-
Langenbeck's Archives of Surgery May 2024Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches... (Meta-Analysis)
Meta-Analysis
PURPOSE
Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.
METHODS
Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.
RESULTS
Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.
CONCLUSIONS
Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
Topics: Humans; Proctocolectomy, Restorative; Anastomotic Leak; Transanal Endoscopic Surgery; Treatment Outcome; Length of Stay; Colonic Pouches; Operative Time; Anastomosis, Surgical
PubMed: 38705912
DOI: 10.1007/s00423-024-03343-7 -
Diseases of the Colon and Rectum Jun 2024Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different... (Review)
Review
BACKGROUND
Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques.
OBJECTIVE
To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy.
DATA SOURCE
Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.
STUDY SELECTION
Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis.
INTERVENTION
IPAA technique.
MAIN OUTCOME MEASURES
Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function).
RESULTS
Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques.
LIMITATIONS
A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy.
CONCLUSIONS
Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
Topics: Humans; Colitis, Ulcerative; Proctocolectomy, Restorative; Anastomosis, Surgical; Surgical Stapling; Anastomotic Leak; Colonic Pouches; Postoperative Complications; Treatment Outcome
PubMed: 38710588
DOI: 10.1097/DCR.0000000000003292 -
European Journal of Surgical Oncology :... Oct 2023Colon cancer in ulcerative colitis patients with liver transplant (UCCOLT) due to primary sclerosing cholangitis carries significant treatment challenges. Aim of this... (Review)
Review
INTRODUCTION
Colon cancer in ulcerative colitis patients with liver transplant (UCCOLT) due to primary sclerosing cholangitis carries significant treatment challenges. Aim of this literature search is to review management strategies and provide a framework to facilitate the decisional process in this clinical setting.
METHODS
PRISMA-compliant systematic search was followed by critical expert commentary of the results and development of a surgical management algorithm. Endpoints included surgical management, operative strategies, functional and survival outcomes. Technical and strategics aspects with particular regard to the choice of reconstruction were evaluated to tentatively develop an integrated algorithm.
RESULTS
Ten studies reporting treatment of 20 UCCOLT patients were identified after screening. Nine patients underwent proctocolectomy and end-ileostomy (PC) and eleven had restorative ileal pouch-anal anastomosis (IPAA). Reported results for perioperative outcomes, oncological outcomes, and graft loss were comparable for both procedures. There were no reports of subtotal colectomies and ileo-rectal anastomosis (IRA).
CONCLUSIONS
Literature in the field is scarce and decision-making is particularly complex. PC and IPAA have been reported with good results. Nevertheless, IRA may also be considered in UCCOLT patients in selected cases, reducing the risks of sepsis, OLT and pouch failure; furthermore, in young patients, it has the advantage of preserving fertility or sexual function. The proposed treatment algorithm may represent a valuable support in guiding surgical strategy.
Topics: Humans; Colitis, Ulcerative; Liver Transplantation; Cholangitis, Sclerosing; Proctocolectomy, Restorative; Anastomosis, Surgical; Colonic Neoplasms; Treatment Outcome; Postoperative Complications
PubMed: 37210276
DOI: 10.1016/j.ejso.2023.04.021 -
Techniques in Coloproctology Jul 2024Comparative outcomes of robotic low anterior resection (rTME) and trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer were evaluated. (Meta-Analysis)
Meta-Analysis Comparative Study Review
Peri-operative, oncological and functional outcomes of robotic versus transanal total mesorectal excision in patients with rectal cancer: A systematic review and meta-analysis.
BACKGROUND
Comparative outcomes of robotic low anterior resection (rTME) and trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer were evaluated.
METHODS
A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies of rTME versus TaTME for low rectal cancer were included. Primary outcomes were postoperative complications, including anastomotic leak, surgical site infection, and Clavien-Dindo complication rate. Total operative time, conversion to open surgery, intra-operative blood loss, intensive therapy unit (ITU) and total hospital length of stay (LOS), oncological outcomes and functional outcomes were the other evaluated outcome parameters.
RESULTS
A total of 12 studies with a total number of 3025 patients divided between rTME (n = 1881) and TaTME (n = 1144) groups were included. There was no significant difference between the two groups for total operative time (P = 0.39), conversion to open surgery (P = 0.29) and intra-operative blood loss (P = 0.62). Clavien-Dindo ≥ 3 complication rate (P = 0.47), anastomotic leak (P = 0.89), rates of re-operation (P = 0.62) and re-admission (P = 0.92), R0 resections (P = 0.52), ITU LOS (P = 0.63) and total hospital LOS (P = 0.30) also showed similar results between the two groups. However, the rTME group had higher rates of total harvested lymph nodes (P = 0.04) and complete total mesorectal excision (TME) resections (P = 0.05). Albeit with a limited dataset, the Wexner and low anterior resection syndrome (LARS) scores showed better functional results in the rTME group compared with the TaTME group (P = 0.0009 and P = 0.00001, respectively).
