Ileoanal Pouch Solves the Problem Bruce D George Department of Surgery John Radcliffe Hospital, Falk Symposium 2-3 May 2008
Ileoanal Pouch Solves the Problem? Sometimes Not always
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
The only reason to do a pouch is to avoid:
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
What do I tell patients? 10 10 40 40 See stomatharapy team? Meet pouch patient (Kangaroo club) Emphasise risks of surgery
Long Term Failure Rates from St Mark s Karoui Cohen and Nicholls DCR 2004
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 28 5 33(48.5%) Pouch fistula 24 4 Crohn s 3 2 Poor function 21 3 24(35.2%) Pouchitis 4 1 other 5 1 Karoui, Cohen, and Nicholls DCR 2004
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
Pouch outcome for indeterminate coliits UC Indeterminate Emergence of Crohn s 2% 15% Pouch failure 11% 27% Mayo clinic DCR 2000: 1487
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
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: 769 41 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
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
Pouches in patients with UC and PSC Gorgun et al 2001 (Cleveland) Case control study 1981-2002 65 patients with PSC, 260 non-psc IBD controls PSC CONTROL p Ca in specimen 14% 5% 0.02 Dysplasia in specimen 40% 7% 0.001 Pelvic sepsis 14% 5% 0.02 Late mortality 35% 4% 0.001 Function and = = NS QoL
Anal Sphincter weakness Structural defects Anterior obstetric defect Thin internal anal sphincter Anal stretch
Risk factors for poor pouch outcome Disease related Indeterminate/Crohn s Primary sclerosing cholangitis Sphincter weakness Systemic Comorbidity Steroids Age smoking Psychology
Restorative Proctocolectomy - Anastomotic Leakage n % leaks single stage 22 32 previous colectomy 49 12* steroids > 15mg 15 33 no steroids 56 14* under 40 yrs 54 13 over 40 yrs 17 35* Pemberton et al 1994
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
Quality of life issues Male impotence Female fertility
Impotence after rectal resection for IBD Male patients 18-80 years Questionnaire International index of erectile function Diseases Colon Rectum 2001; 44: 831-5
Casemix Questionnaire responded 162 / 201 (81%) evaluable 156 excluded 6 Age range 7.8-66.1 yrs median 35.9 yrs Surgery Restorative PC 133 PC and ileostomy (UC) 9 PC and ileostomy (CD) 14
Male sexual dysfunction Normal erectile function 129 (82.7%) Complete impotence 6 (3.8%) Partial impotence 21 (13.5%) Ejaculatory dysfunction 0
Age vs impotence 10 0 Complete impotenc Complete impotence Partial impotence (p < 0.0001) (p = 0.0002) 113 Normal 6 11 16 Under 50 Over 50
Does Viagra help?
Global efficacy 16 14 Sildenafil 79 % ( p = 0.0009) Placebo 17 % 12 10 8 6 11 15 4 2 0 Complete / satisfactory 3 3 Nil / unsatisfactory
Erectile function score 25 20 Sildenafil (p = 0.008) Placebo (p = 0.71) 15 23.6 10 5 10.5 7.3 10.6 0 Baseline Treatment (p = 0.98) (p = 0.005)
Global efficacy - crossover 8 7 6 5 4 3 2 10 Cross 10 over Primary Placebo Sildenafil crossover 100% response (p Š = 0.0001) 1 0 No response 0 Response No response
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 *14.6 48%
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
Timing of pregnancy post-surgery Time post surgery (months) Risk of natural pregnancy (%) Pouch Risk of natural pregnancy (%) Controls 6 36 67 12 47 82 24 56 91 48 73 91 72 76 91 Lepisto et al
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
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
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)
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)
What can be done to reduce infertility problems? Laparoscopic techniques Anti-adhesion prophylaxis Colectomy and ileo-rectal anastomosis
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
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
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
Ileoanal Pouch Solves the Problem? Sometimes Not always