Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review

Restorative proctocolectomy (RPC), also known as ileal pouch-anal anastomosis (IPAA) is typically performed in patients with familial adenomatous polyposis (FAP) or ulcerative colitis (UC). It can be performed either as a single-stage procedure or, in cases where emergency surgery has been required, as a completion proctectomy with pouch formation following emergency colectomy.

In the elderly, the majority of cases are performed in the context of UC which is non-responsive to maximal medical therapy or where there is evidence of associated dysplasia or malignancy [1]. Originally, the general consensus was that surgery in those over 50 should undergo proctocolectomy with formation of an end ileostomy, as the associated morbidity with IPAA was too high for older patients. However, several papers have documented similar outcomes with IPAA in terms of safety when compared to younger patients [2‐4].

This review paper aims to examine the functional outcomes following IPAA in older versus younger patients. This will be performed through analysis of published literature undertaking age-related analysis of functional outcomes with IPAA.

The systematic review was undertaken in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two reviewers (LR and SQ) performed the literature search and data extraction independently. PubMed, Medline and Google scholar databases were searched for relevant articles. The following keywords and phrases were used in various combinations: age, function, outcome, elderly, ileoanal pouch, ileal anal-pouch anastomosis (IPAA) ileal pouch, restorative, proctocolectomy.

All articles identified within the initial search were screened for relevance and content, and their bibliographies searched for any additional relevant articles. Abstracts were initially screened by title and abstract content for relevance. In cases where relevance was uncertain, the papers were scanned for the relevant data.

The criteria for inclusion were as follows: 1. Articles considering postoperative functional outcomes with IPAA stratified according to patient age. 2. Ileoanal pouch formation for any disease condition (e.g. ulcerative colitis, familial adenomatous polyposis).

Exclusion criteria were as follows: 1. No discussion of at least one functional outcome of interest (see below), 2. Non-comparative papers, case reports and review papers. 3. Papers where age has been found to be a significant factor in outcome through multivariate analysis; however, no further information has been provided. 4. Papers published in an alternative language to English where translation was not available. 5. Papers where the ‘older’ age group cut-off was younger than 45 years.

All publications up to and including 1 February 2015 were considered. Major outcomes of interest were as follows:

Data extraction was undertaken independently by two of the authors (LR and SQ) using the pre-determined outcome measures. There were no discrepancies between them.

The following data points were extracted (where presented) from each paper:

Trial design, patient subgroups, sex ratio, diagnosis, indication for surgery, surgery performed, comorbidities, pouch configuration, use of covering ileostomy, handsewn or stapled anastomosis, length of follow-up, postoperative complications.

Functional outcomes: number of bowel movements per 24 h, number of movements/day, number of movements/night, pad usage, seepage, incontinence, urgency, deferral time, use of anti-diarrhoeals.

Anorectal physiology results: maximum/mean resting pressures, maximum/mean squeeze pressures, threshold and maximum tolerated volumes.

In addition to this, quality of life data, sexual function and patient satisfaction data were also retrieved where given.

Figure 1 demonstrates the literature search results. Following exclusion of duplicates, 1103 abstracts were returned through the use of the search terms. A total of 729 papers were excluded based on title alone; 374 abstracts were reviewed for content and 348 were excluded.

A total of 26 papers were identified which contained data regarding age and functional outcomes with restorative proctocolectomy. Twenty-one papers were identified with documented comparative functional outcomes with IPAA across different age groups. One was excluded as this was a case report, and another was excluded as the article was available in Spanish only. The paper written by Pemberton et al. [6] was also excluded as this did not contain the numbers of patients in each sub-group; therefore, incorporation of data into the analysis was not possible.

Of the 18 papers left, five were found to be from the Cleveland Clinic Florida. Four papers contained overlapping patient data [7‐10]. The paper by Ho et al. [10] was included as this was the most recent data; however, outcomes from Takao et al. [9] were included in discussion which were not featured in the more recent paper (anorectal physiology, patient satisfaction, incontinence scoring system).

Likewise, further three papers [10‐13] originated from the same unit (Mayo clinic, Minnesota). The most recent data from Chapman et al. [13] was included in analysis.

Finally, there were three papers from the Cleveland Clinic in Ohio with overlapping patient data [14‐16]. The 2003 paper written by Delaney and colleagues contained more short-term data, whereas the paper by Kiran et al. was concerned more with long-term functional results, with a follow-up of 15 years. Therefore, results published at the 1 year mark from Delaney et al. were used in the general analysis, with long-term results (at 15 years follow-up) taken from the paper by Kiran et al.

Overall, there were 12 papers included in this review. Study characteristics are given in Table 1.

Patient age stratification was non-uniform across the papers. In addition, some studies considered longer-term follow-up. Therefore, in order to allow for data comparison, papers were considered as follows:

Table 2 displays the reported outcomes of interest for each paper.

The incidence of inflammatory bowel disease in the elderly (>60 years) is currently 10–15 % [22], with the majority presenting in their 60s; however, 25 % present in their seventies and a further 10 % in their eighties [23]. With improving healthcare delivery meaning people live for longer, these figures are set to increase.

