Functional outcomes in patients submitted to restorative proctocolectomy with ileal pouch anal anastomosis in a single tertiary center

Silva, Ana Cristina; Sampaio, Mónica; Marcos-Pinto, Ricardo; Lago, Paula; Rocha, Anabela; Matos, Eduarda; Santos, Marisa D.

doi:10.1016/j.jcol.2017.09.416

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Journal of Coloproctology (Rio de Janeiro)

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Original Articles • J. Coloproctol. (Rio J.) 38 (1) • Jan-Mar 2018 • https://doi.org/10.1016/j.jcol.2017.09.416 copy

Functional outcomes in patients submitted to restorative proctocolectomy with ileal pouch anal anastomosis in a single tertiary center

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background:

Functional results after restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis are variable. We assessed functional results in patients with ileal pouch anal anastomosis and evaluated potential factors associated with poor functional results.

Methods:

Retrospective cohort study of 38 patients who were submitted to a restorative proctocolectomy with ileal pouch anal anastomosis, in the context of ulcerative colitis and familial adenomatous polyposis, in at tertiary referral center, in the period between 1993 and 2013. Clinical records were analyzed and telephone interviews with protocoled questionnaire to 32 patients (12 ulcerative colitis, 20 familial adenomatous polyposis) were performed. Pouch functional results were also evaluated based in the Oresland score. The functional results were analyzed at four points of the patient outcome.

Results:

In 25 patients were performed restorative proctocolectomy with ileal pouch anal anastomosis and in 7 patients total colectomy preceded protectomy with ileal pouch anal anastomosis. Protective ileostomy was performed in all patients. There was no mortality and post-operative complications related with the pouch was 12.5% but treated conservatively. The mean follow-up was 13.2 years. Pouch failure occurs in 9.4% (2 in familial adenomatous polyposis and 1 in ulcerative colitis). Familial adenomatous polyposis patients achieved the best outcome but the outcome was acceptable in both groups. The median Oresland score was good with small variations over the years, although the best score being reached at 5 years after the surgery.

Conclusions:

The long-term results in patients undergoing restorative proctocolectomy with ileal pouch anal anastomosis were good in both groups, although better in familial adenomatous polyposis. In both, the best score of functional results seems to be reached at 5 years after surgery.

Keywords:
Ileal pouch anal anastomosis; Functional results; Familial adenomatous polyposis; Ulcerative colitis; Crohn's disease

Pathology	n
FAP	20
- With adenomas	17
- With adenomas and carcinoma	3
UC/IBDU	12
- Refractory to medical treatment	9
- Severe bleeding	1
- Toxic megacolon	1
- High-grade dysplasia	1

Classification Clavien-Dindo	No. of patients (32)	Pathology
		FAP (20)	UC (8)	CD (4)
Grade I	4	1	3	-
Grade II	8	6	1	1
Grade IIIb	1	1	-	-

	No. of patients (32)	FAP (20)	CD (4)	UC (8)
Complications	4	3	1	-
Anastomosis leak	3	2	1	-
Anastomosis bleeding	1	1	-	-

Complications	No. of patients (32)	FAP (20)	UC (8)	CD (4)
Major complications
Anism, difficulty of intubation or dysfunction pouch	3 (9.4%)	2 (10.0%)	1 (12.5%)^a a Patient with pouch dysfunction which led to its excision.	-
Excision pouch	2 (6.3%)	1 (5.0%) (HGD)	1 (12.5%)^a a Patient with pouch dysfunction which led to its excision. (dysfunction)	-
Minor complications
Increase of frequency of defecation per 24 h	8 (25.0%)	6 (30.0%)	1 (12.5%)	1 (25.0%)
Pouchitis	11 (34.4%)	4 (20.0%)	3 (37.5%)	4 (100.0%)
Irritable pouch syndrome	5 (15.6%)	4 (20.0%)	1 (12.5%)	-
Stenoses	4 (12.5%)	1 (5.0%)	1 (12.5%)	2 (50.0%)
Sexual dysfunctions	7 (21.9%)	4 (20.0%)	1 (12.5%)	2 (50.0%)
Urinary dysfunctions	2 (6.3%)	1 (5.0%)	1 (12.5%)	-

