BackgroundThere are no prospective trials comparing the two main reconstructive options after colectomy for Ulcerative colitis, ileal pouch anal anastomosis and ileorectal anastomosis. An attempt on a randomized controlled trial has been made but after receiving standardized information patients insisted on choosing operation themselves.MethodsAdult Ulcerative colitis patients subjected to colectomy eligible for both ileal pouch anastomosis and ileorectal anastomosis are asked to participate and after receiving standardized information the get to choose reconstructive method. Patients declining reconstruction or not considered eligible for both methods will be followed as controls. The CRUISE study is a prospective, non-randomized, multi-center, open-label, controlled trial on satisfaction, QoL, function, and complications between ileal pouch anal anastomosis and ileorectal anastomosis.DiscussionReconstruction after colectomy is a morbidity-associated as well as a resource-intensive activity with the sole purpose of enhancing function, QoL and patient satisfaction. The aim of this study is to provide the best possible information on the risks and benefits of each reconstructive treatment.

BACKGROUND: Kock’s continent ileostomy is an option after proctocolectomy for patients not suitable for ileal pouch anal anastomosis or ileorectal anastomosis. Ulcerative colitis is the most common indication for continent ileostomy.

OBJECTIVE: The aim of this study was to evaluate the long-term outcome of continent ileostomy.

DESIGN: Retrospective cohort register study.

SETTINGS: Data were obtained from the Swedish National Patient Registry.

PATIENTS: All patients with inflammatory bowel disease and a continent ileostomy were identified. Data on demographics, diagnosis, reoperations, and excisions of the continent ileostomy was obtained. Patients with inconsistent diagnostic coding were classified as inflammatory bowel disease-unclassified.

MAIN OUTCOME MEASURES: The main outcome measures was number of reoperations, time to reoperations and time to excision of continent ileostomy.

RESULTS: We identified 727 patients, 428 (59%) with ulcerative colitis, 45 (6%) with Crohn’s disease and 254 (35%) with inflammatory bowel disease-unclassified. After a median follow-up time of 27 (IQR, 21-31) years 191 (26%) patients had never had revisional surgery. Some 1,484 reoperations were performed on 536 (74%) patients, the median number of reoperations was 1 (IQR, 0-3) per patient. The continent ileostomy was excised in 77 (11%) patients. Reoperation within the first year after reconstruction was associated with higher rate of revisions (IRR, 2.90 p < 0.001) and shorter time to excision (HR 2.38 p < 0.001). Constructing the continent ileostomy after year 2000 was associated with increased revision and excision rates (IRR, 2.7 p < 0.001 and HR 2.74 p = 0.013). Inflammatory bowel disese-unclassified was associated with increased revisions (IRR, 1.3 p < 0.001) and the proportion of IBD-unclassified patients almost doubled from the 1980s (32%) to after 2000 (50%).

LIMITATIONS: Retrospective design, data from register. No data on quality of life available.

CONCLUSION: Continent ileostomy is associated with substantial need for revisional surgery, but most patients get to keep their reconstruction for a long time. See Video Abstract at https://links.lww.com/DCR/C122.

Restorative proctocolectomy, or ileal pouch anal anastomosis, is considered the standard treatment for intractable ulcerative colitis. When the pelvic pouch was first introduced in 1978, a two-stage procedure with proctocolectomy, construction of the pelvic pouch, and a diverting loop with subsequent closure were suggested. Over the decades that the pelvic pouch has been around, some principal technical issues have been addressed to improve the method. In more recent days the laparoscopic approach has been additionally introduced. During the same time-period the medical arsenal has developed far more with the increasing use of immune modulators and the introduction of biologicals. Staging of restorative proctocolectomy with a pelvic pouch refers to how many sessions, or stages, the procedure should be divided into. The main goal with restorative proctocolectomy is a safe operation with optimal short- and long-term function. In this paper we aim to review the present knowledge and views on staging of the pouch procedure in ulcerative colitis, especially with consideration to the treatment with biologicals.

BACKGROUND: Continent ileostomy is a solution for patients after proctocolectomy. OBJECTIVE: The aim of this study was to assess the long-term complications and failure rate alongside patient satisfaction, function, and quality of life for patients with a continent ileostomy. DESIGN: This was a retrospective, descriptive cross-sectional study. SETTINGS: All patients were operated in 1 center between 1980 and 2016. PATIENTS: A total of 85 patients received a de novo continent ileostomy in our institution. Sixty-nine patients (80%) had ulcerative colitis, 12 (14%) had Crohns disease, 2 had indeterminate colitis, and 1 each had familial adenomatous polyposis and anal atresia. MAIN OUTCOME MEASURES: Medical charts were reviewed for reoperations and pouchitis. The 36-Item Short Form, Short Health Scale, and a local continent ileostomy questionnaire were used to assess quality of life, function, and satisfaction. RESULTS: After a median follow-up of 24 years, 67 patients (79%) underwent a total of 237 reoperations, of which 15 were conversions to end ileostomies, that is, failures. Fifty patients (59%) underwent repeat laparotomies, excluding loop ileostomy closures. Nipple detachment was the most common cause for repeat laparotomy, and fistulation was the most common cause for pouch removal. IPAA before continent ileostomy was associated with an increased risk for failure. Crohns disease was not associated with an increased risk for reoperation or failure. Forty-three patients (84%) reported that they were satisfied. Seventy patients were available for questionnaires, and 50 patients (71%) answered. There was no difference in the 36-Item Short Form between the continent ileostomy population and an age-matched control population. LIMITATIONS: The retrospective, single-center design of the study alongside &lt;100% response rate are to be considered limitations. CONCLUSIONS: Despite large numbers of complications, patients are generally satisfied with their continent ileostomies, and their quality of life is comparable to the general population. See Video Abstract at http://links.lww.com/DCR/B444.

The incidence of Crohns disease is increasing world-wide and the disease location and behavior is changing towards more colonic as well as inflammatory behavior. As previous data have spoken towards ileal disease and structuring and penetrating disease to be the indications most in need of surgery, one could expect the surgical load to decrease. As these changes are relative, the absolute numbers of surgical interventions are less affected. There are also data showing an increasing complexity among patients at time of surgery. Finally, a new role for surgery as initial therapy to induce remission instead of biologic therapy in ileal or ileocaecal disease has been suggested. In order to improve the care for patients with Crohns disease in general, and the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In conclusion, the role of surgery is changing. Fewer patients need surgery, but when they do they have more complex disease. In the future, ileocaecal resection may be used increasingly as initial therapy to induce remission in a true top-down approach. (C) 2020 Elsevier Inc. All rights reserved.