Background: Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for IBD is low volume surgery. In The Netherlands from 2009 quality and volume indicators have been defined for low volume oncologic procedures and since 2015 also for IPAA surgery following the ECCO guidelines. The two South Netherlands IBD centers (The Zuyderland Hospital [ZH], Maastricht University Medical Center [MUMC]) started to collaborate to meet the volume norm on IPAA surgery and deliver optimal quality. The present study describes the outcome of surgery in this cooperation and aims at defining further priorities in surgical care.
Methods: Data were collected from the prospective South Limburg IBD cohort which includes all newly diagnosed IBD patients of the two centers since 1991. All non-surgical data and the core surgical data are included in this database. More specific surgical information was collected retrospectively.
Results: Fifty-four patients were included that received an IPAA between January 2010 and December 2015. In 2015 the volume norm of >10 was reached, contrary to the 3 preceding years. Mean age was 39.6 (17–82) and mean disease duration 7.5 yrs (1–22.5). 35 patients (62%) previously underwent a subtotal colectomy, 13 in an open procedure, 22 laparoscopically. 41 (76%) of IPAA's were performed laparoscopically, 93% were stapled and in 44% a temporary ileostoma was performed. Three ileostomies were given due to postop complications. Postop diagnosis was UC in 52 patients, IBD-U in 1 and CD in 1. Major early complications were small bowel obstruction (n=14), partial anastomotic dehiscence (n=7), pouch bleeding (n=2), distal anastomotic stricture occurred in 9 patients. Pouch failure occurred in 5 patients resulting in 4 permanent ileostomies, two of which due to chronic pouchitis. Conversion from laparoscopic to open procedure was positively associated with anastomotic dehiscence. Stool frequency at follow-up was median 7.6/24hrs; 41% of patients used no antidiarrheal medication. Full continence was achieved in 77%. No data on sexual function could be retrieved. From 2015, one team (EB and LS) operated all patients. Incidence of leakage seemed lower after cooperation, although conclusions require a larger cohort.
Conclusions: The cooperation resulted in increase from a low- to a medium volume center. Several focus points have been defined based on the results observed: progressive cooperation and optimal multidisciplinary approach to optimize timing of surgery and outcome; continue implementation of novel techniques; prospective registration of all surgical parameters including quality of life and sexuality; evolve as a regional referral and expert center and increase patient numbers.