Consequences of Delayed Ileostomy Closure After Ileal Pouch-Anal Anastomosis Neil H. Hyman, M.D., Victor W. Fazio, M.D., Wayne B. Tuckson, M.D., Ian C. Lavery, M.D. From the Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio Temporary diverting loop ileostomy is a generally accepted component of the ileal pouch-anal anastomosis (IPAA) procedure. Ileostomy closure is usually performed within two to three months but may be delayed because of disruption of the ileoanal anastomosis, suspected leak from the ileal reservoir, concomitant medical problems, or patient convenience. Of 362 patients undergoing IPAA at The Cleveland Clinic Foundation for inflammatory bowel disease, 10 have had their ileostomy closures delayed for more than six months. Clinical and manometric parameters are examined in these patients and compared with those who had earlier closure. There appears to be no significant difference in the functional outcome of IPAA in these patients in terms of number of bowel movements and degree of continence. Reservoir compliance and maximum tolerated volumes are similar. We conclude that delaying ileostomy closure for more than six months after IPAAhas no deleterious effect on pouch function. [Keywords: Loop ileostomy; Pelvic pouch; Delayed closure] Hyman NH, Fazio VW, Tuckson WB, Lavery IC. Consequences of delayed ileostomy closure after ileal pouchanal anastomosis. Dis Colon Rectum I992;35:870-873. otal proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a frequently chosen procedure for many patients with mucosal ulcerative colitis. 1-7 A temporary loop ileostomy is usually created to divert the fecal stream and allow for healing of the pouch and ileoanal suture lines. The ileostomy is generally closed within two to three months if there are no complications. However, ileostomy closure may be delayed for a variety of reasons, including disruptions of the ileoanal anastomosis, suspected leak from the newly constructed reservoir, treatment of concomitant medical problems, or patient convenience. Of concern is that prolonged disuse of the ileal reservoir may lead to diversion pouchitis and/or fibrosis of the pouch with loss of distensibility and compliance.

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Address reprint requests to Dr. Hyman: Fletcher 301, Department of Surgery, University of Vermont, College of Medicine, Burlington, Vermont 05405.

To determine the effects of delay in ileostomy closure, we reviewed our experience with patients having ileostomy closure more than six months after IPAA and assessed the functional and manometric consequences. MATERIALS A N D M E T H O D S Between February 1983 and May 1989, 362 patients underwent IPAA with proximal loop ileostomy at The Cleveland Clinic Foundation for inflammatory bowel disease. Ten patients have had their ileostomy closed more than six months following I PAA. They compose the basis of this report. In our early experience, all patients underwent total abdominal colectomy, endoanal rectal mucosectomy, and handsewn ileoanal anastomosis, Since January 1988, the mucosectomy has generally been omitted and a stapled anastomosis has been performed at the top of the anal canal, approximately 1.5 cm above the dentate line. Both Jpouches and S-pouches have been used, according to the individual surgeon's preference. Follow-up data were obtained from Clinic visit or telephone interview when additional information was n e e d e d (Table 1). The diagnosis of pouchitis was made clinically and usually confirmed histologically. Minor incontinence was defined as a stain less than 3 cm occurring at least three times per week. Major incontinence was defined as a stain greater than 3 cm occurring at least twice per month. Patients were questioned about the need to wear a pad. The reason for delay in the ileostomy closure was also recorded. Anorectal manometry was performed with the patient in the left lateral decubitus position using a water-perfused Arndorfer| catheter (Arndorfer, Inc., Greendale, WI). Hard copy was generated on a Narco | (Narco Biosystems, Austin, TX) amplifier and recorder. The maximum tolerated volume

870

31

50 33 29 56

22

35

45 49

34

1

2 3 4 5

6

7

8 9

10

8

7 7

23

75

7 95 28 7

7

Interval (months)

3

2 5

5

22

24 16 3 18

71

Follow-Up (months)

N N

N

S

N

Y

Y Y Y Y

Y

Mucosectomy

J S

J

S

S S S S

J

Type of Pouch

6

5 10

6

5

5 5 8 7

8

No. of B/M per 24 hr

B/M, bowel movements; MRP, maximal resting pressure; Y, yes; N, no.

Age (yr)

Patient No.

N

N Y

N

N

N Y N N

N

History of Pouchitis

N

N N

N

N

N Y (minor) Y (minor) N

N

Incontinence

N

N N

Y

Y

N Y N Y

N

Wears Pad

70

90 40

45

30

40 38 45 32

50

MRP (mm Hg)

Table 1. Individual Patients Having Ileostomy Closure Greater Than Six Months After IPAA

230

162 300

163

300

380 88 215 290

155

(ml)

MTV

15.3

6.7 10.0

6.5

10.0

15.8 4.2 26.8 9.6

2.6

Compliance (ml/mm Hg)

Cuff abscess with perineal sinus. Viral syndrome. Parapouch abscess. Convenience (?) Ileoanal anastomotic defect on pouchogram. Ileoanal anastomotic defect. Recurrent pre-existing anovaginal fistula. Convenience (?) Ileoanal anastomotic defect on pouchogram. Treatment of collagen vascular disease.

Why Delay?

---I

9

C~

9

9

t-n

E3

rn

9

872

HYMAN E T

(MTV) was taken as that volume which elicited either an extreme urge to defecate or pain which caused the patient to become too uncomfortable to tolerate further distention. Pouch compliance was derived by measuring intrapouch pressure changes during pouch distention.

