Ileoanal Pouch vs. Ileostomy

 

Is there a difference in the quality of life after these surgeries?  This article is an overview of a presentation given by Scott A. Seidel, M.D., Martin Newman, M.D. and Kenneth W. Sharp, M.D. from the Department of Surgery, Vanderbilt University Medical Center in Nashville, Tennessee. 

 

For ulcerative colitis (UC) or familial adenomatous polyposis (FAP) the procedure of choice has become the ileoanal pouch (IAP).  These doctors put together a report on 86 patients over a 10-year study period who had either one of these operation and tracked their progress. 

 

Patients with UC or FAP at our institution choose their operation after counseling with the surgeon, an ET and with other patients who had already had the operation.  Outcomes were assessed by evaluating records and surveyed patients' AOL via a standardized questionnaire.

 

There were 64 UC and 22 FAP patients of which 55 underwent IAP construction and 31 underwent IL.  The IAP group experienced a higher complication rate, 53%, compared to the IL group, 16%.  About half (56%) of the patients completed surveys. 

 

Of the IAP group 87%, and of the IL group 93%,  responded that their overall QOL is always better since their operation.  Both groups reported very favorable responses to questions regarding work, social life, family life, sleep, and relationships without statistically significant difference between the two. 

 

Despite a high complication rate, IAP is an excellent operation for many patients with UC or FAP.  But patients who choose IL after preoperative counseling can be expected to have similar improvement in quality of life.

 

Before the introduction of the ileoanal pouch procedure for reconstruction after proctocolectomy in 1978 by Parks and Nicholls, patients underwent ileostomy for restoration of intestinal continuity.  Since the initial description, the IAP has undergone several modifications, but is now arguably the procedure of choice for UC and FAP. 

 

There are multiple reports demonstrating acceptable results and several large series that have documented the safety and efficacy of this procedure.  In addition, the QOL of patients undergoing IAP has been extensively studied.  QOL assessment has been used and validated in the literature to evaluate the QOL of patients with IBD comparing medical therapy with surgical therapy.  Less well studied are the outcomes of patients who choose IL instead of IAP.

 

Patient Demographics

 

Age                                         Average age 36 years old

Sex                                         

Male                           52%

Female                        48%

                                                Race

                                                            White                          93%

                                                            Black                            7%

                                                Diagnosis

                                                            UC                               74%

                                                            FAP                             26%

                                                Procedure

                                                            IAP                              64%

                                                            IL                                36%

 

Complication Summary

 

                                    Major              Minor              Total

 

IAP                  49%                15%                53%

IL                      3%                13%                16%

 

           

                                                IAP                  IL

 

Major

Pouchitis                                 24%                0%

Stricture                                  15%                0%

Rectal abscess                         5%                0%

Pelvic abscess                          8%                0%

SBO                                        18%                3%

Pouch removal                          5%                n/a

Minor

Incisional hernia                       2%                3%

Wound infection                       5%                3%

Perineal wound problems         9%                9%

Other                                        3%                0%

 

                                                UC                   FAP

Major

Pouchitis                                 19%                5%

Stricture                                  10%              14%

Rectal abscess                         5%                5%

Pelvic abscess                          6%                5%

SBO                                        18%              14%

Pouch removal                          5%                n/a

Minor

Incisional hernia                       3%                0%

Wound infection                       6%                3%

Perineal wound problems       13%                0%

Other                                        2%                0%

 

Length of Stay

(average)

 

                        Proctocolectomy         IAP      Takedown       Total

 

IAP                              9.0                   8                 6.8            23.8

IL                                7.8                   0                    0              7.8

 

Quality of Life Questionnaire IAP

Percentages

 

                                                                              Never  Some- Always NA

                                                                                          times

My present condition interferes with my…

·        Ability to work                                                      65        32        3          0

·        Social life                                                              71        26        3          0

·        Family life                                                             81        19        0          0

·        Ability to enjoy sports                                          65        32        3          0

·        Ability to sleep undisturbed                                 26        65        10        0

·        Intimate relationships                                          68        19        10        3

 

Bowel movements

·        <5 per day                                                            48        39        10        3

·        5-10 per day                                                         3          55        42        0

·        >10 per day                                                          71        26        3          0

·        I experience pain with bowel movements           77        19        0          3

·        I experience abdominal pain/cramping               58        39        3          0

 

Control:  I experience

·        The urgent need to have a bowel movement      13        77        10        0

·        Fecal seepage                                                      28        61        0          0         

 

Diet:  My current condition forces me to limit

·        What I eat                                                            48        26        16        0

·        When I eat                                                            55        42        3          0

 

Medications I take

·        Anti-diarrhea                                                        36        36        29        0

·        Steroid                                                                  100      0          0          0

 

Pouch

·        I experience pouchitis                                          52        36        3          10

·        I seek treatment for pouchitis                             55        13        19        13

 

Mood, my current condition causes me to:

·        Be depressed                                                       81        19        0          0         

·        Take mood-elevation medications                      94        7          0          0

 

