Ileorectal anastomosis in Ulcerative Colitis The better option?

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

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

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

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

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

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

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

Cancer risk 374 UC patients with IRA between 1952-76 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

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

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

IRA in UC All reconstructions for UC in Linköping 1992-2006 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

Reconstruction IPAA IRA n=148 n=104 Time gap colectomy 10 (0-96) 7.2 (0-70.6) reconstruction (months) Op time (min) 190 (106-420) 130 (65-510) Perop bleeding (ml) 300 (25-2000) 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

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

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 %)

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

Survival of reconstruction in UC p=0.67

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

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

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)

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?

Thank you!

Indication to colectomy IPAA IRA n=148 n=104 Severe colitis 72 56 Steroid dependency 62 36 Dysplasia/Ca prophylaxis 7 9 Cancer 6 1 Bleeding 1 1 Unclear 0 1

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

Anastomosis Reconstruction Hand sewn Stapled IPAA 5 143 IRA 3 101

Andrews et al DCR 2007;50:1306-15 85 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

Baker et al BJS 1978;65:862-868 374 UC patients with IRA between 1952-76 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

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

Bülow et al DCR 2008;51:1318-1323 1247 FAP patients from the Danish, Swedish, Finnish and Dutch polyposis registries 1950-2006 IRA safe choice

Börjesson et al Tech Coloproctol 2006;10:237 241 32 consecutive UC patients with IRA Failure rate 12 % - 3 developed intractable proctitis (2 IPAA, 1 ileostomy) and 1 anastomotic leak (loop ileostomy, CD?) Gothenburg

Gothenburg Börjesson et al Tech Coloproctol 2006;10:237 241

Elton et al BJS 2003;90:59 65 215 patients with IRA 1990-1999, 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

Gallone et al World J Surg 1980;4:609-614 27 UC patients with IRA 1969-1977 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

Günther et al Colorectal Disease 2003;5:38-44 151 FAP patients 1971-2000 Mean follow up 12 y 48 IRA IRA patients younger 62 IPAA 41 other procedures Erlangen

Hassan et al DCR 2005;48:2032-2037 184 FAP patients, 1981-1998 SF36 152 IPAA, 94 responded 32 IRA, 21 responded IRA patients older =less energy? Mayo Clinic

Knudsen et al Colorectal Disease 2010;12:e243-e249 196 FAP patients International Multicentre

Ko et al DCR 2000;43:829-837 FAP patients 1980-1998 IRA (n=14) IPAA (n=30) Bowel movements 5.2 7.5 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

Lepistö et al Scand J Surg 2005;94:40-42 20 UC patients with IRA followed for 18 years (3.7-25.2), 1978-2000 7 (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

van Balkom et al DCR 2012;55:939-947 26 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

Mann World J Surg 1988;12(2):155-159 St Marks 4 % at St Marks and 80 % of those cured with surgery

da Luz Moreira et al Clin Colon Rectal Surg 2010;23:269-273 Cleveland Clinic

da Luz Moreira et al BJS 2010;97:65-69 86 patients with IRA followed for 11 (1-37) years, 74 UC and 12 IC 22 UC patients with IRA 1971-2006, 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

Cont da Luz Moreira et al BJS 2010;97:65-69 32 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

Nieuwenhuis et al Ann Surg 2010;252:341-344 Questionnaire - 138 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

Olsen et al BJS 2003;90:227-231 FAP Fecundity pre and post surgery Questionnaire 230 women, IRA and IPAA Sweden, Finland, Norway and Denmark

Olsen et al BJS 2003;90:227-231 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

Olsen et al Gastroenterology 2002;122:15-19 1982-1998 290 female UC patients (18-40 years old) with IPAA 661 controls Århus, Copenhagen and Odense, Denmark and Gothenburg, Sweden

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

Pastore et al DCR 1997;40:1455-1464 90 IBD patients with IRA 1974-1990, 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

Soravia et al DCR 1999;42:1028-1034 131 FAP patients 1980-1997 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

Soravia et al DCR 1999;42:903-908 12 FAP and 8 UC patients with conversion IRA to IPAA 1985-1997 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

von Roon et al BJS 2008;95:494-498 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