RESULTS The functional and manometric outcomes of the 10 patients having their ileostomy closed more than six months after IPAA are summarized in Table 2. Table 3 compares these results with patients undergoing closure within six months of pouch formation. The median number of bowel movements per 24 hours in the greater-than-six-months group is the same as in the within-six-months group. When only the S-pouches are considered, both the mean compliance (13.6 vs. 16.5 m l / m m Hg) and MTV (261 vs. 289 ml) are slightly l o w d in the greater-than-six-months group. However, if the patient with the parapouch abscess is excluded (Patient 3), then the results are quite similar (compliance, 14.6 vs. 16.5 m l / m m Hg; MTV, 286 vs. 289 ml). The three patients with a J-pouch undergoing ileostomy closure more than six months after IPAA have a similar number of bowel movements but a lower MTV and compliance compared with the less-than six-months J-pouch controls. Reasons for delaying the closure included defects or concern about the ileoanal anastomosis in five, treatment of concomitant medical problems in two, patient convenience in two, and a preexisting recurrent anovaginal fistula in one.

Dis Colon Rectum, September 1992

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DISCUSSION The consequences of delaying ileostomy closure in patients undergoing IPAA are not well known. Most patients are eager to have their ileostomy closed promptly and may safely undergo this procedure within three months following IPAA. However, approximately 8 to 25 percent of patients have postoperative pelvic sepsis with or without breakdown of the ileoanal anastomosis, 8 and in some it may be necessary to delay closure until healing has occurred. Concomitant medical conditions may also warrant delay prior to another anesthetic, or the patient may simply not want to have the closure done within three months for personal reasons. To assist in the counseling and management of such patients, it is important to know whether delay will compromise long-term results. Table 3. Comparison of Outcomes with Those Having Ileostomy Closure Less Than Six Months After IPAA

6 months months (n = 352) (n = 10) No. of bowel movements (median) J-pouch S-pouch MTV (ml) J-pouch S-pouch Compliance (ml/mm Hg) J-pouch S-pouch

6 6 236 289 8.6 16.5

* 286 if Patient 3 is excluded. ? 14.6 if Patient 3 is excluded.

Table 2. Functional and Manometric Outcomes After Delayed Ileostomy Closure for J-Pouches and S-Pouches Age (yr) Interval (months) No. of bowel movements (median) No. with incontinence No. of patients using pads* No. with history of pouchitis Mean resting pressure (mm Hg) Compliance (ml/mm Hg) Maximum tolerated volume (ml)

J (n = 3)

S (n = 7)

37.0 12.3 (7-23) 6 (5-8)

39.0 10.6 (7-28) 6 (5-10)

0 1 0 62 (45-90) 5.3 (2.6-6.7) 160 (155-163)

* Either because of minor leakage or for added security.

2 3 2 42 13.0 261

(minor) (32-70) (4.2-26.8) (88-300)

Total (n = 10) 38.4 11.1 (7-28) 6 (5-10) 2 4 2 48 (32-90) 10.9 (2.6-26.8) 229 (88-300)

6 6 160 261 * 5.3 13.0t

Vol. 35, No. 9

DELAYED ILEOSTOMY CLOSURE AFTER IPAA

The data presented do not demonstrate any deleterious effects of delayed closure. Two patients had parapouch abscesses, which were associated with poor compliance and a diminution in the MTV. Despite the adverse effects of pelvic sepsis on manometric parameters in the affected patients, functional results were still quite acceptable, with each having between five and eight bowel movements per day and no incontinence. If these patients are excluded, the compliance and MTV of the study patients are very similar to those in the less-than-six-months group. In fact, the patient with the longest delay (28 months) had the most compliant reservoir in this series. The frequency of bowel movements, degree of continence, and incidence of pouchitis were not affected by a delay in closure. Caution must be exercised in interpreting these results because of the small size of the study group. In addition, the use of both J-pouches and Spouches, as well as differences in technique, further complicate analysis. Follow-up is short for some of the patients, but functional results would only be expected to improve with time. CONCLUSIONS We are unable to document any deleterious functional or manometric consequence of delaying ileostomy closure for more than six months after IPAA. When a delay is warranted to allow for heal-

873

ing of anastomotic defects, treatment of concomitant medical illness, or patient convenience, there does not appear to be any demonstrable compromise of pouch function.

REFERENCES 1. Pemberton JH, Kelly KA, Beart RW Jr, Dozois RR, Wolff BG, Ilstmp DM. Ileal pouch-anal anastomosis for chronic ulcerative colitis: long-term results. Ann Surg 1987;206:504-13. 2. Schoetz DJ, Coles JA, Veidenheimer MC. Ileoanal reservoir for ulcerative colitis and familial polyposis. Arch Surg 1986;121:404-9. 3. Skarsgard ED, Atkinson KG, Bell GA, Pezim ME, Seal AM, Sharp FR. Function and quality of life results after ileal pouch surgery for chronic ulcerative colitis and familial polyposis. Am J Surg 1989;157:467-71. 4. Cohen Z, McLeod RS, Stern H, Grant D, Nordgren S. The pelvic pouch and ileoanal anastomosis procedure. Surgical technique and initial results. Am J Surg 1985;150:601-7. 5. Becker JM, Raymond JL. Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases. Ann Surg 1986;204:375-83. 6. Pemberton JH. Surgery for ulcerative colitis. Surg Clin North Am 1987;67:633-50. 7. Dozois RR, O'Rourke JS. Newer operations for ulcerative colitis and Crohn's disease. Surg Clin North Am 1988;68:1339-52. 8. Mortensen N. Progress with the pouch restorative proctocolectomy for ulcerative colitis. Gut 1988;29: 561-5.

Consequences of delayed ileostomy closure after ileal pouch-anal anastomosis.

Temporary diverting loop ileostomy is a generally accepted component of the ileal pouch-anal anastomosis (IPAA) procedure. Ileostomy closure is usuall...
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