SAN DIEGO – Patients hoping to avoid a permanent stoma by having a salvage surgery to repair or replace a failing ileal pouch–anal anastomosis (IPAA) achieved good functional outcomes and quality of life in one institution’s long-term experience.
A large case series drawn from IPAA re-dos at the Cleveland Clinic over a 20-year span showed that the procedure was successful for four in five patients, and more than 90% were satisfied with their quality of life, despite some functional limitations. Dr. Feza Remzi, chairman of the department of colorectal surgery at the Cleveland Clinic, presented findings from 500 patients undergoing IPAA re-dos via the transabdominal approach. In this group, 80% (401) of transabdominally revised IPAAs were successful.
Dr. Feza Remzi
IPAA is a procedure indicated for patients with Crohn’s disease, ulcerative or indeterminate colitis, or familial adenomatous polyposis. The surgery preserves the capacity for anal defecation with intestinal continuity after proctocolectomy by fashioning a reservoir for stool from the small intestine. However, up to 15% of patients will have pouch failure, necessitating a permanent stoma unless the pouch is surgically revised, he said at the annual meeting of the American Surgical Association.
To determine outcomes for patients having a re-do of a failed IPAA, Dr. Remzi and colleagues assessed 502 IPAA re-do patients (215, male; median age, 38 years) who received their procedure at the Cleveland Clinic from 1983 to 2014. Crohn’s disease was the primary diagnosis for 419 patients (84%); just over half (n = 263) had anastomotic leak or fistula as the cause of first pouch failure, followed by pouch-vaginal fistula in 85 women (17%) and obstruction in 116 patients (23%).
The primary endpoints of the study were surgery morbidity, how many patients had a functioning pouch after re-do, pouch function, and quality of life.
Surgeon discretion dictated whether the pouch was revised, as it was in 295 patients (59%), or whether a new pouch was created. Overall, just over half of patients (n = 270) had postoperative complications, though there were no short-term deaths. Ileus and pelvic sepsis were the most common short-term complications, occurring in 81 (16%) and 50 (10%) patients, respectively. All of the other complications occurred in less than 10% of patients. Patients stayed in the hospital a median of 7 days, and 63 (13%) were readmitted.
Over the duration of the study, 101 patients (20%) had failure of their redone IPAA pouches, and pelvis sepsis and anastomotic stricture each occurred in more than 10% of patients. Short-term postoperative morbidity and occurrence of pelvic sepsis at any point after re-do surgery were associated with failure of the redone IPAA based on a Cox regression model (P = .035 and P < .0001, respectively).
Patients were overall very satisfied with their quality of life after IPAA re-do surgery; 92% of the 261 respondents said they would undergo the surgery again, and 93% would recommend the surgery. This was true although patients reported a mean of six daytime bowel movements, about half of patients reported having stool seepage or requiring pad use, and a third of patients reported dietary restrictions related to their bowel function.
Study limitations included the lack of information regarding patients in whom the re-do attempt was abandoned, or for those referred for surgery who did not have an IPAA re-do. Another limitation was the relatively low number of patients who completed all items on the function and quality of life questionnaires; investigators decided that the most robust analysis would flow from including only data for those who had completed all forms.
Discussion focused on the real-world and technical aspects of lessons learned from this large single-institution data set. Dr. David Rothenberger, Jay Phillips Professor and Chair of the department of surgery at the University of Minnesota, Minneapolis, asked whether patients had been carefully selected for this salvage procedure. In his experience, he said, obese patients or those with a heavily muscled pelvis, as well as those with a significant history of prior pelvic infections, would not necessarily be good candidates for a re-do. He suggested that an intention-to-treat analysis might give a truer denominator, and might even change the conclusion that the salvage surgery has a high likelihood of success. Dr. Remzi agreed that obesity or a high body mass index in a patient “is a very good reason not to do the surgery.”
Dr. Neil Hyman, codirector of the digestive diseases center at the University of Chicago Medicine, asked whether Dr. Remzi preferred to do an S pouch rather than a J pouch. In response, Dr. Remzi said, “We have to think about what the patient will give us. Throughout the years, I’ve learned that I like to divert the patient for 6 months before surgery. This gets them and their family engaged in the process. … It also elongates the mesentery to give you that reach. But I don’t necessarily do an intentional S pouch if the J pouch gives me what I need for the health of that patient.”