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Zentralbl Chir 2001; 126(Supplement I): 36-42
DOI: 10.1055/s-2001-19197
Originalarbeit

J.A.Barth Verlag in Medizinverlage Heidelberg GmbH & Co.KG

Der ileoanale Pouch

Komplikationen, Lebensqualität und SpätergebnisseThe ileo-anal pouch procedure: Complications, quality of life, and long-term resultsU. Heuschen, J. Schmidt, E. Allemeyer, J. Stern, Gundi Heuschen
  • Chirurgische Universitätsklinik Heidelberg (Direktor: Prof. Dr. Ch. Herfarth)
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Publication History

Publication Date:
20 December 2001 (online)

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The ileo-anal pouch procedure: Complications, quality of life, and long-term results

Summary

Restorative proctocolectomy with construction of an ileal pouch-anal anastomosis (IPAA) has evolved as the surgical therapy of choice for patients with ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). 662 patients (493 UC, 169 FAP) consecutively received IPAA. Marked differences were observed between UC and FAP patients regarding the rates of overall complications (33.1 % vs. 12.5 %), pouchitis (29 % vs. 2 %), and pouch extirpation (3.2 % vs. 0.6 %). Pouchitis occurred as primary (79 %) and secundary (21 %) form, with acute (67.2 %) or chronic (32.8 %) course. Each form and course required specific therapy. Chronic pouchitis implies the risk of malignant transformation of the pouch mucosa. Quality of life improves significantly after IPAA in patients with UC and is equal to that in normal individuals, in UC and FAP, if postoperative complications are either prevented or under control.

Zusammenfassung

Die kontinenzerhaltende Proktokolektomie mit ileoanaler Pouchanlage (IAP) gilt heute als chirurgische Therapie der Wahl für Patienten mit Colitis ulcerosa (CU) und Patienten mit familiärer adenomatöser Polyposis coli (FAP). 662 Patienten (493 CU, 169 FAP) erhielten konsekutiv eine IAP. Deutliche Unterschiede bestanden zwischen CU-Patienten und FAP-Patienten in den Raten der Gesamtkomplikationen (33,1 % vs. 12,5 %), Pouchitis (29 % vs. 2 %) und Pouchextirpation (3,2 % vs. 0,6 %). Bei der Pouchitis ließ en sich primäre (79 %) und sekundäre Formen (21 %), sowie akute (67,2 %) und chronische (32,8 %) Verläufe unterscheiden, die jeweils spezifisch therapiert werden müssen. Bei chronischer Pouchitis besteht die Gefahr maligner Entartung der Pouchmukosa. Die Lebensqualität wird bei CU-Patienten durch die IAP signifikant verbessert und entspricht nach IAP bei Vermeidung oder Beherrschung postoperativer Komplikationen bei CU- und FAP-Patienten jener von Gesunden.

