Staging Pouch Surgery in Ulcerative Colitis in the Biological Era

Abstract

Restorative proctocolectomy, or ileal pouch anal anastomosis, is considered the standard treatment for intractable ulcerative colitis. When the pelvic pouch was first introduced in 1978, a two-stage procedure with proctocolectomy, construction of the pelvic pouch, and a diverting loop with subsequent closure were suggested. Over the decades that the pelvic pouch has been around, some principal technical issues have been addressed to improve the method. In more recent days the laparoscopic approach has been additionally introduced. During the same time-period the medical arsenal has developed far more with the increasing use of immune modulators and the introduction of biologicals. Staging of restorative proctocolectomy with a pelvic pouch refers to how many sessions, or stages, the procedure should be divided into. The main goal with restorative proctocolectomy is a safe operation with optimal short- and long-term function. In this paper we aim to review the present knowledge and views on staging of the pouch procedure in ulcerative colitis, especially with consideration to the treatment with biologicals.

Surgical treatment of inflammatory bowel disease: From the gastroenterologist’s stand-point

“…The treatment of patients with dysplasia in the anal transition zone is difficult and includes mucosectomy, pouch removal, or a redo pelvic pouch[ 77 ]. Restorative proctocolectomy with IAPA is also the surgical procedure of choice in patients with familial adenomatous polyposis[ 78 ].…”

Reconstruction after Colectomy for Inflammatory Bowel Disease

“…The patient's way from having the colon in place to eventually ending up with an IPAA can take some different paths with the operation divided into different separate procedures or stages. There are four suggested ways to divide the total procedure into stages; one-stage, traditional two-stage, modified two-stage and three-stage 146 . In the one stage procedure the proctocolectomy and construction of the pouch is performed in one single procedure and no diverting loop ileostomy is constructed 147 .…”

“…Nevertheless, all but one of the available comparisons between the different staging options are retrospective observational studies and selection bias is very likely, i.e. patients in less favorable condition and with risk-factors for anastomotic complications are more likely to be found in the groups with more staged surgery 146 . Consequently, the more cautious (staged) approaches may from the available literature appear less favorable.…”

Phytoplasma Diseases of Trees: A Comprehensive Review

“…However, diseases, adverse weather and insect pests are certain potent threats to sustainable supply of forest products. Few important severe epidemics of tree disease reported in last century include, Dutch elm disease (ED), chestnut blight, heterobasidion root and stem rot, sudden oak death (SOD), eucalyptus myrtle rust, and the most recent ash dieback [109].…”