The Evaluation of Postoperative Patients with Ulcerative Colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the standard surgical treatment modality for patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Normally staged pouch surgery is performed. Endoscopy plays an important role in postoperative monitoring of disease status and delivery of therapy, if necessary. Therefore, ileal pouch surgery significantly alters bowel anatomy, with new organ structures being created. Endoscopy of the altered bowel includes the evaluation of end ileostomy, Hartmann pouch or diverted rectum, loop ileostomy, diverted pouch, and pouchoscopy. Each segment of the bowel has unique landmarks.

Key points

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Restorative proctocolectomy with ileal pouch-anal anastomosis has become the standard surgical treatment modality for patients with ulcerative colitis or familial adenomatous polyposis who require colectomy.
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Normally staged pouch surgery is performed. The classic 2-stage restorative proctocolectomy involves (1) total proctocolectomy, the creation of a J or S pouch with anastomosis to a short rectal stump, and loop ileostomy and (2) closure of loop ileostomy.
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In patients with severe colitis and strong immunosuppression, a 3-stage surgery is advocated, which consists of (1) subtotal colectomy and end ileostomy; (2) ileal pouch construction and anastomosis, loop ileostomy; and (3) closure of the loop ileostomy.
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Endoscopy plays an important role in postoperative monitoring of disease status and delivery of therapy, if necessary.
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Ileal pouch surgery significantly alters bowel anatomy, with new organ structures being created.
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Endoscopy of the altered bowel includes the evaluation of end ileostomy, Hartmann pouch or diverted rectum, loop ileostomy, diverted pouch, and pouchoscopy.
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Each segment of the bowel has unique landmarks. It is important for endoscopists to be familiar with those landmarks and recognize the status of healthy and diseased.

Introduction

The last 2 decades have witnessed a great progress in medical therapy for inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC). The availability and wide use of anti–tumor necrosis factor (TNF) and anti-integrin biological agents have revolutionized the management of IBD. However, approximately 20% to 30% of patients with UC will eventually need colectomy for medically refractory disease or colitis-associated neoplasia. Restorative proctocolectomy (RTC) with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with UC who require colectomy. RTC and IPAA are technically challenging procedures with a risk for the development of various forms of complications. In addition, inflammatory and even neoplastic conditions can develop after colectomy. In most patients, their underlying IBD is still not considered as being cured after RPC and IPAA.

One-stage RPC and IPAA are rarely offered to patients. The standard 2-stage RPC involves (1) total proctocolectomy (TPC), the creation of a J or S pouch with anastomosis to rectal stump, and loop ileostomy (LI) and (2) closure of LI. In patients with severe colitis and strong immunosuppression, a 3-stage surgery is advocated, which consists of (1) subtotal colectomy (STC) leaving a diverted rectum, also named Hartmann pouch, and end ileostomy (EI); (2) ileal pouch construction and anastomosis and LI; and (3) closure of LI. The staged procedures create de novo anatomic structures, including Hartmann pouch, EI, LI, diverted pouch, and connected pouch. Various disease conditions can occur in those segments of the bowel. Anatomic classification of surgery-altered bowel in UC is listed in Table 1 .

Table 1

Bowel anatomy after colectomy for ulcerative colitis

Name	Configuration	Duration of Creation	Purpose of Creation
Ileostomy	End ileostomy	Temporary	Primary (for setting stage for subsequent pouch surgery)
	End ileostomy	Permanent	Primary (for those with colectomy without intention for having an ileal pouch) Secondary (due to failed pouch)
	Loop ileostomy	Temporary	Setup for subsequent initial pouch construction or pouch revision surgery
Pouch	Hartmann pouch	Temporary	Equivalent to diverted rectum
	Diverted pouch		Primary (set-up stage for initial construction or pouch revision)
	Diverted pouch	Permanent	Secondary (due to pouch failure with permanent fecal diversion)
	Connected pouch	Permanent	Functioned pouch

Proctoscopy for Hartmann Pouch

In patients with severe or fulminant colitis, STC, rather than TPC, should be performed. With the extensive immunosuppressive agents, such as corticosteroids and anti-TNF agents, there have been concerns for the increased risk for postoperative infectious complications. The first of the 3-stage RPC and IPAA involves STC, EI, and Hartmann pouch reduce the risk for postoperative infectious complications. The length of a Hartmann pouch can be 10 to 25 cm, depending on the degree of the concern of stump leak. For patients with severe colitis and a significant concern of stump leak, surgeons temporarily leave a long rectal stump, which is connected to the abdominal fascia, to reduce the risk for intrapelvic abscess in case stump leaks.

