Should older patients undergo ileal pouch-anal anastomosis?

doi:10.1016/S0002-9610(96)00253-X

The American Journal of Surgery

Volume 172, Issue 5, November 1996, Pages 444-448

https://doi.org/10.1016/S0002-9610(96)00253-X Get rights and content

Background

Heal pouch-anal anastomosis (IPAA) is a technically demanding, lengthy procedure with substantial associated morbidity. Some have suggested that this procedure should not be performed in older patients. This study was conducted to evaluate whether older patients have a poorer functional outcome and higher complication rate than younger patients who undergo IPAA.

Methods

The 455 patients who have undergone IPAA at this institution were stratified according to age (<55 versus>55) to compare functional outcome and complication rates. The data were prospectively collected. The groups included 32 patients >55 (7%) and 423 patients <55. Comparisons were made with regard to stool frequency, incontinence rates, post-IPAA complications, postileostomy closure complications, and results 12 months postileostomy closure.

Results

Preoperative anal sphincter resting and squeeze pressures were significantly lower in the >55 group. Most complication rates were similar after IPAA except dehydration rates, which were higher in the older patients than the younger ones (27% versus 11%, respectively). Pre-ileostomy closure anal sphincter resting and squeeze pressures were not significantly lower in patients older than 55. Twenty-four hour daytime and nighttime stool frequencies were significantly higher in the >55 group, as were daytime and nighttime stool incontinence.

Conclusion

Although functional outcome is poorer and some complications are higher in the >55 group, the procedure can be safely performed with acceptable results and is greatly preferred by this population over permanent ileostomy.

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Cited by (33)

