NEW ORLEANS —Long-term functional outcomes may decline after ileoanal pouch surgery, but most patients report higher a quality of life than they had before their surgery, Dr. Feza H. Remzi said at the annual clinical congress of the American College of Surgeons.
Dr. Remzi of the Cleveland Clinic Foundation reported the results of a long-term follow-up study of 3,080 patients who underwent ileoanal pouch formation at the clinic from 1983 to 2006.
The patients' mean age at surgery was 38 years. Most (87%) had a final diagnosis of ulcerative or indeterminate colitis. A total of 43% of patients underwent surgery because of failed medical therapy or steroid dependence. Some of the other indications were prior colectomy (33%); dysplasia, cancer, or cancer prevention (11%); and familial polyposis (4%). The most commonly performed surgical technique was a stapled anastomosis (78%). A J-pouch design was used in 82% of patients, and 17% had their pouches created with no need for a diverting ileostomy.
The 30-day complication rate was low. Wound infections occurred in 5% of patients, small bowel obstruction in 4%, sepsis in 4%, postoperative bleeding in 3%, anastomotic separation in 2.5%, and fistula in 1%. Less than 1% of patients had pouch failure in the first 30 days.
At 5–15 years after surgery, however, all complications (sepsis, fistula, anastomotic stricture, obstruction, pouch failure, and pouchitis) had a tendency to increase. Significant increases were seen in small bowel obstruction (from 16% at 5 years to 23% at 15 years) and pouchitis (from 32% to 52% over that same period).
Incontinence increased significantly over time. Although 75% of patients reported complete continence at 3 months post operatively, only 32% reported it 15 years later. But there were some significant long-term improvements. Before surgery, only 60% of patients reported rare incontinence or none at all. By 3 months after surgery, the percentage of that combined group of patients had risen to 80%, and it did not vary significantly during the next 15 years of follow-up.
There was no significant change in the number of daytime or nighttime bowel movements from baseline to 15 years. Urgency decreased significantly over the same period. However, pad usage and seepage increased.
Nonetheless, patients generally reported high quality of life scores as early as 3 months after the procedure, and these scores stayed high throughout the follow-up period, Dr. Remzi said. All patients reported significant decreases in dietary, work, social, and sexual restrictions at each time period.
In discussing the paper, Dr. Robin McLeod stressed that quality of life should be a primary end point in any evaluation of long-term outcomes after this procedure. “Although the functional outcomes are not perfect, the quality of life for these patients is very good, and they are happy with the procedure. This is one of the disconnects that can happen when we focus only on the functional outcome and don't look at the patient globally,” said Dr. McLeod of Mount Sinai Hospital, Toronto.
According to Dr. Remzi, 97% of patients said they would undergo the procedure again, and would recommend it to others. “This is a very important indication of quality of life—that they would do it all over again,” he said.