The Ileo Neo Rectal Anastomosis: Results of the First 50 Candidates with an Alternative Restorative Procedure
Abstracts
|
The Ileo Pouch Anal Anastomosis (IPAA), the restorative procedure of choice for patients with Ulcerative Colitis (UC) or Familial Adenomatous Polyposis (FAP), is attended by 35% pouch related complications and 6-8% failure rate. The Ileo Neo Rectal Anastomosis (INRA), an alternative restorative procedure, was developed to reduce the pouch related complication rate with an (at least) equal functional result. We report on the results of the first 50 INRA candidates and evaluate the primary goals. In 38/ 50 selected patients (43 UC and 7 FAP) an INRA procedure was carried out. 12 (UC) cases were converted to IPAA, because of difficulty to complete rectal mucosectomy. The median operation time for INRA was 323 minutes (range 240-518), with 1400 ml blood loss (400-4500). At present 35 patients had their ileostomy closed after a median of 3.0 months (range 0.4-14.7). 3 are awaiting closure of their temporary diverting ileostomy. The reservoir of one patient, who was reclassified to Crohns disease, was defunctioned because of severe inflammation of both the proximal small bowel and the neorectum. Therefore at present 34 INRA patients have a functioning neorectal reservoir. The median bowel frequency decreased from initially 15x/24 h (7-35; n=34) to 7.5x/24 h at two years (4-12; n=12). Continence was perfect in 23/34 cases. 10/34 cases had occasional nocturnal soiling and passive nocturnal fecal incontinence was seen in 2/34 cases. In 18/38 cases web-like stenoses occurred at the mucosa-anal level, which were treated by single (12) or repeated (6) dilatation. No pouch related complications like pelvic sepsis, fistula or sexual dysfunction occurred. 10 patients had episodes of pouchitis, successfully treated by antibiotics and in 2 other cases, with still functioning reservoirs, the diagnosis was reclassified as Crohns disease due to proximal small bowel inflammation. The neorectal maximum tolerated volume changed from pre-operatively 88 ml (14-300) to 133.5 ml (60-250) at two years (n=12). Mucosal biopsies showed atrophy and inflammation early after INRA, with recovery of small bowel mucosa in time. The INRA procedure shows a low complication rate and good functional result despite the learing curve in these first 50 cases. The learing curve and early difficulty to perform complete rectal mucosectomy are evidenced by long operation times, as well as a high conversion rate. This procedure fulfils its principal terms as alternative restorative procedure. |
