Ileoanal Pouch Solves the Problem

Transcription

1 Ileoanal Pouch Solves the Problem Bruce D George Department of Surgery John Radcliffe Hospital, Falk Symposium 2-3 May 2008

2 Ileoanal Pouch Solves the Problem? Sometimes Not always

3 Key Issues in Pouch Surgery Selecting the right patient Realistic expectations Recognising the high risk patient Discussing quality of life issues Fertility impotence Optimising surgical technique 1/2/3 stage laparoscopic or open avoiding small bowel obstruction

4 The only reason to do a pouch is to avoid:

5 Realistic expectations Bowel function will not be normal 80% continent 34% flatus incontinence 50%pads 75% need antidiarrhoeals Urgency common, but better than attack of UC Frequency: 8/day at 1 month, 4-5/day at 1 year

6 What do I tell patients? See stomatharapy team? Meet pouch patient (Kangaroo club) Emphasise risks of surgery

7 Long Term Failure Rates from St Mark s Karoui Cohen and Nicholls DCR 2004

8 Indications for Pouch Excision at St Mark s St Mark s n=996 Referred n=245 Total No patients 58(5.6%) 10(4%) 68 Pelvic sepsis (48.5%) Pouch fistula 24 4 Crohn s 3 2 Poor function (35.2%) Pouchitis 4 1 other 5 1 Karoui, Cohen, and Nicholls DCR 2004

9 Patient selection Risk factors for poor pouch outcome Disease related Indeterminate colitis Crohn s disease Primary sclerising cholongitis Sphincter weakness Systemic Comorbidity Steroids Age smoking Psychology

10 Pouch outcome for indeterminate coliits UC Indeterminate Emergence of Crohn s 2% 15% Pouch failure 11% 27% Mayo clinic DCR 2000: 1487

11 Pouches for Crohn s Disease - the argument recurrence rates are no worse than IRA around 75% patients avoid stoma failures are not disasters function is equivalent

12 Pouches in Crohn s disease 9-fold increased risk of pouch failure Fazio et al Ann Surg 2003: 605 Regimbeau, Panis et al DCR 2001: patients 26 known Crohn s, no SB/anal disease 15 histological diagnosis after pouch surgery Early complications 25% Chronic perianal problems 25% Pouch failure 7% Generally good pouch function

13 Long Term Results of IPAA in Patients with Crohn s Disease 37 patients Original diagnosis UC (22), indeterminate (9), Crohn s (6), Complex fistulas in 11 Site of Crohn s pouch (20), anal (4), both (10) Failure in 17 Sagar et al Dis Col Rect 1996

14 Pouches in patients with UC and PSC Gorgun et al 2001 (Cleveland) Case control study patients with PSC, 260 non-psc IBD controls PSC CONTROL p Ca in specimen 14% 5% 0.02 Dysplasia in specimen 40% 7% Pelvic sepsis 14% 5% 0.02 Late mortality 35% 4% Function and = = NS QoL

15 Anal Sphincter weakness Structural defects Anterior obstetric defect Thin internal anal sphincter Anal stretch

16 Risk factors for poor pouch outcome Disease related Indeterminate/Crohn s Primary sclerosing cholangitis Sphincter weakness Systemic Comorbidity Steroids Age smoking Psychology

17 Restorative Proctocolectomy - Anastomotic Leakage n % leaks single stage previous colectomy 49 12* steroids > 15mg no steroids 56 14* under 40 yrs over 40 yrs 17 35* Pemberton et al 1994

18 Psychological factors Personality is a predictor of quality of life after pouch surgery Coping personality: good outcome Anxiety / poor socialising skills: poor outcome Weinryb et al 1997

19 Quality of life issues Male impotence Female fertility

20 Impotence after rectal resection for IBD Male patients years Questionnaire International index of erectile function Diseases Colon Rectum 2001; 44: 831-5

21 Casemix Questionnaire responded 162 / 201 (81%) evaluable 156 excluded 6 Age range yrs median 35.9 yrs Surgery Restorative PC 133 PC and ileostomy (UC) 9 PC and ileostomy (CD) 14

22 Male sexual dysfunction Normal erectile function 129 (82.7%) Complete impotence 6 (3.8%) Partial impotence 21 (13.5%) Ejaculatory dysfunction 0

23 Age vs impotence 10 0 Complete impotenc Complete impotence Partial impotence (p < ) (p = ) 113 Normal Under 50 Over 50

24 Does Viagra help?

25 Global efficacy Sildenafil 79 % ( p = ) Placebo 17 % Complete / satisfactory 3 3 Nil / unsatisfactory

26 Erectile function score Sildenafil (p = 0.008) Placebo (p = 0.71) Baseline Treatment (p = 0.98) (p = 0.005)

27 Global efficacy - crossover Cross 10 over Primary Placebo Sildenafil crossover 100% response (p Š = ) 1 0 No response 0 Response No response

28 Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in UC Waljee et al Gut 2006 Meta-analysis of 8 studies Pre-op UC: Infertile 105 Fertile 423 = 19.9% medical infertility rate Post-pouch UC: Infertile 301 Fertile 300 = 50.1% surgical infertility rate * %

29 Female fertility and childbirth after ileal pouch-anal anastomosis for UC 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

30 Timing of pregnancy post-surgery Time post surgery (months) Risk of natural pregnancy (%) Pouch Risk of natural pregnancy (%) Controls Lepisto et al

31 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

32 How should we spin this? Infertility rates: 15% to 50% Waljee et al 2006 threefold increase Eventual chance of becoming pregnant if trying 76-80% Lepisto et al 2007

33 Reasons for reduced fecundity Adhesions and blocked Fallopian tubes evidence from hysterosalpingraphy (Oresland 1994) Reduced sexual function Fear of incontinence 16% 34% pre-op vs 16% post-pouch (Tiainen 1999)

34 Sexual function after ileal pouch surgery Cornish et al 2007 Increased dyspareunia (25%) Vaginal dryness (25%) Fear of incontinence (19%) No change in overall sexual satisfaction (? compensated by increased libido and improved overall health)

35 What can be done to reduce infertility problems? Laparoscopic techniques Anti-adhesion prophylaxis Colectomy and ileo-rectal anastomosis

36 Fecundity after colectomy and ileo-rectal anastomosis No change after ileo-rectal anastomosis in FAP patients Olsen et al 2003 Post-op infertility 33% after IRA for UC Mortier et al 2006

37 Summary Impotence after pouch surgery in men 3-8% (partial) 13.5% complete Age dependent Improved with viagra Fecundity Reduced after pouch surgery, but long-term fertility only slightly reduced? Occasional role for ileorectal anastomosis

38 Selecting patients for Pouches Only reason is to avoid ileostomy Thorough counselling pre-operatively Consider alternatives Think very carefully before offering pouch to high risk patients

39 Ileoanal Pouch Solves the Problem? Sometimes Not always