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20 years of ileal pouch-anal surgery in Fundeni clinical institute – an untold story

20 years of ileal pouch-anal surgery in Fundeni clinical institute – an untold story Restorative proctocolectomy is the standard surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. The first restorative proctocolectomy in Romania was performed by Mihnea Ionescu in 1991 at Fundeni Clinical Hospital. The critical steps of this complex colo-rectal surgical procedure are ileal pouch reconstruction and a tension-free ileal pouch-anal anastomosis. Several technichal refinements of the procedure were associated with better postoperative outcome, especially a decreased rate of pelvic septic complications. Nowadays, this operation can be safely done, with almost nil mortality and good functional results, even in low-volume centers but when performed by high caseload surgical teams. Key words: restorative proctocolectomy, complications, functional results Introduction Restorative proctocolectomy was first proposed by Parks and Nicholls in 1978 for the surgical treatment of ulcerative colitis(1). It has become the standard surgical procedure for the patients with ulcerative colitis requiring surgery and for the patients with diffuse familial adenomatous polyposis (2). This type of surgical procedure is considered as a complex one, being recommended to be performed in high-volume centers by high caseload surgeons (3). Although the advantages of this surgical procedure have gained widely acceptance, the postoperative morbidity rate remains quite high, even in high-volume centers. Thus, around 60% of the patients with an ileal pouch will experience at least one postoperative complication (4). The main advantages of restorative proctocolectomy are related with the good functional results in more than 80% of the patients (5), avoiding the stigmata of a permanent stoma. Nevertheless, the postoperative outcome after restorative proctocolectomy seems to improve over the time, along with gaining surgical performance and expertise in ileal pouch surgery (6). Restorative proctocolectomy in Romania ­ a national priority of Fundeni Clinical Institute Restorative proctocolectomy was first performed in Romania at Fundeni Clinical Hospital in 1991 by Mihnea Ionescu. The initial experience with ileal pouch-anal surgery was published in 1996 (7). The Address for correspondence: Traian Dumitrascu, MD, Dan Setlacec Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328, Bucharest, Romania, e-mail: dumitrascu.ccgth@yahoo.com first restorative proctocolectomy in Fundeni Clinical Institute was made in a young woman with diffuse familial adenomatous polyposis. Her interesting and unusual long-term postoperative outcome was recently published in Colorectal Disease, the official journal of the European Society of Colo-proctology, who's Editor-in-Chief is the famous Professor John Nicholls (8). At the beginning, restorative proctocolectomy was not largely accepted by the Romanian community of surgeons. Thus, the procedure was criticized at the regional meetings of Romanian Surgical Society, considering its value as debatable. However, the surgical team from Fundeni Clinical Hospital, sustained by the head (at that time) of Department of Surgery, Professor Mihai Stancescu, continued to perform this surgical procedure. In time, the good postoperative results of ileal pouchanal surgery obtained by the Fundeni surgical team imposed this procedure as a safe one. Although, this procedure is performed also in other surgical centers in Romania, up to now, the only communications or papers targeting restorative proctocolectomy experience in Romania are coming from Fundeni Clinical Institute. Figure 1 - Diffuse familial adenomatous polyposis (macroscopically aspects) Fundeni Clinical Institute indications for restorative proctocolectomy Ulcerative colitis and diffuse familial adenomatous polyposis are the main indications for restorative proctocolectomy. In Western Europe, most of the reported series of ileal pouch-anal surgery includes predominantly patients with ulcerative colitis. In our series of patients, most of the patients were operated for diffuse familial adenomatous polyposis (with or without malignant transformation). In our experience the number of patients with ulcerative colitis requiring surgery is limited (5,9). Contraindications of the ileal pouch-anal surgery are assessed as absolute and relative. The absolute contraindications includes: Crohn disease, undetermined colitis, low rectal malignancies, and anal incontinence. Relative contraindications of an ileal pouch-anal procedure are: rectal strictures, rectovaginal