Elective surgery for ulcerative colitis, ileo-rectal anastomosis or restorative proctocolectomy An Update.

BACKGROUND

Despite advances in the medical management of Ulcerative Colitis (UC), surgery is required in about a third of patients.

AIMS AND METHODS

A review of the literature of the last 20 years was conducted in order to analyze the results of Ileo-Rectal Anastomosis (IRA) and of Ileal Pouch-Anal Anastomosis (IPAA) in the treatment of mild-to-moderate UC. Postoperative complications, functional results and the risk of cancer were analyzed in each of the two groups of patients.

RESULTS

In IRA group postoperative morbidity is low, varying from 8 to 28%. The risk of urinary and sexual dysfunction are rare and fertility rates are higher, compared to IPAA. The cumulative probability of success (working IRA) is 84% at 5 years and 51-69% at 10 years. The postoperative morbidity of IPAA is higher; dehiscence and pelvic sepsis were observed respectively in 9.5% and in 5.5%. A sexual dysfunction is present in 3.4%. In 18.8% occurs pouchitis. The risk of failure of the pouch is 6.8% and increased to 8.5% after 5 years. The risk of cancer is higher after IRA than after IPAA, with a cumulative risk at 20 years of 6-14% and 4.2% respectively.

DISCUSSION

The choice between IPAA or IRA is based upon patient's preference and clinical criteria (malignancy or sphincter injury). IPAA, intervention of choice, is burdened by a higher rate of complications, such as anastomotic leak with pelvic sepsis and subsequent functional pouch failure, pouchitis, infertility in young women, lesions of the pelvic nerves and portal vein thrombosis. There have been reports of cancer not only in the anal transitional zone, but also in the same pouch, either after mucosectomy that after stapled anastomosis. IRA is less invasive than IPAA and postoperative complications are lower. Does not require dissection of the pelvic and presents no risk of injury of the nerves of the urogenital sphere. The long-term results of the IRA are generally satisfactory and most of the patients stated that after the intervention improve both the health status and quality of life.

CONCLUSION

Today IPAA is the gold standard. The IRA is indicated in selected patients where they meet the following requirements: normal sphincter tone, absence of severe perineal disease, rectum does not actively involved by the disease, absence of dysplasia or cancer. It is also indicated in patients who refuse an ileostomy and it can be proposed as a possible interim procedure in young women, because it does not need a pelvic dissection and because the risk of infertility is minimal or absent when compared to IPAA. Because the risk of cancer is higher, patients undergoing IRA must be adequately informed about the risk, as well as recurrent proctitis, also of cancer, and must fully understand the need for surveillance and accept at least annual endoscopy with rectal biopsies; if these conditions are not met, patients should not be candidates for IRA.

KEY WORDS

IPAA, IRA, Surgical treatment, Ulcerative Colitis.

Si tratta di una review inerente gli articoli pubblicati nel corso degli ultimi 20 anni, con lo scopo di confrontare complicanze post-operatorie, risultati funzionali e il rischio di degenerazione cancerosa tra i pazienti in cui è stata eseguita l’anastomosi ileo-rettale e anastomosi tra pouch ileale e ano a completamento di resezione colica per Rettocolite Ulcerosa. Per la review sono stati utilizzati i dati desunti dalla ricerca sui principali motori di ricerca della letteratura scientifica quali Pub Med, Medline, Scopus, Cochrane database. Sulla base della nostra analisi, dopo aver valutato benefici e svantaggi di entrambe le tecniche chirurgiche, emerge come la anastomosi pouch-ileale sia la tecnica gold standard per la ricostruzione dopo trattamento resettivo chirurgico della Rettocolite Ulcerosa. Si analizzano peraltro le complicanze della procedura quali la deiscenza anastomotica con conseguente sepsi, il fallimento funzionale della pouch, la flogosi della tasca (“pouchite”), l’infertilità nelle donne giovani, la lesione nervosa pelvica e la trombosi venosa portale. In considerazione di tali complicanze conserva una indicazione, in pazienti accuratamente selezionati, la soluzione di ripiego del confezionamento di una anastomosi ileorettale, a condizione di effettuare uno stretto follow-up post operatorio in considerazione dei rischi neoplastici.