Restorative Proctocolectomy: Ochsner Clinic Experience

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Restorative Proctocolectomy: Ochsner Clinic Experience

Blumberg, MD, G. Opelka, MD, Terry C. Hicks, MD, Alan E.

Timmcke, MD, E. Beck, MD, Department of Colon and Rectal Surgery,

Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, La (Dr.

Blumberg is now with the Department of Surgery, Division of Gastrointestinal

Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa.)

[south Med J 94(5):467-471, 2001. © 2001 Southern Medical Association]

Abstract

Background. Restorative proctocolectomy, a standard operation for ulcerative

colitis and familial adenomatous polyposis has significant complications,

even in experienced hands.

Methods. We studied surgical outcome by retrospectively reviewing cases of

restorative proctocolectomy done at Ochsner Foundation Hospital from 1982 to

1995. Demographic and clinical data from two periods (1982 to 1989 and 1989

to 1995) were compared to determine factors associated with improved

outcome.

Results. We performed 145 ileal pouch-anal procedures. In 56 patients, 104

complications occurred. The more recent group had a greater incidence of

inflammatory bowel disease, steroid use, and staged operations; reduced

operative times and hospital stays; more general but fewer pouch-related

complications. Pouch failures were similar for both groups.

Conclusions. Perioperative outcome appeared to be associated with technical

experience, improved perioperative care, exclusion of patients with Crohn's

disease, judicious surgical reoperation for pouch complications, and use of

a 3-stage procedure in malnourished patients or those with acute or toxic

colitis.

Introduction

Restorative proctocolectomy is a technically demanding procedure used to

treat patients with chronic ulcerative colitis (CUC) and familial

adenomatous polyposis (FAP). Even in experienced hands, this procedure is

associated with significant complications. In large series, overall

complication rates have ranged from 29% to 87%, and pouch failure has ranged

from 3% to 13%.[1-6] Several prospective studies have been done to determine

methods to improve surgical outcome. The use of prolonged perioperative

antibiotic prophylaxis[7] and the use of a stapled versus a hand-sewn

anastomosis[8-10] have not been shown to alter outcomes. Similarly, several

retrospective studies have reported no difference in outcome based on pouch

design.[11-13] Although varied surgical techniques do not appear to be

crucial in overall outcome, several studies have suggested that experience

with the operation affects outcome. Several large centers report a

significant learning curve with restorative proctocolectomy.[3,14,15]

Patient factors also seem to influence outcome. Patients with ulcerative

colitis have been shown to have an increased frequency of septic

complications and poorer functional results compared with patients who have

FAP.[16] Additional studies are needed to better define factors important in

surgical outcome.

We have previously reviewed our early experience with restorative

proctocolectomy.[17] Since that report, we have noted significant changes in

our patient referrals: an increased proportion with inflammatory bowel

disease (IBD), malnourishment, and acute and toxic colitis. Despite this

trend, there was no increase in pouch failures or pouch complications. Based

on these clinical observations, we decided to review our more recent

experience with the restorative proctocolectomy or ileal pouch- anal

anastomosis to determine (1) whether there was a difference in surgical

outcome of our early procedures compared with more recent proctocolectomies

and (2) what factors were associated with surgical outcome.

Methods

We retrospectively reviewed hospital and follow-up clinical charts for cases

of restorative proctocolectomy done from July 1982 to April 1995 at the

Ochsner Foundation Hospital. The variables recorded included patient sex,

clinical diagnosis (ulcerative colitis, Crohn's disease, FAP), steroid use,

operative time, type of ileo-anal pouch construction (J or S), number of

operations, and length of hospital stay (LOS). Complications were

categorized as general (ie, those associated with any major abdominal

operation) and pouch-related. We compared our early experience (group 1,

1982 to 1989) with our later experience (group 2, 1989 to 1995) to determine

factors associated with surgical outcome. These periods were chosen because

they roughly divide our experience in half (by time and number of

procedures), and the early group corresponded to our previous report.[17]

The restorative proctocolectomy pouches were constructed as a J-type or

S-type reservoir using two 12 to 18 cm or three 10 to 12 cm loops of ileum,

respectively. The J-pouches themselves were primarily hand sewn in the early

part of this series and stapled during the later years. S-pouches were

usually constructed with suture, with 2 cm efferent limbs. The pouch type

was selected by surgeon preference. A majority of patients received a

mucosectomy with a hand-sewn anastomosis and a diverting loop ileostomy.

Ileostomy closure occurred 6 weeks later, provided there was no evidence of

extravasation during contrast enema examination and no evidence of

anastomotic stricture on anoscopy. Patients with toxic colitis or severe

malnutrition or comorbidities had the procedure done in 3 stages (initial

colectomy and ileostomy, pouch construction, loop ileostomy closure).

Follow-up ranged from 6 weeks to 63 months after ileostomy closure.

Comparisons of complications between patients with IBD and FAP were done

with Fisher exact test, while chi-square analysis was used to compare the

early and later groups. Significance was defined as P < .05.

Results

During this period, 145 patients had restorative proctocolectomy with ileal

pouch-anal anastomosis. The 74 male and 71 female patients ranged in age

from 14 to 70 years (mean, 34 years). The demographics and clinical features

of the entire cohort are presented in Table 1. Preoperative diagnosis was

IBD in 111 patients. There was one perioperative death (within 30 days) due

to pulmonary embolus.

