Functional and Clinical Results of Patients Who Underwent an Ileal Pouch Anal AnastomosisFunctional and Clinical Results of Patients Who Underwent an Ileal Pouch Anal Anastomosis

Background: Our aim is to evaluate the patients who underwent IPAA in our clinic, in terms of their characteristics, early and late complications, the results, and the problems that may emerge after the IPAA such as the quality of life. Methods: Twenty-two of the 26 patients, who underwent IPAA were included in the study. Evaluations were made on the demographic characteristics of the patients, surgical indications, the type of operation, pathological diagnosis, early and late postoperative complications, and functional outcomes. Cleveland Global Quality of Life scoring was administered in order to evaluate the quality of life. Results: Ten of the patients had UC and 12 had FAP. Nineteen of the patients underwent a two-stage surgical procedure. In postoperative period, ileus occurred in 4 patients (18.2%), 5 had wound infections (22.7%), 3 had a pelvic abscess (13.6%), and other complications developed in 5 patients (22.7%). Two patients had pouchitis (9.1%), 2 had anastomotic stenosis (9.1%), and 2 had pouch dysfunction (9.1%). There was incontinence with uid in 6 (27.3%) patients. Four patients (18.2%) used pads during the day, requiring defecation with an average of (4.31±2.37) times during the day and (1.04±0.89) times at night. Half of them (50%) had complaints of sexual dysfunction. The life quality score was observed to be signicantly better in patients with FAP (0.85±0.13) compared to patients with UC patients (0.71±0.11). Conclusion: This procedure could be applied safely with low comorbidity and good functional outcomes in experienced health centers with high caseloads.

There was incontinence with uid in 6 (27.3%) patients. Four patients (18.2%) used pads during the day, requiring defecation with an average of (4.31±2.37) times during the day and (1.04±0.89) times at night.
Half of them (50%) had complaints of sexual dysfunction. The life quality score was observed to be signi cantly better in patients with FAP (0.85±0.13) compared to patients with UC patients (0.71±0.11).
Conclusion: This procedure could be applied safely with low comorbidity and good functional outcomes in experienced health centers with high caseloads.

Background
Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is a surgical procedure with proven effectiveness in the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). (1). They can be performed in experienced hands with acceptable functional outcomes and high success rates.
Ulcerative colitis is an in ammatory bowel disease that often develops in the 3rd and 8th decades, involving the colorectal mucosa. Indications for surgery include unresponsiveness to medical treatment, severe bleeding, cancer risk, obstruction, perforation, and toxic megacolon (2). Familial adenomatous polyposis is an inherited, autosomal dominant disease caused by the germline mutation of the adenomatous polyposis coli gene (3). If the FAP is left untreated, colorectal cancer is inevitable. It has been demonstrated that the complete removal of the colorectal mucosa prevents the lifelong development of colorectal cancer (4).
In the present study, our aim is to evaluate the patients who underwent IPAA in our clinic, in terms of their characteristics, early and late complications, the results, and the problems that may emerge after the IPAA such as the quality of life. of Medicine General Surgery Clinic, were included in the study. Demographic characteristics of the patients such as age and gender were recorded along with the surgical indications, the type of operation (one, two, or three stages), and the results such as the pathological diagnosis. The early and late postoperative complications such as anastomotic stenosis, obstruction, pelvic sepsis, pouchitis, postoperative bleeding, wound infection, pouch failure, anastomotic leakage, and stula formation were examined. Question forms were created to evaluate the functional outcomes regarding the number of defecations per day including day and night, fecal incontinence, use of pads, presence of urinary and sexual dysfunction, use of antidiarrheal medication, and the history of post-operative pregnancy.
Cleveland Global Quality of Life (CGQL) scoring was administered in order to evaluate the quality of life.
The forms were lled out by reaching the patients on the phone or via e-mail.

Results
IPAA was performed to a total of 26 patients in our clinic. All surgeries were performed as open surgeries.
In the preoperative evaluations of the patients, upper GI endoscopy, colonoscopy, pathological analysis, upper abdominal tomography, pelvic MRI, gynecological examinations, and genetic studies were performed as a routine. It was found that 2 of the patients died during their follow-up due to the reasons independent of the operation. One of these two patients had been operated due to FAP and the other one had been operated for a colon tumor with a diagnosis of UC. In one of the patients that we had operated for ulcerative colitis, abdominoperineal resection was performed due to anastomotic recurrence. In a patient we had operated for FAP, ileostomy closure was not performed due to the development of pouch stula. Therefore, these four patients were excluded from the study. Of the 22 patients, 14 were female and 8 were male. At the time of the surgery, the mean age was 40.7 ± 14.2 and the mean body mass index was 26.4 ± 4.3 kg/m 2 . Ten of the patients had UC and 12 had FAP (Table 1). Postoperative pathology results indicated adenocarcinoma in 2 patients with ulcerative colitis and 4 patients with FAP. A 2-stage surgical procedure (ileostomy closure after IPAA) was performed to 19 patients, a 3-stage surgical procedure (complete colectomy + RP complementary to ileostomy, followed by ileostomy closure) was performed on 3 patients. All three-stage surgeries were performed on patients with a diagnosis of UC. After proctocolectomy with total mesorectal excision in all patients, the J pouch of 12-13cm was formed with a stapler, and IPAA was performed with the 25 mm circular stapler. The mean duration of ileostomy closure after the procedure was 4.2 ± 2.7 months. While the mean duration of ileostomy closure in patients with UC was 5.5 ± 3.65 months, it was 3.25 ± 0.86 in patients with FAP. The mean postoperative follow-up period of the patients was 43 (7-115) months. Before ileostomy closure, the pouch was evaluated using endoscopic and imaging methods.  There was fecal incontinence in 6 (27.3%) of the patients. It was found that 4 (18.2%) of them used pads during the day. The patients were observed to require defecation with an average of (4.31 ± 2.37) times during the day and (1.04 ± 0.89) times at night. Half of the patients (50%) had complaints of sexual dysfunction. Two patients (9.1%) were using antidiarrheal drugs. It was found that 1 patient (4.5%) got pregnant twice after the operation and gave birth by cesarean section.