fistulas, malignancies of the colon or medium and superior rectum. The surgical resection in diffuse familial adenomatous polyposis is mandatory due to the very high risk of colo-rectal malignancies (fig. 1). The main issue is related to the optimal timing for surgery since this complex surgical procedure may interfere with the psycho-somatic development of the patient. In our experience, we consider as optimal the age of 15 ­ 16 years. However, surgery is considered as mandatory even in younger ages when alarm signs are present (weight loss, anemia, displazia, big polyps), raising attention to a possible malignancy. Familial adenomatous polyposis is a disease with a high potential for malignancies. Colo-rectal cancer is the main cause of death in the patients with this disease. Thus, the risk for developing colo-rectal cancer in untreated patients is almost 100% till the age of 40 years (10). In ulcerative colitis, surgery is indicated in the following situations: non-response to medical treatment; cortico-dependence, toxic megacolon, nonresponsive acute attack, high-displazia, malignancies of the colon and/ or rectum (9). Prophylactic restorative proctocolectomy in ulcerative colitis management is not widely accepted nowadays since it was associated with a decrease in quality of life. However, it is recommended for patients with fear for malignant transformation who does not accept a screening program, especially when risk factors are present. Risk factors for malignancies in ulcerative colitis are considered: long time evolution (more than 7 years), diffuse disease, presence of primitive cholangitis (11). Fundeni Clinical Institute technique of restorative proctocolectomy Restorative proctocolectomy consists of removal of the entire colon and rectum, with preservation of the anal sphincter; the digestive continuity is established using an ileal pouch, of different shapes. Our technique of restorative proctocolectomy was previously described (2). Briefly, after a large mid-line incision, the abdomen is explored in order to detect malignant transformation. The total colectomy could begin either with the right colon (more frequent) or with the left colon. In cases in which the omentectomy is not required by oncological reasons, it is preferred to preserve the great omentum. In cases with malignancies at the level of the colon, the surgical procedure is tailored to the localization of the tumor (i.e., for left colon malignancies the removal of the central lymph node station is mandatory). In cases with rectal malignancies (excepting low rectal malignization that precludes any sphincter saving operation) the procedure supposes total mesorectal excision (fig. 2). After removal of the total colon and rectum, but with the preservation of the anal sphincter, the digestive continuity is made using an ileal pouch. Mucosectomy is considered as mandatory in cases of familial adenomatous polyposis (fig. 3), while in cases of ulcerative colitis, a small part of the anal mucosa could be preserved in order to facilitate the ileal pouch-anal anastomosis. Complete removal of the anal mucosa in patients with familial adenomatous polyposis is mandatory due to the risk of malignant transformation if normal mucosa is left in place. However, even in patients with complete mucosectomy, the risk for malignancies at the level of the ileal pouch is still present, although exceptional. The ileal pouch is usually made in a "J" fashion. The ileal pouch-anal anastomosis is made hand-sewn in cases of familial adenomatous polyposis, while in cases of ulcerative colitis, the mechanical anastomosis is preferred. Our technique of restorative proctocolectomy has evolved through the years. The critical steps during restorative proctocolectomy are the ileal pouch reconstruction and the ileal pouch-anal anastomosis. At the beginning, the J pouch was hand-sewn made. This type of approach was associated with an increased rate of reservoir leak (5). In the last years, the use of stapled devices in the reconstruction of ileal J-pouches has lead to almost nil pelvic septic complications related to pouch leak (fig. 4). The J-pouch is the most preferred pouch design not only in our technique, but also in most of the worldwide reported series (12). The reasons are Figure 2 - Total mesorectal excision (operative specimen) Figure 3 - Complete mucosectomy for difuse familial adenomatous polyposis (operative specimen) Figure 4 - Ileal pouch reconstruction using stapled devices (intraoperative aspects) Figure 5 - Intraoperative assessment of the small bowel mesenteric length for a tension-free ileal pouch-anal anastomosis related to the simplicity of the design along with the good functional