Salvage surgery for continent ileostomies (CI) after a first successful revision: more long-term blame on the reservoir than the nipple valve

Purpose The aim of the study was to investigate the underlying cause of long-term complications in patients requiring at least one revision surgery of a continent ileostomy (CI) and to analyze functional outcome. Methods Only patients with CI at least one revision were included in the retrospective data analysis. Four different classes of complications (Cl A–D) were defined: Cl A = Nipple valve (NV), Cl B = pouch, Cl C = outlet (stoma), and Cl D = afferent loop (AL). Associations between underlying disease and origin of complications were analyzed. Cumulative probabilities were calculated using Kaplan–Meier analysis. Results A total of 77 patients were identified with a follow-up of 30 years, requiring 133 surgeries for 148 complications (c.). Cl A 49 c. (33.1%), Cl B 50 c. (33.8%), Cl C 39 c. (26.4%), and Cl D 10 c. (6.8%). Cl A and C complications were not correlated to underlying disease, whereas Cl B and D complications were only found in ulcerative colitis (UC) and Crohn’s disease (CD). The cumulative probability of a second revision showed a linear rise, reaching 62.5% after 20 years. Cl A and B complications both reached 42.1%. Eleven (14.3%) patients (10 Cl B) had pouch failure in a follow-up period of 11.5 ± 8.7 years (1–31 years), whereas 66 (85.7%) had successful revisional surgery. Overall CI survival was 78.8% at 44 years. Conclusion CI survival is limited by inflammatory complications of the pouch based on the underlying disease and not by mechanical limitations of the NV

Conversion of ileo-pouch anal anastomosis to continent ileostomy: strategic surgical considerations and outcome

Aim: The aim was to evaluate surgical strategies for conversion of failed ileo-pouch anal anastomosis (IPAA) to continent ileostomy (CI), taking morbidity and overall outcome into account. The hypothesis was that complex conversions are equivalent to the primary construction of a CI at the time of proctocolectomy. Method: This was a retrospective analysis of IPAA conversions acknowledging the underlying disease (inflammatory bowel disease [IBD] and non-IBD) and extent of pouch reconstruction (PR): type 1 (without PR), type 2 (partial PR), and type 3 (complete PR). Results: Twenty-six patients (IBD, n = 16; non-IBD, n = 10) were converted (type 1, n = 13; type 2, n = 7; and type 3, n = 6).12/26 patients (46.2%) presented postoperative complications directly related to the conversion with scarification of two pouches. In a mean follow-up time of 7.5 ± 6.6 years, 5/24 patients required revisional surgery. Of these, three required pouch excision. The cumulative probability of reoperation at the end of the second year increased to 21.7% and remained constant thereafter until the maximum follow-up time of 26 years. The total pouch loss rate was 19.2% (5/26), of which all occurred in the first 3 years. No statistically significant differences were found between the conversion types, complications or pouch survival. For all parameters, IBD patients performed slightly unfavourably. Due to the overall small number of respective patients, a differentiated investigation of IBD was not performed. Conclusion: Complex conversion procedures (types 1 and 2) deliver comparable longterm results to new constructions (type 3), thereby limiting the loss of small bowel. IBD compromises outcome versus non-IBD

A systematic description of continent ileostomy revision techniques

Purpose Comprehensive description of surgical techniques for revision of complications of continent ileostomy (CI). Methods By analyzing 133 revision procedures performed over 30 years, a systematically classified approach to the appropriate techniques for CI revision surgery has been derived. Based on the anatomic site and severity of the respective complication, four classes of revision surgeries have been defined: class 1 refers to the nipple valve, class 2 to the pouch, class 3 to the stoma, and class 4 to the afferent loop. The severity of the complication or the complexity of the revision procedure is indicated by a subdivision from a to d. Results The surgical variants (class 1a–d, class 2a–c, class 3a–b, and class 4a–b) are shown in schematic illustrations with accompanying descriptions of technical details, the respective fields of application, and the special indications. Conclusion Based on these classes of revision surgeries, the specialized surgeon may find differentiated techniques at their disposal to save the CI and avoid unnecessary sacrifice of the artificial continence organ

Ileopouchanale Anastomose (IPAA) – individuelle Erfahrungen hinsichtlich Komplikationen, Pouchüberleben und Lebensqualität

