Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study

Abstract

Objective: To document functional results in patients treated with an ileal pouch anal anastomosis (IPAA).

Summary background data: The restorative proctocolectomy with IPAA has become the procedure of choice for patients with ulcerative colitis, yet the long-term functional results are not well known.

Methods: We performed this prospective observational study in 391 consecutive patients (56% male; mean age, 33.7 +/- 10.8 years; range, 12-66 years) who underwent an IPAA between 1987 and 2002 (mean follow-up, 33.6 months; range, 0 to 180 months).

Results: The majority of patients underwent the procedure under elective circumstances with a hand-sewn ileal pouch anal anastomosis and a protective ileostomy. In 25 patients (6.4%), the procedure was performed under urgent conditions; in 137 patients (35%), the temporary ileostomy was omitted; in 117 patients (29.9%), the ileal pouch anal anastomosis was stapled. There was 1 hospital mortality (0.25%) and 1 30-day mortality. Mean length of stay was 9.2 +/- 5.6 days (3-68 days; median, 8 days) and was increased by the occurrence of septic complications (8.9 versus 13.6 days; P < 0.02) and by the omission of a temporary ileostomy (8.3 versus 10.4 days; P = 0.005). Complications included pelvic abscess (1.3%), anastomotic dehiscence (6.4%), bowel obstruction (11.7%), and anastomotic stenosis in need of mechanical dilatation (10.7%). Patients were asked to record their functional results on a questionnaire for 1 week at 3, 6, 9, 12, 18, and 24 months after the IPAA and yearly thereafter. Our data to 10 years show that median number of bowel movements (bms) was 6 bm/24 hours at all time intervals. The average number of bms increased by 0.3 bm/decade of life (P < 0.001). Throughout the entire follow-up, more than 75% of patients had at least 1 bm most nights, although fewer than 40% found it necessary to alter the time of their meals to avoid bms at inappropriate times. Depending on the time interval, between 57% and 78% of patients were always able to postpone a bm until convenient, and this ability was similar in patients with a stapled or hand-sewn ileoanal anastomosis; only up to 18% were able to always distinguish between flatus and stools, and this ability was similar in patients with a stapled or hand-sewn ileoanal anastomosis. Complete daytime and nighttime continence was achieved by 53-76% of patients depending on the time interval. The percentage of fully continent patients was higher following the stapled rather than the hand-sewn technique (P < 0.001), and this difference persisted over time. When patients experienced incontinence, its occurrence ameliorated over time (P < 0.001), and the occurrence of perianal rash and itching as well as the use of protective pads decreased over time (P < 0.008). At 5 years, patients judged quality of life as much better or better in 81.4% and overall satisfaction and overall adjustment as excellent or good in 96.3% and 97.5%, respectively.

Conclusions: We conclude that the IPAA confers a good quality of life. The majority of patients are fully continent, have 6 bms/d on average, and can defer a bm until convenient. When present, incontinence improves over time.

FIGURE 1. Representation of part II of questionnaire to assess bowel activity and continence over 1 week. A bowel movement (bm) was recorded as B_L, B_P, or B_F (liquid, pasty, or formed, respectively); in the event of fecal leakage, a minor episode of leakage that could be cleaned with toilet paper or a tissue was recorded as S_M, and loss of solid stool as S_X.

FIGURE 2. Frequency (mean ± SD) of bms per 24 hours. Black bars, nighttime; gray bars, daytime.

FIGURE 3. Percentage of patients using antimotility drugs to decrease the number of bms per 24 hours.

FIGURE 4. Percentage of patients experiencing full continence (daytime and nighttime) according to surgical technique.

FIGURE 5. Daytime and nighttime protective pad usage. Bottom shaded bars indicate usage by continent patients.

FIGURE 6. Degree of incontinence during the day and night for patients with occasional spotting (1-2 leaks/wk), minor leakage (3-7 leaks/wk), and major leakage (>7 leaks/wk). Top of figure above zero line indicate awake hours; bottom, sleeping hours. Within each bar, open area indicates percentage of episodes of minor leakage; solid area, percentage of episodes of loss of solid stool. Diurnal and nocturnal use of protective pads is tabulated by the bar on the right side of the graph.