Ploeg, V. van der (Valerie) (2016) Prevalence of chronic peri-pouch sepsis in patients treated as difficult primary idiopathic pouchitis and standardising assessment and documentation of pouchoscopy. thesis, Medicine.
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Abstract
Background: Restorative proctocolectomy with the formation of ileal-pouch-anal anastomosis (RPC-IPAA) is a surgical treatment in patients with intractable ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, pouch dysfunction occurs fairly often. This project looks into secondary causes of pouchitis and the assessment of pouch dysfunction. Antibiotic-dependent or refractory primary idiopathic pouchitis (ADRP) and chronic peri-pouch sepsis (CPPS) have a similar clinical presentation and both may partially respond to empirical treatment with antibiotics. However, if a persistent pre-sacral collection is present, different treatment such as drainage may be more appropriate, and immunosuppressants and biologics should be avoided. We aimed to identify the prevalence of CPPS in patients thought to have ADRP. In an additional study we aimed to standardise assessment and documentation of pouchoscopy. Methods: Records of patients who were managed as ADRP over a period of nine years were reviewed retrospectively. Only those with endoscopic evidence of inflammation and who had MRI were included. Pouchoscopy findings and outcomes of treatment for CPPS were evaluated. In an additional study a group of ileo-anal pouch experts (n = 5) compiled a list of items that should be documented at pouchoscopy. Reports over a period of three months were reviewed for their completeness compared to the template. The template was then introduced for three months and reports obtained during that time were analysed. Results: Sixty-eight patients were treated as ADRP between March 2006 and June 2015 (43 male (63%)). MRI pelvis showed a pre-sacral collection in 26 patients (38%). Pouchoscopy identified localised ulcerative inflammation limited to the lower pouch in 13% of patients with a pre-sacral collection and in 26% without (p = 0.43). Examination under anaesthesia was performed in 13 patients (50%) with a pre-sacral collection. In five patients (19%) a collection was identified and drained; symptoms improved in only one of these patients (4%). The collection was not drained in the other patients (either because it was too small or it was thought to be not contributing to the inflammation). They remained on antibiotics (69%) or had their pouch defunctioned or excised (27%). In the second part of the study 121 pouchoscopy reports, generated between March 2015 and June 2015, were reviewed. The anus and peri-anal area was specifically described in 12% of the reports, rectal cuff in 55%, pouch-anal anastomosis in 37%, pouch body in 98%, pouch inlet in 13% and pre-pouch ileum in 61%. From August 2015 until November 2015 the template was introduced. Sixty-three reports were obtained. There was a significant improvement in documentation of the anus and peri-anal area (to 51%, p < 0.0001), rectal cuff (to 75%, p = 0.0104), pouch-anal anastomosis (to 67%, p = 0.0002) and pouch inlet (to 41%, p < 0.0001). Overall there was a significant improvement in documentation of 15 out of 22 features. Conclusions: In patients thought to have ADRP, 38% had a pre-sacral collection on MRI. There was no specific feature on pouchoscopy suggestive of CPPS. The possibility of CPPS should be considered early in patients with recurrent or refractory pouchitis and MRI pelvis performed. This might lead to earlier detection of the collection and prompt appropriate treatment. However, prognosis is poor if a CPPS is present. Additionally, the introduction of the template improved documentation of pouchoscopy significantly. This may lead to more accurate documentation of pouchoscopy findings in a standerdised manner.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Hofker, Drs Sijbrand and Hoogenboom, Drs Froukje and Department of Surgery, University Medical Centre Groningen and Post Box 30.001, 9700 RB Groningen |
| Supervisor name: | Clark, Prof. Sue and Maeda, Miss Yasuko and Department of Surgery, St. Mark's Hospital and Northwick Park, Watford Road |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 10:52 |
| Last Modified: | 25 Jun 2020 10:52 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/1299 |
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