The devil is in the details: Ileal Pouch series
Wednesday, July 24, 2019
Wednesday, July 24, 2019
In this video, Dr. Roel Hompes speaks about the construction of the ideal ileal pouch. He defends that the transanal approach is the logical next step after the transabdominal subtotal colectomy, since it allows for a total proctectomy under direct vision and facilitates the pouch construction and anastomosis. He also presents the first data from a collaborative study between centers all over Europe that show positive results for the transanal approach.
In this video in the Ileal Pouch Series, Dr. Kienle talks about the disadvantages of TaTME.
Restorative proctocolectomy is indicated for treatment of inflammatory bowel diseases such as ulcerative colitis or in familial polyposis.
Only around 20% of cases require an oncological procedure, performing a total mesolectal excision.
In this video Dr. Kienle presents the disadvantages of TaTME-Pouch from his point of view.
There is no hard evidence on nerve damage, functional impact, or better anastomotic results, for taTME versus lapTME.
According to Dr. Kienle, making a purse-string to create an anastomosis is more difficult because if the purse-string is not tight, the risk of tissue and organ injury is higher due to impaired vision.
Dr. Kienle concludes that using taTME for a restorative proctocolectomy has no proven advantages, may be harmful and more expensive, but it is important to investigate further.
In this talk, Baljit Singh speaks about the recorded data about pouches from 2012 to 2017.
Pouch surgery is not a common surgery within the scope of colorectal surgery. Of the approximately 400 surgeons who have ever performed this surgery, only 26 have performed more than 15 operations.
The majority of them, 126, have only performed one pouch surgery.
The ratio of complications and readmission is high in this surgery.
The most common diagnosis of patients having primary ileoanal pouch surgery is ulcerative colitis and familial adenomatous polyposis.
In recent years there has been a variation in the use of the different Pouch designs. Currently almost 100% of the pouch made are J-Pouch.
Roel Hompes from the Academic Medical Center of Amsterdam talks about the lessons learned from the international TaTME registry for benign disease. After making a comprehensive review of all the developing phases of TaTME, Dr. Hompes explain how the international registry was designed as well as which were the initial variables that were studied. TaTME cases for benign disease represent less than 10% of all the registered data with high variability of indications. Technical variations when compared to TaTME for cancer, learning curve issues, postoperative outcome are discussed. Some of the current drawbacks and areas for improvement of the TaTME benign disease registry are also reviewed.
In this EHTG/ESCP lecture Professor Antonio Spinelli from Humanitas Research Hospital in Milano explains the pros and cons of performing a “near to TME” dissection when performing a pouch for FAP. Despite the fact TME dissection has been considered as the gold standard in these cases, there are some advantages when dissection is performed close to the rectal wall. Some studies indicate that “near to TME ” dissection could be related to a lower pelvic complication rate as well as better functional outcome due to autonomic nerve preservation. Moreover, possible pitfalls and complications regarding anatomical issues and oncological outcome are also discussed.
In the 6th episode of the Ileal Pouch Series, Dr. Roel Hompes MD PhD explains the arguments in favor of close rectal dissection in cases of protectomy for benign disease.
Dr. Hompes highlights the benefits of this technique over TME dissection, mainly, less bleeding, nerve preservation, leak prevention and mitigation.In cases of FAP, close dissection is only beneficial if there is no suspicion of cancer, but more data is required.
In this lecture, Professor Antonino Spinelli talks about the use of fluorescence imaging to confirm vascularisation of the ileal pouch. Fluorescence imaging has been used widely in the recent years as a tool to evaluate perfusion in colorectal surgery. It appears to be of even more importance in pouch construction, but it needs refining and decisions must be guided by clinical experience.
We continue the Ileal Pouch Series with Dr. Nagahise Matsubara’s lecture on the experience of Japanese surgeons in mucosectomy and hand-sewn anastomosis for patients with PAF. Not only it a is a feasible technique, as it can be beneficial regarding adenoma formation.
The ideal pouch size has been on debate for decades. Some authors have defended a longer pouch size, while others advocate the benefits of a shorter one. In this lecture, Dr. Willem Bemelman MD PhD explains the pros and cons of the different lengths and shapes of the pouch, and what other factors are of influence on its functioning.
Vascular dissection and division plays a very important role in pouch formation. Not only it influences the size of the pouch, as the vascularization and failure rate. The division of the ileocolic vessels is still contradictory, with some studies revealing clear benefits, while others relating it with pouch failure. In this 10th episode of the Ileal Pouch Series, Dr. Peter Kienle MD PhD shares the different views and his personnel experience on the matter.
What is the evidence on using pelvic nerve monitoring during pouch construction? The majority of publications are from level V evidence, mainly case reports and short case series. In this lecture Werner Kneist MD explains the rationale behind using this technique and the current data collected. It has been shown that it may preserve function, but further research is necessary.
Pouch dysfunction may be present in up to 15% of patients, depending on the symptoms investigated. When it is suspected, the first step is to investigate the reason behind it: pouchitis, irritable pouch, chronic pelvic sepsis, pelvic desmoid tumor, between others. Dysfunction may also be caused by mechanical complications as outlet obstruction. In this 12th episode of the Ileal Pouch Series, Dr. André d’Hoore MD PhD talks about the diagnostic pathway for patients presenting with pouch dysfunction and the different treatment options.
In this week’s episode of the Ileal Pouch Series, Dr. Antonio de Lacy PhD elucidates the advantages of the transanal approach in patients with carcinoma after proctocolectomy. Dr. Lacy presents a video-clinical case of a 31yr old female with PAF, treated initially with a total proctocolectomy with J-pouch reconstruction, with suspected neoplasia of the remaining rectal mucosa. The transanal approach was chosen to perform the new resection and redo the anastomosis, with favorable results.
Pouch leak can affect up to 20% of patients in the first year after surgery. Treatment options will take in consideration the timing to diagnosis and the presentation. In this lecture, Dr. Willem Bemelman MD PhD shows the role of vacuum therapy in the treatment of pouch leaks and some results of his institution’s study on the matter. Vacuum therapy with early closure was instituted with good results, not only regarding function of the pouch but also chronic sinuses and redo surgery.
After 15 weeks we reached the last lecture of our Ileal Pouch Series. Dr. Gabriela Moslein MD discusses the role of the continent ileostomy and explains, step by step, how to construct it. Although created decades ago, this Kock pouch may still be an option for some of the patients submitted to total proctocolectomy.