Crohn’s colitis patients can be offerred an ileoanal pouch

Feza H. Remzi, MD, FACS,FASCRS, FTSS ( Hon) Chairman

Department of Colorectal SurgeryRupert B. Turnbull Jr., MD Chair

Professor of Surgery Digestive Disease Institute

Cleveland Clinic Cleveland, OH

DisclosuresNone

“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)

• Extensive colonic involvement • Distal rectal sparing

Near total proctocolectomy (TAC + proximal proctectomy)

straight IRA permanent end ileostomy ileal pouch/rectal anastomosis IPRA

Short rectal stump

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 Pouch-Rectal 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 PatientsCleveland 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 colitisIdeal 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 colitisindication

• CD in the colorectum

• Preoperative pathologic confirmation of

diagnosis ????????

• 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 failureFactor Hazard ratio (95% CI) P valueAge <30 yr 1.3 (0.8-3.1) 0.26Delayed CD diagnosis 2.6 (1.1-6.5) 0.03Mouth ulcer 1.9 (0.7-3.8) 0.173-stage IPAA 1.2 (0.8-1.8) 0.36Prior anal fissure 1.5 (0.9-2.5) 0.13Postoperative pouch-vaginal fistula

2.8 (1.3-6.4) 0.01

Postoperative perianal fistula 1.3 (0.6-2.6) 0.56Pelvic sepsis 9.7(3.4-27.3) 0.0001

Melton et al. Ann Surg 2008

Crohn’s and IPAACleveland Clinic Experience

• 204 patients, with median F/U 7.4 years– Preoperative diagnosis N=20 10%– Postoperative diagnosis N=97 47%– Delayed diagnosis 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 Experience10 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

Intentional CD (solid thin line), incidental CD pouch (dotted line), delayed diagnosis (solid thick line)

P= 0.0001)

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

Permission has been granted