Speaker 1Okay, this class is in follow-up to our previous class about ileal pouch anal anastomosis. The good news is it doesn't go on forever like that one did. And in this one, we're going to focus specifically on what are the long-term outcomes. Patients are going to have a lot of questions about that, and you want to be able to give them accurate, evidence-based answers and feedback. And we'll also talk about complications that might occur and prevention. So we'll talk about expected outcomes. As I said, we'll talk about complications that might occur with an IPAA and specific quality of life issues. What can patients expect? So really, the outcomes look really good. When we first started doing these procedures and we would do follow-up questionnaires every time the patient came in because we were building our database to be able to inform patients down the road about what they could expect. The early patients were our true pioneers, and they're like, "I'll give it a try. I know you can't tell me anything for sure, but I'm going to take that step. I'm going to be a pioneer." So here's what we've learned. First of all, patients tend to make steady progress for up to two years. And long term, most of them get down to between four and eight stools a day. So six is average. And interestingly, patient quality of life is very good at that level. Seventy to 80 percent of their stools are thick, non-diarrheal in nature, so they describe them as normal. What about getting up at night? We know that people who have lost the colon, they have much higher volume of stool output, so can they go all night? No. Most people do get up once or twice at night. Most patients state that that doesn't really cause a major impact, that they just get up and go and go back to bed and go back to sleep. Long term, most people have no real fecal urgency, and most of them say they can delay defecation for up to an hour if they need to. And most have either no leakage at all or a minor leakage that is limited to nighttime hours and pretty easily managed with just the little butterfly pads. One checkup. I'm sorry. I'm sorry. I'm sorry. I'm sorry. One challenge and one frustration is that some people who undergo IPAA cannot reliably pass gas without experiencing some leakage. So as they say, I've lost the ability to fart with confidence. And now I typically just go to the bathroom just in case. Now on the positive side, once you remove the colon, you produce less gas. But still, it's kind of frustrating to not be able to eliminate gas without worrying that you're going to have some degree of an accident and always having to go to the bathroom. However, patients state they still are glad they had this procedure. So that's a downside, but not one that would change their decision making. Most of them can eat pretty much anything. Some will tell us that they have increased stool frequency if they eat spicy food, if they eat roughage, if they take in caffeine or carbonated beverages, which we would expect. But again, they say it's not significant enough or severe enough to have a negative impact on their quality of life. Most people report very good quality of life. We should tell our patients is that some people do report occasional blood in their stool, especially after running. And I'm not sure why that is, but obviously it turns out to be benign. These people have been worked up and it's benign. So we just need to let them know that that might occur because a lot of these patients are young. Many of them are very athletic. And so they are running and playing tennis and doing strenuous activities. So we just need to let them know that if they experience minor blood in their stool after strenuous activity, that is normal. They should alert their physician. He or she may or may not decide to do any workup. Now let's talk about complications and we'll talk about some that are pretty rare and then some that are a little more common. So pelvic sepsis is actually fairly common in the early post-op period, but usually pretty easily managed. So it can be caused by a minor leak at the anastomotic line. Now that's one of the advantages of undergoing a staged procedure. Because all of the stool is being diverted through the ostomy and if there is a little bit of an anastomotic breakdown, there's plenty of time for it to heal before stool is coming through there. If they do develop any degree of pelvic sepsis due to an anastomotic leak, they will experience fecal urgency and frequency, that is if they did not have a staged procedure with a staged procedure. Of course, they're protected until the anastomosis is very well healed. They still might feel some tenesma, some sense that they have to pass mucus, that something is there, but they won't have actual fecal output if they still have their diverting ostomy in place. So what they're most likely to experience is the sensation that they need to go, some pain, and they may experience fever. Treatment involves antibiotics, imaging, drainage of any fluid accumulation. But again, the vast majority of patients undergo a staged procedure. They're protected by that diverting ostomy, so they may have tenesmas, bleeding, fever, they may require antibiotics, they may require drainage, but they'll have no significant long-term outcomes. They can also develop an inflammatory reaction at the junction between the reservoir and the anal canal, that anal transition zone. A lot of surgeons refer to this as cuffitis. It can be acute or chronic, more likely to be acute. Again, the symptoms are very much what we've talked about, that sensation of having to go almost all the time. Possibly