Résumé
Objective To analyze the complications of total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) in treatment of severe or refractory ulcerative colitis (UC).Methods The retrospective cross-sectional study was conducted.The clinical data of 67 patients with severe or refractory UC who underwent TPC-IPAA in the Xinhua Hospital Affiliated to Shanghai Jiaotong University from February 2008 to October 2015 were collected.All the patients received open and laparoscopy-assisted TPC-IPAA,and two-stage or three-stage surgery was performed according to the patients' conditions.Observation indicators:(1) treatment and follow-up situations,(2) short-term complications after TPC-IPAA,(3) long-term complications after TPC-IPAA.The follow-up using telephone interview and outpatient examination was performed to detect the quality of postoperative life in patients and occurrence of complications up to July 2016.Measurement data with skewed distribution were described as M (range).The comparison of quality of pre-and post-operative life in patients was done using the paired t test.Results (1) Treatment and follow-up situations:all the 67 patients received successful surgery,including 45 with two-stage surgery and 22 with three-stage surgery.Thirty-seven patients underwent open surgery and 30 underwent laparoscopic surgery.The average frequency of postoperative daily defecation,average scores of quality of pre-and post-operative lifes were 5.6,0.47 and 0.67,respectively,with a statistically significant difference between preoperative indicators and postoperative indicators (t =-4.80,P ＜ 0.05).All the 67 patients were followed up for a median time of 4.6 years (range,1.0-8.4 years).(2) Short-term complications after TPC-IPAA:Of 67 patients,10 had short-term complications (some patients with multiple complications).One patient was complicated with presacral abscess secondary to sinus formation and then was cured by topical incision of sinus under colonoscopy.Five patients were complicated with anastomotic site-related complications of TPCIPAA,and 1 with pouch-anal anastomotic fistula combined with presacral abscess underwent drainage with ileostomy and didn't undergo stoma reversion of ileum.Two patients with fistula at the top of pouch were improved by surgery and repair.Of 2 patients with pouch-vagina fistula,1 underwent resection of pouch stump-vagina fistula and then were cured,and the space between pouch stump and posterior fornix was filled with a free greater omentum flap and temporary ileal bypass was simultaneously conducted.The other patient received twice transanal vaginal fistula repairs with advancement flap,and unclosed fistula was confirmed by angiography,with a clinical symptomatic relief.Eight patients with wound infection received actively dressing change after discharge,and no wound dehiscence was occurred.(3) Long-term complications after TPC-IPAA:28 of 67 patients had long-term complications.Twelve patients with intestinal obstruction underwent conservative treatments of gastrointestinal decompression,anti-inflammatory with corticosteroid and anti-infection with antibiotic,without the occurrence of severe intestinal perforation and prognosis needing surgical intervention,including 9 undergoing open TPC-IPAA and 3 undergoing laparoscopic TPC-IPAA.Thirteen patients with postoperative pouchitis received the conservative treatment of mesalazine.Three patients with failed pouch underwent small intestine permanent colostomy,including 2 with secondary pouch Crohn's disease and 1 with severe pouchitis.Conclusions TPC-IPAA is safe and effective in treatment of UC,with a lower incidence of complications.Anastomotic site-related complication of TPC-IPAA is the main short-term complication.And in the long-term complications,pouchitis is the most,followed it is intestine obstruction.