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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 4 | Page : 497-500
Study of late complications of restorative proctocolectomy with ileal pouch–anal anastomosis for ulcerative colitis operated at a tertiary care center and factors affecting to that
Nikhil Jillawar, Vijetha Bandla, Pushkar Galam, Ramya Vajja, Dakshayani Nirhale
Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
Correspondence Address:
Pushkar Galam
Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune - 411 018, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_177_22
Abstract
Background and Objective: Restorative proctocolectomy with ileal pouch–anal anastomosis (RPC-IPAA) is usually preferred surgical treatment for ulcerative colitis (UC). Although treated primarily medically, some refractory and complicated cases of UC may require surgical intervention. It eliminates chronic UC and the risk of colonic cancer. This research aims to study the risk factors associated with the development of postoperative complications. Methodology: For this cohort study, we included all the patients who underwent RPC-IPAA in the Department of Gastroenterology, Sheth Vadilal Sarabhai General Hospital, Ahmedabad, over 6 years. Data of the patients were obtained retrospectively from the medical records. We collected the data and analyzed using appropriate statistical tests to look for preoperative patient variables associated with late complications. Late complications were defined as those developed after 1 month. Results: Out of 32 patients, 19 were male and 13 were female, with an average age of 32.3 years at the time of operation. Thirteen patients developed complications such as pouchitis (n = 6), incisional hernia (n = 3), bowel obstruction (n = 2), pouch leakage (n = 1), and erectile dysfunction (n = 1). We found serum albumin <3 mg/dl and pancolitis associated with more postoperative late complications with P = 0.007 and 0.04, respectively, which is statistically significant. Conclusion: This study demonstrates that low preoperative albumin level and pancolitis are risk factors for late complications of IPAA. Preoperative nutritional support, especially albumin, could reduce late complications.
Abstract in French Résumé
L'IPAA (iléopouch-anal anastomose) est une procédure chirurgicale complexe qui, lorsqu'elle est réalisée par un chirurgien expérimenté, peut donner d'excellents résultats. De plus, il est important de comprendre les complications et leur prise en charge. Nos résultats mettent en lumière les facteurs associés aux complications chez les patients ayant subi une IPAA (iléopouch-anal anastomose) pour la CU (colite ulcéreuse). Dans notre population d'échantillon, une concentration sérique d'albumine préopératoire inférieure à 3 mg/dl et une pancolite ont été associées à des complications postopératoires. Cette étude démontre que des taux d'albumine préopératoires bas et la pancolite sont des facteurs de risque de complications tardives de l'IPAA. Un soutien nutritionnel préopératoire, en particulier l'albumine, pourrait réduire les complications tardive.
Mots-clés: Iléite de reflux, Hypoalbuminemia, pancolite, colite ulcéreuse, pouchite
Keywords: Backwash ileitis, hypoalbuminemia, pancolitis, pouchitis, ulcerative colitis
Introduction 
Ulcerative colitis (UC) is an inflammatory disease of the colon and rectum that affects millions of adults and children worldwide. Across the globe, the incidence and prevalence of UC are increasing with time, as has been reported by a systematic review.[1] The authors of this systematic review performed a time-trend analysis, showing that 60% of UC studies worldwide demonstrated increasing incidence. The increasing incidence and prevalence of Ulceratice colitis could be due to number of factors. Industrialization has been proposed to cause inflammatory bowel disease, possibly by causing changes in microbial exposures, sanitation, pollution, diet, and medication exposures. Some other factors that could lead to the increasing incidence and prevalence of UC worldwide are increasing awareness of UC by physicians and patients, better diagnostic techniques such as endoscopy, increased utilization of radiological tests, and much greater access to health care by the general public. UC is generally being less common in Asia than in Western countries, although its incidence and prevalence appear to be on rise in Asia. The clinical spectrum of disease can range from inactive to fulminant and is characterized by remissions and exacerbations. Although UC is primarily treated medically, refractory and complicated cases may require surgery. Despite the progress of medical therapy, which has broadened the possible treatments after failure of corticosteroids, surgery is still required in 15%–35% of patients affected by UC.[2],[3] For an elective surgery, restorative proctocolectomy with ileal pouch–anal anastomosis is the most preferred procedure. Since its introduction in 1978 by Parks and Nicholls,[4] the new gold standard surgical treatment of UC is restorative proctocolectomy with ileal pouch–anal anastomosis (RP-IPAA), which offers patients an unchanged body image with no stoma and a preserved anal route of defecation. A restorative proctocolectomy with ileal pouch–anal anastomosis (RPC-IPAA) removes the entire colon and rectum while preserving the anal sphincter and hence normal bowel function and fecal continence.[5],[6],[7] The major benefit of IPAA is that it successfully restores fecal continence in most patients; however, the major problem of the procedure is the high complication rate associated with it. Late complications were defined as those developed after 1 month. The most frequent long-term complication following IPAA is nonspecific and idiopathic inflammation of the ileal mucosa of the pouch, commonly known as pouchitis. In several series, morbidity after IPAA has been regarded as a significant problem, with documented rates of over 60%.[8] We aimed at studying the factors which are associated with late complications of IPAA in patients operated at our institution.
