Crohn s colitis patients can be offerred an ileoanal pouch
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Crohn’s colitis patients can be offerred an ileoanal pouch. Feza H. Remzi, MD, FACS,FASCRS, FTSS ( Hon) Chairman Department of Colorectal Surgery Rupert B. Turnbull Jr., MD Chair Professor of Surgery Digestive Disease Institute Cleveland Clinic Cleveland, OH. Disclosures.

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Crohn’s colitis patients can be offerred an ileoanal pouch

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Crohn s colitis patients can be offerred an ileoanal pouch

Crohn’s colitis patients can be offerred an ileoanal pouch

Feza H. Remzi, MD, FACS,FASCRS, FTSS ( Hon)

Chairman

Department of Colorectal Surgery

Rupert B. Turnbull Jr., MD Chair

Professor of Surgery

Digestive Disease Institute

Cleveland Clinic

Cleveland, OH


Disclosures

Disclosures

None


Crohn s colitis patients can be offerred an ileoanal pouch

“If one can accept and live happily with a permanent ileostomy, trying to convince him/her to have an ileoanal pouch is a great disservice”


Surgical therapy for crohn s colitis

Surgical therapy for Crohn’s colitis

  • Extent of disease is an important consideration in determining the extent of bowel resection in Crohn’s disease (CD)

  • Based on the rectal involvement of Crohn’s colitis (CC), following procedures can be performed after a total procto /colectomy

    • An end ileostomy

    • A straight ileosigmoid or ileorectalanastomosis

    • An ileal pouch- anal anastomosis (IPAA)

    • An ileal pouch-rectal anastomosis (IPRA


Ileal pouch for crohn s colitis

Ileal pouch for Crohn’s colitis

  • An ileal pouch-rectal anastomosis (IPRA)


Crohn s colitis patients can be offerred an ileoanal pouch

Short rectal stump

  • Extensive colonic involvement

  • Distal rectal sparing

    Near total proctocolectomy

    (TAC + proximal proctectomy)

    straight IRA

    permanent end ileostomy

    ileal pouch/rectal anastomosis IPRA


Cleveland clinic experince n 23 patients

Cleveland Clinic Experince N=23 patients

  • IPRA was associated with low perioperative morbidity.

  • Crohn’s disease recurred in most patients after IPRA.

  • Gastrointestinal continuity was established in 91% in 8 years follow-up.

  • Functional outcome and quality of life scores are good and comparable to straight ileorectal and ileosigmoid anastomosis.

  • IPRA is associated with high satisfaction rates with surgery, similar to SIRA.

Kariv et al JACS 2003


Conclusions

Conclusions

When Crohn’sproctocolitis necessitates total colectomy and the length of the rectal stump precludes straight IRA, Ileal Pouch-Rectal Anastomosis can be considered a viable alternative to permanent diversion.

IPRA offers good long term functional results and quality of life.


Ileal pouch for crohn s colitis1

Ileal pouch for Crohn’s colitis

  • An ileal pouch- anal anastomosis (IPAA)


Results over 4000 ipaa patients cleveland clinic experience

Results over 4000 IPAA PatientsCleveland Clinic Experience

97% patients said that they would undergo surgery again

97.4% patients stated that they would be willing to recommend surgery to other patients


Ileal pouch for crohn s colitis ideal indication

Ileal pouch for Crohn’s colitisIdeal indication

  • Limited CD in the colorectum

  • Preoperative pathologic confirmation of diagnosis

  • No history of anoperinealCD

  • No evidence of anoperineal CD involvement

  • No evidence of small-bowel involvement by CD

Panis et al. Lancet 1996.


Ileal pouch for crohn s colitis indication

Ileal pouch for Crohn’s colitisindication

  • CD in the colorectum

  • Preoperative pathologic confirmation of diagnosis ????????

  • Limited evidence of anoperineal CD involvement; excluding rectovaginal fistula

  • No gross evidence of small-bowel involvement by CD


Ileal pouch for crohn s colitis2

Ileal pouch for Crohn’s colitis

  • Intentional IPAA creation, in patients who had prior colectomy confirming the diagnosis = Preop

  • Patients undergoing two stage IPAA with apparent MUC or IndC and diagnosed with CD on the basis of postoperative histopathology = Postop

  • Diagnosed with CD months or years after their surgery on the basis of subsequent clinical course or histopathology = Delayed diagnosis

Melton et al. Ann Surg2008


Predictors of pouch failure

Predictors of pouch failure

Melton et al. Ann Surg 2008


Crohn s and ipaa cleveland clinic experience

Crohn’s and IPAACleveland Clinic Experience

204 patients, with median F/U 7.4 years

Preoperative diagnosis N=20 10%

Postoperative diagnosis N=97 47%

Delayed diagnosis N=87 43%

Pouch retention rate 71 % ( 10 years)

Delayed diagnosis , pouchvaginal fistula and postoperative sepsis were associated with higher failure rates

Melton Ann Surg 2008


Cleveland clinic experience 10 years pouch survival rates

Cleveland Clinic Experience10 years pouch survival rates

Preoperative diagnosis N=20 10% 85 %

Postoperative diagnosis N=97 47% 87 %

Delayed diagnosis N=87 43% 53 %

Pouch retention rate 71 % ( 10 years)

Melton Ann Surg 2008


Survival of ipaa in patients with cd

Survival of IPAA in patients with CD

Melton et al. Ann Surg 2008


Survival of ipaa in patients with cd1

Survival of IPAA in patients with CD

P= 0.0001)

Intentional CD (solid thin line), incidental CD pouch (dotted line), delayed diagnosis (solid thick line)

Melton et al. Ann Surg 2008


Ileal pouch for crohn s colitis3

Ileal pouch for Crohn’s colitis

  • Carefully selected patients with CD undergoing primary restorative proctocolectomy with ileal pouch-anal anastomosis have low pouch loss and favorable functional results

  • Patients with presumed ulcerative colitis or indeterminate colitis diagnosed with CD from operative histopathology can expect similar good results

  • Outcomes in patients with delayed diagnosis are worse but approximately half retain their pouch at 10 years with good functional outcome


Ileal pouch for crohn s colitis4

Ileal pouch for Crohn’s colitis

  • For patients, with good anal sphincter function and associated morbidity, facing definitive end-ileostomy

  • An ileal pouch can be a reasonable alternative keeping continence and gastrointestioanal tract continuity, even for a good period of time


Crohn s colitis patients can be offerred an ileoanal pouch

None

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