Background Ileal pouch–anal anastomosis (IPAA) is the gold standard for proctocolectomy. The present study evaluates surgical outcomes of the authors’ operations over a 30-year period, including pouch survival and quality of life (QOL). Methods Records of patients undergoing IPAA between 1986 and 2015 were retrospectively analyzed regarding early and late complications and pouch survival. An online survey assessed QOL. Results Of 119 patients, 84 had chronic inflammatory bowel disease (IBD) and 35 non-inflammatory bowel disease (non-IBD). Pouch construction was simultaneous with proctocolectomy in 69% and metachronous in 31%. Double-stapler anastomosis with purse string suture was performed in 100 patients. With temporary transanal decompression by catheter insertion in all patients, loop ileostomy (LIS) was selectively omitted in 68%. Three anastomotic insufficiencies occurred both without (4.4%) and with LIS (9.4%). Perioperative morbidity for LIS closure was substantial (33.3%). In the long-term course, 36 patients (30.5%) required revision (cumulative probability after 15 years: 59.1%). IPAA was discontinued in 16 patients (13.6%), reducing cumulative continence preservation to 72.9% after 15 years. By converting the pouch to a continent ileostomy (CI) in 6 patients with uncorrectable functional complications, cumulative pouch survival reached 81.8% after 27 years. The online survey revealed significant improvements in occupation, sports, and travel vs. before proctocolectomy, but no change in sexual life. Physical, psychological, and social scores were still below the age-matched norm values. Whereas >90% were satisfied with the surgical outcome, only 3/25 had no functional improvement requests. Conclusion IPAA in double-stapler technique is safe, even without protective LIS. However, short- and long-term morbidity is considerable, with a non-negligible risk of continence loss. Conversion to CI for purely functional complications can significantly reduce definite pouch failure. Despite patients’ high subjective satisfaction, QOL remains objectively compromised.Hintergrund Die ileopouchanale Anastomose (IPAA) ist Goldstandard bei der Proktokolektomie. Ziel der vorliegenden Untersuchung ist es, die chirurgischen Ergebnisse der Operationen des Autors einschließlich Pouchüberleben und Lebensqualität über 30 Jahre zu überprüfen. Methodik Retrospektiv wurden die Krankenunterlagen von Patienten, bei denen zwischen 1986 und 2015 eine IPAA angelegt wurde, zu Früh- und Spätkomplikationen sowie Pouchüberleben ausgewertet. Mit einer Online-Befragung wurde die Lebensqualität ermittelt. Ergebnisse In einer Gruppe von 119 Patienten, von denen 84 an chronisch-entzündlichen (CED) und 35 an nicht chronisch-entzündlichen Darmerkrankungen (Non-CED) litten, wurde in 69 % der Pouch simultan und in 31 % metachron zur Proktokolektomie angelegt. Bei 100 Patienten wurde eine Doppelstapleranastomose mit zusätzlicher Tabaksbeutelnaht durchgeführt. Bei temporärer transanaler Dekompression mittels Kathetereinlage bei allen wurde selektiv in 68 % auf eine Loop-Ileostomie (LIS) verzichtet. Dabei ereigneten sich 3 Anastomoseninsuffizienzen ohne (4,4 %), aber auch 3 mit (9,4 %) LIS. Die perioperative Morbidität des Verschlusses der Lis war mit 33,3 % beträchtlich. Im Langzeitverlauf erlitten 36 Patienten (30.5 %) revisionspflichtige Komplikationen, deren kumulative Auftrittswahrscheinlichkeit bereits nach 15 Jahren 59,1 % erreichte. Die IPAA musste deswegen bei 16 Patienten (13,6 %) aufgehoben werden, wodurch die kumulative Kontinenzerhaltung nach 15 Jahren auf 72,9 % sank. Da in 6 Fällen mit nicht korrigierbaren funktionellen Komplikationen der Pouch zur kontinenten Ileostomie (CI) konvertiert werden konnte, lag das kumulative Pouchüberleben nach 27 Jahren noch bei 81,8 %. Die Online-Befragung ergab für die Bereiche Beruf, Sport und Reisen eine signifikante Verbesserung gegenüber vor der Proktokolektomie, für das Sexualleben dagegen keine Veränderung. Jedoch erreichten die physischen, psychologischen und sozialen Scores nicht die Werte der gesunden Altersgruppe. Obwohl mehr als 90 % mit dem operativen Ergebnis zumindest zufrieden waren, gaben nur 3 von 25 keine funktionellen Verbesserungswünsche an. Schlussfolgerung Die IPAA in Doppelstaplertechnik ist auch ohne protektive LIS ein sicheres Operationsverfahren. Die Kurz- und Langzeitmorbidität ist allerdings beträchtlich, woraus ein nicht vernachlässigbares Risiko des Kontinenzverlusts resultiert. Durch Konversion zur CI bei rein funktionellen Komplikationen kann das definitive Pouchversagen deutlich verringert werden. Trotz großer subjektiver Zufriedenheit der Operierten bleibt ihre Lebensqualität objektiv kompromittiert. Key phrases/core sentences Anastomosis is the Achilles’ heel of ileal pouch–anal anastomosis Modified Asao suture facilitates the double-stapler technique Continence function takes precedence over body image The disadvantages of loop ileostomy outweigh its benefits Transanal catheter decompression replaces fecal diversion Cumulative morbidity in the long-term course is not negligible Conversion surgery increases pouch survival Subjectively good quality of life is objectively compromised For several decades now, ileal pouch–anal anastomosis (IPAA, or J‑pouch) has been the surgical method of choice after removal of the colon and rectum. Ulcerative (UC) and indeterminate (IC) colitis as well as familial adenomatous polyposis (FAP) are considered classic indications for the procedure [3, 4, 9, 11, 17]. IPAA may also be possible in selected patients with Crohn’s colitis (CC) and severe motility disorders of the colorectum in terms of slow transit constipation (STC) [18, 14]. Technical details of the operation appear solved. Relatively early in the history of its development, the J‑pouch became accepted as the preferred design for pouch construction [9]. However, the type of anastomosis construction, the necessity and usefulness of postoperative temporary fecal deviation, the appropriate surgical approach, and different strategies for various underlying diseases have yet to be definitively clarified. Irrespective of the ultimate answers to open questions, the outcomes—measured in terms of surgical results and quality of life (QOL)—are consistently considered to be satisfactory by both surgeons and patients [9]. Surprisingly, this is not diminished by the fact that perioperative morbidity associated with this demanding operation is not negligible, and that numerous complications, including those with drastic surgical consequences, occur in the long-term course [15]. As a consequence of one or even multiple complications, definitive pouch failure may result in the long term [24]. In the authors’ own practice, despite a comparatively long operation period of 30 years, the surgical procedure has been kept constant since a very early fundamental change. All operations were performed by a single surgeon (KWE), who also performed the follow-up during the entire period. The goal of the follow-up offered to all patients was early detection of surgical complications, to enable their elimination in a function-preserving manner and maintenance of the best possible QOL. Herein, the authors report on their personal experience with a comparatively small but well-documented collective, in order to reevaluate a worldwide gold standard

