Introduction
Restorative proctocolectomy is the intervention of choice in patients with refractory or complicated Ulcerative Colitis (UC). Despite the high success rate of the procedure, a minority of patients experiences recurrent symptoms related to pouch dysfunction. To date, neither a gold standard for instrumental diagnosis of such disorders nor specific reference parameters for studying this population have been established.
Aims & Methods
The main aim of this study was to evaluate the role of dynamic transperineal ultrasound (DTPUS) and ano-pouch manometry (APM) in describing functional changes of the pouch and their correlation with clinical symptoms.
This is a prospective observational study conducted on a consecutive unselected sample of patients who underwent restorative proctocolectomy with J pouch for refractory and/or complicated UC in an Inflammaroty Bowel Disease (IBD) Tertiary Care Centre. Included patients underwent ileostomy closure at least one year before enrollment. Patients were administered a questionnaire to assess the degree of pouch dysfunction, followed by DTPUS and APM performed by different operators who were blind to clinical data. Retrospective data regarding surgery and postoperative course were also collected. Fisher's exact test or chi-square test were used for statistical evaluation of the correlation between variables.
Results
18 patients were analyzed. Based on symptoms severity, they were divided into five groups according to the recently proposed Ileoanal Pouch Syndrome Severity (IPS) score: absence of pouch dysfunction (4), mild dysfunction (4), moderate dysfunction (3), severe dysfunction (2), and extremely severe dysfunction (5). Among DTPUS variables, resting length of puborectalis muscle showed a significant inverse correlation (p=0.03) with the degree of pouch dysfunction. More relevant perineal descent and shorter length of puborectalis muscle during strain were also observed in patients with significantly severe dysfunction, although these correlations were not statistically significant (p=0.08 and 0.13 respectively). High prevalence of dyssynergic defecation (61%) was also found in all groups, regardless of symptom severity. Among manometric variables, resting basal pressure of the anal sphincter showed an inverse correlation with the severity of pouch dysfunction, albeit without reaching statistical significance (p=0.12). Other characteristics observed in all groups, regardless of symptom severity, were a high prevalence of dyssynergic defecation (53%) and absence of the recto-anal inhibitory reflex (77%). Among surgical characteristics, the presence of complications after the first colectomy stage showed significant correlation (p<0.02) with subsequent development of clinically relevant pouch dysfunction.
| US FEATURES |
| 0
NO IPS
| 1
mild IPS
| 2
moderate IPS
| 3
severe IPS
| 4
extremely severe IPS
| P |
Resting lenght of
puborectalis muscle
(expressed in mm) | 60,4 ± 9,3
| 64,1 ± 6,7
| 69,1 + 1,1
| 51,8 ± 0,1
| 53,7 ± 6,3
| 0,03
|
Perineal descent
(expressed in mm)
| 9,7 ± 2,6
| 8,5 ± 6,8
| 3,3 ± 5,8
| 14,5 ± 5,7
| 13,1 ± 2,6
| 0,08 |
|
|
|
|
|
|
|
| MANOMETRIC FEATURES |
| 0
NO IPS
| 1
mild IPS
| 2
moderate IPS
| 3
severe IPS
| 4
extremely severe IPS
| P |
Resting basal pressure of anal sphincter
(expressed in mmHg) | 82,2 ± 12,5
| 86 ± 15,3
| 74,5 ± 11,2
| 55,1 ± 26,3
| 70,6 ± 14,6
| 0,12
|
Conclusion
Our preliminary results seems to highlight the role of APM and DTPS in the diagnosis of functional pouch disorders after restorative proctocolectomy in UC.
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