Anorectal Function After Ileo-Rectal Anastomosis Is Better than Pelvic Pouch in Selected Ulcerative Colitis Patients

Abstract

Background With a lifelong perspective, 12% of ulcerative colitis patients will need a colectomy. Further reconstruction via ileo-rectal anastomosis or pouch can be affected by patients' perspective of their quality of life after surgery. Aim To assess the function and quality of life after restorative procedures with either ileo-rectal anastomosis or ileal pouchanal anastomosis in relation to the inflammatory activity on endoscopy and in biopsies. Method A total of 143 UC patients operated with subtotal colectomy and ileo-rectal anastomosis or pouches between 1992 and 2006 at Linköping University Hospital were invited to participate. Those who completed the validated questionnaires (Öresland score, SF-36, Short Health Scale) were offered an endoscopic evaluation including multiple biopsies. Associations between anorectal function and quality of life with type of restorative procedure and severity of endoscopic and histopathologic grading of inflammation were evaluated. Results Some 77 (53.9%) eligible patients completed questionnaires, of these 68 (88.3%) underwent endoscopic evaluation after a median follow-up of 12.5 (range 3.5-19.4) years after restorative procedure. Patients with ileo-rectal anastomosis reported better overall Öresland score: median = 3 (IQR 2-5) for ileo-rectal anastomosis (n = 38) and 10 (IQR 5-15) for pouch patients (n = 39) (p < 0.001). Anorectal function (Öresland score) and endoscopic findings (Baron-Ginsberg score) were positively correlated in pouch patients (tau: 0.28, p = 0.006). Conclusion Patients operated with ileo-rectal anastomosis reported better continence compared to pouches. Minor differences were noted regarding the quality of life. Ileo-rectal anastomosis is a valid option for properly selected ulcerative colitis patients if strict postoperative endoscopic surveillance is carried out. Keywords Ulcerative colitis • Ileo-rectal anastomosis • Ileal pouch-anal anastomosis • Quality of life Abbreviations BG Baron-Ginsberg score CCGQoL Cleveland clinic global quality of life score IBD Inflammatory bowel disease IPAA Ileal pouch-anal anastomosis IRA Ileo-rectal anastomosis IQR Interquartile range OR Odds ratio SF-36 Short form 36 questions SHS Short health scale tau Kendall-tau correlation coefficient UC Ulcerative colitis VAS Visual analogue scale QoL Quality of life Electronic supplementary material The online version of this article (

Sacral nerve stimulation in patients with ileal pouch-anal anastomosis

“…However, overall stool frequency was not affected by SNS implantation in this analysis. This is reflected in previous work describing low daytime fecal incontinence of 1 to 25% in contrast to nighttime incontinence of 8 to 49% [2][3][4][5][6][7][8].…”

“…Daytime stool incontinence is described in 1 to 25% of patients after J-pouch formation with IPAA [2][3][4][5][6][7]. Incontinence at night seems to be more common at 8 to 49% [3][4][5][6][7][8]. Increased stool frequency is another reported factor that negatively impacts quality of life [9].…”

“…On the one hand, proctocolectomy with IPAA includes thorough intersphincteric excision and, on the other hand, maximum preservation of the sphincter function. Even so, the procedure can affect the upper parts of the internal sphincter and therefore may cause dysfunction, mainly at night [8]. Another possible mechanism could be a delayed function of the puborectalis muscle due to an altered postoperative latency of the sacral nerve [10].…”

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis

“…Total abdominal colectomy with an initial or staged ileorectal anastomosis (IRA) is associated with improved functional outcomes and higher quality-adjusted life-years compared with IPAA and avoids a pelvic dissection which may preserve fertility in women. [250][251][252] Appropriately selected patients for this technique should have a relatively spared, healthy, and compliant rectum. Patients undergoing IRA should be counseled regarding the potential need for future medical therapy to address proctitis, recognizing that at 5, 10, and 20 years post-IRA, 10%, 24% to 27%, and 40% of these patients undergo completion proctectomy for medically refractory disease.…”

Anal defecatory function in ulcerative colitis patients after total proctocolectomy and ileal pouch-anal anastomosis: a prospective cohort study

“…Despite major breakthroughs in the management of ulcerative colitis (UC), surgery remains the only viable option whenever different treatment modalities fail, or major complications appear. Approximately 12% of UC patients will require a colectomy at some point during their lifetime [1]. Since its introduction in the late 1970s, total proctocolectomy (TPC), with an ileal pouch-anal anastomosis (IPAA) has been supported by the European Crohn and Colitis guidelines and has been the gold standard for UC patients subjected to surgery [2].…”