For most patients with ulcerative colitis (UC) and some patients with Crohn’s disease (CD), pouch surgery can offer relief and long-term improvement in quality of life. Under the leadership of Inflammatory Bowel Disease Center director Feza Remzi, MD, professor of surgery and a world-renowned expert in pelvic pouch surgery and reconstruction, and David P. Hudesman, MD, associate professor of medicine and medical director of the Inflammatory Bowel Disease Center, pouch surgery may become an option for certain groups previously considered ineligible for the procedure.
The Inflammatory Bowel Disease Center at NYU Langone Health is known for handling even the most complex cases. Although pouch surgery performed by experienced surgeons is often successful, the operation is complex and may not be appropriate for all patients, notes Dr. Remzi.
Shannon Chang, MD, assistant professor of medicine at the Inflammatory Bowel Disease Center, led a study examining several diseases and characteristics that might put patients at higher risk of postoperative pouch dysfunction or failure. Dr. Remzi, another study investigator, notes that by taking an aggressive but rigorous approach to patient selection, carefully weighing the pros and cons of surgery, individual profile factors that might affect outcomes, and patient preference, the team at NYU Langone has been able to expand the pool of eligible patients. “Our findings confirm that thoughtful patient selection by an experienced team and shared decision making with patients are essential to successful long-term pouch outcomes,” says Dr. Remzi.
“Our findings confirm that thoughtful patient selection by an experienced team and shared decision making with patients are essential to successful long-term pouch outcomes.”
—Feza Remzi, MD
When Not To Pouch
For patients who undergo colectomy due to UC and for some patients with CD, selectively performed ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment. IPAA creates a reservoir as a substitute for the removed rectum, thereby providing an alternative to permanent ileostomy that enables patients to store and pass stool.
Although IPAAs are associated with great outcomes overall, certain patient factors may elevate the risk of postoperative issues such as fecal incontinence. In addition, persistent pouch dysfunction may increase the risk of pouch failure and diminish patients’ quality of life.
“Patients with potential risk factors such as obesity, sphincter dysfunction or damage, advanced age, previous radiation therapy, and Crohn’s disease need to be carefully counseled with regard to pouch surgery,” notes Dr. Remzi.
According to the study, published in Gastroenterology & Hepatology in August 2017, the following risk factors deserve special consideration.
Although obesity does not necessarily preclude pouch surgery, a body mass index of 30 or more is associated with several possible postoperative complications, including incisional hernias and pouch dysfunction. In addition, obese patients may have longer operating times, prolonged hospital stays, and higher risks for wound infection and anastomotic leak. Also, excess weight may necessitate the performance of additional surgical steps, such as a tension-free anastomosis hookup in order for the IPAA to reach the anal canal. Morbidly obese patients who are considering IPAA can participate in a weight-loss program and/or, in certain cases, undergo bariatric surgery to lose sufficient weight to make IPAA feasible. In these cases, Inflammatory Bowel Disease Center experts work in collaboration with the bariatric team.
IPAA preserves anal sphincter function and normal evacuation and allows for gastrointestinal continuity. The study authors note that advanced age and a history of obstetric injury may be of concern but does not necessarily rule out IPAA. In such cases, NYU Langone’s highly skilled surgeons reduce the risks posed by appropriately varying their surgical techniques, such as performing stapled rather than hand-sewn anastomoses.
From September 2016 through October 2017, referred reoperative pouch surgeries performed by Feza Remzi, MD, had a 90-percent success rate.
Being elderly is not an absolute contraindication to IPAA. Age should be considered in the context of the whole person and the person’s health history. Although older patients may be more likely than younger patients to have comorbidities—such as diabetes, hypertension, or chronic obstructive pulmonary disease—and other risk factors that could slow recovery, including gait and mobility issues that interfere with getting to and from the restroom, many elderly patients can safely undergo IPAA with comparable pouch outcomes to younger patients and, despite some reported instances of incontinence, good quality of life.
Patients who undergo radiation therapy may be at higher risk for pouch dysfunction following IPAA. The authors cite studies showing that prior or subsequent radiation will likely result in pouch failure and/or morbidity. Other data suggest that pelvic radiation prior to IPAA can lead to chronic pouchitis and pouch failure. It is thus advisable to limit radiation exposure and target narrower fields to minimize such risks in patients who have undergone or plan to undergo IPAA.
Although patients with CD are often ruled out for IPAA because of the risk of pouch failure, recent studies suggest that favorable outcomes are possible if IPAA feasibility is demonstrated following extensive preoperative evaluation and patient counseling. Potential CD candidates for the procedure include patients with minimal anoperineal or small bowel manifestations and patients diagnosed with CD at the time of initial colectomy and prior to pouch creation. A thorough preoperative evaluation should include a perineal exam and imaging to rule out fistulas and small bowel disease.
Bottom Line: Careful Patient Selection Is Key to Success
Strategic patient selection for IPAA increases the likelihood of long-term improvement in quality of life, notes Dr. Remzi. Favorable outcomes are more likely following a thorough evaluation of individual patients’ comorbidities, surgical history, and functional status. In addition, patients should be counseled at length to prepare them for surgery and recovery.
“The decision to undergo IPAA should be made after an extensive discussion among multidisciplinary team members and the patient,” says Dr. Remzi. And he adds, “Given the potential for complications, the procedure should be performed in high-volume referral centers with specialized pouch management expertise.”