Diversion proctitis can develop, largely because of the lack of nutrients from luminal bacteria to the rectal mucosa. Patients may present with pelvic discomfort and pain, urgency, and mucous or bloody discharge. On endoscopy, there can be extremely friable mucosa, even with minimum air insufflation, edema, erythema, ulcers, nodularity, and exudates ( Fig. 1 A ). Histology of diversion proctitis is characterized by the presence of diffuse lymphoid hyperplasia.

In non-IBD patients, the best treatment option for diversion proctitis is the restoration of fecal continuity. In patients for undergoing for RPC and IPAA, Hartmann pouch or diversion pouchitis is a temporary measure. Symptomatic patients may be treated with topical mesalamine, corticosteroids, or short-chain fatty enema.

Ileoscopy Via Stoma for End Ileostomy

In patients with UC with RPC and IPAA, EI is usually created in the following 2 settings: (1) as an initial temporary part of a 3-stage pouch surgery, with an intention to convert LI during pouch construction or (2) as a permanent diversion in patients who elect not to have a pouch after TPC (the primary EI) or in those with a failed pouch due to various mechanical, inflammatory, or neoplastic complications (the secondary EI).

Ileoscopy via stoma for patients with a temporary EI is needed before pouch construction and conversion of EI to LI for the purpose of ruling out CD of the small bowel, although inflammation and/or ulcers are extremely rare in patients with UC undergoing colectomy. Mucosal biopsy is still needed. In rare occasions, postcolectomy enteritis syndrome can occur soon after colectomy in patients with the primary EI and a preoperative diagnosis of UC. The patients with this disease entity may present with significant increased ileostomy output, dehydration, and malnutrition. On endoscopy, this syndrome is characterized with diffuse mucosal inflammation, which is different from the segmental inflammation in CD.

Pouch failure is defined as permanent fecal diversion with the secondary EI, pouch excision, or pouch revision. Patients with permanent secondary EI due to pouch failure should be closely monitored for disease recurrence, particularly CD-associated inflammation, ulcers, and stricture.

Ileoscopy Via Stoma for Loop Ileostomy

In most cases, LI is created for a temporary purpose with an intention of anticipated closure. Despite the difficulty in the management of stoma, with a higher risk for stomal or peristomal complications than EI, it offers an easier closure procedure than the EI. In staged pouch surgery, LI is created to allow for the maturation of the anastomosis and other sutures of a newly constructed pouch. LI is occasionally performed as a part of treatment of mechanical or inflammatory complications of the pouch to cool down the disease by fecal diversion. In both cases, ileoscopy via stoma to the afferent limb of LI is needed for all patients before undergoing LI closure to rule out CD. Inflammation, ulcers, or strictures in the distal bowel segment through the abdominal wall are not necessarily CD and may result from ischemia.

Pouchoscopy for Diverted Pouch

In the staged pouch surgery, patients typically carry a diverted pouch for 3 to 6 months before restoration of fecal continuity. Because of the lacking nutrients from luminal bacteria, diversion pouchitis is common, which is characterized by erythema, edema, friability, erosions, and ulcers (see Fig. 1 B).

Permanent fecal diversion with ileostomy and pouch in situ is routinely performed in patients with pouch failure. It has been controversial in the management of diverted pouch in long-term, excision of the failed pouch versus keep the pouch in situ. The excision of the pouch is a technically demanding surgery, involving removal of pouch as well as internal and external anal sphincter muscles. Its associated complications include stump leak, sinus, and abscess. Occasionally small bowel obstruction can occur due to the location of stoma and the downward displacement of the space of pouch body with the distal small bowel. On the other hand, keeping the pouch in situ can also have issues, particularly diversion pouchitis, distal pouch stricture, and the risk for neoplasia. Patients with diversion pouchitis can present with excessive discharge of mucus and/or bloody material, urgency, incontinence, abdominal cramps. Long-term diversion increases the risk for the development of the distal pouch or anastomotic stricture. A severe stricture can result in a completely sealed pouch outlet with accumulation of large quantity of liquid luminal contents or even bezoar, which can lead to abdominal and pelvic discomfort and pain ( Fig. 2 ). As the mucosa is often friable, endoscopy for the diverted pouch should be carefully performed, with a minimum air insufflation and avoidance of deep biopsy. The stricture can be treated with endoscopic balloon dilation or endoscopic needle knife stricturotomy. The latter with a targeted spot and depth of treatment seems to be less invasive and more effective.

