studies on the ileal pouch-anal anastomosis

86 Pages·2017·6.2 MB·English

STUDIES ON THE ILEAL POUCH-ANAL
ANASTOMOSIS

Marie Louise Sunde

University of Oslo
Institute of Clinical Medicine
Faculty of Medicine
© Marie Louise Sunde, 2018

Series of dissertations submitted to the
Faculty of Medicine, University of Oslo

ISBN 978-82-8377-196-1

All rights reserved. No part of this publication may be
reproduced or transmitted, in any form or by any means, without permission.

Cover: Hanne Baadsgaard Utigard.
Print production: Reprosentralen, University of Oslo.
ACKNOWLEDGEMENTS:

Many people have been instrumental in conducting the studies this thesis is based on. I am
especially grateful to Dr. Petr Ricanek and Professor Jørgen Jahnsen from the Department of
Gastroenterology for collaborating on our third study, and I would like to extend special
thanks to Dr. Ricanek for performing pouch endoscopies on all patients included. Likewise I
would like to express my gratitude to Dr. Anne Negård, Dr. Njål Bakka, and Professor Jonn
Terje Geitung from the Department of Radiology for collaborating on our fourth study. Again,
a special thanks to Dr. Negård for overseeing the radiological aspects of the study. The
collaboration with both departments has been very fruitful, and I am thankful for the interest,
engagement and positivity from our mentioned colleagues. I also want to thank Dr. Shafique,
Dr. Schive, and Dr. Monteleone from the Department of Surgery for helping with the
manovolumetric examination of our study patients. Lastly, I want to thank nurses at the out-
patient clinic and the radiographs at the MRI lab for coordinating and facilitating the
examination of patients. The statisticians at University of Oslo, campus Ahus, have been very
helpful in advising the statistical analysis in the studies. I also want to thank my brother, Einar
Sunde, for thoughtful help with calculations and statistical analysis, and my mother, Ingrid
Stange, for proof reading.

This thesis would not have been possible without our patients agreeing to being interviewed
and undergo further examinations. I want to express my gratitude to all patients included in
the studies, and special thanks are due to the patients undergoing manovolumetric testing,
endoscopy, and MRI. Our patients have been positive and happy to contribute to research on
pouch surgery. I hope our results will improve the surgery and functional outcome in the
future.

Last but not least, I want to thank my supervisors Dr. Arne Engebreth Færden and Professor
Tom Øresland for supervising, advising, supporting and encouraging me throughout the
research period. I am very grateful for your personal engagement and presence in each study,
and for your support and trust ever since I was invited to join your research group as a
medical student.

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CONTENTS:

THESIS AT A GLANCE……………………………………………………….. 7
PAPERS INCLUDED IN THE THESIS………………………………………. 8
1. BACKGROUND:
1.1 Introduction…………………………………………………………. 9
1.2 History of ulcerative colitis…………………………………………. 10
1.2.1 Aetiological understanding in a historic perspective……….. 10
1.3 History of IPAA surgery…………………………………………..... 12
1.3.1 The continent ileostomy – Kock’s pouch …………………. 14
1.3.2 S-Pouch…………………………………………………...... 14
1.3.3 J- and W-pouch………………………………………………15
1.4 Ulcerative colitis……………………………………………………... 16
1.4.1 Epidemiology……………………………………………….. 16
1.4.2 Aetiology……………………………………………………. 17
1.4.3 Pathogenesis……………………………………………….... 17
1.4.4 Clinical manifestation…………………………………......... 18
1.4.5 Medical treatment…………………………………………... 18
1.4.6 Surgical intervention ……………………………………….. 19
1.5. IPAA physiology…………………………………………………….. 19
1.5.1 Sphincter function…………………………………………... 19
1.5.2 Volume and compliance…………………………………..... 20
1.5.3 Site of anastomosis………………………………………..... 20
1.5.4 Type of anastomosis……………………………………….... 21
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1.6. Complications›……………………………………………………… 21
1.6.1 Septic pelvic complications……………………………….... 21
1.6.2 Pouchitis…………………………………………………….. 22
1.6.3 Other non-septic complications…………………………….. 23
1.6.4 Laparoscopic versus open approach………………………... 23
1.7. Functional outcome and quality of life…………………………..... 24
1.7.1 Functional outcome……………………………………….... 24
1.7.2 Pouch design and functional outcome……………………… 25
1.7.3 Quality of life versus pouch function………………………. 26
1.7.4 Quality of life………………………………………………. 27
1.8. Sexual function……………………………………………………… 27
2. AIM OF THE STUDY……………………………………………………….. 29
3. METHODS……………………………………………………………………. 30
3.1 Patients ……………………………………………………….... 30
3.2 Surgical technique ……………………..………………………….... 30
3.3 Questionnaires……………………………………………………..... 31
3.4 Barostat………….…………………………………………………... 33
3.5 Pouch endoscopy…………….………………………………………. 34
3.6 Biomarkers………………….……………………………………….. 34
3.7 MRI…………….……………………………………………………. 35
4. RESULTS …………………………………………………………………….. 37
4.1 Study 1………………………………………………………….......... 37
4.1.1 Main findings……………………………………………….. 37

