IBD: Elective Surgical Management in Patients with Ulcerative Colitis-How Many Stages?

Pt population

Intervention

Comparator

Outcomes studied

Ulcerative colitis patient Undergoing ileo-anal procedure

Omission of diverting Stoma

Diversion of fecal stream

Anastomotic leaks, pelvic sepsis, long-term function, cost, length of hospital stay

Table 5.2

Total colectomy as initial operation

Pt population	Intervention	Comparator	Outcomes studied
Ulcerative colitis patient Undergoing initial surgery	Total abdominal Colectomy as initial operation	Ileo-anal anastomosis as initial operation	Anastomotic leaks, pelvic sepsis, long-term function, cost, length of hospital stay

1.

When constructing the ileal pouch-anal reservoir and performing the ileoanal anastomosis, should the fecal stream be diverted from the pouch and the anastomosis with a loop ileostomy to allow for healing?
2.

In patients who are temporarily debilitated, should a total abdominal colectomy with end ileostomy and de-functionalized Hartmann’s pouch be performed to allow for physiologic recovery prior to undertaking the more risky reservoir construction and ileoanal anastomosis?

This chapter will review each of these controversies.

Search Strategy

A medline Ovid database search was performed on publications from 1985 through October 2015 comparing ileal pouch-anal anastomosis with or without diverting loop ileostomy. MeSH search headings utilized: restorative proctocolectomy, ileo-anal, ileo-anal anastomosis, ileal pouch, ileal reservoir, ileostomy, loop ileostomy and infliximab. References found from these articles were also searched and reviewed. Additionally “Find Citing Articles” function was utilized to further enhance the extent of the search.

Results

Diverting Loop Ileostomy

Multiple reports have been published regarding the value of diverting loop ileostomy when performing pouch construction and creating the ileoanal anastomosis. No definitive conclusive study exists as each of these studies is flawed by either a lack of adequate numbers, poor study design, or significant bias. Many studies are retrospective reports comparing only highly selected cases. Case control studies do exist, but again in most instances these studies involve highly selected patients or insufficient numbers. Further complicating matters, the results of these studies have been conflicting. Some studies suggest an increased risk for anastomotic leaks and pelvic sepsis when the diverting stoma is omitted [7–12] while other studies suggest that the presence of the stoma does not affect the rate of anastomotic complications [13–29]. The studies supporting and opposing the use of a temporary diverting stoma are listed in Tables 5.3 and 5.4.

Table 5.3

Studies supporting the use of diverting stomas

Author	Date	Study type	Patients with stoma	Patients without stoma	Quality of evidence
Cohen et al. [7]	1992	Retrospective, selected	87	71	Low
Tjandra et al. [8]	1993	Matched controls	50	50	Moderate
Williamson et al. [9]	1997	Selected	50	50	Low
Kienle et al. [10]	2003	Prospective cohort, Selected	27	32	Low
Weston-Petrus [11]	2008	Meta-analysis			Moderate
Mennigen et al. [12]	2011	Selected, retrospective	89	33	Low

Table 5.4

Studies supporting omission of diverting stoma

Author	Date	Study type	Patients with stoma	Patients without stoma	Quality of evidence
Everett et al. [13]	1990	Selected	35	29	Low
Matikainen et al. [14]	1990	Consecutive	21	25	Low
Galandiuk et al. [15]	1991	Retrospective matched controls, selected	37	37	Low
Grobler et al. [16]	1992	Randomized control study, selected	23	22	Low
Sagar et al. [17]	1992	Consecutive, selected	28	30	Very Low
Gorfine et al. [18]	1995	Retrospective, selected	69	74	Low
Gullberg et al. [19]	1995	Consecutive	7	13	Low
Hainsworth et al. [20]	1998	Selected	30	72	Low
Antos et al.	1999	Selected	20	23	Low
Dolgin et al. [22]	1999	Consecutive, prospective nonrandomized	14	16	Low
Mowschenson et al. [23]	2000	Retrospective, selectided	28	102	Low
Heuschen et al. [24]	2001	Matched controls, selected	144	57	Moderate
Lepisto et al. [25]	2002	Retrospective	154	332	Moderate
Ikeuchi et al. [26]	2005	Retrospective, selected	92	150	Low
Remzi et al. [27]	2006	Retrospective, selected	1725	277	Low
Joyce [28]	2010	Retrospective	715	120	Low
Gray et al. [29]	2012	Selected	28	22	Low

A common design strategy employed in many of these reports is to allow the operative surgeon to make a judgment regarding the need for the loop ileostomy (those with “selected” study designs as designated in Tables 5.3 and 5.4). The surgeon therefore decides who is at high risk and then places these patients in the diverted group and patients judged to be a low risk are placed in the un-diverted group. While this strategy may well be a reasonable approach in the management for patients undergoing surgery for ulcerative colitis, when applied to a clinical study, this method of patient selection creates bias such that interpretation of the results can be difficult. So when such studies show no difference between the two groups, it would be difficult to conclude that there is no benefit to the loop ileostomy.

