Risk factors for non-reaching of ileal pouch to the anus in laparoscopic restorative proctocolectomy with handsewn anastomosis for ulcerative colitis

Abstract

Background/Aims: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis and handsewn anastomosis for ulcerative colitis requires pulling down of the ileal pouch into the pelvis, which can be technically challenging. We examined risk factors for the pouch not reaching the anus.Methods: Clinical records of 62 consecutive patients who were scheduled to undergo RPC with handsewn anastomosis at the University of Tokyo Hospital during 1989–2019 were reviewed. Risk factors for non-reaching were analyzed in patients in whom hand sewing was abandoned for stapled anastomosis because of nonreaching. Risk factors for non-reaching in laparoscopic RPC were separately analyzed. Anatomical indicators obtained from presurgical computed tomography (CT) were also evaluated.Results: Thirty-seven of 62 cases underwent laparoscopic procedures. In 6 cases (9.7%), handsewn anastomosis was changed to stapled anastomosis because of non-reaching. Male sex and a laparoscopic approach were independent risk factors of non-reaching. Distance between the terminal of the superior mesenteric artery (SMA) ileal branch and the anus > 11 cm was a risk factor for non-reaching.Conclusions: Laparoscopic RPC with handsewn anastomosis may limit extension and induction of the ileal pouch into the anus. Preoperative CT measurement from the terminal SMA to the anus may be useful for predicting non-reaching.

Preoperative CT Indices Predict Nonreach Before IPAA

“…8 Similarly, we found patients who had 2 or more vessels divided had a median mobilization length of 20.4 cm. Although we could not evaluate the decision to change from an intended handsewn to a stapled anastomosis to increase length in this retrospective study, we did observe shorter mesenteric length and longer mobilization length associated with creation of a stapled anastomosis, consistent with the findings of Emoto et al 7 Finally, Poh et al did not see a statistical difference in ad-hoc CT indices analysis among their 21 nonreach events, which were 3:1 matched with an IPAA completion cohort. 4 Although not statistically significant, their nonreach subgroup did show a 0.9 cm shorter equivalent of mesenteric length and 1.4 cm longer mobilization length.…”

“…A single institution study of laparoscopic IPAA found a distance from the terminal branch of the superior mesenteric artery (SMA) to the anal canal >11 cm on preoperative CT to be a risk factor for conversion to a stapled anastomosis, thereby lessening the required mesenteric length. 7 Another study using a similar methodology reported a terminal ileocolic artery to anal verge distance >21 cm and predicted the need to divide 3 or more mesenteric vessels to achieve adequate mesenteric length. 8 In this article, we use a methodology of CT-guided measurements of anatomic landmarks to predict nonreach before IPAA.…”

Recent Advance in the Management of Dysplasia in the Ulcerative Colitis

“…However, proctocolectomy carries high risk of post-operative complications [20]. Ileal pouch anal anastomosis (IPAA) provides chance to save the anus of the patients who underwent proctocolectomy [21,22], and IPAA was possible 89% of UC patients in a Korean multicenter retrospective analysis [23].…”