1. Restorative Proctocolectomy / Ileal Pouch-Anal Anastomosis
Jenny Zhang, MD
UW General Surgery
Seattle Children’s Hospital

2. JK 11M with UC diagnosed July 2011
Treated with Remicade, Humira, and prednisone with minimal benefit
Planned 3-stage procedure
11/23/2013: Elective total abdominal colectomy with ileostomy
02/05/2014: Partial proctectomy, rectal mucosectomy, hand- sewn ileoanal J-pouch pull-through
Uncomplicated hospital course post-operatively
Tolerating low residue diet with benefiber and immodium supplementation by time of discharge
DC’d home on POD 8

3. DB
18M with refractory UC
Failed medical management including Remicade, azathioprine, and steroids
Planned 3-stage procedure
12/06/2013: laparoscopic total abominal colectomy with ileostomy
02/07/2014: Proctectomy with stapled ileoanal J-pouch pullthrough
Uncomplicated hospital course post-operatively
Tolerating low-residue diet by time of discharge with immodium PRN
DC’d home on POD 6

4. Background
Since the 1980s, RP with IPAA has become procedure of choice for patients with UC requiring surgery
Originally described to be performed in association with full mucosectomy, however subsequently modified to allow retention of short cuff of anorectum
Two types of IPAA:
Mucosectomy with Hand-sewn anastomosis
Stapled anastomosis without mucosectomy

5. Hand-sewn with mucosectomy

6. Anal Transition Zone Kirat et al, 2010 Holder-Murray et al, 2009
Transecting the rectum at the top of the anal columns leaves a 1–2 cm anal transitional zone.
Kirat et al, 2010
Holder-Murray et al, 2009

7. Background
Debate persists about preservation of the Anal Transition Zone (ATZ)
What is the anal transition zone?
“Zone interposed between uninterrupted crypt bearing colorectal type mucosa above and uninterrupted squamous epithelium below”
Thought to play a role in continence in differentiating gas from liquid from solid
Considered at risk for dysplasia and persistent or recurrent disease

8. RP/IPAA: Stapled vs. Hand-Sewn?
Technique used still largely based on institution, surgeon preference, and skills

9. RP/IPAA: Stapled vs. Hand-Sewn?
Mucosectomy with Hand-sewn Anastomosis
Pros:
[Ideally] removing all diseased bowel mucosa thereby eliminating disease and risk of malignancy
Cons:
Requires greater manipulation of anal canal with increased risk of damage to sphincter mechanism
Disrupt anorectal inhibitory reflex (flatus vs. stool)

10. RP/IPAA: Stapled vs. Hand-Sewn?
Stapled Anastomosis without Mucosectomy
Pros:
Quicker operation requiring less manipulation of anal canal -> theoretically less post-operative incontinence
Maintains ATZ thereby preserving anorectal inhibitory reflex
Cons:
Leaves potentially diseased and possibly inflamed rectal mucosa within region of anastomosis
Requires regular follow-up of ATZ for risk of dysplasia/cancer

11. Lovegrove et al, Annals of Surgery, 2006
A Comparison of Hand-Sewn Versus Stapled Ileal Pouch Anal Anastomosis (IPAA) Following Proctocolectomy- A Meta-Analysis of Patients

12. Lovegrove et al, Annals of Surgery, 2006
Difference in post-operative complications between 2 anastomotic techniques
Functional outcomes
Anorectal physiology
Quality of Life
Neoplastic transformation

13. Lovegrove et al, Annals of Surgery, 2006
Adverse outcomes:
Anastomotic leak
Pouch failure
Wound infection
30 day mortality
Anastomotic stricture
Pouch-related fistulas
Pelvic sepsis
Pouchitis
SBO
Neoplastic transformation
Anastomotic leak: presence of contrast medium or fecal matter at level of anastomosis/pouch on imaging or re-operation
Pouch failure: excision of pouch or indefinite proximal diversion
Wound infection: inflammation and/or purulent discharge and/or positive wound swab for bacterial overgrowth
Post-op mortality: death within 30 days from any cause

14. Lovegrove et al, Annals of Surgery, 2006
Functional outcomes
Frequency of defecation per 24 hours and at night
Incontinence
Stool seepage
Pad use during daytime and nighttime
Use of antidiarrheal medication

15. Lovegrove et al, Annals of Surgery, 2006
Results
21 studies, 4183 patients total between
2699 (64.5%) hand-sewn anastomosis with mucosectomy
1484 (35.5%) stapled pouch anastomosis
80% with J-pouch (65% hand-sewn, 35% stapled)
80% with proximal diversion at time of ileal pouch surgery
Mean age
Hand sewn years
Stapled years
Follow up ranged months
Mean 26.8 months hand-sewn
Mean 19.6 months stapled

