ILEAL POUCH-ANAL ANASTOMOSIS FOR CROHN’S DISEASE?
Premise: Ileal pouch / anal anastomosis (IPAA) is a well established procedure with low operative morbidity and good long term functional results. However, it is generally accepted that Crohn’s Disease (CD) is a contraindication for performing IPAA. CD patients who receive IPAA are at risk of recurrence of their disease within the ileal reservoir with fistulas, stricture, suture line failure and abscess formation.
Studies: •
Deutsch AA, McLeod RS, Cullen J, Cohen Z. Results of the pelvic-pouch procedure in patients with Crohn’s Disease. Dis Colon Rectum 1991; 34:475-77 o Method Jan ‘82 – Mar ‘89, 272 patients with diagnosis of Ulcerative colitis (UC) received IPAA 9 patients found to be with CD subsequently o Result 2 patients developed Crohn’s recurrence in pouch 3 patients developed Pouch to vaginal fistula 1 patient with multiple fissures and stenosis. 4 pt have had their pouch removed 5 patients have functioning pouches ( 3 with no complication, 2 with persistant perianal disease) o Interpretation pelvic-pouch procedure should not knowingly be performed in patients with CD because of the high associated complication rate
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Valleur P, Panis Y, Poupard B, Nemeth J, Lavergne A, Hautefeuille P. Ileal Pouch / anal anastomosis for Crohn’s disease. The Lancet 1996;347:854-858 o Method 1985-1992, 31 patients with CD and without anoperineal or smallbowel disease recruited for IPAA Long/short term functional results compared with the 71 UC patients who received the same operation Mean f/u 59 months o Results out of 31 CD patients, 6 patients had specific complications 3 pouch-perineal fistula → 2 excision of pouch 1 pouch-vaginal fistula → Gracilis muscle interposition 2 extrasphincteric abscess No difference in stool frequency compared with UC pt in 5 yr f/u o Interpretation In selected cases of CD without anoperineal or small-bowel manifestations, IPPA can be recommended as an alternative to coloprotectomy with definitive end-ileostomy, when rectal resection is essential. Sagar PM, Dozois RR, Wolff BG. Long-term results of ileal pouch-anal anastomosis in patients with Crohn’s disease. Dis Colon Rectum 1996; 39(8): 893-98 o Method 37 CD patients with IPAA histologic examination of operative specimen initially showed 22 UC, 9 indeterminate, 6 CD o Result 11 of 37 patients developed complex fistulas pouch-cutaneous – 6 pouch-vaginal – 4 pouch-vesical – 1 Crohn's disease has recurred in the pouch (20), anal canal (4), pouch and anal canal (10),and elsewhere (3). After ten years (range, 3-14): the pouch remains in situ in 20 patients in whom frequency of bowel movement is seven times (3-10)/24 hours in situ but defunctioned in seven patients excised in ten patients failure rate - 45% o Interpretation Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45% ) but an acceptable long-term functional result if the pouch can be kept in situ.
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Conclusion / Discussion ?
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References 1. Wexner SD, Jensen L, Rothenberger DA, Wong WD, Goldberg SM. Long term functional analysis of the ileoanal reservoir. Dis Colon Rectum 1989;32:275-81 2. Deutsch AA, McLeod RS, Cullen J, Cohen Z. Results of the pelvic-pouch procedure in patients with Crohn’s Disease. Dis Colon Rectum 1991; 34:475-77 3. Valleur P, Panis Y, Poupard B, Nemeth J, Lavergne A, Hautefeuille P. Ileal Pouch / anal anastomosis for Crohn’s disease. The Lancet 1996;347:854-858 4. Sagar PM, Dozois RR, Wolff BG. Long-term results of ileal pouch-anal anastomosis in patients with Crohn’s disease. Dis Colon Rectum 1996; 39(8): 893-98 Sanghyun Kim, M.D. October 2004
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