Patient Selection for IAP Nigel A. Scott MD FRCS Manchester UK

Patient Selection for IAP Why a Pouch ?

Fulminant Colitis 5-15% of colitics one third - first attack 37% will require colectomy

Chronic ill Health CUC ….. “ know every toilet between home and the supermarket”

Cancer Risk in CUC 3% (95% CI ) at 10 years 5.9% (95% CI ) at 20 years 8.7% (95% CI ) at 30 years. The risk of colorectal cancer in ulcerative colitis: a meta-analysis Gut 2001;48:

Indication for colectomy and IAP (n=105) Patient Selection for IAP

Who ? Patient Selection for IAP IBD Diagnosis

– or who said Crohn’s disease was OK anyway ? Patient Selection for IAP

IBD Diagnosis – or who said Crohns disease was OK anyway ? Patient Selection for IAP

IBD Diagnosis – or who said Crohn’s disease was OK anyway ? no past or present history of anal manifestations no evidence of small bowel involvement Long-term results of Ileal Pouch-Anal anastomosis for Colorectal Crohns disease DCR 2001;44: Patient Selection for IAP 41 patients % Crohn’s related complications in pouch of 20 patients followed for more than 10 years – 7 (35%) excised

IBD Diagnosis – or who said Crohn’s disease was OK anyway ? 92 dysfunctional 24 excised 14 (59%) CROHNS DISEASE

IBD Diagnosis – or who said Crohn’s disease was OK anyway ? “ ……………. There is no obvious explanation for the much better outcome reported by Regimbeau et al ………….”

CUC n= 1135 CD n= 36 Non-closure01 Diversion83 Excision55 (5%)16 (45%) Failure63 (6%) 20 (56%) IBD Diagnosis – or who said Crohn’s disease was OK anyway ?

IBD Diagnosis – or who said Crohns disease was OK anyway ? Patient Selection for IAP However when faced with the prospect of definitive ileostomy in young patients, the possibility to keep even for a few years before the disease recurs, acceptable continence and defaecation should be stressed.

IBD Diagnosis – or who said Crohns disease was OK anyway ? Patient Selection for IAP …. but Pouch Crohns is associated with prolonged septic complications and then a difficult excision, non healing perineal sinus

Who ? Patient Selection for IAP IBD Diagnosis Not CROHN’S Informed Patient

Satisfaction = Result / Expectation Patient Selection for IAP

( National Association for Colitis and Crohns) ( J Pouch Group) Use and influence of the internet on patients undergoing ileoanal pouch surgeryJ. Torkington, L. S. Bevan, A. R. Morgan, J. Beynon and N. D. Carr Colorectal Disease Volume 5 Issue 2 Page March 2003 Patient Selection and the Ileoanal Pouch Patient Selection – information

The Effect of Ageing on Function and Quality of Life in Ileal Pouch Patients: A Single Cohort Experience of 409 Patients With Chronic Ulcerative Colitis – Ann Surg 2004:240(4);

10 % excised at 10 years permanent ileostomy

Patient Selection for IAP not normality BO 5 D/ 1N 40 % medication pads excision pelvic autonomics – impotence/ bladder dysfunction bleeding, infection, DVT/ PE death fertility

34 of 40 consecutive patients made use of preoperative semen preservation – all normal sperm concentrations, motility, and morphology were found 23 patients returned for postoperative analysis - semen characteristics not different from preoperative values None of the preserved semen samples was used, - semen cryopreservation benefited none of these patients. van Duijvendijk P, Slors JF, Taat CW, van Lochem LT, Bonsel GJ, de Vries JW, Obertop H. What is the benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for benign diseases? Dis Colon Rectum Jun;43(6): Chronic Ulcerative Colitis Assessment and Surgical Management Long Term Outcomes – male fertility unaffected

Female Infertility After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Toronto – Dis Colon Rectum 2004;47(7): Chronic Ulcerative Colitis Assessment and Surgical Management Long Term Outcomes – female fertility reduced

Who ? Patient Selection for IAP IBD Diagnosis Not CROHN’S Informed Patient Sphincter

Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW. Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg May-Jun;6(3):316-20; Patient Selection – the sphincter preoperative anal manometry before IAP formation questionaire faecal seepage incontinence quality of life

2 year outcomes<40mmHg>=40mm Hg P value Incontinence35.5%30.2%0.007 Day Seepage34.5%19.3%0.001 Night Seepage44.8%35.3%0.012 Social Restrictions11.5%12.3%0.07 Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW. Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg May-Jun;6(3):316-20; Patient Selection – the sphincter

Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW. Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg May-Jun;6(3):316-20; resting anal sphincter pressures > 40 mm Hg are associated with significantly better function after IAP However low preoperative resting pressures do not preclude successful outcome after IPAA. Patient Selection – the sphincter

Defect mmHg No defect mmHg P value MRP upper MRP mid MRP low Wexner Incontinence Score 11.5%12.3%0.5 Gearhart et al Sphincter defects are not associated with long term incontinence following ileal pouch anal anastomosis. DCR 2005;48: Patient Selection – obstetric sphincter defects on EAUS

Who ? Patient Selection for IAP IBD Diagnosis Not CROHN’S Informed Patient Sphincter ?counselling

Patient Selection for IAP age ???????? Kok Sun Ho, C. C. Chang, M. K. Baig, L. Börjesson, J. J. Nogueras, J. Efron, E. G. Weiss, D. Sands, A. M. Vernava III and S. D. Wexner Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians Colorectal Disease Volume 8 Page March 2006

Patient Selection – age < 70yrs n=313 > 70 yrs n=17 p los5.8d6.0dns Postop complications 40%39%ns Failure2%11%ns IAP is a safe and feasible option in Ulcerative Colitis patients over the age of 70 years – with similar functional results to younger patients

Who ? Patient Selection for IAP IBD Diagnosis Not CROHN’S Informed Patient Sphincter ?counselling age ? Optimisation

Optimisation – No steroids From: Heuschen: Ann Surg, Volume 235(2).February PRSC - the presence of fistulas or abscesses near the pouch (in the small pelvis), in the upper, middle, or lower part of the pouch, in the area of the rectal cuff, in the area of the IPAA, or in the area of the anal sphincter Preoperative Steroid Use (mg/d) PRSC 0 mg/d (n=51)6.2% <40 mg/d (n=193)16.2% >40 mg/d (n=80)23.1%

Obesity and Ileoanal Pouch Construction Efron JE, Uriburu JP, Wexner SD, Pikarsky A, Hamel C, Weiss EG, Nogueras JJ Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients. Obes Surg Jun;11(3): ObeseNon-obesep Operative time mins LOS (d)9.77.7ns Stomal complications10%0%ns Postop morbidity32%9.6%0.058 Pelvic septic complications 16%0%0.05

2 x 20cm lengths of terminal ileum

Who ? Patient Selection for IAP IBD Diagnosis Not CROHN’S Informed Patient Sphincter ?counselling age ? Optimisation no steroids BMI <30

Never, Never, Never, Never, Never, Never, ever... Patient Selection for IAP - one other thing - make sure that they

Never eat beans in a Wet Suit