Safety of transanal ileal pouch-anal anastomosis for ulcerative colitis: a retrospective observational cohort study

Abstract

Background Colectomy with transanal ileal pouch-anal anastomosis (taIPAA) is a surgical technique that can be used to treat benign colorectal disease. Ulcerative colitis is the most frequent inflammatory bowel disease (IBD) and although pharmacological therapy has improved, colectomy rates reach up to 15%. The objective of this study was to determine anastomotic leakage rates and treatment after taIPAA as well as short- and long-term pouch function. Methods We conducted a retrospective analysis of a prospective database of all patients undergoing taIPAA at an academic tertiary referral center in Germany, between 01/03/2015 and 31/08/2019. Patients with indications other than ulcerative colitis or with adjuvant chemotherapy following colectomy for colorectal carcinoma were excluded for short- and long-term follow up due to diverging postoperative care yet considered for evaluation of anastomotic leakage. Results A total of 22 patients undergoing taIPAA during the study time-window were included in analysis. Median age at the time of surgery was 32 ± 12.5 (14–54) years. Two patients developed an anastomotic leakage at 11 days (early anastomotic leakage) and 9 months (late anastomotic leakage) after surgery, respectively. In both patients, pouches could be preserved with a multimodal approach. Twenty patients out of 22 met the inclusion criteria for short and long term follow-up. Data on short-term pouch function could be obtained in 14 patients and showed satisfactory pouch function with only four patients reporting intermittent incontinence at a median stool frequency of 9–10 times per day. In the long-term we observed an inflammation or “pouchitis” in 11 patients and a pouch failure in one patient. Conclusion Postoperative complication rates in patients with benign colorectal disease remain an area of concern for surgical patient safety. In this pilot study on 22 selected patients, taIPAA was associated with two patients developing anastomotic leakage. Future large-scale validation studies are required to determine the safety and feasibility of taIPAA in patients with ulcerative colitis.

Controversies in Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques

“…Table 1, [10][11][12][13][14][15][16][17] [24][25][26][27][28][29] highlight the main characteristics of the studies identified in the systematic review.…”

Colectomy reconstruction for ulcerative colitis in Sweden and England: a multicenter prospective comparison between ileorectal anastomosis and ileal pouch-anal anastomosis after colectomy in patients with ulcerative colitis. (CRUISE-study)

“…The IPAA can be performed both as an open or, preferably as a laparoscopic or robotic procedure. A trans-anal minimal invasive method (TaTME) may be used to facilitate proctectomy [ 16 ]. A pouch is constructed with the last part of the distal ileum and then anastomosed to the anal canal, or to a small rectal remnant, usually 1–2 cm in length, often referred to as the rectal cuff.…”

Laparoscopic Versus Transanal Ileal-Pouch Anal Anastomosis for Ulcerative Colitis: A Patient-Centered Treatment Trade-Off Study

“…It also allows for a better assessment of the distal margin to obtain an appropriate rectal cuff, potentially reducing the risk of anastomotic leaks. [4][5][6] An additional potential benefit of Ta-IPAA is performing a close rectal dissection of the rectum, which is easier to perform transanally than laparoscopically. There is some weak evidence that a close rectal dissection results in a better postoperative outcome.…”

“…2,3 Similarly, the transanal access was introduced for the treatment of UC with IPAA, aiming to improve surgical access to the rectum and to further minimize invasiveness, thereby reducing the number of incisions required. [4][5][6] Transanal IPAA (Ta-IPAA) surgery eases visualization of the anus and rectum for surgeons during pelvic dissection. It also allows for a better assessment of the distal margin to obtain an appropriate rectal cuff, potentially reducing the risk of anastomotic leaks.…”

“…2,3 Similarly, the transanal access was introduced for the treatment of UC with IPAA, aiming to improve surgical access to the rectum and to further minimize invasiveness, thereby reducing the number of incisions required. 4–6…”