Surgical treatment of ulcerative colitis:Ileorectal vs ileal pouch-anal anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis(IPAA) is the current gold standard in the surgical treatment of ulcerative colitis(UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis(IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.

Surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis vs total colectomy with ileorectal anastomosis for intractable slow-transit constipation

Background:Few studies have compared the surgical outcomes of different surgical procedures currently used to treat refractory colonic slow-transit constipation(STC),despite the increase in the number of cases.This study aimed to analyse the long-termsurgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis(SC-ACRA)vs total colectomy with ileorectal anastomosis(TC-IRA)for severe STC.Methods:Between January 2005 and January 2015,we retrospectively collected clinical data of 55 patients who underwent TC-IRA(n=35)or SC-ACRA(n=20)for severe STC at our institution.The post-operative functional outcomes between the two groups were compared.Results:There were no significant differences in age(P=0.655),sex(P=0.234),period of constipation(P=0.105)and defecation frequency(P=0.698)between the TC-IRA and SC-ACRA groups.During a median follow-up period of 72 months(range,12–120 months),there were no significant differences between the TC-IRA and SC-ACRA groups regarding the median number of bowel movements per day[3(1/6–7)vs 3(1/6–5),P=0.578],Cleveland Clinic Florida Constipation Score[2(0–20)vs 2(0–19),P=0.454],Cleveland Clinic Incontinence Score[0(0–5)vs 0(0–2),P=0.333]and Gastrointestinal Quality of Life Index[122(81–132)vs 120(80–132),P=0.661].Moreover,there was no significant difference in the incidence of postoperative complications between the two groups(37.1%vs 25.0%,P=0.285).Conclusions:Our findings indicate that both TC-IRA and SC-ACRA are effective treatments for severe STC,with similar long-termoutcomes.

Preservation of superior rectal artery in laparoscopic colectomy:The best choice for slow transit constipation?

Laparoscopic colectomy with ileorectal anastomosis may be beneficial for patients with slow transit constipation who do not respond to conservative treatment,particularly if the superior rectal artery(SRA)is preserved.Several important concerns have been addressed in this commentary.It is important to first go over the definition of surgical procedure as it is used in this text.Second,the current study lacked a control group that had SRA preservation.Thirdly,it would be best to use a prospective,randomized controlled study.Lastly,a description of the mesenteric defect’s state following a laparoscopic colectomy is necessary.

Surgical treatment of familial adenomatous polyposis: Dilemmas and current recommendations

Familial adenomatous polyposis (FAP) is an autosomal dominant inherited syndrome characterized by multiple adenomatous polyps (predisposing to colorectal cancer development) and numerous extracolonic manifestations. The underlying genetic burden generates variable clinical features that may influence operative management. As a precancerous hereditary condition, the rationale of performing a prophylactic surgery is a mainstay of FAP management. The purpose of the present paper is to bring up many controversial aspects regarding surgical treatment for FAP, and to discuss the results and perspectives of the operative choices and approaches. Preferably, the decision-making process should not be limited to the conventional confrontation of pros and cons of ileorectal anastomosis or restorative proctocolectomy. A wide discussion with the patient may evaluate issues such as age, genotype, family history, sphincter function, the presence or risk of desmoid disease, potential complications of each procedure and chances of postoperative surveillance. Therefore, the definition of the best moment and the choice of appropriate procedure constitute an individual decision that must take into consideration patient’s preferences and full information about the complex nature of the disease. All these facts reinforce the idea that FAP patients should be managed by experienced surgeons working in specialized centers to achieve the best immediate and long-term results.

Adenocarcinomas after Prophylactic Surgery for Familial Adenomatous Polyposis

The incidence of familial adenomatous polyposis (FAP) is one in 7,000 to 12,000 live births. Virtually, all surgically untreated patients with FAP inevitably develop colorectal-cancer in their lifetime because they carry the adenomatous polyposis coli gene. Thus prophylactic proctocolectomy is indicated. Surgical treatment of FAP is still controversial. There are however, four surgical options: ileorectal anastomosis, restorative proctocolectomy with ileal pouch-anal anastomosis, proctocolectomy with ileostomy, and proctocolectomy with continent-ileostomy. Conventional proctocolectomy options largely lie between colectomy with ileorectal anastomosis or ileal pouch-anal anastomosis. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis because of better functional results and quality of life. The functional outcome of total colectomy with ileorectal anastomosis is undoubtedly far superior to that of the ileoanal pouch;however, the risk for rectal cancer is increased by 30%. Even after mucosectomy, inadvertent small mucosal residual islands remain. These residual islands carry the potential for the development of subsequent malignancy. We reviewed the literature (1975-2012) on the incidence, nature, and possible etiology of subsequent ileal-pouch and anal transit zone adenocarcinoma after prophylactic surgery procedure for FAP. To date there are 24 studies reporting 92 pouch-related cancers;15 case reports, 4 prospective and 5 retrospective studies. Twenty three of 92 cancers (25%) developed in the pouch mucosa and 69 (75%) in anal transit zone (ATZ). Current recommendation for pouch surveillance and treatment are presented. Data suggest lifetime surveillance of these patients.