Ileorectal anastomosis in Ulcerative Colitis The better option?

Transcription

1 Ileorectal anastomosis in Ulcerative Colitis The better option? Pär Myrelid MD, PhD Department of Surgery, Unit of Colorectal Surgery Linköping University Hospital Linköping Sweden October 11, 2012

2 Bowel movements IRA (UC and FAP ) Bowel movements/24 h Börjesson et al 5.6 Newton & Baker 4.5 Parc et al 4.5 Tonelli et al 4.5 Elton et al 3 Gallone et al 3 Pastore et al 6 Leijonmarck et al 4 da Lus Moreira et al 6 Ko et al 5.2 Börjesson et al Tech Coloproctol 2006, Elton et al, BJS 2003, Gallone et al World J Surg 1980, Ko et al, DCR 2000, da Luz Moreira et al Clin Colon Rectal Surg 2010

3 Continence Günther et al, Colorectal Disease 2003, Börjesson et al, Tech Coloproctol 2006

4 Sexual function Better physical and sexual functioning with IRA than IPAA in 85 young FAP patients - IRA first procedure in FAP, IPAA at later age? 50 % sexual dysfunction in women with IPAA Andrews et al, DCR 2007, van Balkom et al, DCR 2012

5 The probability to conceive during a given menstrual cycle Ileorectal anastomosis in FAP UC? Fertility and Fecundability No difference in 138 Dutch FAP patients Young age at primary surgery only risk factor (regardless of procedure) Ørding-Olsen K Br J Surg 2003, Nieuwenhuis et al Ann Surg, 2010

6 Fertility and Fecundity The ability (potential) to conceive UC - normal fecundity prior to surgery - decreased to 0.20 after IPAA surgery Ørding-Olsen K Gastroenterology 2002

7 QoL No differences - even though better continence in IRA group Older patients with IRA in the Hassan study=less energy? Ko et al, DCR 2000, Hassan et al, DCR 2005, da Luz Moreira et al BJS 2010

8 Cancer risk 374 UC patients with IRA between Followed up to 23 years No rectal cancer within 10 years of onset of disease Cumulative risk of RC 6 % at 20 years and 15 % at 30 years (onset of disease) The risk mainly among those who do not attend follow up Baker et al, BJS 1978, Mann World J Surg 1988, Pastore et al DCR, 1997

9 Failure Cleveland Clinic n=86 (UC) Gothenburg n=32 (UC) 38 (44%) still IRA after median 11 y Failure rate 12 % 2 (3%) loop-ileostomy 2 ileostomy 46 (53%) proctectomy (32 IPAA) 2 IPAA Helsinki n=20 (UC) Mayo n=90 (IBD) 84 % after 5 years 16.7 % in UC 69 % after 10 years 26.2 % in CD 56 % after 20 years da Luz Moreira BJS 2009, Börjesson Tech Coloproctol 2006, Lepistö et al, Scand J Surg 2005, Pastore et al, DCR 1997

10 IPAA after previous IRA (mainly FAP) Danish polyposis registry (n=84) Primary Secondary Early postop complications 6 0 p<0.001 Pouch removal 6 (11 %) 2 (8 %) p=0.64 No differences in function apart from less nocturnal defecation among secondary IPAA:s St Marks (n=185) Anastomotic leak 6 (5.6 %) 1 (1%) NS Wound infection 1 (0.9 %) 7 (9 %) p=0.012 No differences after 1, 5 or 10 years post IPAA Toronto (n=20) More problems with night time incontinence and skin irritation post IPAA but no differences in QoL Bülow et al Colorectal Disease In press 2012, Soravia et al DCR 1999, von Roon et l, BJS 2008

11 IRA in UC All reconstructions for UC in Linköping IPAA IRA n=148 n=104 Age colectomy 34 (11-64) 31 (7-75) Duration UC at 5 (0-32) 3 (0-35) colectomy (years) Age reconstruction 35 (13-65) 31 (10-75) Follow up (months) 67 (2-195) 51 (2-174) Median, Range

12 Reconstruction IPAA IRA n=148 n=104 Time gap colectomy 10 (0-96) 7.2 (0-70.6) reconstruction (months) Op time (min) 190 ( ) 130 (65-510) Perop bleeding (ml) 300 ( ) 50 (5-600) In hospital post op (days) 8.5 (4-54) 6 (2-73) Incl closure loop 13 (7-62) 6 (2-73) Median, Range

13 Complications reconstruction (<30 days) IPAA IRA n=148 n=104 Anastomotic dehiscence 7 3 Bleeding/hematoma 4 4 Ileus/high output 19 7 Wound dehiscence 1 1 SBO 1 2 UTI 2 1 Small bowel perforation 0 1 Abdominal infection 1 3 Infection (unknown origin) 5 1 Pneumonia 1 0 Thromboembolism 2 0 Pancreatitis 1 0 Other minor 5 1 TOTAL 49 (33 %) 24 (23 %) p=0.042

