel A. Scott MD FRCS

Manchester UK

Patient Selection for IAP

Why a Pouch ?

Fulminant Colitis

• 5-15% of colitics

• one third - first attack

• 37% will require colectomy

Chronic ill Health CUC

….. “ know every toilet between home and the supermarket”

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

Ill health32%

Urgent64%

Cancer4%

Indication for colectomy and IAP (n=105)

Patient Selection for IAP

Who ?

Patient Selection for IAP

IBD Diagnosis

IBD Diagnosis

– or who said Crohn’s disease was OK anyway ?

Patient Selection for IAP

IBD Diagnosis

– or who said Crohns disease was OK anyway ?

Patient Selection for IAP

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

IBD Diagnosis

– or who said Crohn’s disease was OK anyway ?

92 dysfunctional

24 excised

14 (59%) CROHNS DISEASE

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 ………….”

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 ?

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.

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

Who ?

Patient Selection for IAP

IBD Diagnosis

Not CROHN’S

Informed Patient

Satisfaction = Result / Expectation

Patient Selection for IAP

•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

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

10 % excised at 10 years

permanent ileostomy

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

• 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

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

Who ?

Patient Selection for IAP

IBD Diagnosis

Not CROHN’S

Informed Patient

Sphincter

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

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

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

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

Who ?

Patient Selection for IAP

IBD Diagnosis

Not CROHN’S

Informed Patient

Sphincter ?counselling

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

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

Who ?

Patient Selection for IAP

IBD Diagnosis

Not CROHN’S

Informed Patient

Sphincter ?counselling

age ?

Optimisation

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%

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

2 x 20cm lengths of terminal ileum

Who ?

Patient Selection for IAP

IBD Diagnosis

Not CROHN’S

Informed Patient

Sphincter ?counselling

age ?

Optimisation

no steroids

BMI <30

Never, Never, Never, Never, Never, Never,  Never,

Never,

Never,

ever...

Patient Selection for IAP - one other thing

- make sure that they

Never eat beans in a Wet Suit