Comparing continent ileostomy (CI) conversion to repair/redo IPAA: favorable outcomes

Purpose This study aims to compare the outcomes of repair/redo ileal pouch-anal anastomosis (repair/redo-IPAA) with the conversion of IPAA to continent ileostomy (CI) in an effort to prevent the need for a permanent ileostomy (IS) following IPAA failure. Methods This research involved a retrospective analysis of surgical records, employing descriptive statistics and KaplanMeier survival analysis. Results Among 57 patients with an IPAA, up to three revisions were necessary due to complications or complete failure. Ultimately, repair/redo-IPAA preserved the IPAA in 14 patients (24.6%), conversion to CI salvaged the pouch in 21 patients (36.8%), and IS was unavoidable in 22 patients (38.6%). The cumulative probability of requiring conversion surgery was calculated to be 54.0% at 20 years, thereby reducing the cumulative risk of IS to 32.3%. The 20-year cumulative probability of pouch salvage by repair/redo IPAA was only 21.9%. However, this rate increased to 67.7% when conversion procedures were considered. Following repair/redo-IPAA, only 8.3% of patients reported evacuation frequencies of≤4 during the day, and 16.7% were evacuation-free at night. In contrast, after conversion to CI, 98.0% of patients reported a maximum of four evacuations in a 24-h period. After undergoing repair/redo IPAA, between half and two-thirds of patients reported experiencing incontinence or soiling, while complete continence was achieved in all patients following conversion to CI. Notably, the majority of patients expressed overall satisfaction with their respective procedures. A positive correlation was identified between very high subjective satisfaction and positive objective surgical outcomes exclusively in patients who underwent conversion to CI. Conclusion When complications or failure of IPAA occur, conversion to CI emerges as a highly viable alternative to repair/ redo IPAA. This conclusion is supported by the observation that patient satisfaction appears to be closely tied to stable surgical outcomes. To reinforce these findings, further prospective studies are warranted

