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

2. 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

3. 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: > polyps inc 5-6 in rectum
3/16/11 Lap Total Abdominal Colectomy, Ileoanal Pull-Through, J Pouch Reconstruction

4. Questions
Reconstruction options for Ileoanal Pull-Through?

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

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

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

8. 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

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

10. J Pouch

11. 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

12. The Data

13. The Data

14. The Data
13 studies identified between

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Results-Stooling/Day-time

31. Results-Stooling/Night-time

32. Results-Pouchitis

33. 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)

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

35. 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?

36. 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):
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

37. Results-Functional Outcomes