CONCLUSION
Compared with TaTME, rTME seems to provide better functional outcomes, higher lymph node yield and more complete TME resections with a similar post-operative complications profile.
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Postoperative Complications; Proctectomy; Operative Time; Length of Stay; Treatment Outcome; Transanal Endoscopic Surgery; Female; Male; Middle Aged; Rectum; Aged; Anastomotic Leak; Blood Loss, Surgical; Conversion to Open Surgery; Adult
PubMed: 38951249
DOI: 10.1007/s10151-024-02947-x -
Colorectal Disease : the Official... May 2024Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative... (Meta-Analysis)
Meta-Analysis Review
AIM
Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC.
METHOD
Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed.
RESULTS
Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported.
CONCLUSIONS
This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.
Topics: Humans; Proctocolectomy, Restorative; Colitis, Ulcerative; Postoperative Complications; Treatment Outcome; Colonic Pouches; Anal Canal; Female; Male; Adult; Retrospective Studies; Middle Aged; Anastomosis, Surgical; Anastomotic Leak; Transanal Endoscopic Surgery; Inflammatory Bowel Diseases
PubMed: 38594838
DOI: 10.1111/codi.16977 -
Diseases of the Colon and Rectum Jun 2024The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard...
BACKGROUND
The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard to define because pouch anatomy is not normal and pouch physiology is a distortion of normal defecation. Patients with pouches develop multiple symptoms: some are expected, some are disease related, and some are the result of surgical complications. It is important to understand the cause of pouch-related symptoms so that appropriate management is offered.
OBJECTIVES
The study aimed to review pouch symptoms and discuss their likely cause, review the literature on pouch function and dysfunction, and provide clarity to clear the confusion.
DATA SOURCES
PubMed and Cochrane databases were searched using the terms "ileoanal pouch function" and "ileoanal pouch dysfunction."
STUDY SELECTION
From 1983 to 2023, 553 articles related to "ileoanal pouch function" and 178 related to "ileoanal pouch dysfunction" were reviewed. Nine studies appeared under both headings. Case studies, duplicate publications, and articles concerning pouch diseases were excluded.
MAIN OUTCOME MEASURES
Definitions of pouch function and dysfunction, methods of describing and scoring symptoms, and understanding of expected changes in pouch function given the nature of the surgery.
RESULTS
Twenty-seven studies were reviewed from the ileoanal pouch dysfunction search and 38 from ileoanal pouch function. Three studies tried to define normal pouch function, 10 attempted to measure pouch function, and 4 aimed to score pouch function. Only 3 studies addressed pouch physiology.
LIMITATIONS
A full discussion of pouch dysfunction is limited by the lack of studies focussing on the anatomic and physiologic consequences of turning the terminal ileum into an organ of storage.
CONCLUSIONS
Most studies of pouch function and dysfunction do not consider expected changes in the physiology of defecation that follow restorative proctocolectomy. Thus, most studies of pouch function produce conclusions that lack an important dimension. See video from symposium.
Topics: Humans; Colonic Pouches; Proctocolectomy, Restorative; Postoperative Complications; Defecation; Anal Canal
PubMed: 38459724
DOI: 10.1097/DCR.0000000000003332 -
Inflammatory Bowel Diseases Nov 2023Total proctocolectomy with ileal pouch anal anastomosis (IPAA) for medically refractory ulcerative colitis or dysplasia may be associated with structural and...
BACKGROUND
Total proctocolectomy with ileal pouch anal anastomosis (IPAA) for medically refractory ulcerative colitis or dysplasia may be associated with structural and inflammatory complications. However, even in their absence, defecatory symptoms secondary to dyssynergic defecation or fecal incontinence may occur. Although anorectal manometry is well established as the diagnostic test of choice for defecatory symptoms, its utility in the assessment of patients with IPAA is less established. In this systematic review, we critically evaluate the existing evidence for anopouch manometry (APM).
METHODS
A total of 393 studies were identified, of which 6 studies met all inclusion criteria. Studies were not pooled given different modalities of testing with varying outcome measures.
RESULTS
Overall, less than 10% of symptomatic patients post-IPAA were referred to APM. The prevalence of dyssynergic defecation as defined by the Rome IV criteria in symptomatic patients with IPAA ranged from 47.0% to 100%. Fecal incontinence in patients with IPAA was characterized by decreased mean and maximal resting anal pressure on APM, as well as pouch hyposensitivity. The recto-anal inhibitory reflex was absent in most patients with and without incontinence.
CONCLUSION
Manometry alone is an imperfect assessment of pouch function in patients with defecatory symptoms, and confirmatory testing may need to be performed with dynamic imaging.
Topics: Humans; Fecal Incontinence; Proctocolectomy, Restorative; Anastomosis, Surgical; Rectum; Colitis, Ulcerative; Anal Canal; Colonic Pouches
PubMed: 36351035
DOI: 10.1093/ibd/izac234 -
Diseases of the Colon and Rectum Jun 2024Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the...