16. Lovegrove et al, Annals of Surgery, 2006
Results: Perioperative complications
Post-op adverse events in ~20% pts undergoing RP/IPAA
No significant difference in rates of post-op adverse events between hand-sewn and stapled groups

18. Lovegrove et al, Annals of Surgery, 2006
Results: Functional Outcomes
No difference between stool frequency over 24 hours, nighttime defecation, or use of antidiarrrheal medication
However, increased frequency of incontinence to liquid stool in HS
29.4% vs. 22.1% (OR 2.32, P = 0.009)
Also increased seepage at night in HS
29.8% vs 16.8% (OR = 2.78, P < 0.001)
Increased nighttime pad usage in HS
26.&% vs. 8.1% (OR = 4.12, P = 0.007)

19. Lovegrove et al, Annals of Surgery, 2006
Results: Anorectal Physiology
Significant reduction in resting and squeeze pressure in HS by and 14.4 mmHg, respectively (P < 0.018)
No difference in neorectal volume nor length of high-pressure zone
Results: QOL
No significant differences in reported QOL or reported sexual dysfunction
Results: ATZ Pathology
No significant differences regarding dysplasia, inflammation, or neoplasia

20. Lovegrove et al, Annals of Surgery, 2006
Conclusion
Stapled IPAA allows better functional outcomes and less disruption of anal sphincter mechanism
Need studies with longer follow-up time and larger sample size to adequately quantify risk of dysplasia/cancer.

21. Kirat et al, Surgery, 2009
Comparison of outcomes after hand-sewn versus stapled ileal pouch anastomosis in 3,109 patients
Single institution,
Group A: Hand-sewn
Group B: Stapled
Compared short-term and long-term outcomes

22. Kirat et al, Surgery, 2009 Results 474 (15%) HS, 2635 (85%) Stapled
Similar age at operation, sex, albumin level, rate of prior colectomy, use of steroids
Mean age 37.9 ± 13.2 years
BMI for Group B higher
Group A more FAP patients, Group B more indeterminate colitis
Hospital LOS significantly longer for Group A
10 ± 5 days for Group A
7.5 ± 4 days for Group B
Group A longer follow up (10 ± 7 yrs vs 6 ± 5 yrs)

23. Kirat et al, Surgery, 2009 Postoperative complications
Group A > Group B:
Anastomotic stricture (p = 0.02)
Septic complications (p = 0.019)
SBO (p <0.027)
Pouch failure (p <0.001)
No significant difference in pouchitis

24. Kirat et al, Surgery, 2009 Functional results Group A > Group B
Incontinence (p < 0.001)
Seepage (p < .001)
Pad usage (p < .001)
Dietary restrictions (p < .001)
Social restrictions (p < .001)
Work restrictions (p < .025)
Group B > Group A
QOL (p < 0.001)
Happiness with operation ( p = 0.001)
Health (p = 0.019)

25. Kirat et al, Surgery, 2009 Conclusions:
In closely matched groups of patients with FAP and UC, pts in UC group had higher overall complication rate, more pouch-related septic complications, and pouchitis
Stapled IPAA seems to be safer in terms of complications and provides better long-term functional outcomes and QOL than hand-sewn IPAA

26. RP/IPAA: Stapled vs. Hand-Sewn?
So, what about the risk of dysplasia?

27. Remzi et al, Dis Colon Rectum, 2003
Dysplasia of the Anal Transition Zone After Ileal Pouch-Anal Anastomosis: Results of Prospective Evaluation After a Minimum of Ten Years
Goal: Establish risk of dysplasia in the ATZ and outcome of a conservative management policy for ATZ dysplasia with minimum of 10 years’ f/u after IPAA
289 pts underwent stapled IPAA for IBD
Followed with serial ATZ biopsies for at least 10 years post-op (n = 178)
Median f/u 130 months (range months)

28. Remzi et al, Dis Colon Rectum, 2003
Results
ATZ dysplasia in 8 patients occurring months after surgery
High grade: 2 patients
Low grade: 6 patients
2 of 6 with LGD underwent completion mucosectomy
1 of 2 with HGD underwent partial mucosectomy (2/2 technical difficulty)
No association with gender, age, preoperative disease duration, or extent of colitis
Significant association with cancer/dysplasia as preop diagnosis or in proctocolectomy specimen

29. Remzi et al, Dis Colon Rectum, 2003
Conclusions
ATZ dysplasia after stapled IPAA is infrequent and usually self- limiting
ATZ preservation did not lead to development of cancer with minimum follow up of 10 years
Recommend long-term surveillance
If repeat biopsy confirms dysplasia, recommend completion mucosectomy with advancement and neo IPAA