Short-Term Outcomes for Restorative and Non-Restorative Proctocolectomy in Older Adults
2022, Journal of Surgical Research
Citation Excerpt :
In contrast to this concern, our findings suggest that for appropriately selected older adults, IPAA is not associated with increased 30-day complications compared to non-restorative surgery. There have been multiple prior studies from single-centers that have reported outcomes for older individuals undergoing IPAA surgery.8,11-15,21-23 Though definitions of older adults are heterogeneous (range >50 to >70), and the measures of successful outcome variable (functional, short-term and long-term complications, pouch failure), in general these studies have offered a favorable appraisal, with nearly all concluding that IPAA is suitable in selected older adults.
Curative surgery for ulcerative colitis can be subdivided into restorative (with pouch and anastomosis) and non-restorative operations. Restorative surgery in older adults is controversial, due to concerns about surgical risk and long-term functional outcome. The goal of this study is to compare 30-day outcomes for restorative and non-restorative surgery in older adults with ulcerative colitis.
Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from 2012-2018. Patients were included if they were >65 years old and had ulcerative colitis. Restorative and non-restorative surgeries were defined with procedure codes. Patient characteristics and adverse surgical outcomes were compared between restorative and non-restorative surgeries utilizing chi-square tests and Fisher's exact tests. Multivariate logistic regression models were constructed to evaluate the association of restorative versus non-restorative surgery with adverse surgical outcomes while adjusting for potential confounders.
Of 392 total patients, 95 had restorative and 297 had non-restorative surgery. Patients undergoing restorative surgery, compared to non-restorative surgery, were significantly younger (P<0.01), had lower incidences of steroid usage (P<0.001) and higher rates of readmission (P = 0.02). There were no differences in post-operative complications between the groups in both unadjusted analyses and covariate-adjusted regression analysis (P > 0.05).
In carefully selected older patients with ulcerative colitis, restorative surgery is associated with increased readmission, but otherwise similar rates of morbidity or mortality compared to non-restorative surgery. Data regarding postoperative functional outcome and quality of life are also needed to help select the most appropriate curative option for older adults.
Ileal pouch-anal anastomosis: Points of controversy
2014, Journal de Chirurgie Viscerale
Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current “hot topics” for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn's disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues.
Comparable Pouch Retention Rate Between Pediatric and Adult Patients After Restorative Proctocolectomy and Ileal Pouches
2014, Clinical Gastroenterology and Hepatology
Citation Excerpt :
With the improvement in the surgical techniques and increasing experience in the past 2 decades, IPAA has been more widely applied, even to a carefully selected patient population with isolated Crohn’s colitis.25,26 The impact of elderly age on pouch outcome has been studied; this showed that advanced age does not adversely affect QOL or pouch outcomes.13,27–29 In contrast, limited data are available in the literature regarding the long-term pouch outcomes in pediatric patients.16,18
We compared long-term outcomes between adult and pediatric patients with inflammatory bowel disease (IBD) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis.
We performed a retrospective study that analyzed data from consecutive patients with ileal pouches who presented to the subspecialty Pouch Center at the Cleveland Clinic from 2002–2011. Pouch outcomes of 104 pediatric patients (having pouch surgery at age <18 years; 53 male) were compared with those of 1135 adults (having pouch surgery at an age 18 years or older; 632 male).
Pediatric patients had a shorter duration from time of IBD diagnosis to colectomy than adult patients. Fewer pediatric than adult patients had a history of smoking, concomitant extraintestinal manifestations, or dysplasia as the indication for colectomy. However, pediatric patients had higher rates of pouch procedure-related complications, postoperative pouch-associated hospitalization, and postoperative use of anti–tumor necrosis factor (TNF) agents. In multivariate analysis, risk factors for pouch failure included preoperative use of anti-TNF agents (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.05–3.13; P = .032), postoperative use of anti-TNF agents (HR, 2.07; 95% CI, 1.31–3.27; P = .002), Crohn’s disease of the pouch (HR, 2.21; 95% CI, 1.28–3.82; P = .005), pouch procedure-related complications (HR, 2.68; 95% CI, 1.55–4.64; P < .001), and postoperative pouch-associated hospitalization (HR, 25.20; 95% CI, 14.44–43.97; P < .001). Being a pediatric patient was not significantly associated with pouch failure in univariate or multivariate analyses (HR, 0.6; 95% CI, 0.32–1.16; P = .13).
On the basis of an analysis of patients with IBD who underwent restorative proctocolectomy and presented at a subspecialized Pouch Center, patients who had the surgery at a pediatric age tend to have a higher incidence of postoperative pouch complications than adults. However, long-term rates of pouch retention were comparable.
Medical and surgical therapy of inflammatory bowel disease in the elderly - Prospects and complications
2011, Journal of Crohn's and Colitis
Citation Excerpt :
Functional outcome after ileal anal pouch surgery has been encouraging in the elderly, provided that the patient retains preoperatively good anal sphincter function.60,68–70 The double-stapled technique has resulted in a much better functional outcome compared to hand-sewn anastomosis in patients over 50 or 55 years.68–71 The incidence of anastomotic leaks, pouch-related septic complications,4 and ileal anal pouch failure rates do not differ between younger and older patients undergoing surgery for UC.60,69,72
Population ageing is a global phenomenon. People aged 65 years and older comprise approximately 16% of the population of Europe. The medical management of elderly patients with inflammatory bowel disease (IBD) is challenging with respect to diagnosis, pharmaceutical and surgical treatment, and complications. IBD has a late onset in 10%–15% of patients, with the first flare occurring at 60 to 70 years of age; others suffer from the disease for several decades. Even though the natural course of the disease in geriatric populations and the diagnostic options may not differ much from those in younger patients, distinct problems exist in the choice of medical therapy. Recommended clinical practise has been rapidly evolving towards an intensified initial treatment in IBD. However, in patients older than 65 years, a gentler approach should be used, and a combination of immunosuppressive agents should be avoided because of increased risk of infectious and neoplastic complications. Furthermore, elderly patients with severe IBD show prolonged, complicated post-operative clinical courses with worse hospital outcomes, so early surgical intervention for elderly patients is recommended. This article provides an overview of elderly IBD patient care, including medical and surgical therapeutic considerations and emphasises the necessity of close collaborations between gastroenterologists and surgeons.
Surgery for ulcerative colitis
2007, Surgeon
Ulcerative colitis is an inflammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are specific indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the final decision regarding choice of procedure.
Patterns of disease and surgical treatment among United States veterans more than 50 years of age with ulcerative colitis
2003, American Journal of Surgery
Ulcerative colitis (UC) is a clinical entity that predominantly affects young adults yet large series of middle age or elderly patients with UC are infrequently reported. The aim of this study is to identify patterns of disease, indications for operation, surgical treatment, and outcome of patients more than 50 years of age who required surgery for UC in Department of Veterans Affairs (DVA) Medical Centers.
A population-based study on all patients in 159 hospitals of the DVA from 1997 to 2001 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information including demographic information, discharge summaries, operative reports and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-square and Fisher's exact tests. Statistical significance is designated as P < 0.05.
One hundred fifty-eight patients were evaluable. The mean age was 59 years (range 51–81); 99% were male. The mean duration of UC was 23 years (range 2 to 50). One hundred of the 158 patients had proctocolitis; 58 had either left-sided colitis or proctosigmoiditis. The mean dose of prednisone prior to surgery was 20 mg; the mean duration of steroid use was 8 years. The indications for elective surgery were intractability (59%), mass or stricture (27%), and dysplasia (14%). Twenty of the 158 patients (12%) were operated on emergently for either toxic colitis, perforation, or hemorrhage. One hundred three of the 158 underwent proctocolectomy and permanent ileostomy, 55 underwent a restorative proctocolectomy, and underwent a segmental colectomy. Twenty of the 158 patients were found to have dysplasia in their colectomy specimens; an additional 10 (7%) were found to have invasive cancer. Surgical morbidity was 22%. Overall mortality was 4% (7 of 158); all but 1 death occurred after emergent surgery. Mean hospitalization was 36 days (range 2 to 297).
Restorative proctocolectomy was performed in 36% of veterans more than 50 years of age requiring surgery for UC. The majority required surgery for intractable symptoms. Dysplasia and invasive cancer was found in 18% of patients. Mortality after surgery for acute surgical emergencies remains high.

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^**: Presented at the 48th Annual Meeting of the Southwestern Surgical Congress, Scottsdale, Arizona, April 28–May 1, 1996.

View full text

Should older patients undergo ileal pouch-anal anastomosis?**

Background

Methods

Results

Conclusion

Am J Surg

Am J Surg

Am J Surg

Am J Surg

J Surg Res

Ileal “J” pouch-anal anastomosis: clinical outcome

Ann Surg

Ileoanal reservoir for ulcerative colitis and familial polyposis

Arch Surg

Proctocolectomy and ileoanal anastomosis

World J Surg