Advertisement

European Radiology

, Volume 29, Issue 4, pp 1754–1761 | Cite as

Are radiologic pouchogram and pouchoscopy useful before ileostomy closure in asymptomatic patients operated for ulcerative colitis?

  • Georgios ExarchosEmail author
  • Linda Metaxa
  • Antonios Gklavas
  • Vassilis Koutoulidis
  • Ioannis Papaconstantinou
Gastrointestinal
  • 86 Downloads

Abstract

Objectives

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the “gold standard” procedure for patients with ulcerative colitis (UC) requiring surgical intervention. A de-functioning ileostomy is usually performed, as a step for the IPAA procedure. The aim of this study is to present the methodology and results of the routine double assessment of IPAA integrity in asymptomatic patients prior to the ileostomy reversal and evaluate its necessity.

Methods

This is a retrospective study of 61 UC patients, who underwent IPAA construction, in 2010–2016. A diverting ileostomy was created after IPAA construction, which was reversed at least 3 months later. A double assessment, with pouchogram and pouchoscopy, of IPAA integrity was performed, before stoma closure. Post-operative symptoms and signs of complications, imaging studies, and endoscopic findings were recorded during follow-up.

Results

Prior to the ileostomy reversal, both pouchoscopy and pouchogram identified no patient with evidence of anastomotic leakage. During a mean follow-up of 3.67 years after ileostomy reversal, 11 patients developed complications but only one had signs of leakage, which presented as a pouch-vaginal fistula. The specificity of both the pouchogram and pouchoscopy reached 100% and the negative predictive value ranged between 98.4 and 100%.

Conclusions

The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis, but their combination did not alter the diagnostic accuracy or had any effect in further management. At least, pouchogram could be selectively performed only in patients with high-risk clinical indicators.

Key Points

The double assessment of ileal pouch-anal anastomosis with pouchogram and pouchoscopy, prior to ileostomy closure, specifically in patients with ulcerative colitis has not been evaluated before.

The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis.

However, their combination did not alter the diagnostic accuracy or had any effect in further management, in asymptomatic patients.

Keywords

Ileal pouch-anal anastomosis Endoscopy, gastrointestinal Fluoroscopy Ulcerative colitis Proctocolectomy, restorative 

Abbreviations

IC

Ileostomy closure

IPAA

Ileal pouch-anal anastomosis

MD CT

Multi-detector computerized tomography

MRE

Magnetic resonance enterography

MRI

Magnetic resonance imaging

n

Number of cases

NPV

Negative predictive value

PES

Pouchoscopy

PPV

Positive predictive value

Q

Quartile

SD

Standard deviation

UC

Ulcerative colitis

WCE

Contrast pouchogram-water-soluble contrast enema study

Notes

Funding

The authors state that this work has not received any funding.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Ioannis Papaconstantinou.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Approval was obtained by hospital’s scientific committee.

Methodology

• Retrospective

• Diagnostic or prognostic study

• Performed at one institution

Supplementary material

330_2018_5760_MOESM1_ESM.avi (164.2 mb)
Video 1 Lateral View of Pouchogram- Fluoroscopic water-soluble contrast enema study: there is leakage of contrast from the anterior wall of the pouch to the posterior wall of the vagina, which is opacified (AVI 168135 kb)