results. However, the clue for a successful and safe ileal pouch-anal anastomosis is a tension-free anastomosis. Thus, sometimes, gaining length in ileal pouch-anal reconstruction is an important issue (fig. 5). An ileal pouch-anal anastomosis under tension may be associated with important morbidity, especially with pelvic sepsis. Pelvic sepsis, along with ileal pouch ischemia are potentially life threatening complications after restorative proctocolectomy (12). Nevertheless, no matter what technique/ techniques of lengthening the small bowel mesentery is/ are used, if the inferior part of the J-pouch reaches the inferior border of the symphysis pubis it is widely accepted that maximize the chances of a safe ileal pouch-anal anastomosis. Restorative proctocolectomy is usually made as a two-step operation. Protective ileostomy is widely used, mainly to prevent the consequences of a potential ileal pouch leak or ileal pouch-anal anastomosis dehiscence. In special cases of patients with ulcerative colitis, restorative proctocolectomy is made as a three step procedure: first colectomy, second ileal pouch-anal reconstruction with anastomosis, and, finally, loop ileostomy closure. Postoperative outcome after restorative proctocolectomy ­ Fundeni Clinical Institute experience Complications after restorative proctocolectomy are mainly represented by pelvic sepsis. The causes of pelvic sepsis are represented by pelvic haematoma, ileal reservoir leak or dehiscence of the ileal pouch-anal anastomosis. The consequences may range from external fistula, pelvic abscess to even acute peritonitis. Most of the external fistula can be conservatively managed, while pelvic abscesses can be safely solved by radiological approach. Reintervention is imposed by the presence of the acute peritonitis or ileal pouch necrosis. The second most frequent complication after restorative proctocolectomy is intestinal obstruction. It occurs more frequent after loop ileostomy closure, and in up to 50% of the cases require surgical management. The most specific late complication after ileal pouch-anal surgery is represented by the reservoir inflammation ("pouchitis"). The causes of pouchitis remains unknown, several factors like inflammation, bacterial contamination being presumed. It is more frequent in patients with restorative proctocolectomy for ulcerative colitis. Most of the cases can be conservatively managed, while in some rare situations ileal pouch excision is mandatory. Functional results after restorative proctocolectomy are considered as stable at least one year after loop ileostomy closure. The factors taken into consideration for functional results are: continence (most of the patients will experience at least minor incontinence in the early postoperative outcome), number of stools per day, the need for antidiarrhea medication (most of the patients will need it in the early postoperative recovery), soiling, capacity of differentiation between gases and faeces, sexual dysfunctions. It is widely accepted that a good functional results implies normal continence during the day time with an up to 4 stools per day. Fundeni Clinical Institute experience in ileal pouch-anal surgery includes over 60 restorative proctocolectomies during the last 20 years. The average number of procedures around 3/year includes our institution as a low-volume center. However, most of these surgical procedures (more than 90% of the cases) were performed by a singlesurgeon team. Thus, our experience can be related to a high caseload surgeon. The postoperative mortality was almost nil (one patient died of a cause unrelated to the type of procedure). The early postoperative morbidity was dominated by pelvic sepsis and intestinal obstruction (29%). Early removal of the ileal pouch was needed in 6% of the cases due to ileal pouch necrosis (most of the cases in the early period of the study). Pouchitis, as a late complication after restorative proctocolectomy was noticed in 8% of the cases (mainly in patients with ulcerative colitis), most of them conservatively managed. However, the ileal pouch excision was necessary in one case for this complication. Good and very good functional results were noticed in almost 90% of the patients, excluding the cases that required ileal pouch excision and one death. Conclusions Fundeni Clinical Institute represents the most important center in Romania dealing with ileal pouch-anal surgery. Restorative proctocolectomy can be safely performed even in a low-volume institution. Good postoperative outcomes can be achieved when this surgical procedure is performed by a high caseload surgeon. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Fundeni Hospital de Gruyter

