Functional results after proctocolectomy with ileal pouch formation for adenomatous polyposis syndrome

INTRODUCTION: the most pathogenetically justified treatment for adenomatous polyposis syndrome (APS) is restorative proctocolectomy with ileal pouch formation (RP+IPF). Currently, there are no specialized or universally accepted tools in global practice for assessing the quality of life of patients with ileal pouch and pouch-anal anastomosis based on the functional characteristics of bowel function.

AIM: to evaluate the functional outcomes after restorative proctocolectomy with ileal pouch formation for APS and to identify factors negatively affecting the quality of life of operated patients.

PATIENTS AND METHODS: between January 2013 and July 2024, 244 patients underwent RP+IPF for APS. Indications for surgery included the presence of more than 100 colonic polyps and/or histologically confirmed colorectal cancer in the setting of multiple (more than 20) colonic polyps. Patients operated on before 2019 underwent demucozation of the distal rectum and formation of a stapled pouch-rectal anastomosis at a height of 6-8 cm from the anal verge. In the group of patients operated on after 2019, the rectum was transected transabdominaly at the level of the upper edge of the anal canal, and a pouch-anal anastomosis was also created using a stapling device. All patients had a diverting ileostomy. For the measurement of quality of life, patients with > 6 months past ileostomy closure were asked to complete a Russian-validated questionnaire assessing the score of low anterior resection syndrome (LARS). A multivariate analysis was also performed to identify risk factors for the development of severe functional disorders leading to reduced quality of life.

RESULTS: the LARS questionnaire was completed by 176 patients (86 men and 90 women) with a median age at surgery of 31 (18-63) years. Forty-five patients (25.6%) underwent surgery with rectal demucozation, 121 (68.8%) - with creation of a stapled pouch-anal anastomosis, and 10(5.6%) patients underwent a hand-sewn pouch-anal anastomosis. The median bowel movement frequency was 6 times per day (range 2-15), and the median frequency of nocturnal bowel movements was 1 (range 0-5). Major LARS (≥30 points) were noted in 17 patients (9.7%). According to multivariate (binary logistic) regression analysis, risk factors for the development of severe functional disorders leading to reduced quality of life were: age at surgery >34 years (OR 6.82; 95% CI 1.8-25.9; p=0.004), performing rectal demucozation (OR 49.9; 95% CI 5.7-440.6; p=0.005), and formation of a hand-sewn pouch-anal anastomosis (OR 39.2; 95% CI 3.5-439.2; p=0.003).

CONCLUSION: the use of the LARS questionnaire in patients after RP+IPF for APS allows to evaluate the quality of life of operated patients and to identify the subgroup with significantly reduced indicators. To prevent severe functional disorders, avoiding the use of rectal demucozation appears preferable, while the method of creating stapled pouch-anal anastomosis should be considered the priority.

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