Management of pouch related symptoms in patients who underwent ileal pouch anal anastomosis surgery for adenomatous polyposis

BACKGROUND Adenomatous polyposis syndromes(APS)patients with ileal pouch anal anastomosis(IPAA)suffer frequent symptoms with scarce signs of inflammation,distinct from ulcerative colitis patients.While the management of pouchitis in ulcerative colitis patients is well established,data regarding response to treatment modalities targeting pouch-related disorders in APS patient population is scarce.AIM To assess clinical,endoscopic and histologic response to various treatment modalities employed in the therapy of pouch related disorders.METHODS APS patients who underwent IPAA between 1987-2019 were followed every 6-12 mo and pouch-related symptoms were recorded at every visit.Lower endoscopy was performed annually,recording features of the pouch,cuff and terminal ileum.A dedicated gastrointestinal pathologist reviewed biopsies for signs and severity of inflammation.At current study,files were retrospectively reviewed for initiation and response to various treatment modalities between 2015-2019.Therapies included dietary modifications,probiotics,loperamide,antibiotics,bismuth subsalicylate,mebeverine hydrochloride,5-aminosalicylic acid compounds and topical rectal steroids.Symptoms and endoscopic and histologic signs of inflammation before and after treatment were assessed.Pouchitis disease activity index(PDAI)and its subscores was calculated.Change of variables before and after therapy was assessed using Wilcoxon signed rank test for continuous variables and using McNemar's test for categorical variables.RESULTS Thirty-three APS patients after IPAA were identified.Before treatment,16 patients(48.4%)suffered from abdominal pain and 3(9.1%)from bloody stools.Mean number of daily bowel movement was 10.3.Only 4 patients(12.1%)had a PDAI≥7.Mean baseline PDAI was 2.5±2.3.Overall,intervention was associated with symptomatic relief,mainly decreasing abdominal pain(from 48.4%to 27.2%of patients,P=0.016).Daily bowel movements decreased from a mean of 10.3 to 9.3(P=0.003).Mean overall and clinical PDAI scores decreased from 2.58 to 1.94(P=0.016)and from 1.3 to 0.87(P=0.004),respectively.Analyzing each treatment modality separately,we observed that dietary modifications decreased abdominal pain(from 41.9%of patients to 19.35%,P=0.016),daily bowel movements(from 10.5 to 9.3,P=0.003),overall PDAI(from 2.46 to 2.03,P=0.04)and clinical PDAI(1.33 to 0.86,P=0.004).Probiotics effectively decreased daily bowel movements(from 10.2 to 8.8,P=0.007),overall and clinical PDAI(from 2.9 to 2.1 and from 1.38 to 0.8,P=0.032 and 0.01,respectively).While other therapies had minimal or no effects.No significant changes in endoscopic or histologic scores were seen with any therapy.CONCLUSION APS patients benefit from dietary modifications and probiotics that improve their pouch-related symptoms but respond minimally to anti-inflammatory and antibiotic treatments.These results suggest a functional rather than inflammatory disorder.

Risk factors for postoperative stoma outlet obstruction in ulcerativecolitis

BACKGROUND Current medical treatments can achieve remission of ulcerative colitis (UC).Surgery is required when potent drug treatment is ineffective or when coloncancer or high-grade dysplasia develops. The standard procedure is restorativeproctocolectomy (RPC) with ileal pouch-anal anastomosis, commonly performedas two- or three-stage RPC with diverting ileostomy. Postoperative stoma outletobstruction (SOO) is frequent, but the causes are not well known.AIM To identify the risk factors for SOO after stoma surgery in patients with UC.METHODS We retrospectively reviewed the files of 148 consecutive UC patients whounderwent surgery with stoma construction. SOO was defined as small bowelobstruction symptoms and intestinal dilatation just below the penetrating part ofthe stoma on computed tomography. Patients were divided into two groups:Those who developed SOO within 30 d after surgery and those who did not.Patient characteristics, intraoperative parameters, the stoma site, and rectusabdominis muscle thickness were collected. Moreover, we identified the patientswho repeatedly developed SOO. Univariate and multivariate analyses wereperformed to identify risk factors for SOO and recurring SOO.RESULTS Eighty-nine patients who underwent two-stage RPC were included betweenJanuary 2008 and March 2020. Postoperatively, SOO occurred in 25 (16.9%)patients after a median time of 9 d (range 2-26). Compared to patients withoutSOO, patients with SOO had a significantly higher rate of malignant tumors ordysplasia (36.0% vs 17.1%, P = 0.032), lower total glucocorticoid dose one monthbefore surgery (0 mg vs 0 mg, P = 0.026), higher preoperative total protein level(6.8 g/dL vs 6.3 g/dL, P = 0.048), higher rate of loop ileostomy (88.0% vs 55.3%, P= 0.002), and higher maximum stoma drainage volume (2300 mL vs 1690 mL, P =0.004). Loop ileostomy (OR = 6.361;95%CI 1.322–30.611;P = 0.021) and maximumstoma drainage volume (OR = 1.000;95%CI 1.000–1.001;P = 0.015) wereconfirmed as independent risk factors for SOO. Eighteen patients with SOO weretreated conservatively without recurrence (sSOO group). Seven (28.0%) patientsrepeatedly developed SOO (rSOO group) during the observation period. Asignificant difference was observed in the rectus abdominis muscle thicknessbetween the two groups (sSOO 9.3 mm, rSOO 12.7 mm, P = 0.006). Musclethickness was confirmed as an independent risk factor for recurring SOO (OR =2.676;95%CI 1.176-4.300;P = 0.008).CONCLUSION In this study, high maximum stoma drainage volume and loop ileostomy areindependent risk factors for SOO. Additionally, among patients with a thickrectus abdominis muscle, the risk of SOO recurrence is high.

Cumulative incidence and risk factors for pouch adenomas associated with familial adenomatous polyposis following restorative proctocolectomy

BACKGROUND The emergence of restorative total proctocolectomy has significantly reduced the lifetime colorectal cancer risk associated with familial adenomatous polyposis(FAP).However,adenomas may develop in the ileal pouch over time and may even progress to carcinoma.We evaluated the cumulative incidence,time to development,and risk factors associated with ileal pouch adenoma.AIM To evaluate the cumulative incidence,time to development,and risk factors associated with pouch adenoma.METHODS In this retrospective,observational study conducted at a tertiary center,95 patients with FAP who underwent restorative proctocolectomy at our center between 1989 and 2018 were consecutively included.The mean follow-up period was 88 mo.RESULTS Pouch adenomas were found in 24(25.3%)patients,with a median time of 52 mo to their first formation.Tubular adenomas were detected in most patients(95.9%).There were no high-grade dysplasia or malignancies.Of the 24 patients with pouch adenomas,13 had all detected adenomas removed.Among the 13 patients who underwent complete adenoma removal,four(38.5%)developed recurrence.Among 11(45.8%)patients with numerous polyps within the pouch,seven(63.6%)exhibited progression of pouch adenoma.The cumulative risks of pouch adenoma development at 5,10,and 15 years after pouch surgery were 15.2%,29.6%,and 44.1%,respectively.Severe colorectal polyposis(with more than 1000 polyps)was a significant risk factor for pouch adenoma development(hazard ratio,2.49;95% confidence interval:1.04-5.96;P=0.041).CONCLUSION Pouch adenomas occur at a fairly high rate in association with FAP after restorative proctocolectomy,and a high colorectal polyp count is associated with pouch adenoma development.