Reoperative Inflammatory Bowel Disease Surgery

Rowena L. Ramirez; Phillip Fleshner

doi:10.1055/s-2006-956440

Clinics in Colon and Rectal Surgery, Table of Contents

Clin Colon Rectal Surg 2006; 19(4): 195-206
DOI: 10.1055/s-2006-956440

Reoperative Inflammatory Bowel Disease Surgery

Rowena L. Ramirez¹ , Phillip Fleshner¹

¹Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California

Abstract

ABSTRACT

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

KEYWORDS

Restorative proctocolectomy - pouch failure - salvage/reoperation - ulcerative colitis - recurrent Crohn's disease

Full Text

References

REFERENCES

1 Corman M. Colon and Rectal Surgery. 5th ed. Philadelphia; Lippincott, Williams, & Wilkins 2004: 1319-1535
2 Penner R, Madsen K, Fedorak R. Postoperative Crohn's disease. Inflamm Bowel Dis. 2005; 11 765-777
3 Fazio V W, Ziv Y, Church J M et al.. Ileal pouch anal anastomosis complications and function in 1005 patients. Ann Surg. 1995; 222 120-127
4 MacLean A, Cohen Z, MacRae H et al.. Risk of small bowel obstruction after the ileal pouch-anal anastomosis. Ann Surg. 2002; 235 200-206
5 Francois Y, Dozois R R, Kelly K A et al.. Small intestinal obstruction complicating ileal pouch-anal anastomosis. Ann Surg. 1989; 209 46-50
6 Becker J M, Dayton M T, Fazio V W et al.. Prevention of post-operative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg. 1996; 183 297-306
7 Kelly K A. Anal sphincter-saving operations for chronic ulcerative colitis. Am J Surg. 1992; 163 5-11
8 Becker J M. Ileal pouch-anal anastomosis: current status and controversies. Surgery. 1993; 113 599-602
9 Gemlo B T, Wong W D, Rothenberger D A et al.. Ileal pouch-anal anastomosis-patterns of failure. Arch Surg. 1992; 127 784-787
10 Korsgen S, Keighley M R. Causes of failure and life expectancy of the ileoanal pouch. Int J Colorectal Dis. 1997; 12 4-8
11 Bullard K M, Madoff R D, Gemlo B T. Is ileoanal pouch function stable with time? Results of a prospective audit. Dis Colon Rectum. 2002; 45 299-304
12 Meagher A P, Farouk R, Dozois R R, Kelly K A, Pemberton J H. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and outcome in 1310 patients. Br J Surg. 1998; 85 800-803
13 Tulchinsky H, Cohen C RG, Nicholls R J. Salvage surgery after restorative proctocolectomy. Br J Surg. 2003; 90 909-921
14 Tulchinsky H, Hawley P, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg. 2003; 238 229-234
15 Becker J M, Raymond J L. Ileal pouch-anal anastomosis: a single surgeon's experience with 100 consecutive cases. Ann Surg. 1986; 204 375-383
16 Sandborn W J. Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment. Gastroenterology. 1994; 107 1856-1860
17 Tekkis P P, Heriot A G, Smith J J, Das P, Canero A, Nicholls R J. Long-term results of abdominal salvage surgery following restorative proctocolectomy. Br J Surg. 2006; 93 231-237
18 Belliveau P, Trudel J, Vasilevsky C A et al.. Ileoanal anastomosis with reservoirs: complications and long-term results. Can J Surg. 1999; 42 345-352
19 Heuschen U A, Allenmeyer E H, Hinz U, Lucas M, Herfarth C, Heuschen G. Outcome after septic complications in J pouch procedures. Br J Surg. 2002; 89 194-200
20 Dayton M T, Larsen K P. Outcome of pouch-related complications after ileal pouch-anal anastomosis. Am J Surg. 1997; 174 728-732
