Functional Outcomes After Ileal Pouch-Anal Anastomosis for Chronic Ulcerative Colitis

Abstract

ObjectiveTo assess long-term outcomes after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) with specific emphasis on patient sex, childbirth, and age. Summary Background DataChildbirth and the process of aging affect pelvic floor and anal sphincter function independently. Early function after IPAA is good for most patients. Nonetheless, there are concerns about the impact of the aging process as well as pregnancy on long-term functional outcomes after IPAA. MethodsFunctional outcomes using a standardized questionnaire were prospectively assessed for each patient on an annual basis. ResultsOf the 1,454 patients who underwent IPAA for CUC between 1981 and 1994, 1,386 were part of this study. Median age was 32 years. Median length of follow-up was 8 years. Pelvic sepsis was the primary cause of pouch failure irrespective of sex or age. Functional outcomes were comparable between men and women. Eighty-five women who became pregnant after IPAA had pouch function, which was comparable with women who did not have a child. Daytime and nocturnal incontinence affected older patients more frequently than younger ones. Incontinence became more common the longer the follow-up in older patients, but this was not found in younger patients. Poor anal function led to pouch excision in only 3 of 204 older patients. ConclusionsIncontinence rates were significantly higher in older patients after IPAA for CUC compared with younger patients. However, this did not contribute to a greater risk of pouch failure in these older patients. Patient sex and uncomplicated childbirth did not affect long-term functional outcomes.Early reports of function after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) have indicated favorable outcomes, with an excellent quality of life for more than 90% of patients.1-3 Areas of concern remain, however, regarding long-term functional outcome after vaginal delivery and the natural aging process, which may affect pelvic floor function regardless of sex. 4,5 Chronic ulcerative colitis has a bimodal distribution of incidence based on age, with a peak at 25 years and a second peak at 60 years.6 A selected group of older patients choose, in the absence of contraindications, to undergo IPAA. Short-term follow-up has shown that such patients may have comparable or only marginally worse functional outcomes compared with younger patients. 7-9Our aim was to assess long-term outcomes after IPAA for CUC with specific reference to the impact of age, aging, and childbirth to determine how these factors affect the incidence of pouch failure. METHODSBetween January 1981 and December 1994, 762 men and 692 women were identified from the Mayo Ileal Pouch Registry as having undergone proctocolectomy, endoanal mucosal resection, and hand-sewn ileal J pouch-anal anastomosis for CUC. Ethical permission to review patient records was obtained from the Institutional Review Board.

Risk factors for complications after total colectomy in ulcerative colitis

“…Pouch failure occurred in 1 patient (1.2%), who was then converted to permanent ileostomy. The majority of studies have reported that pouchitis is the most frequent long-term complication of the IPAA, ranging from 12% to 50% (18,19). Pouch-vaginal fistula has been reported as a major complication in women undergoing IPAA, of which the incidence ranges from 3.3%-12% (20)(21)(22).…”

Resultados funcionales del reservorio ileal

“…No obstante la ausencia aparente de complicaciones sépticas de la anastomosis en ese tiempo quirúrgico, tres pacientes presentan complicaciones de la anastomosis luego de cierre de la ileostomía (una fístula a la vagina y dos fístula perineales complejas entre 2 y 8 meses). Los tres pacientes tenían una reservoriografía normal, lo que es consistente con otras series de mayor volumen 1,5,6,[10][11][12] . Los resultados funcionales de esta serie se han cotejado según el puntaje de Öresland, score modifi cado por el mismo autor en publicaciones posteriores 3,13 .…”

“…Por otra parte, en seguimientos por sobre 15 años se puede constatar un deterioro de la función esfi nteriana en algunos pacientes por efecto de la edad 13 . Al igual que en series numerosas, el 70% de los pacientes presenta al menos una evacuación nocturna, cifra que en la literatura fl uctúa entre 24% y 76% [10][11][12][13][14] . Es llamativa la ausencia de difi cultad para la evacuación (disquezia que se defi ne como más de 15 minutos en el baño al menos 1 vez a la semana) en esta serie.…”

“…Globalmente hubo un 5,7% de falla del reservorio, lo que podría subir al 8% en los años venideros si un paciente solicita una ileostomía por complicaciones perineales, porcentaje similar a otras series publicadas [10][11][12][13][14][15] . Un tercio de los pacientes sufre de ensuciamiento nocturno y un porcentaje similar requiere de un paño protector en la noche, lo que se explica por la ausencia del control voluntario durante el sueño, cifras muy variables en lo publicado y que en parte dependen del método utilizado (entrevista versus cuestionario por correo) 1-3, 7, 10-15 .…”

“…Un tercio de los pacientes sufre de ensuciamiento nocturno y un porcentaje similar requiere de un paño protector en la noche, lo que se explica por la ausencia del control voluntario durante el sueño, cifras muy variables en lo publicado y que en parte dependen del método utilizado (entrevista versus cuestionario por correo) 1-3, 7, 10-15 . Asimismo, un 20% de la serie global tiene resultados defi cientes según el score de Öresland, cifras similares a las obtenidas en serie más numerosas [10][11][12][13][14][15] . Es interesante destacar que estos pacientes con resultados pobres señalan su rechazo a la ileostomía, tanto en esta pequeña serie como en las publicaciones con gran volumen de pacientes 16,17 .…”