Fifty-six patients had 104 complications, a 39% overall complication rate.

Patients with IBD had a twofold greater likelihood of a complication than

patients with FAP (P = .02 by Fisher exact test, odds ratio = 2.9,

confidence interval 1.2 to 7.3). Of 111 patients with IBD, 49 (44%) had a

complication compared with 7 (21%) of the 34 patients with FAP. Of 104

complications, 71 were general (Table 2), and 33 were pouch-specific

complications (Table 3). Surgery was required for small bowel obstruction in

13 patients (34% of the total), incisional hernias in 2 patients, and

evisceration in 1 patient.

Several patients with asymptomatic anastomotic strictures were treated

successfully with simple anal dilatation in the office and without sedation.

Surgery was required for 13 pouch-related complications. Of 10 patients with

abscesses, 6 required surgical drainage, and 4 were treated with antibiotics

alone. All 3 patients with pelvic abscess who were surgically treated also

required surgical correction of a concomitant anastomotic sinus. Surgical

excision was required for 4 of 145 pouches (2.8%). Pouch excision was done

for severe pouchitis not responding to antibiotics in 1 patient, anastomotic

dehiscence/leak (n = 1), ischemia (n = 1), and pouch fistula (n = 1).

In Table 4, we compare perioperative parameters of our early experience

(group 1) with those of our later experience (group 2). Group 2 consisted of

a significantly greater percentage of patients with IBD rather than FAP (P =

..004). In group 2, 88% had IBD, compared with 66% in group 1. Of patients

with IBD, twice as many in group 2 used steroids (P = .008). In addition,

patients in group 2 were taking a higher dosage of steroids than those in

group 1.

Patients in group 2 had a 3-stage procedure more frequently than those in

group 1 (28% vs 2.7%, P </= .001). With experience, we have been able to

reduce the operative times for both J and S pouches. Patients in group 2 had

shorter operative times for both J and S pouches than those in group 1. The

two groups also had significant differences in LOS: in group 2, LOS was

approximately 2 days shorter for patients with FAP and for those with IBD.

While the frequency of general complications has risen in group 2 patients,

the incidence of pouch-related complications is slightly lower. In addition,

the low percentage of pouch failures (2.8%) has been similar for both

groups.

Discussion

Overall, restorative proctocolectomy is a successful operation for patients

with CUC and FAP, but it carries a risk of short-term, resolvable

morbidities and a small but recognized mortality and major morbidity. Our

results in 145 patients compare favorably with those from other large

series. Our overall morbidity of 39% is similar to that reported in other

series,[1-6] and only 1 perioperative death has occurred. The pouch-related

complication rates also compare favorably with those in other large referral

series.[1-6,12,14,18] The incidence of pelvic or cuff abscesses (7%) is

similar to a median incidence of 5% (range, 0% to 24%) in these referral

series.[1-6,14,18] Our anastomotic sinus and leak rate of 2.1% is equivalent

to the reported median incidence of 2% (range, 0% to 14%) of

others.[1-6,14,18] Similarly, the incidence of pouch fistula in our series

is 1.4%, which is low compared with a median incidence of 4% (range, 0% to

16%) reported in other series.[1-6,14,18] Among our pouch complications, 4

anastomotic sinus tracts were corrected by advancement flap repairs.[19] We

excised 4 pouches (3%). This compares well with other series, which have

reported excision rates of 3% to 13% (median of 6%).[1-6,18]

From 1989 to 1995, patients referred for ileal pouch-anal anastomosis had a

higher frequency of IBD, steroid use, and 3-stage procedures. The frequency

of total complications was greater in the more recent period. Despite this,

our pouch-related outcomes have actually improved in the more recent years.

The frequency of pouch-related complications was less during the recent

period, and the number of pouches requiring excision was no different.

Several factors are associated with surgical outcome of this procedure. One

factor is experience with the procedure. We have been able to significantly

reduce our operative times for patients having ileo-anal anastomosis with

both J and S reservoirs. Length of hospitalization has also been reduced in

patients with CUC and those with FAP.

We have also aggressively managed pouch-related complications. We did 13

reoperations in 33 pouch complications, with a 97% salvage rate. Similarly,

other series have suggested that aggressive reoperations are worthwhile to

salvage a pouch.[15,20-22] In our series, final pathologic report and

follow-up documented 97% of patients with IBD had ulcerative colitis, 2

patients had Crohn's disease, and 1 patient had indeterminate colitis. The

current standard of care contraindicates an ileal pouch-

anal anastomosis in a patient with known Crohn's disease. Two other studies

in the literature concur with the use of staged procedures in selected

patients.[23,24]

The factors affecting our surgical outcome include technical experience,

perioperative care, surgical reoperation for pouch complications when

indicated, exclusion of patients with Crohn's disease, and the judicious use

of a 3-stage procedure in patients who are malnourished or who have acute or

toxic colitis.

Reprint requests to E. Beck, MD, Ochsner Clinic, Department of Colon

and Rectal Surgery, 1514 Jefferson Highway, New Orleans, LA 70121.