bleeding. If their ostomy's been closed, they can have fecal frequency and urgency. Pretty easily treated with topical anti-inflammatory agents like 5-ASA or steroid enemas or suppositories usually calms it down. Perianal skin breakdown, yes, pretty common during the early period. Following ostomy takedown, when everything is going through the reservoir, everything is being controlled by the anal sphincters. Until we get stool frequency under 10 a day, then perianal skin breakdown is much more common. As stool frequency diminishes, so does the likelihood of any perianal skin breakdown. We can prevent most of this. We can treat this with careful attention to patient education, so we want them to know up front this is a potential problem during that period of time when they're stretching their reservoir, they're working to reduce stool frequency, when stool is gradually progressing from more liquid to thicker, more like mush, so we want them to do very gentle perianal skin care. We want them to use the very best, softest, gentlest toilet paper, or maybe routinely use moistened wipes to prevent any trauma to the skin. We want them to routinely use moisture barrier creams or ointments so that they have a level of protection. We recommend cotton underwear, not anything that would trap moisture. So the benefit of cotton underwear, you don't trap moisture. I also routinely recommend pads that are butterfly-shaped, those anorectal dressings, so that you wick the moisture away. And again, of course, we're going to emphasize the importance of dietary modifications, psyllium, and anti-diarrheal medications to reduce stool frequency. If they develop any kind of yeast rash, which they may because the area is very moist, so it's a pretty good environment for proliferation of yeast organisms. So if they develop that, of course, they need to use an antifungal cream or ointment. If they develop any denuded areas, then we will recommend a zinc oxide-based product. So as long as they're just doing preventive care, there's no actual skin breakdown. Typically, they can use a dimethicone-based or petrolatum-based cream or ointment, but if they develop any actual breakdown, they need to shift to zinc oxide. So one of your desitin-type products, any of the zinc oxide-based moisture barrier products. If they have a lot of burning perianal pain, they'll benefit from a salt binding agent like Questran, cholestyramine, and again, there's those butterfly pads. Pouchitis is by far the most common late complication. And what is it? It's inflammation of the mucosal lining of the reservoir, most likely due to some imbalance in the bacterial mix within the reservoir, because we've changed things around. We've taken a section of the bowel that is typically part of the conveyor belt, and we've turned it into a holding area. So we can definitely get overgrowth of some of the pathogenic bacteria. We can get reduced levels of protective bacteria. And that is thought to be the basis of pouchitis. How common is it? Twenty-five to 40 percent, so a significant minority of patients, experience at least one episode. But for many individuals, that one episode is the only one they ever have. So there's a lot of patients who might say, oh, yeah, I did have that one time, or I had that a couple of times. It's only a small percentage of patients who develop chronic pouchitis. So if patients are asking you about potential complications preoperatively, you would want to say there's a small, small percentage of patients who develop chronic inflammation in the pouch. But that does not affect the majority of patients. The majority of patients either never have a pouchitis episode or have only one or two. Can you identify patients who are higher risk for chronic pouchitis? Yes, we actually can. Any patient who had very extensive ulcerative colitis, where almost the entire colon was involved, or maybe the entire colon was involved, and they also had some backwash iliitis, they are higher risk. Patients who had a preop history of extravasation, where they had a preop history of extravasation, are at higher risk. Patients who have a preop history of extravasation, are at higher risk. Patients who had a preop history of extravasation, are at higher risk. manifestations, such as sclerosing cholangitis. They're at higher risk. Any patient who has a history of extensive use of NSAIDs, and interestingly, people who do not smoke. I thought not smoking was supposed to be a good thing, but in very select patient populations, it appears to be a bad thing. So non-smoking status is a potential risk factor for pouchitis. What are the symptoms? Well, think what's going on. You have inflammation of that reservoir. So you have both localized symptoms that relate specifically to the inflammation of the reservoir itself, and then you have systemic symptoms that relate to the inflammation of the reservoir itself. So you have both localized symptoms that relate specifically to the inflammation of the reservoir itself, and then you have systemic symptoms that relate specifically to the inflammation of the reservoir itself. So you have both localized symptoms that relate specifically to the inflammation of the Typically we manage them with chronic antibiotics. We might begin them on probiotics like VSL-3. And then we try to taper off the antibiotics and leave them on the probiotics to help prevent recurrence. So what probiotics do, of course, is to help regulate and restore normal flora, help to maintain high levels of good bacteria, that keep the mucosal layer healthy, that reduce the risk of bacterial adherence and penetration. If you have