20 years of ileal pouch-anal surgery in Fundeni clinical institute – an untold story

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Abstract

Restorative proctocolectomy is the standard surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. The first restorative proctocolectomy in Romania was performed by Mihnea Ionescu in 1991 at Fundeni Clinical Hospital. The critical steps of this complex colo-rectal surgical procedure are ileal pouch reconstruction and a tension-free ileal pouch-anal anastomosis. Several technichal refinements of the procedure were associated with better postoperative outcome, especially a decreased rate of pelvic septic complications. Nowadays, this operation can be safely done, with almost nil mortality and good functional results, even in low-volume centers but when performed by high caseload surgical teams. Key words: restorative proctocolectomy, complications, functional results Introduction Restorative proctocolectomy was first proposed by Parks and Nicholls in 1978 for the surgical treatment of ulcerative colitis(1). It has become the standard surgical procedure for the patients with ulcerative colitis requiring surgery and for the patients with diffuse familial adenomatous polyposis (2). This type of surgical procedure is considered as a complex one, being recommended to be performed in high-volume centers by high caseload surgeons (3). Although the advantages of this surgical procedure have gained widely acceptance, the postoperative morbidity rate remains quite high, even in high-volume centers. Thus, around 60% of the patients with an ileal pouch will experience at least one postoperative complication (4). The main advantages of restorative proctocolectomy are related with the good functional results in more than 80% of the patients (5), avoiding the stigmata of a permanent stoma. Nevertheless, the postoperative outcome after restorative proctocolectomy seems to improve over the time, along with gaining surgical performance and expertise in ileal pouch surgery (6). Restorative proctocolectomy in Romania ­ a national priority of Fundeni Clinical Institute Restorative proctocolectomy was first performed in Romania at Fundeni Clinical Hospital in 1991 by Mihnea Ionescu. The initial experience with ileal pouch-anal surgery was published in 1996 (7). The Address for correspondence: Traian Dumitrascu, MD, Dan Setlacec Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328, Bucharest, Romania, e-mail: dumitrascu.ccgth@yahoo.com first restorative proctocolectomy in Fundeni Clinical Institute was made in a young woman with diffuse familial adenomatous polyposis. Her interesting and unusual long-term postoperative outcome was recently published in Colorectal Disease, the official journal of the European Society of Colo-proctology, who's Editor-in-Chief is the famous Professor John Nicholls (8). At the beginning, restorative proctocolectomy was not largely accepted by the Romanian community of surgeons. Thus, the procedure was criticized at the regional meetings of Romanian Surgical Society, considering its value as debatable. However, the surgical team from Fundeni Clinical Hospital, sustained by the head (at that time) of Department of Surgery, Professor Mihai Stancescu, continued to perform this surgical procedure. In time, the good postoperative results of ileal pouchanal surgery obtained by the Fundeni surgical team imposed this procedure as a safe one. Although, this procedure is performed also in other surgical centers in Romania, up to now, the only communications or papers targeting restorative proctocolectomy experience in Romania are coming from Fundeni Clinical Institute. Figure 1 - Diffuse familial adenomatous polyposis (macroscopically aspects) Fundeni Clinical Institute indications for restorative proctocolectomy Ulcerative colitis and diffuse familial adenomatous polyposis are the main indications for restorative proctocolectomy. In Western Europe, most of the reported series of ileal pouch-anal surgery includes predominantly patients with ulcerative colitis. In our series of patients, most of the patients were operated for diffuse familial adenomatous polyposis (with or without malignant transformation). In our experience the number of patients with ulcerative colitis requiring surgery is limited (5,9). Contraindications of the ileal pouch-anal surgery are assessed as absolute and relative. The absolute contraindications includes: Crohn disease, undetermined colitis, low rectal malignancies, and anal incontinence. Relative contraindications of an ileal pouch-anal procedure are: rectal strictures, rectovaginal fistulas, malignancies of the colon or medium and superior