Key words

Ileo-anal pouch procedure - postoperative complications - quality of life

Schlüsselwörter

Ileoanale Pouchanlage - postoperative Komplikationen - Lebensqualität

Literatur

  • 1 Braun J. et al . Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis.  Dis Colon Rectum. 1991;  34 8-16
    PubMedGoogle Scholar
  • 2 Braun J, Lerch M, Harder M, Schumpelick V. Die direkte ileopouch-anale Anastomose.  Chirurg. 1989;  60 578-583
    PubMedGoogle Scholar
  • 3 Buhr H J, Heuschen U, Stern J, Herfarth C H. Kontinenzerhaltende Operation nach Proktokolektomie.  Chirurg. 1993;  64 601
    PubMedGoogle Scholar
  • 4 Buhr H J, Kroesen A J. Typische Komplikationen und ihre Beherrschung nach restorativer Proktokolektomie.  Chirurg. 1998;  69 1035-1044
    PubMedGoogle Scholar
  • 5 Farouk R, Duthie G S, Bartolo D C. Recovery of the internal anal sphincter and continence after restorative proctocolectomy.  Br J Surg. 1994;  81 1065-1068
    PubMedGoogle Scholar
  • 6 Fazio V W, Ziv Y. et al . Ileal pouch-anal anastomosis complications and function in 1 005 patients.  Ann Surg. 1995;  222 120-127
    CrossrefPubMedGoogle Scholar
  • 7 Ferrara A, Pemberton J H, Grotz R L, Hanson R B. Preservation of continence after ileoanal anastomosis by the coordination of ileal pouch and anal canal motor activity.  Am J Surg. 1992;  163 83-89
    CrossrefPubMedGoogle Scholar
  • 8 Foley E F, Schoetz D J, Roberts P L. Rediversion after ileal pouch-anal anastomosis.  Dis Colon Rectum. 1995;  38 793
    CrossrefPubMedGoogle Scholar
  • 9 Galandiuk S, Scott N A, Dozois R R, Kelly K A. et al . Ileal pouch-anal anastomosis.  Ann Surg. 1990;  212 446
    PubMedGoogle Scholar
  • 10 Gemlo B T, Wong W D, Rotheberger G A, Goldberg S M. Ileal pouch-anal anastomosis: patterns of failure.  Arch Surg. 1992;  127 784
    PubMedGoogle Scholar
  • 11 Grove D, Mahmoud A A, Warren K S. Suppression of cell-mediated immunity by metronidazole.  Int Arch Allergy Appl Immun. 1977;  54 422-427
    PubMedGoogle Scholar
  • 12 Herbay V A, Stern J, Herfarth Ch. Pouchanal cancer after restorative proctocolectomy for FAP.  Am J Surg Pathol. 1996;  20 995-999
    CrossrefPubMedGoogle Scholar
  • 13 Herbst F, Sielezneff I, Nicholls R J. Salvage surgery for ileal pouch outlet obstruction.  Br J Surg. 1996;  83 368-371
    PubMedGoogle Scholar
  • 14 Herfarth Ch. Intrapelvic reservoir with direct anal anastomosis.  Langenbecks Arch Chir. 1987;  372 391
    PubMedGoogle Scholar
  • 15 Herfarth Ch, Heuschen G, Heuschen U A. Die maligne Entartung im Verlauf der Colitis ulcerosa und ihre chirurgischen Implikationen.  Chirurg. 1998;  69 1020-1027
    CrossrefPubMedGoogle Scholar
  • 16 Herfarth Ch, Stern J. Rectumersatz durch Dünndarm - Das intrapelvine Reservoir.  Chirurg. 1988;  59 133-142
    PubMedGoogle Scholar
  • 17 Herfarth Ch, Stern J. Colitis ulcerosa - adenomatosis coli. Funktionserhaltende Therapie. Springer, Berlin, Heidelberg 1990
    Google Scholar
  • 18 Herfarth Ch, Stern J. The ileum pouch: indications, technics and long-term results.  Dtsch Med Wochenschr. 1991;  116 1485
    PubMedGoogle Scholar
  • 19 Heuschen G, Heuschen U, Herfarth Ch. Primär sklerosierende Cholangitis - Colitis ulcerosa-assoziierte Erkrankung mit chirurgischen Konsequenzen.  Chirurg. 1998;  69 1028-1034
    CrossrefPubMedGoogle Scholar
  • 20 Heuschen U, Heuschen G, Stern J, Herfarth Ch. Onkologische Aspekte der chirurgischen Therapie der Colitis ulcerosa. In: Schumpelick V, Schippers E (Hrsg). Pouch - Grundlagen, Funktion, Technik. Ergebnisse. Springer, Heidelberg, Berlin 1998; 441-446
    Google Scholar
