R. S. Parra*1, M. R. Feitosa1, F. C. Pereira1, R. S. Rodrigues1, O. Féres1, J. J. Ribeiro da Rocha1
1Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil, Surgery and Anatomy, Ribeirão Preto, SP, Brazil
Present the experience of a tertiary Brazilian centre in surgical management of inflammatory bowel disease (IBD) focussing on the long-term outcomes of IPAA.
Retrospective analysis of medical records of all patients with Ulcerative colitis (UC) who underwent surgical treatment with IPAA at Clinical Hospital of Ribeirão Preto Medical School, University of São Paulo, Brazil. Electronic medical records consisted of sex, age, average hospital stay, post-operative complications such as pouchitis, nocturne diarrhoea, faecal incontinence, pouch failure and definitive ileostomy.
Fifty-four (n = 54) patients with UC had been submitted to IPAA between 1987 and 2018. Thirty-four (63%) were female and the mean age at IPAA was 36.4 years. The most common indication for surgery was failure of medical treatment (57.8%), followed by fulminant colitis or toxic megacolon (22.2%), refractory intestinal bleeding (14.8%) and high-grade dysplasia (3.8%). All patients with toxic megacolon, fulminant colitis or severe intestinal bleeding were submitted to total colectomy (first stage) and then to IPAA. The surgical approach for IPAA was via laparotomy in all patients except for 2 patients who had the operation by laparoscopic technique. All patients had a J-shaped pouch configuration. The majority of patients had a defunctioning ileostomy added to IPAA (98.1%). Mean hospitalisation length was 9.87 days (2–42) and the mean time to ileostomy closure was 163 days (14–650 days). Mean surgical time was 243.7 min (165–425). Early complications after IPAA occurred in 35.3% of patients and included pelvic sepsis (n = 5), pouch fistula (n = 5). Anastomotic stricture occurred in 15 patients and was successfully treated by anal dilatation under anaesthesia as an outpatient procedure. Median post-IPAA stool frequency was six motions at daytime (4–10). Nine patients had nocturne evacuation and six patients had faecal incontinence. Four patients (7.4%) developed Crohn’s disease (CD) at postoperative follow-up. Pouch failure and excision had been reported in five patients, one due to post-operative complications and others due to severe pouchitis or development of CD. Pouchitis was reported in 66.6% of patients; however, it was considered severe only in five (9.2%) patients. There were three deaths in the follow-up (two related to post-operative complications and one due to suicide).
Ileal J-pouch anal anastomosis is a major surgery with potential complications. However, short- and long-term results are acceptable and present good functional results, if well indicated and performed in referral IBD centres.1
1. Fazio VW, Kiran RP, Remzi FH, et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg, 2013;257:679–85. doi:10.1097/SLA.0b013e31827d99a2