1	"Experiences and Controversies in" Experiences and Controversies in Pelvic Pouch Surgery Zane Cohen, M.D.,F.R.C.S.[C],F.A.C.S. The Bernard & Ryna Langer Chairman Division of General Surgery University of Toronto
2	Travelling Fellowship June 26-August 10, 2007
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5	Ileal Pouch-Anal Anastomosis Total abdominal colectomy Complete anal mucosal excision J pouch Ileal pouch-anal anastomosis Diverting loop ileostomy Ileostomy closure 3 months later
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7	Overall Results
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24	"Sexual Function," Sexual Function, Fertility and Delivery 1998-2007
25	Patient Questions In males: You’ve mentioned that ED and ejaculation problems can occur, albeit very infrequently. What about other aspects of sexual function? In females: Will sexual function be affected by surgery? Will I have difficulty conceiving after the pelvic pouch procedure? If I should become pregnant, what method of delivery should I choose?
26	Assessment of Sexual Function following IPAA - U of Toronto Experience All patients undergoing IPAA between February 2005 and June 2006 were studied prospectively Two validated instruments used: IIEF (males): includes 15 questions covering 5 domains: erectile and function, sexual desire and intercourse and overall satisfaction FSFI (females): includes 19 questions cover 6 domains: desire, arousal, lubrication, orgasm, satisfaction and pain Patients completed questionnaires pre-operatively and at 6 and 12 months post-op
27	Assessment of Sexual Function following IPAA - U of Toronto Experience 110 patients having IPAA surgery 54 UC, 4 FAP, 1 IC 59 patients (53.6%) agreed to participate 56 patients at 6 months post-op 39 patients at 12 months post-op 33 males median age 37 (28-45) 26 females median age 36.5 (31-46)
28	Sexual Function Males
29	Erectile Function
30	Sexual Function Females
31	Summary IPAA does not appear to have a negative impact on male sexual function Approximately 30% of males preoperatively vs. 25% post-operatively had abnormal sexual function scores Proportion of males having abnormal erectile function scores was similar pre- and post-operatively A high proportion of females had abnormal sexual function scores pre-operatively with significant improvement at 12 months (75% vs. 25%) Sexual dysfunction did not appear to be correlated with quality of life
32	Fertility following UC Diagnosis Data suggest that UC per se does not impact female fertility Willoughby and Truelove 1980 147 women with UC in England 6.8% infertile (tried to become pregnant but failed) Hudson et al. 1997 138 women with UC in Scotland 12% infertile (tried to become pregnant but failed)
33	Fertility following IPAA Only recently have studies examined the impact of IPAA on female fertility Olsen et al . (1999 and 2002) Significantly fewer pregnancies were observed than expected in a cohort of 250 Danish females (34 vs. 69; OR 0.49) Fecundability (probability of becoming pregnant per month on unprotected intercourse) was significantly lower after IPAA compared to prior to the diagnosis of UC, prior to surgery and to a reference population
34	Fertility after IPAA- University of Toronto Experience Cross sectional study Patients All women who had UC treated non operatively or surgically (IPAA) at MSH were identified from the IBD database Inclusion criteria 18 at the time of the study less than 44 at the time of IPAA or UC diagnosis married or cohabiting for at least 12 months after surgery or diagnosis
35	Definition of Infertility Infertility rate failure to become pregnant during 12 months of unprotected intercourse while between the ages of 18-44 and married or cohabiting # women reporting infertility # infertile + using birth control + surgically sterilized + not sexually active accepted definition used in North America may underestimate the risk in women specifically trying to become pregnant on the other hand, women who conceive after 12 months are included in the infertile group
36	Fertility after IPAA- University of Toronto Experience IPAA Patients 153 patients met inclusion criteria mean age at diagnosis 24 (2-42) mean age at IPAA 31 (18-43) mean follow up after IPAA 11yrs (5-21) Patients with UC managed non-operatively 60 patients met inclusion criteria mean age at diagnosis 28 (11-42) mean follow up after diagnosis 15yrs (5-57)
37	Fertility after IPAA- University of Toronto Experience Infertility Rate: Population Sample Size Infertility Rate (95% CI) IPAA 153 36.8% (30.9-46.3) Non-op Management 60 13.3% (4.7-21.9)
38	Fertility after IPAA- University of Toronto Experience Among IPAA patients (n=59) infertility occurred: Before diagnosis with UC 13.6% After diagnosis but before surgery 6.7% After IPAA 79.7% Among patients managed non-operatively (n=8) infertility occurred: before diagnosis with UC 62.5% after diagnosis with 37.5%
39	Fertility after IPAA- University of Toronto Experience Were women trying to become pregnant? 66/153 (43%) tried to become pregnant 1/153 (0.7%) was not sexually active 41/153 (26.8%) were using birth control 45/153 (29.4%) had been surgically sterilized
40	Fertility after IPAA- University of Toronto Experience Cohort Tried to become pregnant Success IPAA Before Surgery 95/153 95.8% After Surgery 66/153 56.1% Non-op Management Before Diagnosis 32/60 96.9% After Diagnosis 40/60 97.5%
