Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the treatment of choice in some cases of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) [8,9]. Most of our patients (98,4%) are operated on for UC or FAP. Depending on the circumstances and the operative indication, the surgery could be performed in 2-stage or 3-stage procedure. At the time of primary pouch surgery, the « J » pouch was protected by defunctioning ileostomy [1].
Surgical teams tend to use stapled anastomosis and laparoscopic approach. In our series, stapled anastomosis and the laparoscopic approach recently became a standard. Although it is a well-codified intervention, IPAA has significant short- and long-term morbidity, widely discussed in series published in the literature. In addition, it has the particularity of having functional results that can influence the quality of life of patients [8].
This study is the first study from North Africa. Our post operative morbidity was like the other series. For example, the incidence of anastomotic leak and bleeding after IPAA can reach 19% and 3.5%, respectively [9]. In our series, they were 0,8% and 1,6% respectively. An anastomosis leak occurred in two patients who had retrospectively been diagnosed with Crohn's disease.
Our mortality rate is higher compared to the rates published in the literature. The mortality rate, in a meta-analysis of 96 observational studies, ranges from 0 to 2.9% [10].
Pouchitis is a non-specific inflammation of the ileal reservoir, and the most common, inflammatory, and long-term, complication after pouch surgery for ulcerative colitis [11]. It is not frequent when indicated for FAP. It occurs in about one-quarter to nearly one-half of the people who have IPAA [11]. In our series, we had 16% of pouchitis with favorable antibiotic response.
In recent published series, pouch failure rates have declined due to better patient selection and improved surgical techniques. Indications for pouch reconstruction can be divided into mechanical and infectious/inflammatory [12]. In study, the incidence rates for failure, pr. 1000 person years range from 9 to 19,5 [13]. In our series, this rate was 5,6%.
Several factors are likely to influence the quality of life of patients operated on for an IPAA: extra-intestinal manifestations of UC [14], as well as anxiety related to the risk of cancer in FAP carriers [15].
The results that we report show that in a Tunisian population of patients operated on for IPAA: the quality of life, as measured by the « CGQL score », is close to that of the general population; and a significant proportion of patients do not report major digestive function disorders, since more than two thirds of them have less than 6 stools during the day and one stool during the night. Based in St Mark’s score, incontinence was minimal in 59,6%, with no cases of major incontinence. In a review of 2016, Overall, 74.75 % of the younger patients (n = 1353) versus 55.09 % of older patients (n = 285) experienced perfect or near-perfect continence [16].
The deterioration of functional pouch with aging is a known problem. In a study of Ana Cristina Silva and al. [17] patients after one year were 87.5% of proper functioning of the pouch, and this number decreased to 84% at 10 years and 61.1% at 15 years follow-up. In our study, based on « Orsland Score » and « Pouch Functional Score », more than half of patients have a proper functioning pouch.
Sexual function is the least reported in the literature, particularly in women. Sexual disorders resulting from damage to the sympathetic and/or parasympathetic plexuses during coloproctectomy are better known in men, in particular impotence and ejaculatory disorders such as retrograde ejaculation.
A meta-analysis included 22 studies, with1852 female reported that sexual dysfunction after RPC was 25%. The main complaints were vaginal dryness in 36,4% of patients, dyspareunia in 36%, pain interfering with the possibility of feeling sexual pleasure in 40,5% and fear of bowel movement during sexual activity in 28,8%. In our study, the decrease in the frequency of sexual intercourse could be explained by dyspareunia (25,8%) and Bowel movement during sexual activity (10,3%). We should also mention the decrease in fertility after ileo-anal pouches described in certain series [18]. Julie A. et al. [18] found an infertility rate of 26% after surgery, whereas it was 12% before IPAA was made.
In a study of David and al. [19], erectile dysfunction occurred in 27%. In our study, retrograde ejaculation and anejaculation occurred in 17,54% and 36,84% respectively.
Urinary function was assessed in our study, most of patients (98,4%) had excellent urine control and no patient was presented with urinary incontinence.
Deterioration of pouch function and thus quality of life is a known problem. In our series, the OS, PFS and CGQL scores change from 5 to 15 years of follow-up with reduction of patients with good functional results. This was reported by A Silva et al. [2] and Zhang et al [17].
For pregnant women with IPAA, it should be noted that it seemed reasonable to propose a cesarean section in light of the risk that vaginal delivery could impair sphincter function [20].
The search for factors that could influence the results of quality of life or the functional score, such as the type of pouch, the initial pathology or the presence of major surgical complications did not allow the identification of statistically significant elements. Whereas, age less than 40 years was found to be associated with significantly better outcomes.
The problem in all retrospective studies of function is that preoperative function of patients is unknown, and thus comparisons are impossible. Future sexual and quality of life studies will need to elicit preoperative baselines.