Medical treatment in ulcerative colitis is similar across all age groups, with similar response rates to treatment [24]. Failure of medical treatment remains the most common reason for proceeding to surgical intervention; however, the presence of dysplasia is another common indication amongst this patient population [25], with Bauer et al. demonstrating a significantly higher rate of dysplasia and malignancy in older patients [1]. A recent meta-analysis found that older patients with ulcerative colitis were no more likely to undergo surgery when compared to younger patients [26], which is in the region of a third of all cases [4]. This is in spite of the fact that disease severity tends to be less in the older population [23].

The undertaking of major reconstructive surgery in the form of ileoanal pouch creation following proctocolectomy in older patients has been a fairly contentious issue. Initially, it was believed that due to the high incidence of complications, with around a 20 % morbidity [27], that restorative proctocolectomy should not be performed in patients older than 50. Instead patients were left with an end ileostomy, which is in itself associated with a relatively high morbidity, although several studies have demonstrated a similar quality of life when compared to the general population [28, 29]. More recent studies, including those in this review have advised that IPAA can be safely performed in older patients, even those in their 70s or 80s [30, 31]. Guidance published by the American Society of Colon and Rectal Surgeons recommend that chronological age should not be a reason in itself to deny IPAA in older patients [32].

This analysis supports the view that in terms of safety, IPAA in patients over 50 is feasible with comparable complication rates to those seen in younger patients. A recent multicentre registry analysis undertaken by Cohan and colleagues [4] which included 2493 patients undergoing IPAA, with 254 above the age of 60, found that in terms of postoperative complications rates, there was no significant increase in older patients; however, there was an increased length of stay in the older group.

Small-bowel obstruction was found to be significantly more common in younger patients in this review. The reasons as to why this is remain unclear; however, this difference was not replicated in the separate analysis of patients over 65. Otherwise, the only other difference worthy of note was the significantly increased risk of dehydration and electrolyte imbalance (23.68 versus 60 % in those over 65). This was in the context of loop ileostomy formation in the early postoperative phase. Several studies have shown dehydration to be the most common cause of patient readmission following ileostomy creation [33, 34]. Paquette et al. [35] found age >50 to be an independent factor for a readmission with renal failure following ileostomy creation, with IPAA associated with readmission for dehydration in their series of 201 patients. Overall, they found that 30-day readmission rates with dehydration following loop ileostomy creation were in the region of 25 %. Sixteen percent of those >50 versus 5 % of those <50 were admitted within 30-days with renal failure secondary to ileostomy. The rate of renal failure with IPAA was 8 % in >50 versus 7 % in <50. The reasons as to why the rates of dehydration and electrolyte imbalance in the papers included in the review are much higher are unclear; this may be secondary to these patients being at the extremes of age i.e. >65 years old, where there is more likely to be a degree of pre-existing renal impairment or the concomitant use of diuretic agents.

With regards to functional outcomes, there was a significant difference noted in terms of incontinence rates, with older patients significantly more likely to suffer incontinence, both during the day and nocturnally. The number of bowel motions per 24 h was statistically higher in those over 50 years of age; however, the likely impact of this on overall daily living is likely to be minimal, with an average of only one extra visit to the toilet in 24 h. Functional results were seen to decline across all age groups over time. In both of the papers where long-term functional data was analysed, the significantly different incontinence rates between older and younger groups seen at 1 year were diminished in the longer term.

The authors Pellino et al. have published a further paper discussing outcomes with patients over the age of 80 years [31]. Although at 6 months older patients had more nocturnal seepage, anti-diarrhoeal usage and a trend towards higher daytime incontinence rates, these issues were largely resolved by 12 months, with only nocturnal seepage more common in the elderly patient group. Most importantly, all older patients were satisfied with their outcomes and would undergo surgery again. Patient satisfaction and perceived quality of life following surgery are arguably the most important aspect of this review, as beyond ensuring comparable outcomes in terms of safety, the acceptability of results to patients is of utmost importance. Unfortunately, only three papers considered this outcome; however, these showed that overall patient satisfaction and quality of life were maintained following surgery in older patients, with the exception of Delaney et al. [16], who did report a significant difference in CGQL scores in older patients at 1, 3 and 5 years following surgery. Happiness levels were comparable across all ages. These positive outcomes with respect to satisfaction with surgery and QoL are in spite of the statistically significant increase in day and night incontinence rates.

Overall, the outcomes shown demonstrate that the consideration of RPC in older patients is warranted, with acceptable complication rates not dissimilar to those seen in younger patients. Careful fluid balance must however be achieved to avoid dehydration, in particular when older patients have a temporary loop ileostomy formed as this predisposes them to a significantly higher risk of electrolyte imbalance and dehydration. Additionally, the operating surgeon should ensure that there is at least 200 cm of small bowel proximal to the site of stoma creation in order to reduce this risk further. A shorter segment of proximal small bowel will also predispose the patient to a greater risk of incontinence, faecal urgency, seepage and looser stool once the stoma is reversed. Older patients should also be counselled as to the higher likelihood of faecal incontinence and nocturnal seepage following stoma reversal.

Further studies should include age-related analysis regarding postoperative quality of life and satisfaction with surgery, as these aspects are fundamental in the decision to recommend this major surgery to older patients.

As with all surgery, thorough patient optimisation and careful case selection are vital, with consideration given to the suitability of each case on its own merit; age as a number alone is insufficient as a basis for decision regarding the type of surgery performed. Patients should receive adequate support with regards to management of any functional deterioration in order to maintain high levels of patient satisfaction and acceptable postoperative quality of life.