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Kangaroo Club Information Day

Explore the treatment options for a 25-year-old woman with ulcerative colitis (UC) and troublesome proctitis, who is considering pouch surgery, ileo-rectal anastomosis, or deferring surgery. Factors such as bowel and sexual function, morbidity, cancer risk, and body image are important considerations. Decision-making in pouch surgery is challenging and requires a multidisciplinary approach, while the medico-legal landscape is evolving.

joelcaldwell
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Kangaroo Club Information Day

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  1. Kangaroo Club Information Day Bruce George 7th October 2017

  2. Should I have a Pouch? • 25 year old woman • UC since age 20 • colectomy + ileostomy with retained rectal remnant age 24 • troublesome proctitis and doesn’t like ileostomy • What operation? • Ileo-anal pouch • Ileo-rectal anastomosis • Defer surgery • Proctectomy and permanent ileostomy

  3. How long does X have to be to choose treatment B over treatment A? Forced choice question Diagnosed with terminal illness 2 treatments approved by NICE Treatment A: 50:50 chance of complete cure or death Treatment B: Gives X period of time in complete remission and then death

  4. Nadine and Sam Montgomery

  5. Montgomery vs Lanarkshire Health Board • Replaces Bolam principle • Dovetails with GMC guidelines about informed consent • Individualised approach to informed consent • Dr must discuss issues even if low risk which may be particularly important to that patient

  6. Should I have a pouch? • 25 year old woman • UC since age 20 • colectomy + ileostomy and retained rectal remnant age 24 • Troublesome proctitis and doesn’t like ileostomy • What operation? • Ileo-anal pouch • Ileo-rectal anastomosis • Defer surgery • Proctectomy and permanent ileostomy

  7. 25 year old woman • UC since age 20 • colectomy + ileostomy and retained rectal remnant age 24 • Troublesome proctitis and doesn’t like ileostomy • What factors are important to this patient? • Bowel function • Sexual function and fecundity • Morbidity of surgery/ returning to work • Cancer risk/surveillance • Body image

  8. Body image is important Blake Beckford

  9. Function • BO x 5-7, night 53%, urgency 16% • Failure rate 10-20%:

  10. UK Ileoanal Pouch Report 2017 • > 5000 patients (1980- today) • Supplemented by SWORD (surgical workload outcome reporting database) • Key findings: • Length of stay 10 days • 25% re-admission within 30 days • 20% complication • Gradual increase in laparoscopic procedures (33%) • Concerns about low volume hospitals and surgeons • Only 26 surgeons undertook >15 ops in 5 yrs • 126 surgeons only 1 op • 108 (of 126) hospitals less than 5/yr

  11. Meta-analysis of 8 studies Pre-op UC: Infertile 105 Fertile 423 = 19.9% “medical” infertility Post-pouch UC: Infertile 301 Fertile 300 = 50.1% “surgical” infertility Fertility Waljee et al Gut 2006

  12. Questionnaire to 160 post pouch patients (and 160 post appendicectomy controls) 54 (39%) attempted to become pregnant post pouch 60 (46%) of controls Of pouch patients trying to become pregnant 36 of 54 (67%) succeeded naturally 49 (82%) of controls Lepisto et al BJS 2007

  13. 13 of 18 infertile post-pouch patients underwent fertility investigations: Ultimately 8 conceived Overall cumulative pregnancy after 72 months, including after infertility treatment = 80% Need for fertility investigations Lepisto et al 2007

  14. Infertility rates: x 2-3 fold increase 20% to 50% Waljee et al 2006 Eventual chance of becoming pregnant if trying 76-80% (91% in controls) Lepisto et al 2007 How should we spin this?

  15. Ileo-rectal anastomosis in UC • Initially described in 1950’s • Fell into disrepute due to high cancer risk • Recent resurgence of interest • selected patients with: • Mild proctitis • No dysplasia • No PSC • Compliant with surveillance

  16. Ileo-rectal anastomosis in UC (compared to pouch) • Lower bowel frequency, better continence • Similar urgency • Less complicated procedure , faster return to normal activities • No (or postponed) pelvic surgery • Better preservation of fertility • Need for surveillance/cancer risk

  17. Deferred surgery • Persisting ileostomy • Persisting rectal remnant symptoms (10 year rule) • No risk to fertility • No change in sexual function/quality of life

  18. Proctocolectomy and permanent ileostomy • Negative impact on body image and sexual function • Relatively straightforward surgery, return to normal activities • Preservation of fertility

  19. Summary • 25 year old woman • UC since age 20 • colectomy + ileostomy and retained rectal remnant age 24 • Troublesome proctitis and doesn’t like ileostomy • What operation? • Ileo-anal pouch • Ileo-rectal anastomosis • Defer surgery • Proctectomy and permanent ileostomy

  20. Decision making in Pouch Surgery • Challenging • Find out what matters most to the patient • Need for multidisciplinary care • Changing medico-legal landscape

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