14 Medication IPAA IRA n=148 n=104 Antibiotics, episodic 21 (14 %) 0 (0 %) Antibiotics, chronic 5 (3 %) 0 (0 %) Steroids, episodic 1 (0.7 %) 25 (25 %) Thiopurines 3 (2 %) 7 (7 %) Probiotics 12 (8 %) 0 (0 %) 5-ASA 0 (0 %) 78 (78 %) None 89 (60 %) 7 (7 %)

15 Long term complications IPAA IRA n=148 n=104 Pouchitis, episodic 27 (18 %) N/A Pouchitis, chronic 18 (12 %) N/A Pouch dysfunction 7 (5 %) N/A Proctitis, BG 1 N/A 34 (34 %) BG 2 N/A 30 (30 %) Failure 17 (11 %) 9 (9 %) p=0.47 Bowel frequency 4 (1-11) Median, Range

16 Survival of reconstruction in UC p=0.67

17 IRA in UC Selection criteria Suitable Young patients (temporary solution) Late onset/short history Poor sphincter function Controllable rectum (BG 1 or 2 with topical therapy) IC or possibly Crohn s Not suitable Cancer or dysplasia (HGD colon or any in rectum) Proctitis despite topical therapy PSC Hereditary CRC Non distensible rectum

18 IRA in UC Surveillance Flexible endoscopy with multiple random biopsies Early onset (20 years) and <10 years duration: Yearly interval Early onset and >10 years duration: Twice yearly All others: Yearly interval Topical mesalamine 2000 mg BD

19 IRA vs. IPAA IRA IPAA Pros Trans anal defecation Trans anal defecation Remaining rectal function No remaining disease (continence) Fertility? Cons Remaining disease Continence (specially night time) Medication Surveillance Cancer risk Pelvic dissection (erectile disturbance, retrograde ejaculation and dyspareunia) Decreased fecundity and fertility Failure (convert to IPAA) Pouchitis (any time 50%, chronic 10%) Failure (redo pouch less good)

20 IRA in UC The better option? Colectomy A good option! In selected cases probably a better option A stepwise approach temporary solution Suitable for IRA IRA Failure Not suitable for IRA IPAA Failure What is the patient s view? Redo IPAA? Kock pouch? Brooke stoma?

21 Thank you!

22 Indication to colectomy IPAA IRA n=148 n=104 Severe colitis Steroid dependency Dysplasia/Ca prophylaxis 7 9 Cancer 6 1 Bleeding 1 1 Unclear 0 1

23 Why not IRA Proctitis (despite medication) 89 Intolerance medication 2 Patients own wish 36 Dysplasia 11 Cancer 5 Pseudo polyposis 1 Bleeding 1 PSC 1 Surgical difficulties 2

24 Anastomosis Reconstruction Hand sewn Stapled IPAA IRA 3 101

25 Andrews et al DCR 2007;50: young FAP patients IRA 33 IPAA 21 No surgery 31 IPAA adverse physical functioning and sexual functioning IPAA vs IRA IRA first procedure, IPAA at later age Sydney

26 Baker et al BJS 1978;65: UC patients with IRA between Followed up to 23 years No rectal cancer within 10 years of onset of disease Cumulative risk of RC 6 % at 20 years and 15 % at 30 years (onset of disease) Gordon Hospital, London

27 Bülow et al Colorectal Disease In press 2012 Danish polyposis registry - 84 patients, 59 (70 %) primary IPAA and 25 (30 %) secondary IPAA after previous IRA Primary Secondary Early postop complications 6 0 p<0.001 Late complications 8 (15 %) 8 (33 %) p=0.13 Pouch removal 6 (11 %) 2 (8 %) p=0.64 No differences in frequencies, continence, urgency, use of pads or obstipants. Less nocturnal defection among secondary IPAA:s

28 Bülow et al DCR 2008;51: FAP patients from the Danish, Swedish, Finnish and Dutch polyposis registries IRA safe choice

29 Börjesson et al Tech Coloproctol 2006;10: consecutive UC patients with IRA Failure rate 12 % - 3 developed intractable proctitis (2 IPAA, 1 ileostomy) and 1 anastomotic leak (loop ileostomy, CD?) Gothenburg

30 Gothenburg Börjesson et al Tech Coloproctol 2006;10:

31 Elton et al BJS 2003;90: patients with IRA , whereof 18 with UC Median follow up 2.75 years Complications mainly in CD Average of 3 daily bowel movements Approx 90 % fully continent St Marks

32 Gallone et al World J Surg 1980;4: UC patients with IRA Topical therapy (steroids and/or sulfasalazine) Bowel movements 2-3 in 12 patients 3-4 in 10 patients 4-5 in 4 patients Improving after 2 nd year Milan

33 Günther et al Colorectal Disease 2003;5: FAP patients Mean follow up 12 y 48 IRA IRA patients younger 62 IPAA 41 other procedures Erlangen