References

  1. 1.
    Gorgun E, Remzi FH (2004) Complications of ileoanal pouches. Clin Colon Rectal Surg 17:43–55CrossRefGoogle Scholar
  2. 2.
    Wagner-Bartak NA, Levine MS, Rubesin SE, Laufer I, Rombeau JL, Lichtenstein GR (2005) Crohn’s disease in the ileal pouch after total colectomy for ulcerative colitis: findings on pouch enemas in six patients. AJR Am J Roentgenol 184:1843–1847CrossRefGoogle Scholar
  3. 3.
    Francone TD, Champagne B (2013) Considerations and complications in patients undergoing ileal pouch anal anastomosis. Surg Clin North Am 93:107–143CrossRefGoogle Scholar
  4. 4.
    Liszewski MC, Sahni VA, Shyn PB et al (2012) Multidetector-row computed tomography enterographic assessment of the ileal-anal pouch: descriptive radiologic analysis with endoscopic and pathologic correlation. J Comput Assist Tomogr 36:394–399CrossRefGoogle Scholar
  5. 5.
    Tang L, Cai H, Moore L, Shen B (2010) Evaluation of endoscopic and imaging modalities in the diagnosis of structural disorders of the ileal pouch. Inflamm Bowel Dis 16:1526–1531CrossRefGoogle Scholar
  6. 6.
    Sahi KS, Lee KS, Moss A et al (2015) MR enterography of the ileoanal pouch: descriptive radiologic analysis with endoscopic and pathologic correlation. AJR Am J Roentgenol 205:W478–W484CrossRefGoogle Scholar
  7. 7.
    Hong SY, Kim DY, Oh SY, Suh KW (2012) Routine barium enema prior to closure of defunctioning ileostomy is not necessary. J Korean Surg Soc 83:88–91CrossRefGoogle Scholar
  8. 8.
    Karsten BJ, King JB, Kumar RR (2009) Role of water-soluble enema before takedown of diverting ileostomy for low pelvic anastomosis. Am Surg 75:941–944Google Scholar
  9. 9.
    Lawal TA, Falcone RA, von Allmen D et al (2011) The utility of routine pouchogram before ileostomy reversal in children and adolescents following ileal pouch anal anastomosis. J Pediatr Surg 46:1222–1225CrossRefGoogle Scholar
  10. 10.
    da Silva GM, Wexner SD, Gurland B et al (2004) Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary? Colorectal Dis 6:117–120CrossRefGoogle Scholar
  11. 11.
    Jeyarajah S, Sutton C, Miller A, Hemingway D (2008) Colo-anal pouches: lessons from a prospective audit. Colorectal Dis 10:599–604CrossRefGoogle Scholar
  12. 12.
    Kalady MF, Mantyh CR, Petrofski J, Ludwig KA (2008) Routine contrast imaging of low pelvic anastomosis prior to closure of defunctioning ileostomy: is it necessary? J Gastrointest Surg 12:1227–1231CrossRefGoogle Scholar
  13. 13.
    Yanai H, Ben-Shachar S, Mlynarsky L et al (2017) The outcome of ulcerative colitis patients undergoing pouch surgery is determined by pre-surgical factors. Aliment Pharmacol Ther 46:508–515CrossRefGoogle Scholar
  14. 14.
    Parks AG, Nicholls RJ (1978) Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 2:85–88CrossRefGoogle Scholar
  15. 15.
    Feza H, Remzi VWF (2012) Ιleoanal pouch procedure for UC and FAP. In: Fischer DBJ JE, Pomposelli FB, Upchurch GR, Suzanne Klimberg V, Schwaitzberg SD, Bland KI (eds) Fischer's Mastery of Surgery. Lippincott Williams and Wilkins, Philadelphia, pp 1631–1645Google Scholar
  16. 16.
    McLaughlin SD, Clark SK, Thomas-Gibson S, Tekkis PP, Ciclitira PJ, Nicholls RJ (2009) Guide to endoscopy of the ileo-anal pouch following restorative proctocolectomy with ileal pouch-anal anastomosis; indications, technique, and management of common findings. Inflamm Bowel Dis 15:1256–1263CrossRefGoogle Scholar
  17. 17.
    Crema MD, Richarme D, Azizi L, Hoeffel CC, Tubiana JM, Arrivé L (2006) Pouchography, CT, and MRI features of ileal J pouch-anal anastomosis. AJR Am J Roentgenol 187:W594–W603CrossRefGoogle Scholar