30. Fichera et al, J Gastrointest Surg, 2007
Preservation of the Anal Transition Zone in Ulcerative Colitis. Long-Term Effects on Defecatory Function.
Select patients offered stapled IPAA, primarily based on presence of dysplasia on multiple pre-operative colonoscopic biopsies, regardless of location or degree
Goal: to determine oncologic risk of retained ATZ in stapled IPAA over time, assess the inflammatory changes during follow up, and evaluate impact on long-term functional outcome measures

31. Fichera et al, J Gastrointest Surg, 2007
Methods
Consecutive UC patients with stapled IPAA
Surveillance of ATZ
Rigid anoscopy with 4-quadrant biopsies of ATZ performed annually to evaluate for new-onset dysplasia
Inflammatory component graded as acute, chronic, or absent by expert GI pathologist
Bx’s excluded if contained small intestinal mucosa or squamous epithelium
Bx’s with concurrent detailed survey analysis were included in analysis of defecatory function and QOL
Two-part Questionnaire mailed at 3, 6, 9, 12, 18, and 24 months post-op and then yearly thereafter

32. Fichera et al, J Gastrointest Surg, 2007
Results
225 consecutive UC patients with no pre-operative cancer or dysplasia nor unexpected cancer or dysplasia on final pathology review of surgical specimen
Mean age 34.7 ±11.5 years (range 13-66)
Median follow up 36 months (range months)
238 successful biopsies of ATZ during study period
No dysplasia or cancer in any biopsies
No patients developed cancer in pouch, retained ATZ, or pelvic floor

33. Fichera et al, J Gastrointest Surg, 2007
Results cont’d
238 successful biopsies of ATZ during study period
No patients developed cancer in pouch, retained ATZ, or pelvic floor
11 biopsies (4.6%) with acute inflammation
9 asymptomatic, 2 with cuffitis (resolved with medical treatment)
202 biopsies (84.9%) with chronic inflammation
25 (10.5%) with normal biopsies

34. Fichera et al, J Gastrointest Surg, 2007
Results cont’d
72 successful biopsies with concurrent questionnaires
5 biopsies with acute inflammation (7%)
59 biospies with chronic inflammation (82%)
8 biopsies normal (11%)
No significant difference in any of the measures surveyed for defecatory function
No patients with major incontinence episodes
CI group: 96% reported perfect continence, 93% able to defer BM if needed, and 5% use protective pads

35. Fichera et al, J Gastrointest Surg, 2007
Conclusions
Retained ATZ after stapled IPAA predominantly demonstrated persistence of chronic inflammation
CI shown to have minimal impact on both stooling function and QOL
Patients free of dysplasia or cancer in median follow-up of 36 months
Majority of reports of cancer in retained ATZ have been in patients with preop evidence of cancer or dysplasia

36. Alessandroni et al, Updates in Surgery, 2012
Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis
Case report and literature review

37. Alessandroni et al, Updates in Surgery, 2012
39M with 20 year h/o UC s/p RP/ stapled IPAA, negative pathology
: serial endoscopy with negative exams and biopsies
Sept 2001, increase in stool frequency. Endoscopy with acute pouchitis. Partial resolution with topical steroids and systemic abx
Then began having BRBPR. Pouch endoscopy with nodular adenocarcinoma (CEA WNL)
Aug 2002 underwent pouch excision & permanent ileostomy with pathology revealing Stage III adenoCA by AJCC 2002 classification
Underwent post-op chemoradiation however died 24 months after operation 2/2 cancer progression

38. Alessandroni et al, Updates in Surgery, 2012
On literature review, there are 50 reported cases of carcinoma following IPAA for UC
25 (50%) after HS with mucosectomy
25 (50%) after stapled
48% of patients had pre-operative dysplasia or cancer at time of colectomy
Conclusion: Routine long-term endoscopic surveillance is needed in patients with long-standing ileal pouches

39. Summary Stapled IPAA is associated with better functional outcomes
Stapled IPAA does not appear to be associated with increased risk of dysplasia/cancer
Current studies limited by small sample-size and short follow-up time
Long-term surveillance of ATZ recommended

40. References
Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, et al. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proc- tocolectomy: a meta-analysis of 4183 patients. Ann Surg 2006;244:18-26.
Remzi FH, Fazio VW, Delaney CP, Preen M, Ormsby A, Bast J, et al. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation af- ter a minimum of ten years. Dis Colon Rectum 2003;46:6- 13.
Kirat H T, Remzi F H, Kiran R P, Fazio V W. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009;146(4):723–729. discussion 729–730.
Fichera A, Ragauskaite L, Silvestri MT, Elisseou NM, Rubin MA, Hurst RD, Michelassi F. Preservation of the anal transition zone in ulcerative colitis. Long-term effects on defecatory function. J Gastrointest Surg. 2007;11:1647–1652; discussion
L. Alessandroni, A. Kohn, M. Capaldi, I. Guadagni, A. Scotti, R. Tersigni. Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis. Updates Surg, 64 (2012), pp. 149–152