1. Kangaroo Club Information Day
Bruce George
7th October 2017

2. Should I have a Pouch? 25 year old woman What operation?
UC since age 20
colectomy + ileostomy with retained rectal remnant age 24
troublesome proctitis and doesn’t like ileostomy
What operation?
Ileo-anal pouch
Ileo-rectal anastomosis
Defer surgery
Proctectomy and permanent ileostomy

3. Forced choice question
How long does X have to be to choose treatment B
over treatment A?
Diagnosed with terminal illness
2 treatments approved by NICE
Treatment A:
50:50 chance of complete cure or death
Treatment B:
Gives X period of time in complete remission and then death

4. Nadine and Sam Montgomery

5. Montgomery vs Lanarkshire Health Board
Replaces Bolam principle
Dovetails with GMC guidelines about informed consent
Individualised approach to informed consent
Dr must discuss issues even if low risk which may be particularly important to that patient

6. Should I have a pouch? 25 year old woman What operation?
UC since age 20
colectomy + ileostomy and retained rectal remnant age 24
Troublesome proctitis and doesn’t like ileostomy
What operation?
Ileo-anal pouch
Ileo-rectal anastomosis
Defer surgery
Proctectomy and permanent ileostomy

7. What factors are important to this patient?
25 year old woman
UC since age 20
colectomy + ileostomy and retained rectal remnant age 24
Troublesome proctitis and doesn’t like ileostomy
What factors are important to this patient?
Bowel function
Sexual function and fecundity
Morbidity of surgery/ returning to work
Cancer risk/surveillance
Body image

8. Body image is important
Blake Beckford

9. Function
BO x 5-7, night 53%, urgency 16%
Failure rate 10-20%:

10. UK Ileoanal Pouch Report 2017
> 5000 patients (1980- today)
Supplemented by SWORD (surgical workload outcome reporting database)
Key findings:
Length of stay 10 days
25% re-admission within 30 days
20% complication
Gradual increase in laparoscopic procedures (33%)
Concerns about low volume hospitals and surgeons
Only 26 surgeons undertook >15 ops in 5 yrs
126 surgeons only 1 op
108 (of 126) hospitals less than 5/yr

11. Fertility Meta-analysis of 8 studies Pre-op UC: Post-pouch UC:
Infertile 105
Fertile 423 = 19.9% “medical” infertility
Post-pouch UC:
Infertile 301
Fertile 300 = 50.1% “surgical” infertility
Waljee et al Gut 2006

12. Lepisto et al BJS 2007
Questionnaire to 160 post pouch patients (and 160 post appendicectomy controls)
54 (39%) attempted to become pregnant post pouch
60 (46%) of controls
Of pouch patients trying to become pregnant 36 of 54 (67%) succeeded naturally
49 (82%) of controls

13. Need for fertility investigations
13 of 18 infertile post-pouch patients underwent fertility investigations:
Ultimately 8 conceived
Overall cumulative pregnancy after 72 months, including after infertility treatment
= 80%
Lepisto et al 2007

14. How should we spin this? Infertility rates: x 2-3 fold increase
20% to 50%
Waljee et al 2006
Eventual chance of becoming pregnant if trying
76-80% (91% in controls)
Lepisto et al 2007

15. Ileo-rectal anastomosis in UC
Initially described in 1950’s
Fell into disrepute due to high cancer risk
Recent resurgence of interest
selected patients with:
Mild proctitis
No dysplasia
No PSC
Compliant with surveillance

16. Ileo-rectal anastomosis in UC (compared to pouch)
Lower bowel frequency, better continence
Similar urgency
Less complicated procedure , faster return to normal activities
No (or postponed) pelvic surgery
Better preservation of fertility
Need for surveillance/cancer risk

17. Deferred surgery Persisting ileostomy
Persisting rectal remnant symptoms (10 year rule)
No risk to fertility
No change in sexual function/quality of life

18. Proctocolectomy and permanent ileostomy
Negative impact on body image and sexual function
Relatively straightforward surgery, return to normal activities
Preservation of fertility

19. Summary 25 year old woman What operation? UC since age 20
colectomy + ileostomy and retained rectal remnant age 24
Troublesome proctitis and doesn’t like ileostomy
What operation?
Ileo-anal pouch
Ileo-rectal anastomosis
Defer surgery
Proctectomy and permanent ileostomy

20. Decision making in Pouch Surgery
Challenging
Find out what matters most to the patient
Need for multidisciplinary care
Changing medico-legal landscape