BACKGROUND
Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joints, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis, can persist after colectomy.
OBJECTIVES
A systematic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and IPAA for ulcerative colitis.
DATA SOURCES
PubMed, Google Scholar, and Cochrane database.
STUDY SELECTION
Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between January 2001 and July 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
INTERVENTION
Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and IPAA were included.
MAIN OUTCOME MEASURES
Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management.
RESULTS
Primary sclerosing cholangitis and extraintestinal manifestations are associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with chronic pouchitis, enteritis, and possible pouch neoplasia. However, the disease severity and course of primary sclerosing cholangitis and pouchitis do not appear to be parallel. Despite the fact that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may also be beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking.
LIMITATIONS
This is a qualitative, not quantitative, review of case series and case reports.
CONCLUSIONS
Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. Although the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See video from the symposium .
Topics: Cholangitis, Sclerosing; Humans; Proctocolectomy, Restorative; Pouchitis; Colitis, Ulcerative; Colonic Pouches; Eye Diseases; Skin Diseases
PubMed: 38411984
DOI: 10.1097/DCR.0000000000003231 -
Journal of Crohn's & Colitis Mar 2024We evaluated short- and long-term outcomes of temporary faecal diversion [FD] for management of refractory Crohn's disease [CD], focusing on outcomes in the biologic era. (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
We evaluated short- and long-term outcomes of temporary faecal diversion [FD] for management of refractory Crohn's disease [CD], focusing on outcomes in the biologic era.
METHODS
Through a systematic literature review until March 15, 2023, we identified 33 studies [19 conducted in the biologic era] that evaluated 1578 patients with perianal and/or distal colonic CD who underwent temporary FD [with intent of restoring bowel continuity] and reported long-term outcomes [primary outcome: successful restoration of bowel continuity, defined as remaining ostomy-free after reconnection at a minimum of 6 months after diversion or at the end of follow-up]. We calculated pooled rates (with 95% confidence interval [CI]) using random effects meta-analysis, and examined factors associated with successful restoration of bowel continuity.
RESULTS
Overall, 61% patients [95% CI, 52-68%; 50% in biologic era] experienced clinical improvement after FD. Stoma takedown was attempted in 34% patients [28-41%; 37% in biologic era], 6-18 months after diversion. Among patients where bowel restoration was attempted, 63% patients [54-71%] had successful restoration of bowel continuity, and 26% [20-34%] required re-diversion. Overall, 21% patients [17-27%; 24% in biologic era] who underwent FD were successfully restored; 34% patients [30-39%; 31% in biologic era] required proctectomy with permanent ostomy. On meta-regression, post-diversion biologic use and absence of proctitis was associated with successful bowel restoration after temporary FD in contemporary studies.
CONCLUSION
In the biologic era, temporary FD for refractory perianal and/or distal colonic CD improves symptoms in half the patients, and bowel continuity can be successfully restored in a quarter of patients.
Topics: Humans; Crohn Disease; Feces; Proctectomy; Proctitis; Biological Products
PubMed: 37707480
DOI: 10.1093/ecco-jcc/jjad159 -
Diseases of the Colon and Rectum Jun 2024Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous...
BACKGROUND
Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous polyposis.
OBJECTIVE
This systematic review aims to assess the diagnosis and treatment of pouch disorders in pediatric patients who undergo IPAA.
DATA SOURCES
A literature search was performed using MEDLINE, Google Scholar, and Embase for all publications describing outcomes of pediatric IPAA.
STUDY SELECTION
Studies between January 1, 2000, and September 7, 2022, published in English were included. Studies were excluded on the basis of title, abstract, and full-length review.
INTERVENTIONS
IPAA.
MAIN OUTCOME MEASURES
Pouch disorders described include anastomotic leaks, pouch strictures, pouch failure, pouchitis, cuffitis, and de novo Crohn's disease of the pouch.
RESULTS
Thirty-three studies were included in this review, all of which were retrospective in nature. The outcomes of 2643 pediatric patients were included in the 33 studies.
LIMITATIONS
Management is largely informed by clinical practices in adult patients with scant data on treatment efficacy in children.
CONCLUSIONS
The reported incidence of disorders of the pouch in children varies widely and is likely attributable to differences in definitions and follow-up periods across studies. Pouchitis was the most frequently described outcome. The overall rate of pouch failure in children is relatively low, with de novo Crohn's disease of the pouch being the most significant risk factor. Multicenter prospective studies are needed in the pediatric population to accurately identify risk factors, standardize the assessment of pouch complications, and determine effective treatment strategies. See video from the symposium .
Topics: Humans; Proctocolectomy, Restorative; Child; Pouchitis; Postoperative Complications; Colonic Pouches; Colitis, Ulcerative; Adenomatous Polyposis Coli; Anastomotic Leak; Crohn Disease
PubMed: 38422401
DOI: 10.1097/DCR.0000000000003317