  • 21 Heuschen U A, Heuschen G, Herfarth Ch. Lebensqualität nach Proktokolektomie wegen Colitis ulcerosa.  Chirurg. 1998;  69 1045-1051
    PubMedGoogle Scholar
  • 22 Heuschen U A, Heuschen G, Lucas M, Hinz U, Stern J, Herfarth Ch. Prä- und postoperative Lebensqualität von Patienten mit Colitis ulcerosa und familiärer adenomatöser Poyposis bei ileoanaler Pouchoperation.  Chirurg. 1998;  69 1329-1333
    CrossrefPubMedGoogle Scholar
  • 23 Heuschen U A, Heuschen G, Rudek B, Hinz U, Stern J, Herfarth Ch. Lebensqualität im Langzeitverlauf nach kontinenzerhaltender Proktokolektomie wegen Colitis uclerosa und familiärer adenomatöser Polyposis.  Chirurg. 1998;  69 1052-1058
    PubMedGoogle Scholar
  • 24 Heuschen U A, Heuschen G, Stern J, Kienle P. et al .Backwash ileitis in ulcerative colitis - new aspects n the assessment of the disease. In: Andus T, Goebell H, Layer P, Schölmerich J (eds). Falk Symposium 96: Inflammatory bowel diseases - from bench to bedside. Kluver, Dordrecht, Boston, London 1996; 245
    Google Scholar
  • 25 Hosie K B, Sachaguchi M, Tudor R, Gourevitch D, Kmiot W, Keighley M R B. Pouchitis after restorative proctocolectomy is associated with mucosal ischemia.  Gut. 1989;  30 A1471
    PubMedGoogle Scholar
  • 26 Hulten L. Pouch workshop: pouchitis-incidence and characteristics in the continent ileostomy.  Int J Colorectal Dis. 1989;  4 208
    PubMedGoogle Scholar
  • 27 Keighley M R, Yoshioka K, Kmiot W, Heyen F. Physiological parameters influenceing function in restorative proctocolectomy and ileo-pouch-anal anastomosis.  Br J Surg. 1988;  75 997-1002
    PubMedGoogle Scholar
  • 28 Keighley M R B. Abdominal mucosectomy reduces the incidence of soiling and sphincter damage after restorative proctocolectomy and J pouch.  Dis Colon Rectum. 1987;  30 386-390
    PubMedGoogle Scholar
  • 29 Keränen U, Luukonen P, Järvinen H. Functional results after restorative proctocolectomy complicated by pouchitis.  Dis Colon Rectum. 1997;  40 752-759
    PubMedGoogle Scholar
  • 30 Körsgen S, Keighley M R B. Causes of failure and life expactancy of the ileoanal pouch.  Int J Colorectal Dis. 1997;  12 4
    CrossrefPubMedGoogle Scholar
  • 31 Kroesen A J, Stern J, Buhr H J, Herfarth Ch. Incontinence after ileo-pouch-anal anastomosis.  Chirurg. 1995;  66 385-391
    PubMedGoogle Scholar
  • 32 Laverey I C, Sirimarci M T, Ziv Y, Fazio V W. Anal canal inflammation after ileal pouch-anal anstomosis. The need for treatment.  Dis Colon Rectum. 1995;  38 803-806
    CrossrefPubMedGoogle Scholar
  • 33 Lerch M M, Braun J, Hander M. et al . Postoperative adaptation of the small intestine after total colectomy and J pouch-anal anastomosis.  Dis Colon Rectum. 1989;  32 600
    CrossrefPubMedGoogle Scholar
  • 34 Levin K E, Pemberton J H, Philips S F. et al . Role of oxygen free radicals in the aetiology of pouchitis.  Dis Colon Rectum. 1992;  35 452
    PubMedGoogle Scholar
  • 35 Lindquist K. Anal monometry with microtransducer technique before and after restorative proctocolectomy.  Dis Colon Rectum. 1990;  33 91-98
    PubMedGoogle Scholar
  • 36 Lohmüller J L, Pemberton J H, Dozois R R. et al . Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis.  Ann Surg. 1990;  211 622-629
    PubMedGoogle Scholar
  • 37 Luukonen P. Manometric follow up of anal sphincter function after an ileoanal pouch procedure.  Int J Colorect Dis. 1988;  3 43-46
    CrossrefPubMedGoogle Scholar
  • 38 Madden M V, McIntyre A, Nicholls R J. Double blind cross-over trial of metronidazole in chronic unremitting pouchitis.  Dis Dis Sci. 1994;  39 1193
    PubMedGoogle Scholar
