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Patient Selection for IAP

Patient Selection for IAP. Nigel A. Scott MD FRCS Manchester UK. Patient Selection for IAP. Why a Pouch ?. Fulminant Colitis. 5-15% of colitics one third - first attack 37% will require colectomy. Chronic ill Health CUC. ….. “ know every toilet between home and the supermarket”.

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Patient Selection for IAP

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  1. Patient Selection for IAP Nigel A. Scott MD FRCS Manchester UK

  2. Patient Selection for IAP Why a Pouch ?

  3. Fulminant Colitis • 5-15% of colitics • one third - first attack • 37% will require colectomy

  4. Chronic ill Health CUC ….. “ know every toilet between home and the supermarket”

  5. Cancer Risk in CUC • 3% (95% CI 2.2-3.8) at 10 years • 5.9% (95% CI 4.3-7.4) at 20 years • 8.7% (95% CI 6.4-10.9) at 30 years. The risk of colorectal cancer in ulcerative colitis: a meta-analysis Gut 2001;48:526-535

  6. Patient Selection for IAP Indication for colectomy and IAP (n=105)

  7. Patient Selection for IAP Who ? IBD Diagnosis

  8. Patient Selection for IAP IBD Diagnosis – or who said Crohn’s disease was OK anyway ?

  9. Patient Selection for IAP IBD Diagnosis – or who said Crohns disease was OK anyway ?

  10. Patient Selection for IAP IBD Diagnosis – or who said Crohn’s disease was OK anyway ? • 41 patients 1985 - 1998 • 27 % Crohn’s related complications in pouch • of 20 patients followed for more than 10 years – 7 (35%) excised • no past or present history of anal manifestations • no evidence of small bowel involvement Long-term results of Ileal Pouch-Anal anastomosis for Colorectal Crohns disease DCR 2001;44:769-778

  11. IBD Diagnosis – or who said Crohn’s disease was OK anyway ?

  12. IBD Diagnosis – or who said Crohn’s disease was OK anyway ? “ ……………. There is no obvious explanation for the much better outcome reported by Regimbeau et al ………….”

  13. IBD Diagnosis – or who said Crohn’s disease was OK anyway ?

  14. Patient Selection for IAP IBD Diagnosis – or who said Crohns disease was OK anyway ? However when faced with the prospect of definitive ileostomy in young patients, the possibility to keep even for a few years before the disease recurs, acceptable continence and defaecation should be stressed.

  15. Patient Selection for IAP IBD Diagnosis – or who said Crohns disease was OK anyway ? …. but Pouch Crohns is associated with prolonged septic complications and then a difficult excision, non healing perineal sinus

  16. Patient Selection for IAP Who ? Informed Patient IBD Diagnosis Not CROHN’S

  17. Patient Selection for IAP Satisfaction = Result / Expectation

  18. Use and influence of the internet on patients undergoing ileoanal pouch surgeryJ. Torkington, L. S. Bevan, A. R. Morgan, J. Beynon and N. D. CarrColorectal DiseaseVolume 5 Issue 2 Page 193  - March 2003 Patient Selection and the Ileoanal Pouch Patient Selection – information • www.ileostomypouch.co.uk • www.nacc.org.uk (National Association for Colitis and Crohns) • www.j-pouch.org(J Pouch Group)

  19. The Effect of Ageing on Function and Quality of Life in Ileal Pouch Patients: A Single Cohort Experience of 409 Patients With Chronic Ulcerative Colitis – Ann Surg 2004:240(4);615-623

  20. 10 % excised at 10 years permanent ileostomy

  21. Patient Selection for IAP • not normality BO 5 D/ 1N • 40 % medication • pads • excision • pelvic autonomics – impotence/ bladder dysfunction • bleeding, infection, DVT/ PE death • fertility

  22. Chronic Ulcerative ColitisAssessment and Surgical Management • 34 of 40 consecutive patients made use of preoperative semen preservation – all normal sperm concentrations, motility, and morphology were found • 23 patients returned for postoperative analysis - semen characteristics not different from preoperative values • None of the preserved semen samples was used, - semen cryopreservation benefited none of these patients. Long Term Outcomes – male fertility unaffected van Duijvendijk P, Slors JF, Taat CW, van Lochem LT, Bonsel GJ, de Vries JW, Obertop H. What is the benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for benign diseases? Dis Colon Rectum. 2000 Jun;43(6):838-42.

  23. Chronic Ulcerative ColitisAssessment and Surgical Management Long Term Outcomes – female fertility reduced Female Infertility After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Toronto – Dis Colon Rectum 2004;47(7):1119 - 1126

  24. Patient Selection for IAP Who ? Informed Patient IBD Diagnosis Not CROHN’S Sphincter

  25. Patient Selection – the sphincter • preoperative anal manometry before IAP formation • questionaire • faecal seepage • incontinence • quality of life Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;

  26. Patient Selection – the sphincter Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20;

  27. Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW.Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002 May-Jun;6(3):316-20; Patient Selection – the sphincter • resting anal sphincter pressures > 40 mm Hg are associated with significantly better function after IAP • However low preoperative resting pressures do not preclude successful outcome after IPAA.

  28. Patient Selection – obstetric sphincter defects on EAUS Gearhart et al Sphincter defects are not associated with long term incontinence following ileal pouch anal anastomosis. DCR 2005;48:1410-1415

  29. Patient Selection for IAP Who ? Informed Patient IBD Diagnosis Not CROHN’S Sphincter ?counselling

  30. Patient Selection for IAP age ???????? Kok Sun Ho, C. C. Chang, M. K. Baig, L. Börjesson, J. J. Nogueras, J. Efron, E. G. Weiss, D. Sands, A. M. Vernava III and S. D. Wexner Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians Colorectal Disease Volume 8 Page 235  - March 2006

  31. Patient Selection – age IAP is a safe and feasible option in Ulcerative Colitis patients over the age of 70 years – with similar functional results to younger patients

  32. Patient Selection for IAP Who ? Informed Patient IBD Diagnosis Not CROHN’S age ? Optimisation Sphincter ?counselling

  33. Optimisation – No steroids PRSC - the presence of fistulas or abscesses near the pouch (in the small pelvis), in the upper, middle, or lower part of the pouch, in the area of the rectal cuff, in the area of the IPAA, or in the area of the anal sphincter From:   Heuschen: Ann Surg, Volume 235(2).February 2002.207-216

  34. Obesity and Ileoanal Pouch Construction Efron JE, Uriburu JP, Wexner SD, Pikarsky A, Hamel C, Weiss EG, Nogueras JJRestorative proctocolectomy with ileal pouch anal anastomosis in obese patients.Obes Surg. 2001 Jun;11(3):246-51

  35. 2 x 20cm lengths of terminal ileum

  36. Patient Selection for IAP Who ? Informed Patient IBD Diagnosis Not CROHN’S age ? Optimisation no steroids BMI <30 Sphincter ?counselling

  37. Patient Selection for IAP - one other thing- make sure that they Never,Never,Never,Never,Never,Never, Never,Never,Never,ever...

  38. Never eat beans in a Wet Suit

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