21 Dehni N, Remacle G, Dozois R, Banchini F, Tiret E, Parc R. Salvage reoperation for complications after ileal pouch-anal anastomosis. Br J Surg. 2005; 92 748-753
22 Ziv Y, Fazio V W, Church J M, Lavery I C, King T M, Ambrosetti P. Stapled ileal pouch anal anastomoses are safer than hand-sewn anastomoses in patients with ulcerative colitis. Am J Surg. 1996; 171 320-323
23 Lee P Y, Fazio V W, Church J M, Hull T L, Eu K W, Lavery I C. Vaginal fistula following restorative proctocolectomy. Dis Colon Rectum. 1997; 40 752-759
24 Lindquist K, Nilsell K, Liljeqvist L. Cuff abscesses and ileoanal anastomotic separations in pelvic pouch surgery-an analysis of possible etiologic factors. Dis Colon Rectum. 1987; 30 355-359
25 Fazio V W, Wu J S, Lavery I C. Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment. Ann Surg. 1998; 228 588-597
26 Baixauli J, Delaney C, Wu J S et al.. Functional outcome and quality of life after repeat ileal pouch-anal anastomosis for complications of ileoanal surgery. Dis Colon Rectum. 2004; 47 2-11
27 Whitlow C B, Opelka F G, Gathright Jr J B, Beck D E. Treatment of colorectal and ileoanal anastomotic sinuses. Dis Colon Rectum. 1997; 40 760-763
28 Williamson M E, Lewis W G, Sagar P M, Hodlsworth P J, Johnston D. One stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: a note of caution. Dis Colon Rectum. 1997; 40 1019-1022
29 MacLean A R, O'Connor B, Parkes R, Cohen Z, McLeod R S. Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results. Dis Colon Rectum. 2002; 45 880-886
30 Dehni N, Cunningham C, Parc R. Use of a jejunal pouch with ileal interposition in salvage surgery after restorative proctocolectomy. Dis Colon Rectum. 1998; 41 1587-1589
31 Loriau J, Benoist A, Panis Y, Joly F, Messing B, Valleur P. Salvage of ileal pouch-anal anastomosis by a reversed jejunal segment. Surgery. 2005; 137 111-113
32 Galandiuk S, Scott N A, Dozois R R et al.. Ileal pouch-anal anastomosis. Reoperation for pouch-related complications. Ann Surg. 1990; 212 446-454
33 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
34 Korsgen S, Nikteas N, Ogunbiyi O A, Keighley M R. Results from pouch salvage. Br J Surg. 1996; 83 372-374
35 Ogunbiyi O A, Korsgen S, Keighley M R. Pouch salvage. Long-term outcome. Dis Colon Rectum. 1997; 40 548-552
36 Paye F, Penna C, Chiche L, Tiret A, Frileux P, Parc R. Pouch-related fistula following restorative proctocolectomy. Br J Surg. 1996; 83 1574-1577
37 Ozuner G, Hull T, Lee P, Fazio V W. What happens to a pelvic pouch when a fistula develops?. Dis Colon Rectum. 1997; 40 543-547
38 Cohen Z, Smith D, McLeod R. Reconstructive surgery for pelvic pouches. World J Surg. 1998; 22 342-346
39 Heriot A, Tekkis P, Smith J, Bona R, Cohen R, Nicholls R. Management and outcome of pouch-vaginal fistulas following restorative proctocolectomy. Dis Colon Rectum. 2005; 48 451-458
40 Shah N, Remzi F, Massmann A, Baixauli J, Fazio V. Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy. Dis Colon Rectum. 2003; 46 911-917
41 Keighley M, Grobler S. Fistula complicating restorative proctocolectomy. Br J Surg. 1993; 80 1065-1067
42 Wexner S D, Rothenberger D A, Jensen L et al.. Ileal pouch vaginal fistulas: incidence, etiology, and management. Dis Colon Rectum. 1989; 32 460-465