The absence of a difference between the two groups may result from the loop ileostomy effectively taking high risk patients and decreasing their risk to that of the lower risk group. It should also be noted that there are several studies with results that would indicate that even in patients selected in this manner, those without a loop ileostomy have an inferior outcome [7, 9, 12].

So one can really only claim that patients judged to be at low risk for anastomotic complications will do as well as a high risk cohort when the loop ileostomy is omitted.

There is only one randomized controlled trial looking at the value of diverting loop ileostomy in restorative proctocolectomy [16]. But this study was markedly underpowered with only 23 patients in the loop ileostomy group and 22 patients in the un-diverted group. In each group there is only one incidence of anastomotic leak; even with this study the patients that were randomized had been preselected by the operating surgeon as having had a low risk for anastomotic leak.

Perhaps the best the available study to suggest that loop ileostomy may not be necessary is a matched-pair controlled study conducted by Heuschen et al. [24] In this study 57 patients in the study group (no diversion) were compared to 114 matched controls. Heuschen et al. found no significant differences in early complications including pouch related septic complications. Conversely, Tjandra, et al., also reported a study with matched controls with 50 patients in each group and found a 14 % risk for anastomotic leak and pelvic sepsis in patients who had not been diverted compared to 4 % in the controls [8].

In 2008, Weston-Petrides published a meta-analysis for the data available from 1978 through 2005 from all comparative studies looking at restorative proctocolectomy with or without covering ileostomy [11]. This analysis indicated that restorative proctocolectomy without a diverting loop ileostomy resulted in similar long-term functional results but was associated with an increased risk for anastomotic leak and pelvic sepsis. The conclusion of the authors was that the loop ileostomy should only be omitted in carefully selected patients.

The goal of avoiding an anastomotic leak is worthwhile as poor anastomotic healing has major consequences both in the short and long term. Pelvic sepsis after ileal pouch-anal anastomosis has significant effects on long-term outcomes. For instance, patients who experience pelvic sepsis are five times more likely to require excision of their pouches when compared to those patients who avoided anastomotic leakage and pelvic sepsis [1, 30, 31]. Those patients who have pelvic sepsis but are able to retain their pouches are more likely to have anal incontinence [1].

While many of the studies looking at the value of fecal diversion focus on the risk for anastomotic leak, there are other considerations that come into play when deciding which operative strategy is best for the patient. Studies looking at the total length of stay and total costs have favored the approach of performing the ileoanal anastomosis without a loop ileostomy. While performing the operation in a single step tends to lead to a longer initial hospitalization, when the length of hospital stay for the reversal of the loop ileostomy is taken into account, the total hospitalization is shorter with the one step approach [9, 12, 14, 16–18, 20, 21, 26, 28]. Additionally total costs have been shown to be lower in those patients undergoing the procedure without a diverting loop ileostomy [28].

When considering a staged approach the morbidity associated with the loop ileostomy itself must also be considered [32]. Some have suggested that the overall morbidity associated with loop ileostomy is substantial [33], but others have noted that severe complications are not frequent [34]. Additionally a large study published in 2005 involving 1504 patients from the Cleveland Clinic demonstrated that closure of the ileostomy can be accomplished with an overall complication rate of 11.4 % and a risk of intra-abdominal sepsis of only 1 % [35].

Initial Colectomy Prior to IPAA

The value of an initial total abdominal colectomy prior to ileal pouch-anal anastomosis in patients with intra-abdominal sepsis or severe co-morbid disease has not been subject to comparative studies, as the risks to these sick patients would be difficult to justify. However, reports of patients who have undergone either a two or three step approach have identified certain parameters under which a three stage approach would be prefered [36–38]. Traditionally these have included urgent surgery, sepsis, fulminate disease, anemia, hypoalbuminemia, steroids, and uncertain diagnosis [3, 5, 38, 39].

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