41	Fertility after IPAA- University of Toronto Experience Logistic regression for outcome success becoming pregnant Covariate OR for pregnancy (95% CI) P value Increase in age of 1yr 0.88 (0.79-0.987) 0.028 After diagnosis with UC vs. 0.68 (0.359-1.291)* 0.239 prior to diagnosis Prior to IPAA vs. prior to 0.97 (0.095-9.812)* 0.977 diagnosis with UC After IPAA vs. Prior to IPAA 0.021(0.004-0.097)* <0.0001
42	Fertility after IPAA- University of Toronto Experience Use of fertility treatments Cohort Used fertility treatment Before Surgery 5/95 (5.3%) After Surgery 20/66* (30.3%) Non-op Management Before Diagnosis 2/32 (6.3%) After Diagnosis 0/40 (0%)
43	Summary IPAA patients Infertility rate 36.8% after surgery Success becoming pregnant was significantly reduced after surgery Use of fertility treatments was high IPAA has a significant negative impact on female reproductive ability
44	What to do? Patients need to be informed of the risks Delaying surgery is often not an option Consider subtotal colectomy and ileostomy with postponement of reconstructive surgery following pregnancies Laparoscopic approach may decrease adhesions and therefore decrease infertility rate ? Strategies to decrease adhesion formation
45	Pregnancy following IPAA- University of Toronto Series
46	Pregnancy following IPAA-University of Toronto Results
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48	Complications and Functional Results following Pregnancy and Delivery Caesarian section- 4 (17%) Two patients each had 2 small bowel obstructions. Vaginal delivery- 1 (4%) One patient developed uterine prolapse Increased stool frequency during pregnancy but returned to pre-pregnancy status in most patients No difference in functional results post partum whether a vaginal delivery or C section was performed
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53	Pouchitis in Continent Ileostomies (n = 84) and Pelvic Pouches (n = 96) Cumulative risk of developing pouchitis (5 year follow-up) 33% Cl; 47% PP *Risk of developing episode of pouchitis is greatest during first 2 years post-op
54	Pouchitis: Occurrence of First Episode
55	Swedish Results Gullberg et al Gasroenterol 1997 Cohort 149 Group C 7 (5%) (Group C = severe villous atrophy and pouchitis) 5 of 7 dysplasia 2 of 5 with dysplasia had aneuploidy
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59	POUCH MALIGNANCIES FOLOWING RPC ADENOCARCINOMA IN UC PATIENTS = 20 ADENOCARCINOMA IN FAP PATIENTS = 14 LYMPHOMA IN UC PATIENTS = 4
60	IAA AND POUCH ADENOCARCINOMAS IN UC PATIENTS (n=20) 16 Males, 4 Females Duration of UC 14 Yrs (range 2-28 yrs)
61	"Type of Anastomosis" Type of Anastomosis - 14 mucosectomy and hand-sewn anastomosis - 6 stapled anastomosis Time from Sx to Dx of cancer (6.1 Yrs, range 2-18 Yrs)
62	CANCERS
63	WHAT CAN WE DEDUCE? There is a risk of cancer developing The risk is likely to increase over time Cancers often appear late, quite advanced, and after a prolonged duration of disease; usually where indication for surgery is dysplasia /cancer Controversies 1) Type of anastomosis 2) Follow-up
64	STAPLED OR HAND-SEWN ANASTOMOSIS
65	MSH ROUTINE Pre-op biopsies of anus and low rectum when indication for surgery is dysplasia/cancer Stapled anastamosis where possible for better visualization of anus, provided no dysplasia in anus pre-operatively Consider different surgical option for high-grade dysplasia in low rectum or for cancer anywhere in rectum Consider age of patient when recommending surgical choice Post-operative surveillance, although not proven or perfect, should be performed at least yearly in this patient population- endoscopy and biopsy where possible + imaging, at least for baseline
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72	Objectives To determine if differences in LOS, 30 day re-admission, re-operation and excision rates exist between 1, 2 and 3 stage PPP To determine if differences in these clinical outcomes exist between low, medium and high volume hospitals
73	Definitions for CIHI Data LOS Combined/total LOS for each stage of the PPP as well as LOS for any hospital admissions between the first and last stage of the procedure 30 day re-admission Any hospital admission within 30 days of the last stage of the PPP Hospital Volume Total number of PPP performed at each hospital from January 1992 to June 1998 Low = < 10; Medium = 11 – 100; High = > 100
74	Variables and Outcomes of Interest Clinical variables Age Gender Year of PPP (i.e., ileo-anal anastomosis) Staging of PPP Hospital volume Outcome variables Length of hospital stay (LOS) 30 day re-admission rate Re-operation rate (all abdominal and anal) Excision rate
75	Overall Results 1285 PPP performed in Ontario between January 1992 – June 1998 198 PPP/year (range 180-213) 64.4% < 40 yrs of age; 57.4% male 58 hospitals 2 high volume (>100/PPP) – 622 PPP 13 medium volume (11-100/PPP) – 558 PPP 43 low volume (<10/PPP) – 105 PPP
76	Overall Results LOS = 21.2 days 30 day re-admission rate = 10.5% Re-operation rate = 36.2% Excision rate = 4.9%
77	Overview of Results
78	Effect of Year of PPP
79	Effect of Staging
80	Effect of Hospital Volume
81	"Both modifications in surgical technique..." Both modifications in surgical technique and increasing surgical experience have led to improved clinical outcomes
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