43 Groom J S, Nicholls R J, Hawley P R, Phillips R K. Pouch-vaginal fistula. Br J Surg. 1993; 80 936-940
44 O'Kelly T J, Merrett M, Mortensen N J, Dehn T C, Kettlewell M. Pouch-vaginal fistulas after restorative proctocolectomy: aetiology and management. Br J Surg. 1994; 81 1374-1375
45 Burke D, VanLaarhoven C J, Herbst F, Nicholls R J. Transvaginal repair of pouch vaginal fistula. Br J Surg. 2001; 88 241-245
46 Zinicola R, Wilkinson K H, Nicholls R J. Ileal pouch-vaginal fistula treated by abdominoanal advancement of the ileal pouch. Br J Surg. 2003; 90 1434-1435
47 Thompson J S, Quigley E M. Anal sphincteroplasty for incontinence after ileal pouch-anal anastomosis. Report of two cases. Dis Colon Rectum. 1995; 38 215-218
48 Fonkalsrud E W, Bustorff-Silva J. Reconstruction for chronic dysfunction of ileoanal pouches. Ann Surg. 1999; 229 197-204
49 Nicholls R J, Gilbert J M. Surgical correction of the efferent ileal limb for disordered defaecation following restorative proctocolectomy with the S ileal reservoir. Br J Surg. 1990; 77 152-154
50 Liljeqvist L, Lindquist K. A reconstructive operation on malfunctioning S-shaped pelvic reservoirs. Dis Colon Rectum. 1985; 28 506-511
51 Fazio V W, Tjandra J J. Transanal mucosectomy. Ileal pouch advancement for anorectal dysplasia or inflammation after restorative proctocolectomy. Dis Colon Rectum. 1994; 37 1008-1011
52 Tulchinsky H, McCourtney J, Subba Rao K et al.. Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis. Br J Surg. 2001; 88 1602-1606
53 Sequens R. Cancer in the anal canal (transitional zone) after restorative proctocolectomy with stapled ileal pouch-anal anastomosis. Int J Colorectal Dis. 1997; 12 254-255
54 Oresland T, Fasth S, Nordgren S, Akervall S, Hulten L. Pouch size, the important functional determinant after restorative proctocolectomy. Br J Surg. 1990; 77 265-269
55 Klas J, Myers G A, Starling J R, Harms B A. Physiologic evaluation and surgical management of failed ileoanal pouch. Dis Colon Rectum. 1998; 41 854-861
56 Hulten L, Fasth S, Hallgren T, Oresland T. The failing pelvic conversion to continent ileostomy. Int J Colorectal Dis. 1992; 7 119-121
57 Ecker K W, Haberer M, Feifel G. Conversion of the failing ileoanal pouch to reservoir-ileostomy rather than to ileostomy alone. Dis Colon Rectum. 1996; 39 977-980
58 Karoui M, Cohen R, Nicholls J. Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum. 2004; 47 869-875
59 Ryan J A. Gracilis muscle flap for persistent perineal sinus of inflammatory bowel disease. Am J Surg. 1984; 148 64-70
60 Rius J, Nessim A, Nogueras J J, Wexner S D. Gracilis transposition in complicated perineal fistula and unhealed perineal wounds in Crohn's disease. Eur J Surg. 2000; 166 218-222
61 Bernell O, Lapidus A, Hellers G. Risk factors for surgery and recurrence in 907 patients with primary ileocecal Crohn's disease. Br J Surg. 2000; 87 1697-1701
62 Borley N R, Mortensen N J, Jewell D P. Preventing post-operative recurrence of Crohn's disease. Br J Surg. 1997; 84 1493-1502
63 Keh C, Shatari T, Yamamoto T, Menon A, Clark M A, Keighley M R. Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease. Colorectal Dis. 2005; 7 366-368
64 Heimann T M, Grenstein A J, Lewis B, Kaufman D, Heimann D M, Aufses Jr A H. Comparison of primary and reoperative surgery in patients with Crohn's disease. Ann Surg. 1998; 227 492-495
