Abstract: Objective:To analyze the complications of total proctocolectomy with ileal pouchanal anastomosis (TPC-IPAA) in treatment of severe or refractory ulcerative colitis (UC).
Methods:The retrospective cross sectional study was conducted. The clinical data of 67 patients with severe or refractory UC who underwent TPC-IPAA in the Xinhua Hospital Affiliated to Shanghai Jiaotong University from February 2008 to October 2015 were collected. All the patients received open and laparoscopyassisted TPC-IPAA, and twostage or threestage surgery was performed according to the patients′ conditions. Observation indicators: (1) treatment and followup situations, (2) shortterm complications after TPC-IPAA, (3) longterm complications after TPC-IPAA. The followup using telephone interview and outpatient examination was performed to detect the quality of postoperative life in patients and occurrence of complications up to July 2016. Measurement data with skewed distribution were described as M (range). The comparison of quality of pre and postoperative life in patients was done using the paired t test.
Results:(1) Treatment and followup situations: all the 67 patients received successful surgery, including 45 with twostage surgery and 22 with threestage surgery. Thirtyseven patients underwent open surgery and 30 underwent laparoscopic surgery. The average frequency of postoperative daily defecation, average scores of quality of pre and postoperative lifes were 5.6, 0.47 and 0.67, respectively, with a statistically significant difference between preoperative indicators and postoperative indicators (t=-4.80, P<0.05). All the 67 patients were followed up for a median time of 4.6 years (range, 1.0-8.4 years). (2) Shortterm complications after TPC-IPAA: Of 67 patients, 10 had shortterm complications（some patients with multiple complications）. One patient was complicated with presacral abscess secondary to sinus formation and then was cured by topical incision of sinus under colonoscopy. Five patients were complicated with anastomotic siterelated complications of TPC-IPAA, and 1 with pouchanal anastomotic fistula combined with presacral abscess underwent drainage with ileostomy and didn′t undergo stoma reversion of ileum. Two patients with fistula at the top of pouch were improved by surgery and repair. Of 2 patients with pouchvagina fistula, 1 underwent resection of pouch stumpvagina fistula and then were cured, and the space between pouch stump and posterior fornix was filled with a free greater omentum flap and temporary ileal bypass was simultaneously conducted. The other patient received twice transanal vaginal fistula repairs with advancement flap, and unclosed fistula was confirmed by angiography, with a clinical symptomatic relief. Eight patients with wound infection received actively dressing change after discharge, and no wound dehiscence was occurred. (3) Longterm complications after TPC-IPAA: 28 of 67 patients had longterm complications. Twelve patients with intestinal obstruction underwent conservative treatments of gastrointestinal decompression, antiinflammatory with corticosteroid and antiinfection with antibiotic, without the occurrence of severe intestinal perforation and prognosis needing surgical intervention, including 9 undergoing open TPC-IPAA and 3 undergoing laparoscopic TPC-IPAA. Thirteen patients with postoperative pouchitis received the conservative treatment of mesalazine. Three patients with failed pouch underwent small intestine permanent colostomy, including 2 with secondary pouch Crohn′s disease and 1 with severe pouchitis.
Conclusions:TPC-IPAA is safe and effective in treatment of UC, with a lower incidence of complications. Anastomotic siterelated complication of TPC-IPAA is the main shortterm complication. And in the longterm complications, pouchitis is the most, followed it is intestine obstruction.