The effects of their nal diagnosis on functional outcomes and quality of life
According to the results of the questionnaire that was administered by reaching all patients, the quality of life score was found to be signi cantly better in patients with FAP patients (0.85 ± 0.13) compared to the patients with UC (0.71 ± 0.11). There was no signi cant difference between the groups in terms of other results.

Discussion
The colon and rectum are completely resected with RP and IPAA, ensuring the intestinal continuity of the patients and defecation via the anus (1). Park et al. rst described this procedure in 1978 as the anastomosis of the S-shaped pouch manually to the dentate line level after mucosectomy was performed in the remaining rectum (5). Over the years, J, W, and K-shaped pouch designs have also been de ned. Since the 1980s, J pouch and stapler anastomosis have become the most common techniques with the development of surgical stapler technology. It has a simple design, the construction with the linear stapler is easier compared to the other techniques, and the application time is shorter (6). IPAA procedure has various complications such as the postoperative anastomotic leak, stricture, stula, pelvic abscess, obstruction, and pouchitis. In addition, there are consequences that negatively affect daily life activities, social life, and quality of life, such as an increase in the number of defecations during the day and at night, the urgent need to urinate, excessive weight loss, fecal and gas incontinence problems, which are de ned as the functional outcomes of this surgery after the procedure.
In the present study, we evaluated the postoperative functional outcomes, complications, approaches to complications, and quality of life in patients, who underwent IPAA in our clinic. The results of this procedure have been discussed since the day Park et al. presented their IPAA results in 1978. According to the previous studies, morbidity rates after IPAA varied between 30-60% (7-10). The surgical technique is constantly changing and improving to reduce these morbidity rates. We used total mesorectal excision and J pouch stapler anastomosis technique in all our patients. In many studies, the J pouch has been reported as the most common pouch type due to its ease of application and good long-term functional outcomes (11)(12)(13). The studies comparing stapled anastomosis with hand-sewn anastomosis concluded that the functional outcomes were observed to be better. (11,14). Considering the functional outcomes of the patients, we avoided mucosectomy in patients with no suspicion of dysplasia and neoplasia in the anal canal (15).
The most common complications we encountered in our study were wound infection, pouchitis, anastomotic stenosis, pelvic abscess, and pouch dysfunction. Fazio et al. demonstrated that such complications affected functional outcomes and the quality of life (16,17). Tiainen & Matikainen (18) mentioned that pouchitis was the most common complication after IPAA. Similar to our study, certain studies reported that small bowel obstruction was one of the most common complications of restorative proctocolectomy and is encountered in 12-17% of all patients (19)(20)(21). When we compared the patients with UC and FAP, the development of ileus and pelvic abscess in patients with UC was signi cantly higher compared to the patients with FAP. In a study, Fazio et al. reported the increase of many complications in patients with UC (22).
Kıran et al. mentioned that the protective ileostomy would not prevent pelvic sepsis; (23) and some other studies indicated that protective ileostomy did not prevent anastomotic leaks (24,25). However, we performed protective ileostomy in all patients and closed the ileostomies after controlling with endoscopy and pouch radiography in an average of 4.2 months. When we identi ed problems such as pouch stula and pouchitis on endoscopy and pouch radiography, we postponed the ileostomy closure process and started treatment, where necessary.
We performed the 2-stage RP surgery in all patients diagnosed with FAP and the patients with UC, who underwent elective surgery. 3-stage surgery is recommended for patients with acute severe colitis, who received steroid therapy or anti-TNF therapy for a long time (11,26). We performed the 3-stage surgery to 3 patients diagnosed with UC.
Patients, who undergo IPAA, are expected to have defecations 4-6 times during the day and 0-1 times at night, with complete continence (27,28). In our study, it was observed that the number of day and night defecations were compatible with the literature, 27.3% of the patients, 2 of whom used pads, had fecal incontinence; and these results were found to be acceptable (29). Half of the patients stated that they suffered from sexual dysfunction; and one of our patients got pregnant after the operation.
We saw that our patients were satis ed with the IPAA operation and the quality of life score was similar to the study conducted by Özdemir et al. (1).
When we compared the patients with UC and FAP, it was seen that the results of patients with FAP were better in terms of complications, functional outcomes, and quality of life score. It is believed that the patients with UC required emergency surgery, which was caused by the preoperative treatments received by the patients and malnutrition during the preoperative period.
It was observed that the IPAA procedure had a certain complication rate as well as functional outcomes and results affecting the quality of life; however, these were at an acceptable level when compared to the preoperative period. In a study by Lichtenstein et al., 10 clinical studies investigating the quality of life after IPAA were examined. The quality of life was found to have increased in 8 of the studies, remained the same in one of the studies, and was worse than the general population in the other study.
The insu cient number of patients and the retrospective nature of the study have been the limitations. However, the postoperative complication rates, functional outcomes, and quality of life of the patients were similar when compared with the literature. This procedure could be applied safely with low comorbidity and good functional outcomes in experienced health centers with high caseloads. Informed Consent: Informed consent was obtained from all individual participants included in the study.

Abbreviations
Data availability: The data that support the ndings of this study are available from the corresponding author on request.
Con ict of Interest: The authors have no con ict of interest to declare