65 Polle S W, Slors J FM, Weverling G J, Gouma D J, Hommes D W. Recurrence after segmental resection for colonic Crohn's disease. Br J Surg. 2005; 92 1143-1149
66 Krupnick A S, Morris J B. The long-term results of resection and multiple resections in Crohn's disease. Semin Gastrointest Dis. 2000; 11 41-51
67 Steinhart H. Maintenance therapy in Crohn's disease. Can J Gastroenterol. 2000; 14(Suppl C) 23C-28C
68 Ellis L, Calhoun P, Kaiser D L. Post-operative recurrence in Crohn's disease. The effect of the initial length of bowel resection and operative procedure. Ann Surg. 1984; 199 340-347
69 Pennington L, Hamilton S R, Bayless T M, Cameron J L. Surgical management of Crohn's disease. Influence of disease at margin of resection. Ann Surg. 1980; 192 311-318
70 Fazio V W, Marchetti F, Church M et al.. Effect of resection margin on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial. Ann Surg. 1996; 224 563-573
71 Tersigni R, Alessandroni L, Barreca M, Piovanello P, Prantera C. Does stapled functional end-to-end anastomosis affect recurrence of Crohn's disease after ileocolonic resection?. Hepatogastroenterology. 2003; 50 1422-1425
72 Hashemi M, Novell J R, Lewis A A. Side-to-side stapled anastomosis may delay recurrence in Crohn's disease. Dis Colon Rectum. 1998; 41 1293-1296
73 Munoz-Juarez M, Yamamoto T, Wolff B G, Keighley M R. Wide-lumen stapled anastomosis vs conventional end-to-end anastomosis in the treatment of Crohn's disease. Dis Colon Rectum. 2001; 44 20-26
74 Scarpa M, Angriman I, Barollo M et al.. Role of stapled and hand-sewn anastomosis in recurrence of Crohn's disease. Hepatogastroenterology. 2004; 51 1053-1057
75 Aeberhard P, Berchtold W, Riedtmann H J, Stadelmann G. Surgical recurrence of perforating and non-perforating Crohn's disease. A study of 101 surgically treated patients. Dis Colon Rectum. 1996; 39 80-87
76 Sachar D B, Subramani K, Mauer K et al.. Patterns of post-operative recurrence in fistulizing and stenotic Crohn's disease, a retrospective cohort of 71 patients. J Clin Gastroenterol. 1996; 22 114-116
77 Yamamoto T, Allan R N, Keighley M R. Perforating ileocecal Crohn's disease does not carry a high risk of recurrence but usually re-presents as perforating disease. Dis Colon Rectum. 1999; 42 519-524
78 McDonald P J, Fazio V W, Farmer R G et al.. Perforating and non-perforating Crohn's disease. An unpredictable guide to recurrence after surgery. Dis Colon Rectum. 1989; 32 117-120
79 Ryan W R, Yamamoto T, Keighley M R. Crohn's disease patients who quit smoking have a reduced risk of operation for recurrence. Am J Surg. 2004; 187 219-225
80 Bernell O, Lapidus A, Hellers G. Recurrence after colectomy in Crohn's colitis. Dis Colon Rectum. 2001; 44 647-654
81 Borley N R, Mortensen N J, Chaudry M A et al.. Recurrence after abdominal surgery for Crohn's disease: relationship to disease site and surgical procedure. Dis Colon Rectum. 2002; 45 377-383
82 Post S, Herfarth C, Bohm E et al.. The impact of disease pattern, surgical management, and individual surgeons on the risk for relaparotomy for recurrent Crohn's disease. Ann Surg. 1996; 223 253-260
83 Kumar D, Alexander-Williams J. Crohn's Disease and Ulcerative Colitis: Surgical Management. London; Springer-Verlag 1993: 89-101
