Ileoanal Pull-Through Straight vs. J Pouch Morgan Richards 3.24.2011

CK and CH Ulcerative Colitis 4 y/o boy failed medical management UC Bloody diarrhea, abd pain, fevers, leukocytosis Fecal incontinence 8-10 bowel movements per day 2/15/11 Lap Total Abdominal Colectomy, End Ileostomy 3/15/11 Proctectomy, Ileoanal J Pouch Reconstruction

CK and CH 17 y/o girl, f hx of FAP Ulcerative Colitis Familial Adenomatous Polyposis 4 y/o boy failed medical management UC Bloody diarrhea, abd pain, fevers, leukocytosis Fecal incontinence 8-10 bowel movements per day 2/15/11 Lap Total Abdominal Colectomy, End Ileostomy 3/15/11 Proctectomy, Ileoanal J Pouch Reconstruction 17 y/o girl, f hx of FAP Colonoscopy: >150-200 polyps inc 5-6 in rectum 3/16/11 Lap Total Abdominal Colectomy, Ileoanal Pull-Through, J Pouch Reconstruction

Questions Reconstruction options for Ileoanal Pull-Through?

Questions Reconstruction options for Ileoanal Pull-Through? Pros and cons?

Questions Reconstruction options for Ileoanal Pull-Through? Pros and cons? Reconstruction of choice btw J pouch and straight pull-through?

Operative Options Reservoir vs. straight pull through Reservoir J pouch S pouch W pouch K pouch H pouch U pouch B pouch

Operative Options Reservoir vs. straight pull through Reservoir J pouch S pouch W pouch H pouch (side to side) K pouch U pouch B pouch

Operative Options Reservoir vs. straight pull through Reservoir J pouch S pouch W pouch K pouch H pouch U pouch B pouch

J Pouch

The Theory Pouch Straight Pros Cons Decreased stool frequency Increased length Cons Increased pouchitis Increased stool frequency S and W higher failure rates compared to J Dilation of reservoir, stasis, elongation at the anastomosis leading to stenosis S with higher pouchitis rate More length with straight pull through Pouches dilate over time Decrease stool frequency vs. pouchitis, all enlarge over time

The Data

The Data

The Data 13 studies identified between 1984-2004

The Data 13 studies identified between 1984-2004 5 included in final analysis (all retrospective)

The Data 13 studies identified between 1984-2004 5 included in final analysis (all retrospective) 306 pts (86 SIAA, 220 IPAA)

Meta-Analysis Results Outcome of Interest No of Studies No of Patients P Short-term Perianal sepsis 3 284 0.05 Enterovaginal fistula 4 306 0.14 Anastomotic leak 240 0.75 Small bowel obstruction 0.80 Long-term Failure 0.02 Abdominal salvage <0.0001 Anastomotic stricture 233 0.24 Inflammation of neorectum/pouch 0.49 Functional Bowel Frequency per 24h 2 35 <0.001 Defecation at night 1 22 0.005

Meta-Analysis Results Outcome of Interest No of Studies No of Patients P Short-term Perianal sepsis 3 284 0.05 Enterovaginal fistula 4 306 0.14 Anastomotic leak 240 0.75 Small bowel obstruction 0.80 Long-term Failure 0.02 Abdominal salvage <0.0001 Anastomotic stricture 233 0.24 Inflammation of neorectum/pouch 0.49 Functional Bowel Frequency per 24h 2 35 <0.001 Defecation at night 1 22 0.005

Meta-Analysis Results Outcome of Interest No of Studies No of Patients P Short-term Perianal sepsis 3 284 0.05 Enterovaginal fistula 4 306 0.14 Anastomotic leak 240 0.75 Small bowel obstruction 0.80 Long-term Failure 0.02 Abdominal salvage <0.0001 Anastomotic stricture 233 0.24 Inflammation of neorectum/pouch 0.49 Functional Bowel Frequency per 24h 2 35 <0.001 Defecation at night 1 22 0.005

Meta-Analysis Results Outcome of Interest No of Studies No of Patients P Short-term Perianal sepsis 3 284 0.05 Enterovaginal fistula 4 306 0.14 Anastomotic leak 240 0.75 Small bowel obstruction 0.80 Long-term Failure 0.02 Abdominal salvage <0.0001 Anastomotic stricture 233 0.24 Inflammation of neorectum/pouch 0.49 Functional Bowel Frequency per 24h 2 35 <0.001 Defecation at night 1 22 0.005

Meta-Analysis Critique No randomized control trials Which patients are selected for straight pull-through procedures Length constraints may be indication for straight Limited long term data Straight pull-through said to expand with time Large disparity btw # SIAA vs. IPAA

The Data Mean age 15+/- 7 years 168 UC 35 FAP SIAA 112 vs JPAA 91

The Data Retrospective Mean age 15+/- 7 years 168 UC 35 FAP SIAA 112 vs JPAA 91

The Data Retrospective 250 children s/p straight vs. J pouch (203 with suff. data) Mean age 15+/- 7 years 168 UC 35 FAP SIAA 112 vs JPAA 91

The Data Retrospective 250 children s/p straight vs. J pouch (203 with suff. data) 3 year follow-up Mean age 15+/- 7 years 168 UC 35 FAP SIAA 112 vs JPAA 91

The Data Retrospective 250 children s/p straight vs. J pouch (203 with suff. data) 3 year follow-up 3 major medical centers Mean age 15+/- 7 years 168 UC 35 FAP SIAA 112 vs JPAA 91

The Data Retrospective 250 children s/p straight vs. J pouch (203 with suff. data) 3 year follow-up 3 major medical centers 112 SIAA, 91 JPAA Mean age 15+/- 7 years 168 UC 35 FAP SIAA 112 vs JPAA 91

Results SIAA (n = 112) JPAA (n = 91) P Wound Infection 9% 5% .272 Anastomotic Leak 3% .470 Intraabdominal Abscess 6% 2% .142 Anastomotic Stenosis 14% .050 Intestinal Obstruction 23% 28% .511 Incisional Hernia 1% - Fistula 13% Pouchitis 24% 49% .006

Results-Stooling/24 hours 8.4 mean bm/day +/- 3.9 for SIAA and 6.2 +/- 2.8 stools per day at 24 months. P=0.003

Results-Stooling/Day-time

Results-Stooling/Night-time

Results-Pouchitis

Results-Pouchitis Rate of pouchitis correlated with baseline diagnosis (p=0.028) 25.5% in UC 3% in FAP Enteritis for straight pull through Not significantly different (13% UC vs. 17% FAP)

Multi-Center Critique Not randomized control trial Limited long term data Less disparity btw # SIAA vs. IPAA Stapled vs. hand sewn

Conclusions SIAA increased stooling frequency JPAA increased pouchitis JPAA when possible SIAA is feasible option Future directions: Randomized Control Trial to accurately compare the two surgical approaches Is there another option?

References Tilney H, Constantinides V, Loannides A, et al. Pouch-anal anastomosis vs straight ileoanal anastomosis in pediatric patients: a meta-analysis. J Pediatr Surg 2006;41(11):1799-808. Seetharamaiaha R, Westb B, Ignasha S, et al. Outcomes in pediatric patients undergoing straight vs J pouch ileoanal anastomosis: a multicenter analysis. Journal of Pediatric Surgery (2009) 44, 1410–1417 Stone M, Mulvihill S, Snape W, Fonkalsrud E. Comparison of the Myoelectrical Activity of the Lateral and J-Shaped Ileal Reservoirs. Journal of Pediatric Surgery, Vol 21, No 6 (June), 1986: pp 500-505.

Results-Functional Outcomes