  • 39 McHuge S M, Diamant N E, McLeod R, Cohen Z. S-pouches vs. J-pouches. A comparison of functional outcomes.  Dis Colon Rectum. 1987;  30 I-677
    PubMedGoogle Scholar
  • 40 McRae H M, McLeod R S, Cohen Z, O'Connor B I, Ton E N C. Risk factors of pelvic pouch failure.  Dis Colon Rectum. 1997;  40 257
    PubMedGoogle Scholar
  • 41 Meuwissen S C M, Hoitsma H, Boot H, Seldenrijl C A. Pouchitis (Pouch ileitis).  Neth J Med. 1989;  35 554
    PubMedGoogle Scholar
  • 42 Mignon M, Stettler C, Phillips S F. Pouchitis - a poorly understood entity.  Dis Colon Rectum. 1995;  38 100-103
    PubMedGoogle Scholar
  • 43 Morgado P J, Wexner S D, James K. et al . Ileal pouch-anal anastomosis: is properative anal manometry predictive of postoperative functional outcome?.  Dis Colon Rectum. 1994;  37 224-228
    CrossrefPubMedGoogle Scholar
  • 44 Moskowitz R L, Shepherd N A, Nicholls R J. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir.  Int J Colorectal Dis. 1986;  1 167
    CrossrefPubMedGoogle Scholar
  • 45 Nasmyth D G, Godwin P G R, Dixon M F, Williams N S, Johnston D. Ileal ecology after pouch anal anastomosis or ileostomy.  Gastroenterology. 1989;  96 817
    PubMedGoogle Scholar
  • 46 Nasmyth D G, Johnston D, Williams N S. Comparison of the function of triplicated and duplicated pelvic ileal reservoir after mucosal proctectomy and ileoanal anastomosis for ulcerative colitis and adenomatous polyposis.  Br J Surg. 1986;  73 361-366
    PubMedGoogle Scholar
  • 47 O'Connell P R, Rankin D H, Weilan L H, Kelly K H. Enteric bacteriology, absorption, morphology and emptying after ileal pouch anal anastomosis.  Br J Surg. 1986;  73 909
    PubMedGoogle Scholar
  • 48 O'Connell P R, Stryker S J. et al . Anal cancal pressure and motility after ileal anastomosis.  Surg Gynecol Obstet. 1988;  166 47-54
    PubMedGoogle Scholar
  • 49 Öresland T, Fasth S, Akervall S, Nordgren S, Hulten L. Manovolumetric and sensory characteristics of ileoanal J pouch compared with healthy rectum.  Br J Surg. 1990;  77 803-806
    PubMedGoogle Scholar
  • 50 Ozuner G, Hull T, Lee P Y, Fazio V W. What happens to a pelvic pouch when a fistuly develops?.  Dis Colon Rectum. 1997;  40 543-547
    PubMedGoogle Scholar
  • 51 Parks A G, Nicholls R J. Proctocolectomy without ileostomy for ulcerative colitis.  Br Med J. 1978;  2 85-88
    CrossrefPubMedGoogle Scholar
  • 52 Pemberton J H. Surgery for ulcerative colitis.  Surg Clin North Am. 1987;  67 633-650
    PubMedGoogle Scholar
  • 53 Penna C, Dozois R R, Tremaine W, Sandborn W. et al . Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis.  Gut. 1996;  38 504
    PubMedGoogle Scholar
  • 54 Pescatori M. The results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease.  World J Surg. 1992;  16 872-879
    PubMedGoogle Scholar
  • 55 Proniov A, Montesani C, Vecchione A, Giovagnoli M G. et al . Restorative proctocolectomy.  Hepatogastroenterol. 1997;  44 691
    PubMedGoogle Scholar
  • 56 Rubinstein M C, Fisher R L. Pouchitis, pathogenesis, diagnosis and management.  Gastroenterologist. 1996;  4 129
    PubMedGoogle Scholar
  • 57 Sagar P M, Dozois R R, Wolff B G, Kelly K A. Disconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis.  Br J Surg. 1996;  83 1401-1405
    CrossrefPubMedGoogle Scholar
  • 58 Sandborn W J, Tremaine W J, Batts K P. et al . Pouchitis after pouch-anal anastomosis.  Mayo Clin Proc. 1994;  69 410
    PubMedGoogle Scholar
  • 59 Schippers E, Braun J, Willis S, Schumpelick V. Die direkte ileumpouchanale Anastomose bei der CU.  Zentralbl Chir. 1998;  123 381-387
    PubMedGoogle Scholar