84 Tichansky D, Cagir B, Yoo E, Marcus S M, Fry R D. Stricturoplasty for Crohn's disease: meta-analysis. Dis Colon Rectum. 2000; 43 911-919
85 Ozuner G, Fazio V W, Lavery I C, Milsom J W, Strong S A. Reoperative rates for Crohn's disease following stricturoplasty. Long-term analysis. Dis Colon Rectum. 1996; 39 1199-1203
86 Hurst R D, Michelassi F. Stricturoplasty for Crohn's disease: techniques and long-term results. World J Surg. 1998; 22 359-363
87 Futami K, Arima S. Role of stricturoplasty in surgical treatment of Crohn's disease. J Gastroenterol. 2005; 40(Suppl 16) 35-39
88 Tonelli F, Ficari F. Stricturoplasty in Crohn's disease: surgical option. Dis Colon Rectum. 2000; 43 920-926
89 Dietz D W, Laureti S, Strong S A et al.. Safety and long-term efficacy of stricturoplasty in 314 patients with obstructing small bowel Crohn's disease. J Am Coll Surg. 2001; 192 330-338
90 Shatari T, Clark M A, Yamamoto T et al.. Long stricturoplasty is as safe and effective as short stricturoplasty in small-bowel Crohn's disease. Colorectal Dis. 2004; 6 438-441
91 Tonelli F, Fedi M, Paroli G M, Fazi M. Indications and results of side-to-side isoperistaltic stricturoplasty in Crohn's disease. Dis Colon Rectum. 2004; 47 494-501
92 Tjandra J J, Fazio V W. Stricturoplasty for ileocolic anastomotic strictures in Crohn's disease. Dis Colon Rectum. 1993; 36 1099-1104
93 Yamamoto T, Keighley M R. Long-term results of stricturoplasty for ileocolonic anastomotic recurrence in Crohn's disease. J Gastrointest Surg. 1999; 3 555-560
94 Andersson P, Olaison G, Hallbrook O, Sjodahl R. Segmental resection or subtotal colectomy in Crohn's colitis?. Dis Colon Rectum. 2002; 45 47-53
95 Cattan P, Bonhomme N, Panis Y et al.. Fate of the rectum in patients undergoing total colectomy for Crohn's disease. Br J Surg. 2002; 89 454-459
96 Brown C, MacLean A, Cohen Z, MacRae H, O'Connor B, McLeod R. Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum. 2005; 48 1542-1549
97 Regimbeau J M, Panis Y, Pocard M et al.. Long-term results of ileal pouch-anal anastomosis for colorectal Crohn's disease. Dis Colon Rectum. 2001; 44 769-778
98 Mylonakis E, Allan R N, Keighley M R. How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis?. Dis Colon Rectum. 2001; 44 1137-1143
99 Lowney J, Dietz D, Birnbaum E, Kodner I, Mutch M, Fleshmen J. Is there any difference in recurrence rates in laparoscopic ileocolic resection for Crohn's disease compared with conventional surgery? A long-term follow-up study. Dis Colon Rectum. 2006; 49 58-63
100 Bergamaschi R, Pessaux P, Arnaud J P. Comparison of conventional and laparoscopic ileocolic resection for Crohn's disease. Dis Colon Rectum. 2003; 46 1129-1133
101 Rosman A S, Melis M, Fichera A. Meta-analysis of trials comparing laparoscopic and open surgery for Crohn's disease. Surg Endosc. 2005; 19 1549-1555
102 Gutt C N, Onui T, Schemmer P, Mehrabi A, Buchler M W. Fewer adhesions induced by laparoscopic surgery?. Surg Endosc. 2004; 18 898-906
103 Hasegawa H, Watanabe M, Nishibori H, Okabayashi K, Hibi T, Kitajima M. Laparoscopic surgery for recurrent Crohn's disease. Br J Surg. 2003; 90 970-973

Phillip FleshnerM.D.

8737 Beverly Blvd., Ste. 101, Los Angeles, CA 90048

Email: pfleshner@aol.com