- The question is, what does it do to their risk
if they fail that treatment and need to have surgery?
This is a study reported last year from the Mayo Clinic
in which they looked at a series
of consecutive patients with pouches,
47 of which had been treated with infliximab
within the last 12 weeks, and 254 without,
and found that there were increased risks,
pouch-specific complications
and overall infectious complications in the subgroup
that had been treated with infliximab,
and after a multi-variant analysis,
the only independent predictive factor was infliximab.
A similar, slightly different design study
was recently published from the Cleveland Clinic.
They took 46 two-stage pouch patients
who had been treated with infliximab
and matched them to 46 who had not been given infliximab,
again, within a 12-week period.
And they also found a significant increase
in the risk of sepsis and the risk of anastomotic leak.
So here we are again, given pause about the patients
who need an operation.
Does this change the emerging consensus about pouches
in the subset of patients treated with infliximab?
Of course, nothing's completely crystal clear,
and there is some data that suggests
that there is no difference in complications.
There's a study from Belgium that looked at patients, again,
treated with infliximab and compared to those who did not,
and they did not find any difference.
A report from Mass General includes
a much bigger group of patients, both Crohn's patients,
ulcerative colitis in patients with indeterminate colitis,
and they also found no increase
in the risk of complications.
So I think the jury is still out about that,
although the larger studies from the larger institutions
are giving us all pause.
So where we are in terms of ulcerative colitis
is still that there's been almost near universal adoption
of a J-pouch, near universal use
of a double-stapled technique.
We do do a one stage technique
in very carefully selected patients.
And laparoscopy is certainly gaining
as a favorable operative technique for this,
but in the subset of women of childbearing age,
it certainly requires careful counseling
about their fertility.
Perhaps doing a fully laparoscopic procedure
will protect them,
but one which there's more data to support
is that we do just a subtotal colectomy
and stay out of the pelvis completely,
and then all of us are considering what we should be doing
in patients who have been recently on infliximab
and whether they should always have
just a subtotal colectomy with an ileostomy
and a Hartmann as their first stage procedure.
So then I'm gonna move onto Crohn's colitis.
There are a number of options
for the surgical treatment of this, as you all know,
and the questions involved in the decision making
are what are the recurrence rates
and what is the quality of life.
And the first one is,
is a total proctocolectomy always necessary?
And this is data from 20 years ago now
that compared the recurrence rates,
depending on what type of operation patients had,
either a right colectomy, abdominal colectomy,
or total proctocolectomy,
and obviously, this is a selected group
because it's dependent on where their disease is located.
But the lowest risk of recurrence was in the group
that had a total proctocolectomy.
More recent data also shows this,
that although there are less striking differences,
perhaps due to better medical management,
but pretty safely we can say that the patients
who undergo a total proctocolectomy
have the lowest recurrence rates.
However, historically, that's meant permanent diversion.
What is the risk in those patients
of getting permanent diversion?
This is a study that looked at the location of disease.
Not surprisingly, if you have distal disease,
you're more likely to get permanent diversion,
but that risk is pretty high at 54%.
Another group analyzed,
what are the particular risk factors for that?
Women are more likely to need permanent diversion.
Clearly, people with perianal disease are more likely,
and those with left sided colitis.
So total proctocolectomy has the lowest recurrence rates.
It's probably inevitable in some patients.
The partial colectomy has a fairly high recurrence rate,
but there is a substantial percentage of patients
who can avoid a permanent stoma
and presumably have an improved quality of life.
But it raises the question, is an ileoanal reservoir
a reasonable conclusion?
Some would say even asking this question
is sort of raising Mae West's point,
that we would choose the one we haven't tried.
The interest came at it from a group in France
that 31 patients with Crohn's colitis,
who were carefully selected,
they did not have small bowel or perianal disease,
underwent ileoanal reservoirs or J-pouches.
20% had significant complications
and two of those required pouch excision.
Another two had recurrence in the pouch,
but responded to azathioprine.
So this is a little bit of how you view the movie,
but this group felt that that meant it was reasonable
to do this operation.
They then compared their patients
with no ulcerative colitis who underwent a pouch procedure
to patients with known Crohn's disease
who underwent a pouch procedure,
and in a five-year follow-up, they found no difference
in stool frequency, continence, leakage,
use of protective pads, or sexual activity.
They have updated that series with additional patients,
and now in a larger series with a mean follow-up
of over 100 months, they have found that about 1/3 of them
have recurrence of Crohn's disease,
while only 10% have required excision of the pouch.
There have been a number of other authors
who've looked at this since that initial interest,
and they have relatively small series,
but some of them have reasonable follow-up,
and the range of failures varies quite a bit.
It probably averages out at about 30%,
but you can see that it ranges from 12% up to 60%
of patients who had to have their pouch removed.
This is a study from the Cleveland Clinic,
looking at their patients.
This was just recently reported,
looking at their patients with Crohn's disease
who underwent a pouch procedure
and compared them to the patients with ulcerative colitis
or indeterminate colitis.
So it's not a pure group
of just ulcerative colitis patients,
but certainly a large number.
They also found that there was a significant difference
in pouch failure, about tenfold,
that there was much more incidence of pouch fistulas.
Pouchitis was about the same.
Strictures were about the same
and obstruction was about the same,
but this clearly is a group that's at risk
for failure of their pouch.
The possible candidates are patients
who do not have any perianal disease.
they have no small active or history of small bowel disease,
that they clearly understand what the risks are,
and that they're highly motivated.
But I certainly feel this, maybe the rest of us would agree,
that you'd perhaps be the surgeon,
but not choose to be the patient in that subset of patients.
However, it is all a matter of perspective,
and some people are really motivated to try
an ileoanal reservoir.
If we're not gonna do that,
or maybe they don't need a total proctocolectomy,
is the total abdominal colectomy preferable
to a segmental colectomy?
There's been another meta-analysis
published about this as well,
and this looks at studies from 1988 to 2002,
looking at the endpoints of recurrence,
morbidity, and permanent stomas.
There were six studies that qualified
in a pretty even split between abdominal colectomy
and segmental colectomy.
There was no difference in morbidity from the procedure.
There was no significant difference in surgical
or overall recurrence rate.
There was a trend that if two or more segments
had been involved with disease,
there was a lower surgical recurrence rate
with the ileorectal anastomosis.
There was a different in terms of time to recurrence,
that the patients who had a segmental colectomy
recurred sooner, and this was statistically significant.
There was no difference in the rate of permanent stomas,
and some suggestion that quality of life was better
with a segmental colectomy.