34 Hassan et al DCR 2005;48: FAP patients, SF IPAA, 94 responded 32 IRA, 21 responded IRA patients older =less energy? Mayo Clinic

35 Knudsen et al Colorectal Disease 2010;12:e243-e FAP patients International Multicentre

36 Ko et al DCR 2000;43: FAP patients IRA (n=14) IPAA (n=30) Bowel movements p<0.05 Leakage 0 % 43 % p<0.01 Use of pads 0 % 17 % p<0.01 Perianal skin problems 7 % 33 % p<0.01 Inability of gas distinction 7 % 37 % p<0.01 But QoL with SF36 - No differences! Lahey Clinic, Massachusetts

37 Lepistö et al Scand J Surg 2005;94: UC patients with IRA followed for 18 years ( ), (35 %) removed, mainly due to proctitis No rectal cancer but one moderate dysplasia Cumulative success rate 84 % after 5 years 69 % after 10 years 56 % at 20 years Helsinki, Finland

38 van Balkom et al DCR 2012;55: consecutive young (median 18 years, 10-24) UC/FAP patients Median follow up 12.5 years Long term complications 88 % Five IPAA excisions QoL, bowel function and body image lower than in historic controls Sexual dysfunction in 50 % of women Maastricht, The Netherlands

39 Mann World J Surg 1988;12(2): St Marks 4 % at St Marks and 80 % of those cured with surgery

40 da Luz Moreira et al Clin Colon Rectal Surg 2010;23: Cleveland Clinic

41 da Luz Moreira et al BJS 2010;97: patients with IRA followed for 11 (1-37) years, 74 UC and 12 IC 22 UC patients with IRA , sex and age matched with 66 IPAA Median interval until proctectomy 10 years Proctitis 24 Dysplasia 15 Cancer 7 Cumulative dysplasia risk was 7 % at 5, 9 % at 10, 20 % at 15 and 25 % at 20 years Cumulative cancer risk was 0 % at 5, 2 % at 10, 5 % at 15 and 14 % at 20 years and associated with poor surveillance and long standing disease Cleveland Clinic

42 Cont da Luz Moreira et al BJS 2010;97: of 46 who went through proctectomy received IPAA Estimated success rate was 81 % at 5, 74 % at 10, 56 % at 15 and 46 % at 20 years No differences in QoL Cleveland Clinic

43 Nieuwenhuis et al Ann Surg 2010;252: Questionnaire FAP patients, 23 (17 %) reported fertility problems IRA 16 % IPAA 15 % Ileostomy 25 % NS Young age at first surgery associated with fertility problems 22 (10-36) vs 28 (10-59) years, p=0.01 The Netherlands

44 Olsen et al BJS 2003;90: FAP Fecundity pre and post surgery Questionnaire 230 women, IRA and IPAA Sweden, Finland, Norway and Denmark

45 Olsen et al BJS 2003;90: FAP No difference in fecundity compared with controls preop or after IRA but only 0.46 after IPAA (p=0.001) Fecundability dropped to 0.54 in IPAA (p=0.004) for FAP but only 0.17 in IPAA for UC (p<0.001) Sweden, Finland, Norway and Denmark

46 Olsen et al Gastroenterology 2002;122: female UC patients (18-40 years old) with IPAA 661 controls Århus, Copenhagen and Odense, Denmark and Gothenburg, Sweden

47 Olsen et al Gastroenterology 2002;122:15-19 Århus, Copenhagen and Odense, Denmark and Gothenburg, Sweden

48 Pastore et al DCR 1997;40: IBD patients with IRA , 48 UC and 42 CD 8 (16.7 %) failures in UC 11 (26.2 %) failures in CD 1 rectal cancer in UC 11.5 years after IRA Mayo Clinic

49 Soravia et al DCR 1999;42: FAP patients IPAA 62 (incl 12 with previous IRA) IRA 72 (incl 12 converted to IPAA) IRA IPAA Postop complication rate 23.3 % 26 % NS Reop rate 13.3 % 16 % NS Bowel movements <6 75 % 70 % NS Compl day time continence 90 % 75 % NS Compl night time continence 87 % 51 % p<0.001 Perineal skin irritation 40 % 67 % p<0.001 QoL Toronto No differences

50 Soravia et al DCR 1999;42: FAP and 8 UC patients with conversion IRA to IPAA IRA IPAA Bowel movements <6 75 % 25 % p=0.01 Compl day time continence 94 % 62 % NS Compl night time continence 88 % 38 % p=0.009 Perineal skin irritation 19 % 68 % p=0.01 QoL No differences Toronto

51 von Roon et al BJS 2008;95: Primary IPAA (n=107) vs. conversion IRA to IPAA (n=78) in FAP Prim IPAA Sec IPAA Postop complications Anastomotic leak 6 (5.6 %) 1 (1%) NS Wound infection 1 (0.9 %) 7 (9 %) p=0.012 Functional outcome No differences after 1, 5 or 10 years post IPAA St Marks