Prospective analysis of surgical and functional outcomes after total proctocolectomy with ileal pouch-anal anastomosis in 86 patients with ulcerative colitis

Abstract

Proctocolectomy with an ileal pouch‑anal anastomosis is currently considered the procedure of choice for the majority of patients with ulcerative colitis. Certain controversies about pouch design and pouch‑anal anastomosis technique remain a matter of debate, and possible advantages of laparoscopic approach are still being discussed.

Objective — to investigate short‑term and long‑term outcomes of laparoscopic and open restorative proctocolectomy for UC in terms of postoperative morbidity and pouch function depending on the three types of construction of a neorectum described in our research.

Materials and methods. 86 patients with inflammatory bowel disease underwent one‑stage or two‑stage restorative proctocolectomy. The two ileal pouch configurations were used: S‑pouch — in 16 patients and J‑pouch — in 70 patients. Removal of the distal rectum and ileal pouch‑anal anastomosis were performed using transanal distal rectum mucosectomy followed by a handsewn pouch‑anal anastomosis (n = 45) or a double‑stapled technique (n = 31). Laparoscopic approach was applied in 39 patients, and open surgery — in 47 patients. The short‑term (30 days after surgery) and long‑term surgical outcomes were prospectively studied. The analysis of functional outcomes was based on the number of bowel movements a day, episodes of fecal incontinence, seepage, and urgency. Instrumental investigation included measurement of the anal sphincter pressures and ileal pouch threshold volume as well as the study of its residual volume. Statistical analysis was performed using SPSS statistical software.

Results. There was no postoperative mortality. In the laparoscopic group, 4 (10.3 %) patients had early postoperative complications compared with 13 (27.7 %) patients in the open surgery group, but the difference was not statistically significant (Fisher exact test value is 0.0579 at p < 0.05). Pouch failure occurred in 4 patients. The second‑stage laparoscopic restorative procedure revealed the abdominal cavity almost free of adhesions in 19 (86.4 %) patients after laparoscopic total colectomy. The total number of early and late mucosectomy complications was significantly higher, 12 (75.0 %) vs. 10 (26.0 %) (p = 0.0018), in patients managed with a handsewn S pouch‑anal anastomosis than in patients treated with a J‑pouch‑anal anastomosis. Good functional outcomes were observed in 44 (51.0 %) patients. A strong negative correlation was found between the pouch threshold volume and the number of bowel movements per 24 hours (r = –0.7347, p < 0.0001). The seepage episodes were detected in 30 (34.8 %) patients. The resting anal sphincter pressure was the only measured parameter which correlated accurately with the number of day and night seepage episodes (r = –074, p < 0.0001).

Conclusions. Good functional outcomes of construction of a neorectum were associated with the resting anal sphincter pressure (≥ 30 mm Hg) and ileal pouch threshold volume (150 — 250 ml). The S‑shaped and J‑shaped pouches demonstrated the same functional outcomes and posed similar risks. The S‑pouch was associated with a higher postoperative morbidity (p = 0.0018). There was no significant difference between laparoscopic and open surgery groups in terms of morbidity rate and functional outcomes. However, it was much easier to perform the second‑stage surgery after laparoscopy due to less adhesion formation.