Which Ulcerative Colitis Patients Should Not Have Ileal Pouch-Anal Anastomosis

Patients

Intervention

Comparator

Outcome

Patients with ulcerative colitis requiring operation

Proctocolectomy with ileal pouch-anal anastomosis

Proctocolectomy with end ileostomy

Health-related quality of life (HRQOL)

Search Strategy

A comprehensive literature search of Cochrane Database of Collected Research, EMBASE, MEDLINE, and PubMed was performed to identify all of the English-language publications related to ulcerative colitis, colectomy, and ileal pouch-anal anastomosis and quality of life (QOL) outcomes from 1985 to 2015. Key search terms included the following: “colectomy,” “colitis,” “ileal pouch-anal anastomosis,” “inflammatory bowel disease,” “proctocolectomy,” and “ulcerative colitis.” Studies were excluded if they did not directly contrast proctocolectomy with ileal pouch-anal anastomosis to proctocolectomy with ileostomy, failed to measure any component of health-related quality of life, included patients with Crohn’s disease or familial adenomatous polyposis, included only patients with ulcerative colitis plus specific conditions (e.g., primary sclerosing cholangitis), or included pediatric patients. Only the most recent study was included if similar studies from the same institution were encountered. The references of the included studies were reviewed to identify additional studies that were incorporated as appropriate.

Results

Over the past three decades, only a few studies have reported health-related quality of life outcomes in patients with ulcerative colitis undergoing proctocolectomy and ileal pouch-anal anastomosis or ileostomy. Some of the initial studies were plagued by poor methodology using quality of life metrics that had not been validated. However, reports published in past 15 years have tended to use validated global, generic, or disease-specific instruments to measure health-related quality of life [5–12].

Studies that employed global instruments to contrast health-related quality of life between patients who underwent proctocolectomy and ileal pouch-anal anastomosis or ileostomy reported conflicting results. Emblem and associates [5] used a non-validated questionnaire that showed patients managed by an ileostomy were markedly more likely to experience social restrictions. While McLeod et al. [6] found no differences in several global measures, Kuruvilla and colleagues [11] reported the Cleveland Global QOL was significantly better for patients with an ileal pouch-anal anastomosis, particularly related to current energy level and current quality of health.

Of the studies using a generic measure, no difference in scores was found between the two patient groups regardless whether the non-validated “lifestyle satisfaction score,” [7] validated EuroQol Group’s EQ-5D-3 L questionnaire [11], or validated Short Form (SF)-36 Health Survey [9, 10] was used. However, O’Bichere and associates [8] used a questionnaire developed in-house to specifically measure seven selected items, and they found patients with an ileostomy were significantly less bothered by altered bowel emptying and diet.

A disease-specific instrument, the Inflammatory Bowel Disease Questionnaire (IBDQ), was employed in three studies [9, 10, 12] and an abbreviated version, the short (S) IBDQ, was used in another report [11]. No differences in scores were found between the two groups in any of the studies [9–12], but van der Kalk et al. [12] did report ileal pouch-anal anastomosis patients had higher quality-adjusted life years compared to ileostomy patients.

Health-related quality of life is obviously a different outcome measure than morbidity. But, it is interesting that the morbidity rate of ileostomy patients was higher in three of the four studies that reported this outcome parameter [5, 6, 10, 12].

Study	Patients (N) IPAA vs Ileostomy	QOL measure	Results IPAA vs Ileostomy	Quality of evidence
Emblem [5]	19 vs 35	Social restriction	0 % vs 67 % (P < 0.05)	Low
McLeod [6]	37 vs 28	Direct questioning of objections Sickness-Impact Profile Time trade-off	Comparable Comparable Comparable	Moderate
Liddell [7]	25 vs 10	Lifestyle satisfaction	Comparable	Low
O’Birchere [8]	30 vs 30	SF-36 Altered bowel emptying Body image Clothes Diet Noise Odor Sexual relationship	Comparable 8 vs 5 (P = 0.01) Comparable Comparable 5.5 vs 2 (P = 0.02) Comparable Comparable Comparable	Moderate
Nordin [9]	56 vs 42	IBDQ SF-36	Comparable Comparable	Moderate
Camilleri-Brennan [10]	19 vs 19	IBDQ SF-36	Comparable Comparable	High
Kuruvilla [11]	35 vs 24	EQ-5D-3 L Cleveland QOL FIQL SIBDQ	Comparable 0.9 vs 0.8 (P = 0.03) Comparable Comparable	Moderate
van der Valk [12]	81 vs 48	IBDQ Quality-adjusted life years	Comparable 0.9 vs 0.84 (P < 0.01)	High

Recommendations

Patients requiring an operation for ulcerative colitis can undergo proctocolectomy and ileostomy rather than proctocolectomy and ileal pouch-anal anastomosis without compromising their health-related quality of life. (Evidence: moderate; Recommendation: strong)

Patients needing surgery for ulcerative colitis are typically offered a proctocolectomy and ileal pouch-anal anastomosis in one, two, or three stages with the two-stage approach most often employed in elective scenarios. However, this restorative procedure is occasionally contraindicated because of disease-related complications, unachievable for technical reasons, or ill-advised due to excessive risk for operative morbidity or impaired quality of life. In these selected settings, proctocolectomy and ileostomy may be offered, and the patient can be reassured that her/his health-related quality of life will be comparable to that associated with a sphincter-sparing procedure.

Personal View

Patients with colorectal adenocarcinoma complicating their ulcerative colitis need to undergo a sound oncologic operation. If the tumor encroaches upon the sphincter mechanism, excision of the levators and anal canal is usually required, and a sphincter-sparing procedure such as an ileal pouch-anal anastomosis is contraindicated. Colorectal cancers that have metastasized to distant sites are commonly managed with chemotherapy unless bleeding or obstruction mandates resection or diversion. Regardless, a restorative proctocolectomy and ileal pouch-anal anastomosis would be generally contraindicated because it would potentially delay the more important systemic therapy.

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