My overall quality of life is

·        Better since the operation                                   7          7          87        0         

·        Worse since the operation                                   90        7          3          0

 

 

Quality of Life Questionnaire IL

Percentages

 

                                                                              Never  Some- Always NA

                                                                                          times

My present condition interferes with my…

·        Ability to work                                                      79        14        7          0

·        Social life                                                              79        14        7          0

·        Family life                                                             86        0         14        0

·        Ability to enjoy sports                                          64        29        7          0

·        Ability to sleep undisturbed                                 50        36        14        0

·        Intimate relationships                                          64        22        14        0

 

Diet:  My current condition forces me to limit

·        What I eat                                                            36        50        14        0

·        When I eat                                                            71        29        0          0

 

Medications I take

·        Anti-diarrhea                                                        86        14        0          0

·        Steroid                                                                  100      0          0          0

 

Mood, my current condition causes me to:

·        Be depressed                                                       64        22        14        0

·        Take mood-elevation medications                      100      0          0          0

 

My overall quality of life is

·        Better since the operation                                   7          0          93        0         

·        Worse since the operation                                   93        7          0          0

 

Discussion

 

IAP construction after proctocolectomy is clearly an excellent option for patients desiring to avoid an IL and its potential effects on life satisfaction.  The complication rate following IAP is not trivial. 

 

The results are similar to those in much larger series.  The vast majority of patients experienced favorable improvements in QOL and reported minimal interference with a variety of QOL issues, regardless of the procedure chosen.

 

Two other studies have examined QOL after IAP and IL.  In a large series from the Mayo Clinic, the authors demonstrated improved IAP performance in several daily life activities over IL, although  functional and overall satisfaction was not different between the groups.

 

In a follow-up study to their original article, the Mayo group suggested that it was the preservation of continence that had a positive bearing on QOL, not just the absence of a stoma, by comparing patients with a continent IL, Kock pouch with IAP and Brook IL patients.  Jimmo and Hyman reported a series of 67 UC patients undergoing either IAP or IL.  Patient satisfaction in their series was high with both procedures, similar to the current study.  The complication rate was higher in the IAP group in their study as well, with pouchitis being the predominant complication.

 

Patients choosing IL can look forward to fewer complications with their stoma since the modification of the Brooke technique.  This was also suggested by a contemporary study of patients with inflammatory bowel disease (ratio of UC to Crohn's colitis 2:1) who had IL performed.  The authors, Awad et al., found that 93% of their patients were happy with their stoma.  And, they experienced a 20% improvement in lifestyle activities.

 

In addition, when informed about IAP, 87% stated that they would keep their IL over undergoing IAP.  Weinryb et al. demonstrated that it was the resolutions of symptoms, not the reconstructive procedure, that predicted QOL improvement after proctocolectomy.

 

The patients choosing IL in this series were an average of 13.% years older than those electing to undergo IAP.  Other authors have noted a similar trend.  This may be important for long-term function, as increasing age is associated with a higher incidence of incontinence, even in the un-operated population.  In addition, Oresland et al. demonstrated that increasing age is associated with a worsened outcome for IAP patients.

 

The data also suggest that a diagnosis of UC affects patients in the two areas examined by this study:

·        Negatively regarding complications

·        Positively regarding QOL improvement potential

Patients in this series tended to experience more complications if they had UC as the indication for operation.  Other authors have demonstrated similar results.

 

Despite the possibility of an increased complication rate, UC patients had a greater QOL improvement over patients with FAP.  This is undoubtedly due to the preoperative QOL of UC patients compared with those with FAP.  In a study of IAP patients, Fujita et al. found that colitis patients were more satisfied than FAP patients despite similar stool frequencies.  As most patients with FAP are asymptomatic before their operation, it is difficult to believe their QOL will be improved by the construction of a pouch or IL.

 

Several limitations of this study are apparent.  The response rate, although not statistically significant, was lower in the IL group.  Also, a higher percentage of UC patients responded than FAP patients, which may have skewed the results in a favorable direction in the QOL responses, although it is probably minor.

 

Another limitation was the retrospective nature of the outcomes measurements.  There will probably never be a randomized, controlled trial comparing IAP with IL, as both procedures have proven efficacy.  In addition , the sample size precluded detailed subset analysis, although the overall results were similar to studies of much larger patient size.

 

In a recent review of the subject, Kohler and Troidl emphasize that because the QOL with IAP is not much greater than with IL, the increased complication rate must be carefully weighted against the marginal QOL improvement.  Despite the limitations of the current study, data and analysis of this sort are useful in learning more about the operations' potential risks and benefits.  This allows more accurate patient education and counseling with the goal of enabling an informed patient to make the right decision.

 

Conclusions

 

Despite a high complication rate with IAP, the majority of patients may expect an improvement in QOL after undergoing an IAP procedure after proctocolectomy for UC or FAP.  Importantly, patients who choose IL over IAP after appropriate patient education have a similar QOL and QOL improvement after the procedure.