  • 60 Schmitt S L, Cohen S M, Wexner S D, Nogueras J J, Jegelman D G. Does laparoscopic-assisted ileal pouch anal anastomosis reduce the length of hospitalization?.  Int J Colorectal Dis. 1994;  9 134-137
    CrossrefPubMedGoogle Scholar
  • 61 Seow-Choen A, Tsunoda A, Nicholls R J. Prospective randomized trial comparinganal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy.  Br J Surg. 1991;  78 430-434
    CrossrefPubMedGoogle Scholar
  • 62 Sequens R. Cancer in the anal canal (transitional zone) after restorative proctocolectomy with stapled ileal pouch-anal anastomosis.  Int J Colorectal Dis. 1997;  12 254
    CrossrefPubMedGoogle Scholar
  • 63 Sharp F R, Bell G A, Seal A M, Atkonsonv K G. Investigations of the anal sphincter before and after restorative proctocolectomy.  Am J Surg. 1987;  153 469-472
    CrossrefPubMedGoogle Scholar
  • 64 Stern H, Walfish S, Mullen B, McLeod R. et al . Cancer in an ileal anal reservoir. A new late complication?.  Gut. 1990;  31 473
    CrossrefPubMedGoogle Scholar
  • 65 Stern J, Buhr H J, Herfarthv Ch. Chirurgische Therapie der CU - neue technische und pathophysiologische Aspekte.  Internist. 1991;  32 540-548
    PubMedGoogle Scholar
  • 66 Stern J, Heuschen U, Heuschen G, Rudek B, Herfarth Ch. Technische Modifikationen der ileoanalen Pouchoperation. In: Schumpelick V, Schippers E (Hrsg). Pouch - Grundlagen, Funktion, Technik. Ergebnisse. Springer, Heidelberg, Berlin, New York 1998; 419-423
    Google Scholar
  • 67 Takesue Y, Yokoyama T. et al . Influence of ileal pouch capacity and anal sphincter function on the clinical outcome after ileal pouch-anal anastomosis.  Surg Today. 1997;  27 392-397
    PubMedGoogle Scholar
  • 68 Thibault C, Poulin E C. Total laparoscopic proctocolectomy and laparoscopy-assisted proctocolectomy for inflammatory bowel disease.  Surg Laparosc Endosc. 1995;  5 472-467
    PubMedGoogle Scholar
  • 69 Thompson- Fawcett M, Mortensen N J. Anal transitional zone and columnar cuff in restorative proctocolectomy.  Br J Surg. 1996;  83 1047-1055
    PubMedGoogle Scholar
  • 70 Tsunoda A, Talbot I C, Nicholls R J. Incidence of dysplasia in the anal mucosa in patients having restorative colectomy.  Br J Surg. 1990;  77 506-508
    CrossrefPubMedGoogle Scholar
  • 71 Utsonomiya J. Ileoanal anastomosis with ilal reservoir. J-Pouch. In: Fielding LP, Goldberg SM (eds). Rob & Smith's operative surgery of the colon, rectum and anus. Buterworth and Heineman, London 1994; 629 -649
    Google Scholar
  • 72 Utsunomiya J, Iwama T, Imajo J. et al . Total colectomy, mucosal proctectomy and ileoanal anastomosis.  Dis Colon Rectum. 1980;  23 459-466
    PubMedGoogle Scholar
  • 73 Vieth M, Grunewald M, Niemeyer C, Stolte M. Adenocarcinoma in an ileal pouch after prior proctocolectomy for carcinoma in a patient with ulcerative colitis pancolitis.  Virchows Arch. 1998;  433 218-222
    PubMedGoogle Scholar
  • 74 Wexner S D, Gensen L, Rotrenberger D A, Wong W D, Goldberg S M. Long-term functional analysis of the ileal reservoir.  Dis Colon Rectum. 1989;  32 275-281
    PubMedGoogle Scholar
  • 75 Williams N S, Johnston D. The current status of mucosal proctectomy and ileo-anal anastomosis in the surgical treatment of ulcerative colitis and adenomatous polyposis.  Br J Surg. 1985;  72 159-168
    PubMedGoogle Scholar
  • 76 Winter T A, Dalton H R, Merrett M N. et al . Cyclosporin A retention enemas in refractory distal ulcerative colitis and pouchitis.  Scand J Gastroenterol. 1993;  28 701
    PubMedGoogle Scholar

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Priv.-Doz. Dr. Jan Schmidt

Chirurgische Universitätsklinik Heidelberg

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