rectum. The surgical resection in diffuse familial adenomatous polyposis is mandatory due to the very high risk of colo-rectal malignancies (fig. 1). The main issue is related to the optimal timing for surgery since this complex surgical procedure may interfere with the psycho-somatic development of the patient. In our experience, we consider as optimal the age of 15 ­ 16 years. However, surgery is considered as mandatory even in younger ages when alarm signs are present (weight loss, anemia, displazia, big polyps), raising attention to a possible malignancy. Familial adenomatous polyposis is a disease with a high potential for malignancies. Colo-rectal cancer is the main cause of death in the patients with this disease. Thus, the risk for developing colo-rectal cancer in untreated patients is almost 100% till the age of 40 years (10). In ulcerative colitis, surgery is indicated in the following situations: non-response to medical treatment; cortico-dependence, toxic megacolon, nonresponsive acute attack, high-displazia, malignancies of the colon and/ or rectum (9). Prophylactic restorative proctocolectomy in ulcerative colitis management is not widely accepted nowadays since it was associated with a decrease in quality of life. However, it is recommended for patients with fear for malignant transformation who does not accept a screening program, especially when risk factors are present. Risk factors for malignancies in ulcerative colitis are considered: long time evolution (more than 7 years), diffuse disease, presence of primitive cholangitis (11). Fundeni Clinical Institute technique of restorative proctocolectomy Restorative proctocolectomy consists of removal of the entire colon and rectum, with preservation of the anal sphincter; the digestive continuity is established using an ileal pouch, of different shapes. Our technique of restorative proctocolectomy was previously described (2). Briefly, after a large mid-line incision, the abdomen is explored in order to detect malignant transformation. The total colectomy could begin either with the right colon (more frequent) or with the left colon. In cases in which the omentectomy is not required by oncological reasons, it is preferred to preserve the great omentum. In cases with malignancies at the level of the colon, the surgical procedure is tailored to the localization of the tumor (i.e., for left colon malignancies the removal of the central lymph node station is mandatory). In cases with rectal malignancies (excepting low rectal malignization that precludes any sphincter saving operation) the procedure supposes total mesorectal excision (fig. 2). After removal of the total colon and rectum, but with the preservation of the anal sphincter, the digestive continuity is made using an ileal pouch. Mucosectomy is considered as mandatory in cases of familial adenomatous polyposis (fig. 3), while in cases of ulcerative colitis, a small part of the anal mucosa could be preserved in order to facilitate the ileal pouch-anal anastomosis. Complete removal of the anal mucosa in patients with familial adenomatous polyposis is mandatory due to the risk of malignant transformation if normal mucosa is left in place. However, even in patients with complete mucosectomy, the risk for malignancies at the level of the ileal pouch is still present, although exceptional. The ileal pouch is usually made in a "J" fashion. The ileal pouch-anal anastomosis is made hand-sewn in cases of familial adenomatous polyposis, while in cases of ulcerative colitis, the mechanical anastomosis is preferred. Our technique of restorative proctocolectomy has evolved through the years. The critical steps during restorative proctocolectomy are the ileal pouch reconstruction and the ileal pouch-anal anastomosis. At the beginning, the J pouch was hand-sewn made. This type of approach was associated with an increased rate of reservoir leak (5). In the last years, the use of stapled devices in the reconstruction of ileal J-pouches has lead to almost nil pelvic septic complications related to pouch leak (fig. 4). The J-pouch is the most preferred pouch design not only in our technique, but also in most of the worldwide reported series (12). The reasons are Figure 2 - Total mesorectal excision (operative specimen) Figure 3 - Complete mucosectomy for difuse familial adenomatous polyposis (operative specimen) Figure 4 - Ileal pouch reconstruction using stapled devices (intraoperative aspects) Figure 5 - Intraoperative assessment of the small bowel mesenteric length for a tension-free ileal pouch-anal anastomosis related to the simplicity of the design along with the good functional results. However, the clue for a successful and safe ileal