Variable	Global result	Score 1 (1-year)	Score 5 (5-year)	Score 10 (10-year)	Score 15 (15-year)
Sex	.53	.20	.70^a a 50% have expected values <5.	.67^a a 50% have expected values <5.	.69^b b 75% have expected values <5.
Age	.42	.93	.37^b b 75% have expected values <5.	.52^b b 75% have expected values <5.	.60^a a 50% have expected values <5.
ASA	.85	.71	.16^a a 50% have expected values <5.	.23^a a 50% have expected values <5.	.73^b b 75% have expected values <5.
CMI	.93	.32	.70^a a 50% have expected values <5.	.16^a a 50% have expected values <5.	.019^a a 50% have expected values <5.
					.065 with correction of continuity
Post surgical diagnosis	.76	.93	.47^a a 50% have expected values <5.	.86^a a 50% have expected values <5.	.49^b b 75% have expected values <5.
Pouch	.96	.32	.049^a a 50% have expected values <5.	.27^b b 75% have expected values <5.	.71^b b 75% have expected values <5.
			.22 with correction of continuity
Anastomosis type	.30	.17	.62^a a 50% have expected values <5.	.95^a a 50% have expected values <5.	.29^b b 75% have expected values <5.
Surgery procedure	.09	.44	.34^a a 50% have expected values <5.	.41^a a 50% have expected values <5.	.71^b b 75% have expected values <5.
Laparoscopy	.21	.48	.03^a a 50% have expected values <5.
			.14 with correction of continuity	-	-
Surgery time	.42	.85	.11^a a 50% have expected values <5.	.10^a a 50% have expected values <5.	.74^a a 50% have expected values <5.
Surgeon	.77	.55	.93^a a 50% have expected values <5.	.57^a a 50% have expected values <5.	.045^b b 75% have expected values <5.
					.16 with correction of continuity
Per operative complications	.42^a a 50% have expected values <5.	.58	.49^b b 75% have expected values <5.	.59^b b 75% have expected values <5.	.18^a a 50% have expected values <5.

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[1] *Corresponding author. ana_cris_f_silva@hotmail.com

Sex (male, female)	14; 18
Age at operation (years) (mean ± SD)	33 ± 12.3
Body mass index (kg/m²) (average)	23.6
Diagnosis (FAP and neoplasms; UC and IBDU)	20; 12
Resection type (2-stage procedure; 3-stage procedure)	25;7
Pouch type ("J"; "S")	25; 7
Anastomosis (hand-sewn; stapled)	17; 15
Laparoscopic surgery (no; yes)	26; 6
Operative time (minutes) [median (range)]	277.5 (180-676)
Morbidity (Clavien-Dindo II/III)	9 (28%)

(a) Discrimination of Orsland score
Parameters of Orsland score	1 yr (n = 32) %	5 yr (n = 32) %	10 yr (n = 25) %		15 yr (n = 18) %
24-h stool frequency (score)
<5 (score = 0)	81.2	75	72		44.4
5-8 (score = 1)	18.8	18.8	16		38.9
>8 (score = 2)	0	6.2	12		16.7
Night time defecation (score)
Never (score = 0)	53.1	56.2	48		27.8
Weekly (score = 1)	6.3	0	8		33.3
Every night (score = 2)	40.6	43.8	44		38.9
Urgency of defecation (score)
>30 min (score = 0)	96.9	96.9	96		83.3
10-30 min (score = 1)	3.1	3.1	4		5.6
<10 min (score = 2)	0	0	0		11.1
Use of pad daytime (score)
No (score = 0)	100	100	100		77.8
Yes (score = 1)	0	0	0		22.2
Use of pad at night (score)
No (score = 0)	93.7	90.6	96		66.7
Yes (score = 1)	6.3	9.4	4		33.3
Soiling or seepage during daytime (score)
No (score = 0)	96.9	100	100		77.8
Yes (score = 1)	3.1	0	0		22.2
Soiling or seepage at night (score)
No (score = 0)	75	86.4	84		66.7
Yes (score = 1)	25	15.6	16		33.3
Peri-anal soreness (score)
No (score = 0)	96.9	93.8	80		50
Occasional (score = 1)	3.1	6.3	20		44.4
Permanent (score = 2)	0	0	0		5.6
Dietary restrictions (score)
No (score = 0)	93.7	87.5	80		72.2
Yes (score = 1)	6.3	12.5	20		27.8
Regular medication for stool regulation (score)
No (score = 0)	75	78.1	80		94.4
Yes (score = 1)	25	21.9	20		5.6
Social handicap (score)
No (score = 0)	93.7	93.7	92		88.9
Yes (score = 1)	6.3	6.3	8		11.1
(b) Functional groups based in Orsland score
Functional Oresland score	Functioning	1 yr (n = 32) %	5 yr (n = 32) %	10 yr (n = 25) %	15 yr (n = 18) %
0-4	Proper	87.5	81.2	84	61.1
5-7	Moderate	9.4	18.8	8.0	22.2
8-15	Poor	3.1	0.0	8.0	16.7