Methodology Study design
The study was performed according to the prescribed guidelines provided by the Indian Council of Medical Research, New Delhi. We included all patients who were admitted with a diagnosis of UC and operated with IPAA, in the last 6 years. Patients with incomplete records were excluded from the study. We conducted a hospital-based cohort study at our tertiary care hospital after obtaining approval from the Institutional Ethics Subcommittee of V. S. General Hospital, Ahmedabad.
Data collection
Medical records from the central record office were searched and identified patients who fulfilled our study criteria. A case report form was used to collect preoperative information of the patient from the medical records, which included gender, age at diagnosis, age at which ileal pouch–anal anastomosis (IPAA) was done, dietary habits of the patient, and previous medical and surgical history of the patient. Postoperative data such as clinical status, complications, or other medical issues were noted for each patient. Late complications were defined as those appearing after 1 month postoperatively.
Statistical analysis
Collected data were compiled and entered in Microsoft Excel sheets. Using IBM SPSS Statistics ,Version 22.0, (Armonk, NY: IBM Corp), we analyzed the data using appropriate statistical tests and results tabulated. A descriptive analysis was performed and tabulated. The Chi-square test was used to find associations between various risk factors and complications noted in the patients. P < 0.05 was taken to be statistically significant.
Results A total of 32 patients, in which 19 were male and 13 were female with UC, underwent RPC with IPAA, with a mean age at the operation of 32.3 years. Two patients underwent emergency surgery and thirty were operated electively. Only four patients had extraintestinal manifestations. There were 10 patients with duration of disease more than 36 months. The average duration of follow-up was 4.8 years. Out of 32 patients, 13 developed complications. Reported complications were pouchitis (n = 6), incisional hernia (n = 3), bowel obstruction (n = 2), pouch leakage (n = 1), and erectile dysfunction (n = 1) [Table 1]. On comparing the risk factors present in patients who developed postoperative complications and those who did not develop any complications, we found the presence of serum albumin <3 mg/dl and pancolitis to be statistically significant, P = 0.007 and 0.04, respectively [Table 1]. Other patient variables such as gender, duration of disease more than 36 months, extraintestinal manifestations, smoking, dietary pattern, family history, medical comorbidities, body mass index <20 kg/m2, erythrocyte sedimentation rate >30, backwash ileitis, or stapler anastomosis were not statistically associated with postoperative complications in these patients.
Table 1: Comparison of patients who developed postoperative complications with those who did not develop Discussion During the study period, 32 patients with UC underwent RPC-IPAA at our center. Of these, 40% developed late complications which corroborate well with previously published data.[9] In our patient population, low preoperative serum albumin and the presence of pancolitis were significantly associated with postoperative complications. Hypoalbuminemia in UC patients is significantly associated with intra-abdominal sepsis and delayed wound healing.[10] Cho et al have also demonstrated a relationship between low preoperative serum albumin and late complications following IPAA.[11] Nisar et al reported pouch failure after 30days, anastomotic leak and longer hospital stay to be independently associated with preoperative hypoalbuminuria.[12] In addition, the patients with hypoalbuminemia who underwent a single-stage total proctocolectomy had a significantly longer inpatient stay and increased perioperative blood transfusion requirements compared to two-stage subtotal colectomy. Furthermore, previous reports have indicated the presence of extraintestinal manifestations, younger age, and smoking to be risk factors for developing complications after IPAA.[13] These variables were not associated with late complications in our data set. Rottoli et al. highlighted the gender differences in long-term outcomes of patients undergoing IPAA and found that females were more likely to develop bowel obstruction, pouch-related fistula, and urgency.[14] However, our study did not show any such association. The type of technique staple versus handsewn seems to have little effect on the rate of complications post-IPAA, as is evident from a meta-analysis of over 4000 patients, which reported that there are no significant differences in postoperative complications between a handsewn versus stapled anastomosis.[15]
The most common complication after IPAA is pouchitis, which is nonspecific inflammation of the pouch.[16] It was seen in 18% of our patients, while the reported incidence is 23%–59%.[17] It is accepted that pouchitis has a multifactorial aetiology and both host and commensal microflora play an important role, in addition to genetic factors and mucosal immunity. Our study showed pancolitis to be a significant risk factor for late complications. It could be because of the association beetween pancolitis and pouchitis as shown in a prospective study of 201 patients, that the risk of pouchitis is increased three-fold with extensive colitis as compared to those patients with limited disease.[18] Extraintestinal manifestations, specifically primary sclerosing cholangitis and high serological levels of perinuclear antineutrophil cytoplasmic antibody have been shown to correlate with higher incidence of pouchitis and chronic pouchitis.[19] Smoking, on the other hand, has been shown to decrease the rates of chronic pouchitis and probiotics have shown some results in reducing episodes of acute pouchitis as well as maintaining remission.[20] However, in our study, both smoking and extraintestinal manifestations were not associated with late complications. There are several limitations of our study such as single-center study, so our results could not be generalized to other parts of the world. Second, this is a relatively small sample size but that is in part due to the low incidence of UC in the Indian population. Third, part of the data collection was done retrospectively, which has inherent limitations.
Conclusion IPAA is a complex surgical procedure which if performed by an experienced surgeon can produce excellent results. Furthermore, understanding the complications and their management is important. Our results shed light on the factors which are associated with complications in patients who underwent IPAA for UC. In our sample population, preoperative serum albumin <3 mg/dl and pancolitis were found to be associated with complications postoperatively. Future research should focus on understanding the complications of postoperative patients in the long term and at multiple sites using a uniform study methodology.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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