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4.1.2 Surgical outcome………………………………………….... 37
4.1.3 Functional outcome ……………………………………….... 38
4.1.4 Quality of life………………………………………………. 39
4.1.5 Quality of life and functional outcome……………………... 40
4.2 Study 2……………………………………………………………….. 41
4.2.1 Main findings……………………………………………….. 41
4.2.2 Sexual function …………………………………………….. 41
4.2.3 Pouch function versus sexual function……………………… 43
4.3 Study 3……………………………………………………………….. 44
4.3.1. Main findings………………………………………………. 44
4.3.2 Barostat……………………………………………………... 45
4.3.3 Pouch endoscopy and biomarkers….……………………..... 47
4.4 Study 4……………………………………………………………….. 48
4.4.1 Main findings……………………………………………….. 48
4.4.2 MRI…………………………………………………………. 48
5. METHODOLOGICAL CONSIDERATIONS…………………………….... 51
5.1 Study 1………………………………………………………... 51
5.2 Study 2………………………………………………………... 52
5.3 Study 3………………………………………………………... 54
5.4 Study 4………………………………………………………... 55
6. GENERAL DISCUSSION………………………………………………….... 56
7. CONCLUSION ………………………………………………………………. 60
8. FUTURE PERSPECTIVES…………………………………………………. 61
9. REFERENCES……………………………………………………………….. 62
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10 APPENDIXES……………………………………………………………….. 72
Scores……………………………………………………………………. 73
Pouch functioning score…………………………………………... 73
SF-36……………………………………………………………… 74
PISQ………………………………………………………………. 79
IIEf-5……………………………………………………………… 80
Studies......................................................................................................... 81
1. Restorative proctocolectomy with two different pouch
designs: few complications with good function.
2. Correlation between pouch function and sexual function
in patients with IPAA.
3. Determinants of optimal bowel function in ileal pouch-anal anastomosis –
physiological differences contributing to pouch function.
4. Morphological MRI with defecography of the ileal pouch anal
anastomosis – Contributes little to the understanding of
functional outcome.

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THESIS AT A GLANCE:
STUDY 1 STUDY 2 STUDY 3 STUDY 4
AIM To investigate To correlate To perform physiological To evaluate the
surgical outcome postoperative tests and endoscopic morphology and
after IPAA at our bowel function examination on the well emptying in well
unit, determine if with sexual and poorly functioning and poorly
there are differences function pouches to determine functioning
in functional factors contributing to pouches with a
outcome or QoL functional outcome. pelvic MRI, and to
between patients establish a
with J and K reference of normal
pouches, and MRI findings in
investigate the pelvic pouch
correlation between patients.
QoL and functional
outcome.
PATIENTS All patients operated on between 2000- Based on pouch function, the best and worst
AND 2013 (N=103) were interviewed regarding functioning patients were invited to undergo
METHODS QoL, sexual function and pouch function by manovolumetric testing, pouch endoscopy and a
a pouch functioning score (PFS) ranging pelvic MRI
from 0-16 (low numbers indicate good
function) .
RESULTS There were few 68 responded to the N=47. Well functioning N = 43. There were
complications and no questionnaire pouches have a no differences in
pouch failures. 88 regarding sexual significantly larger MRI findings
responded to the function and pouch volume. Sensibility between the groups,
QoL questionnaire function. Poor thresholds are triggered and no findings
and PFS. There were pouch function is by pressure and not by correlated to
no differences in negatively volume. More patients malfunction. Pelvic
QoL or functional correlated to sexual with poor function have volume was not
outcome, although a function in women, histological pouchitis, correlated to pouch
tendency towards not in men. hand sewn anastomosis volume.
better function in K and longer rectal cuff. Inflammation signs
patients. A PFS ≥ 8 on MRI seems to
was the best cut off be normal also
to predict when among well
functional outcome functioning
significantly impairs pouches.
quality of life
CON- Small improvements Pouch function has In this study volume is the It seem MRI does
CLUSION in function have an a stronger most prominent predictor not increase the
impact on the QoL. correlation with of functional outcome. understanding of
Other designs than sexual function in The reason for variability factors contributing
the J-pouch deserve women compared in pouch volumes remains to functional
further evaluation. to men. unexplained. outcome after
IPAA surgery,
unless septic pelvic
complications are
suspected.

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PAPERS INCLUDED IN THE THESIS:

1. Restorative proctocolectomy with two different pouch designs: few complications
with good function.
Sunde ML, Øresland T, Faerden AE.
Colorectal Disease. 2016. Vol 19. 363-371.

2. Correlation between pouch function and sexual function in patients with IPAA
Sunde ML, Øresland T, Faerden AE.
Scandinavian Journal of Gastroenterology. 2015. Vol 51. 295-303.

3. Determinants of optimal bowel function in ileal pouch anal anastomosis –
physiological differences contributing to pouch function.
Sunde ML, Ricanek P, Øresland T, Jahnsen J, Naimy N, Faerden AE.
Submitted to Scandinavian Journal of Gastroenterology, and resubmitted with minor
revision.

4. Morphological MRI with defecography of the ileal pouch anal anastomosis –
Contributes little to the understanding of functional outcome.
Sunde ML, Negård A, Øresland T, Bakka N, Geitung JT, Færden AE.
Submitted to Colorectal Disease.

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