 

Discussion

 

Comments from J. Patrick O'Leary, MD:  This is an interesting study that I have found to be well written.  It compares two groups of patients who have the complete removal of their colon followed by two different types of reconstruction:  a Brooke ileostomy and an ileoanal pull-through. 

 

Another interesting aspect is that the patients for whom these operations were performed had two distinct diseases:  the first, ulcerative colitis, and the second, familial polyposis.  One would assume that the symptom complexes in the patients with ulcerative colitis might have been substantial while patients with familial polyposis probably had no symptoms at all.

 

One group of patients who had their colon removed and an ileostomy performed had only minimal complication, and as a group they thought that they had done very well.  The other group of patients who also had their colon removed, had an ileoanal pouch, and had a complication rate of 46%, likewise thought that they had done very well.

 

There was only one major complication in the ileostomy group, and that was a partial small bowel obstruction that was treated non-operatively.  In the ileoanal pouch patients, serious complications abounded, with a number of these patients requiring operative intervention and all of the patients requiring a second operation to close the diverting ileostomy.  Yet, both groups were pleased with the procedure.

 

Another subtle finding was that patients who had complications had a higher percentage of returns on their questionnaires.  A number of patients did not return the questionnaire, and a higher percentage of these were in the ileostomy group.  There was also a much higher percentage of ulcerative colitis patients in the ileostomy group.

 

So how can we interpret the results?  Perhaps the authors have a prejudice in favor of the ileoanal pull-through operation.  If that is so, perhaps the patients are taking cues from the surgeons and, wishing to please them, report back that they, in fact, are feeling fine. 

 

Patients with complications see their surgeons more frequently and, if you are counting on your surgeon to help you manage a particular problem, you don't want to hurt their feelings.  There may also be another explanation.  The instrument that the authors used was developed by this group and may not be truly validated.

 

How did you validate the questionnaire that you used as your instrument?  Is it a good instrument and does it really seek out correct answers?  I would next ask why you believe the follow-up rates were different?  Was there a difference in the patient population?  Did the complication rate decrease as you gained experience in doing the procedure?  Finally, what about costs?  In the group of patients with the ileoanal anastomosis, there was a second hospitalization and a number of complications that required the expenditure of resources.

 

Comments from Eugene F. Foley, M.D.:  Your group of patients is a little bit uncharacteristic of most of the pouch groups of patients we see, in that 25% of the patients had polyposis.

 

Most large pouch studies experiences would have that group of patients around 10%.  Functionally, they are very different and, as Dr. O'Leary pointed out, there were different percentages of people in the polyposis group from those in the colitis group, who chose different options.  You have a high percentage of polyposis patients compared with most series, and do you think that that has impacted in any way upon their satisfaction with their choice of operation?

 

Comments by Scott Seidel, M.D. closing the discussion:  I will answer these questions in reverse order.  As far as a cost-benefit analysis, we have not performed one of those yet.  As far as the complication rate, did it decline over time, the answer to that question is yes, slightly, but not statistically significantly so.

 

As far as the validation of our instrument, we did not validate our particular questionnaire per se; however, it was fairly strict based upon several instruments present in the literature, notably the inflammatory bowel disease questionnaire that the Cleveland Clinic uses, and it, as an instrument, has been validated in the literature.

 

As far as the difference in responders and non-responders, I actually have an extra slide I would like to show that we pulled for lack of time but I will show in the discussion.  When we did look at those patients who responded and those who didn't respond to the survey, which obviously can skew the results as terms of the quality of life outcomes, there was actually no difference in terms of their demographics.

 

The differences in age, sex, follow-up months, and procedure choice were not statistically significant.  However, when we looked at the diagnosis from the disease standpoint, there was a higher percentage of patients who are diagnosed with UC who responded here, and in addition the complication rate, as you might expect, since those patients responded with a higher frequency, was also higher. 

 

So perhaps the results may have been skewed, but I would suggest that they may have been skewed against what we would suspect in that the quality of life was excellent, and if these patients that responded would do anything, they might lessen the quality of life outcomes as they were discovered.

 

To the first question, why choose an ileostomy, and perhaps based on this data set would you make the conclusion that an ileostomy may actually be the procedure of choice?  We set out to answer the question was there a difference in the quality of life between patients undergoing either.  And, I think we did that.  The answer is no, there is no difference.

 

However, a couple of things I think are important to point out as you alluded to:  the ileostomy patients were older, and additionally mostly these patients had the diagnosis of UC.  Pre-operatively, patients with UC are in a much more miserable state than patients with FAP.  They are sicker.  97% of our UC patients were on steroids pre-operatively, and they have a much higher rate of hospitalization prior to their initial surgery.

 

In addition, in the quality of life assessment that we did, not only do they have a better quality of life, but the FAP patients as a group responded that their overall quality of life was better 57% of the time versus 92% of the UC patients.  So you start out with sicker patients who have much more to gain in terms of improvement in quality of life, and I think that is where the differences in those come from.  There are several report in the literature, and I think perhaps the summary is that it is not necessarily the restoration of intestinal continuity, but the resolution of symptoms, which makes the impact.

Back