Ileal pouch–anal anastomosis—a personal experience reevaluating complications, pouch survival, and quality of life

<jats:title>Abstract</jats:title><jats:sec> <jats:title>Background</jats:title> <jats:p>Ileal pouch–anal anastomosis (IPAA) is the gold standard for proctocolectomy. The present study evaluates surgical outcomes of the authors’ operations over a 30-year period, including pouch survival and quality of life (QOL).</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>Records of patients undergoing IPAA between 1986 and 2015 were retrospectively analyzed regarding early and late complications and pouch survival. An online survey assessed QOL.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>Of 119 patients, 84 had chronic inflammatory bowel disease (IBD) and 35 non-inflammatory bowel disease (non-IBD). Pouch construction was simultaneous with proctocolectomy in 69% and metachronous in 31%. Double-stapler anastomosis with purse string suture was performed in 100 patients. With temporary transanal decompression by catheter insertion in all patients, loop ileostomy (LIS) was selectively omitted in 68%. Three anastomotic insufficiencies occurred both without (4.4%) and with LIS (9.4%). Perioperative morbidity for LIS closure was substantial (33.3%). In the long-term course, 36 patients (30.5%) required revision (cumulative probability after 15 years: 59.1%). IPAA was discontinued in 16 patients (13.6%), reducing cumulative continence preservation to 72.9% after 15 years. By converting the pouch to a continent ileostomy (CI) in 6 patients with uncorrectable functional complications, cumulative pouch survival reached 81.8% after 27 years. The online survey revealed significant improvements in occupation, sports, and travel vs. before proctocolectomy, but no change in sexual life. Physical, psychological, and social scores were still below the age-matched norm values. Whereas >90% were satisfied with the surgical outcome, only 3/25 had no functional improvement requests.</jats:p> </jats:sec><jats:sec> <jats:title>Conclusion</jats:title> <jats:p>IPAA in double-stapler technique is safe, even without protective LIS. However, short- and long-term morbidity is considerable, with a non-negligible risk of continence loss. Conversion to CI for purely functional complications can significantly reduce definite pouch failure. Despite patients’ high subjective satisfaction, QOL remains objectively compromised.</jats:p> </jats:sec&gt

Salvage surgery for continent ileostomies (CI) after a first successful revision: more long-term blame on the reservoir than the nipple valve

Purpose!#!The aim of the study was to investigate the underlying cause of long-term complications in patients requiring at least one revision surgery of a continent ileostomy (CI) and to analyze functional outcome.!##!Methods!#!Only patients with CI at least one revision were included in the retrospective data analysis. Four different classes of complications (Cl A-D) were defined: Cl A = Nipple valve (NV), Cl B = pouch, Cl C = outlet (stoma), and Cl D = afferent loop (AL). Associations between underlying disease and origin of complications were analyzed. Cumulative probabilities were calculated using Kaplan-Meier analysis.!##!Results!#!A total of 77 patients were identified with a follow-up of 30 years, requiring 133 surgeries for 148 complications (c.). Cl A 49 c. (33.1%), Cl B 50 c. (33.8%), Cl C 39 c. (26.4%), and Cl D 10 c. (6.8%). Cl A and C complications were not correlated to underlying disease, whereas Cl B and D complications were only found in ulcerative colitis (UC) and Crohn's disease (CD). The cumulative probability of a second revision showed a linear rise, reaching 62.5% after 20 years. Cl A and B complications both reached 42.1%. Eleven (14.3%) patients (10 Cl B) had pouch failure in a follow-up period of 11.5 ± 8.7 years (1-31 years), whereas 66 (85.7%) had successful revisional surgery. Overall CI survival was 78.8% at 44 years.!##!Conclusion!#!CI survival is limited by inflammatory complications of the pouch based on the underlying disease and not by mechanical limitations of the NV.!##!Trial registration numbers!#!None