Evaluating lleal Pouch Anal Anastomosis Function: Time to Expand Our ARM-amentarium

Abstract

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.

Review article: A practical approach to persistent gastrointestinal symptoms in inflammatory bowel disease in remission

“…103,161 Furthermore, these symptoms are more present in patients who underwent pelvic surgery, in particular in those with an ileo-anal pouch. 162 Moreover, in patients with UC, rectal compliance can be decreased compared to healthy controls due to increased thickness of the muscular layer and increased fibrosis in the submucosa. 163,164 Pelvic floor muscles play an important role in bowel function, as they help to control the release of stool from the rectum.…”

“…Pelvic floor dysfunction might develop as an unconsciously learned response to discomforting stimuli often experienced by patients with IBD, such as abdominal pain, loose stools and urgent bowel movements 103,161 . Furthermore, these symptoms are more present in patients who underwent pelvic surgery, in particular in those with an ileo‐anal pouch 162 . Moreover, in patients with UC, rectal compliance can be decreased compared to healthy controls due to increased thickness of the muscular layer and increased fibrosis in the submucosa 163,164 .…”