  18. 18.
    Akbari RP, Madoff RD, Parker SC et al (2009) Anastomotic sinuses after ileoanal pouch construction: incidence, management, and outcome. Dis Colon Rectum 52:452–455CrossRefGoogle Scholar
  19. 19.
    Nyam DC, Wolff BG, Dozois RR, Pemberton JH, Mathison SM (1997) Does the presence of a pre-ileostomy closure asymptomatic pouch-anastomotic sinus tract affect the success of ileal pouch-anal anastomosis? J Gastrointest Surg 1:274–277CrossRefGoogle Scholar
  20. 20.
    Sahami S, Bartels SA, D'Hoore A et al (2016) A multicentre evaluation of risk factors for anastomotic leakage after restorative proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease. J Crohns Colitis 10:773–778CrossRefGoogle Scholar
  21. 21.
    Sahami S, Buskens CJ, Fadok TY et al (2016) Defunctioning ileostomy is not associated with reduced leakage in proctocolectomy and ileal pouch anastomosis surgeries for IBD. J Crohns Colitis 10:779–785CrossRefGoogle Scholar
  22. 22.
    Exarchos G, Gklavas A, Metaxa L, Papaconstantinou I (2018) Quality of life of ulcerative colitis patients treated surgically with proctocolectomy and J-pouch formation: a comparative study before surgery and after closure of the defunctioning ileostomy. Ann Gastroenterol 31:350–355Google Scholar
  23. 23.
    Fazio VW, Tekkis PP, Remzi F et al (2003) Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. Ann Surg 238:605–614 discussion 614-607Google Scholar
  24. 24.
    Pellino G, Selvaggi F (2015) Outcomes of salvage surgery for ileal pouch complications and dysfunctions. The experience of a referral centre and review of literature. J Crohns Colitis 9:548–557CrossRefGoogle Scholar
  25. 25.
    Deepak P, Bruining DH (2014) Radiographical evaluation of ulcerative colitis. Gastroenterol Rep (Oxf) 2:169–177CrossRefGoogle Scholar
  26. 26.
    Gao XH, Lan N, Chouhan H, Stocchi L, Remer E, Shen B (2017) Pelvic MRI and CT images are interchangeable for measuring peripouch fat. Sci Rep 7:12443CrossRefGoogle Scholar
  27. 27.
    Seo SI, Lee JL, Park SH, Ha HK, Kim JC (2015) Assessment by using a water-soluble contrast enema study of radiologic leakage in lower rectal cancer patients with sphincter-saving surgery. Ann Coloproctol 31:131–137CrossRefGoogle Scholar
  28. 28.
    Navaneethan U, Shen B (2010) Diagnosis and management of pouchitis and ileoanal pouch dysfunction. Curr Gastroenterol Rep 12:485–494CrossRefGoogle Scholar
  29. 29.
    Alfisher MM, Scholz FJ, Roberts PL, Counihan T (1997) Radiology of ileal pouch-anal anastomosis: normal findings, examination pitfalls, and complications. Radiographics 17:81–98 discussion 98-89CrossRefGoogle Scholar
  30. 30.
    Tang CL, Seow-Choen F (2005) Digital rectal examination compares favourably with conventional water-soluble contrast enema in the assessment of anastomotic healing after low rectal excision: a cohort study. Int J Color Dis 20:262–266CrossRefGoogle Scholar
  31. 31.
    Ourô S, Thava B, Shaikh I, Clark SK (2016) Management of pouch dysfunction in a tertiary centre. Colorectal Dis 18:1167–1171CrossRefGoogle Scholar
  32. 32.
    Cai JX, Barrow J, Parian A et al (2018) Routine pouchoscopy prior to ileostomy takedown may not be necessary in patients with chronic ulcerative colitis. Dig Dis 36:72–77CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.2nd Department of SurgeryNational and Kapodistrian University of Athens - Aretaieion HospitalAthensGreece
  2. 2.Radiology DepartmentSt Bartholomew’s HospitalLondonUK
  3. 3.Radiology DepartmentNational and Kapodistrian University of Athens, Aretaieion HospitalAthensGreece

Personalised recommendations