antibiotic-resistant paltritas, they might move to anti-inflammatory agents, the same kind of medications we use to treat inflammatory bowel disease: steroids, 5-ASA supplements, immunomodulators, biologic agents. And pouch excision is strictly limited to patients with severe refractory paltritas where they're like, "I can't do this anymore," but very rare. What about sexual and reproductive dysfunction? Well, a lot of women who require colectomy and partial progesterone. They get proctectomy and then IPAA. They get scar tissue in the pelvic area. And that scar tissue can alter the angle of the vagina, so they might have pain with intercourse. And we encourage them to experiment with different positions, and specifically with positions where the female can control the depth and angle of penetration until they figure out what works for them and their partner. This is almost always a fairly easily solved problem. Occasionally, women will have fertility issues due to adhesions that prevent the eggs passing through the tubes normally, so it's usually adhesions wrapped around the fallopian tubes that causes the problem. And some patients have to undergo surgical procedures to release the adhesions and restore patency of the fallopian tubes. Probably the most common reported issue is during late pregnancy when there's a lot of pelvic pressure. They're going to experience increased stool frequency because the reservoir doesn't have as much capacity under those situations, under those conditions. And they might have occasional leakage. Some obstetricians prefer cesarean delivery because they're afraid to do vaginal delivery in a woman who's had IPAA and all of that reconstructive surgery in the pelvis, but there's no consensus. have delivered vaginally and safely. What about in the male? Well, remember that when you're removing the colon, removing the rectum, anastomosing the ileal pouch to the anal canal, you are messing around in the peri-rectal tissue. And the nerves that control erection and ejaculation pass through the peri-rectal tissue on their way to the erectile tissue and to the prostate gland and ejaculatory ducts. So can they potentially experience potential problems or temporary problems with erection and ejaculation? Yes. But those problems are uncommon and almost always very short term because surgery surgeons are very conscious of these issues. Many of these procedures are done laparoscopically. Some are done robotically. Laparoscopic approach, robotic approach reduces the level of tissue trauma. Surgeons are now much more skilled at identifying the autonomic nerves that control erection and ejaculation and avoiding them. So it's very, very unlikely that there would be any kind of long term issue. If so, we would get urology involved to identify a solution. What about quality of life data? Well, as I said earlier, actually quality of life is very good among IPAA patients. Now, we don't have extensive studies, but the studies we have suggest that quality of life for these individuals is better than patients who have an ileostomy, better than patients with a continent ileostomy, and better than patients who have ulcerative colitis that's being treated medically. So those are very positive findings. When they do follow-up studies, the major thing contributing to the marked increase in quality of life seems to be disease eradication. That once we get rid of the diseased colon, the diseased rectum, people feel so much better. They're able to go back to their preferred activities. And as a result, we see a marked improvement in quality of life. Obviously, more research is needed. We don't have a lot of data, but the data we do have is very encouraging. So in summary, ileal pouch anal anastomosis is an alternative to proctocolectomy with permanent end ileostomy. On the negative side, stool consistency for the rest of that person's life is going to be liquid to mushy because the colon is gone. Stool elimination will be controlled by the anal sphincters, but in most patients with either familial polyposis or ulcerative colitis, there are sphincter are uninvolved and in great shape. So usually, continence is not an issue. Quality of life data supports IPAA as an excellent option for patients who do require proctocolectomy for benign disease. Ulcerative colitis, select few patients with Crohn's disease of the colon, patients with familial adenomatous polyposis. The major concerns and issues are going to be stool frequency and urgency, which improves rapidly over the first few months and continues to improve for up to two years. The potential for fecal leakage, which in actuality is not a common complication. Most people do not experience leakage, and if they do, it's typically low volume and at night. There's also the potential for perianal skin breakdown again. If we assist patients in maintaining continence, we can protect the perianal skin. So everything we teach patients about dietary modifications, about perianal skin care, about use of psyllium products to thicken the stool, all the reinforcement we give to surgical instructions about use of loperamide oxalate, all of those measures help that patient establish reduced stool frequency, improved continence. And then we want to make sure that if our patient develops signs of pouchitis, we get them treated promptly. We want them to end up in that category that has only one to two episodes of pouchitis. We want to keep them out of that category. We want to keep them out of that very small percentage of patients who develop chronic pouchitis. And that's it for this class. Thank you.
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