There are no published data on the prevalence or incidence of neoplasia of diverted pouch, anal transitional zone (ATZ) or cuff in patients with UC or FAP. Because the prognosis of pouch cancer is poor, this author recommends that patients at high risk, such as those with a precolectomy diagnosis of colon neoplasia or FAP, should have a yearly pouchoscopy with biopsy, even in those with mucosectomy during IPAA surgery. Special attention should be paid to the ATZ and cuff.

Pouchoscopy for Connected Pouch

The purpose of pouchoscopy here are severalfold: (1) diagnosis of mechanical and inflammatory complications of the pouch, (2) surveillance for neoplasia, and (3) delivery of endoscopic therapy. The common mechanical complications of IPAA surgery can roughly be divided into 2 categories: (1) obstruction and (2) leak. The obstructive disease conditions include (1) strictures at the anastomosis, pouch body, inlet, and afferent limb and LI site; (2) angulation of bowel loop, such as afferent limb and efferent limb syndromes; and (3) twisted pouch and pouch prolapse. The leak conditions of the pouch include acute and chronic complications, including acute anastomotic leak with or without abscess or pelvic sepsis and chronic leak with sinus. The common locations of the leak are the tip of the J and anastomosis. In the latter condition, there can be presacral sinus posteriorly and pouch vaginal fistula anterior. This author recommends that in patients with suspected surgery-associated mechanical complications, abdominal/pelvic imaging is needed to provide the roadmap for the subsequent diagnostic and/or therapeutic pouchoscopy. The mechanical complications of the pouch, which may be amenable for endoscopic therapy, include strictures (treated with endoscopic balloon dilation or needle knife stricturotomy), presacral sinus (treated with needle knife sinusotomy), and the leak at the tip of the J (treated with over-the-scope clipping system).

The main inflammatory complications of the IPAA are pouchitis, CD of the pouch (CDP), and cuffitis. Endoscopy is the most important diagnostic modality for those disorders. The endoscopy should carefully examine all segments and landmarks of IPAA, including LI site, afferent limb, pouch inlet, tip of the J, pouch body, and ATZ or cuff, along with perianal regions. The distribution and severity of inflammation and the location of stricture or fistula should be carefully documented. The Pouchitis Disease Activity Index with its endoscopy subscore has been used for the assessment of the degree of inflammation in pouchitis, which is also extrapolated into CDP or cuffitis.

It is thought that the cause and pathogenesis of pouchitis are related to dysbiosis and dysregulated mucosal immunity. The genetic factors and surgery-associated ischemia may play a role in a subset of patients. Pouchitis may be classified into 3 main categories based on etiopathogenesis: (1) microbiota-associated pouchitis, (2) immune-mediated pouchitis, and (3) ischemia-associated pouchitis. Endoscopic features, particularly the distribution pattern of inflammation, may provide clues for the cause of pouchitis. Inflammation of dysbiosis-associated pouchitis is usually limited to the pouch body, sparing the afferent limb and cuff. Inflammation of immune-mediated pouchitis usually involves both the pouch body and afferent limb and in some cases the cuff. The classic example of immune-mediated pouchitis is primary sclerosing cholangitis (PSC)-associated pouchitis/enteritis with the presence of a long segment of enteritis above the pouch inlet in addition to diffuse pouch inflammation. Ischemic pouchitis is presented with asymmetric distribution of inflammation; and inflammation may only involve the afferent limb side of the pouch body, the distal pouch body only, or the suture line only ( Fig. 3 A–C ). For pouchitis, endoscopic biopsy is needed, not for grading inflammation, rather, for the assessment of features of pyloric gland metaplasia (indicating chronic mucosa injury), mucosal hemorrhage, cytomegalovirus, granulomas, and neoplasia.