pouch-anal anastomosis is a tension-free anastomosis. Thus, sometimes, gaining length in ileal pouch-anal reconstruction is an important issue (fig. 5). An ileal pouch-anal anastomosis under tension may be associated with important morbidity, especially with pelvic sepsis. Pelvic sepsis, along with ileal pouch ischemia are potentially life threatening complications after restorative proctocolectomy (12). Nevertheless, no matter what technique/ techniques of lengthening the small bowel mesentery is/ are used, if the inferior part of the J-pouch reaches the inferior border of the symphysis pubis it is widely accepted that maximize the chances of a safe ileal pouch-anal anastomosis. Restorative proctocolectomy is usually made as a two-step operation. Protective ileostomy is widely used, mainly to prevent the consequences of a potential ileal pouch leak or ileal pouch-anal anastomosis dehiscence. In special cases of patients with ulcerative colitis, restorative proctocolectomy is made as a three step procedure: first colectomy, second ileal pouch-anal reconstruction with anastomosis, and, finally, loop ileostomy closure. Postoperative outcome after restorative proctocolectomy ­ Fundeni Clinical Institute experience Complications after restorative proctocolectomy are mainly represented by pelvic sepsis. The causes of pelvic sepsis are represented by pelvic haematoma, ileal reservoir leak or dehiscence of the ileal pouch-anal anastomosis. The consequences may range from external fistula, pelvic abscess to even acute peritonitis. Most of the external fistula can be conservatively managed, while pelvic abscesses can be safely solved by radiological approach. Reintervention is imposed by the presence of the acute peritonitis or ileal pouch necrosis. The second most frequent complication after restorative proctocolectomy is intestinal obstruction. It occurs more frequent after loop ileostomy closure, and in up to 50% of the cases require surgical management. The most specific late complication after ileal pouch-anal surgery is represented by the reservoir inflammation ("pouchitis"). The causes of pouchitis remains unknown, several factors like inflammation, bacterial contamination being presumed. It is more frequent in patients with restorative proctocolectomy for ulcerative colitis. Most of the cases can be conservatively managed, while in some rare situations ileal pouch excision is mandatory. Functional results after restorative proctocolectomy are considered as stable at least one year after loop ileostomy closure. The factors taken into consideration for functional results are: continence (most of the patients will experience at least minor incontinence in the early postoperative outcome), number of stools per day, the need for antidiarrhea medication (most of the patients will need it in the early postoperative recovery), soiling, capacity of differentiation between gases and faeces, sexual dysfunctions. It is widely accepted that a good functional results implies normal continence during the day time with an up to 4 stools per day. Fundeni Clinical Institute experience in ileal pouch-anal surgery includes over 60 restorative proctocolectomies during the last 20 years. The average number of procedures around 3/year includes our institution as a low-volume center. However, most of these surgical procedures (more than 90% of the cases) were performed by a singlesurgeon team. Thus, our experience can be related to a high caseload surgeon. The postoperative mortality was almost nil (one patient died of a cause unrelated to the type of procedure). The early postoperative morbidity was dominated by pelvic sepsis and intestinal obstruction (29%). Early removal of the ileal pouch was needed in 6% of the cases due to ileal pouch necrosis (most of the cases in the early period of the study). Pouchitis, as a late complication after restorative proctocolectomy was noticed in 8% of the cases (mainly in patients with ulcerative colitis), most of them conservatively managed. However, the ileal pouch excision was necessary in one case for this complication. Good and very good functional results were noticed in almost 90% of the patients, excluding the cases that required ileal pouch excision and one death. Conclusions Fundeni Clinical Institute represents the most important center in Romania dealing with ileal pouch-anal surgery. Restorative proctocolectomy can be safely performed even in a low-volume institution. Good postoperative outcomes can be achieved when this surgical procedure is performed by a high caseload surgeon.

Journal

Annals of Fundeni Hospital – de Gruyter

Published: Dec 1, 2011

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