Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for patients with inflammatory bowel disease (IBD), including ulcerative colitis and colonic Crohn’s disease. The procedure leaves the anal sphincter intact and restores bowel continuity. In recent years, minimally invasive laparoscopic surgical techniques have led to better cosmetic results, faster return to bowel function, and less pain and discomfort for patients following IPAA. However, between 3 percent and 15 percent of patients with IPAA eventually experience pouch failure and may require redo surgery. Redo IPAA is an effective option for maintaining intestinal continuity and avoiding a permanent stoma. However, there is a lack of data comparing outcomes of transabdominal redo IPAA surgery following minimally invasive versus open techniques.
Pouch Redo Outcomes Assessed Based on Initial Technique
In a recent study, published in the August 2020 issue of Diseases of the Colon and Rectum, researchers at NYU Langone sought to compare short- and long-term outcomes of redo surgery on the basis of which technique was used to create the original pouch. “Our study revealed that a long rectal cuff is an important and potentially preventable risk factor for pouch failure following initial minimally invasive IPAA,” says the study’s senior author, Feza Remzi, MD, professor in the Department of Surgery and director of the Inflammatory Bowel Disease Center at NYU Langone. “We also found that hand-sewn anastomoses are associated with increased risk of abscess formation, underscoring the importance of surgical expertise and experience in successful outcomes following redo IPAAs.”
For the study, investigators compared short- and long-term outcomes for 42 patients who underwent failed minimally invasive IPAA with a matched cohort of patients with failed open IPAA. Short-term morbidity and functional outcomes were similar between the two groups. A long rectal stump was more common after minimally invasive IPAA, while patients who had open procedures were more likely to develop abscess formation. Leaving a short anal transitional zone (ATZ) of less than 2 cm is one of the fundamental steps in IPAA creation, regardless of the technique employed, says Dr. Remzi. However, deep rectal dissection is especially challenging with minimally invasive techniques and requires high levels of surgical dexterity and experience. These technical challenges may explain why there was a shorter time to IPAA failure in the minimally invasive versus open IPAA group in the study, he notes.
However, redo IPAA is often less complex in patients with failed minimally invasive procedures because having a residual long rectum allows surgeons to perform stapled anastomoses, says study co-author Shannon Chang, MD, MBA, assistant professor in the Department of Medicine and associate director of the Gastroenterology Fellowship Program at NYU Langone. Stapled anastomoses are often preferred because they are likely associated with higher pouch survival rates compared with hand-sewn IPAA, due to lower risk of pelvic sepsis, which is associated with pouch failure. In the study, pelvic abscess formation was less prevalent after stapled redo IPAA, says Dr. Chang. Other larger studies have reported that stapled IPAA has better functional outcomes and carries less risk of incontinence and seepage compared with mucosectomy and hand-sewn anastomoses. Thus, although the number of patients who underwent stapled redo IPAA was higher in the minimally invasive group, outcomes after redo surgery were similar with both techniques.
While both techniques can produce good outcomes, it is important to inform patients that they are likely to experience worse function following redo versus initial IPAA, says Dr. Remzi. Patients should expect five or six bowel movements per day and one or two per night, and a much improved quality of life. “Ninety-five percent of the patients were happy with the results of their surgery and felt the subsequent restrictions they might experience were acceptable in order to avoid a permanent stoma for life,” he says. Patients in the study had high 3-year estimated survival rates ranging from 81 percent (prior open surgery) to 95 percent (prior minimally invasive).
At NYU Langone, a national referral center for complex surgeries, surgeons routinely perform a three-stage procedure in patients who are eager to have it or are candidates for redo pouch surgery, starting with initial proximal diverting loop ileostomy for six months, followed by redo IPAA with temporary stoma, and stoma closure. The process helps to optimize the patient physically and psychologically and helps the pelvic sepsis to resolve before revision surgery. “Our study is important in that it is the first to evaluate the impact of the technique used for IPAA creation on redo IPAA outcomes,” says Dr. Remzi. “The single-surgeon, case-matched design of this study overcomes some of the limitations of past investigations that included multiple surgeons of various experience levels and patients with different characteristics.” Having performed more redo pouch surgeries per year to repair complications from initial j-pouch surgery than any other team in the world, NYU Langone physicians attribute the program’s success to a multidisciplinary team led by a highly experienced surgeon, access to a wide range of clinical trials, and a commitment to quality, safety, and patient-focused care.