Looking forward to Bournemouth 2017

Debate – reconstructive IBD surgery: ileoanal pouch, ileorectal anastomosis and Kock pouch – an interview with Pär Myrelid

Continuing our series of interviews previewing this year’s ACPGBI annual meeting in Bournemouth, 3-5 July, we spoke to Dr Pär Myrelid, Consultant Surgeon at the University Hospital Linköping, Linköping, Sweden and President of the Swedish Society for Colorectal Surgeons. Dr Myrelid will be taking part in a debate with Professors Per Nilsson (Sweden) and Tom Øresland (Norway), who will examine the relative merits of ileoanal pouch, ileorectal anastomosis and Kock pouch when performing reconstructive IBD surgery.

“We know from our own research1 that the rate of reconstructive surgery after colectomy in patients with IBD is about 46% and that older age and low hospital volume were risk factors for non-reconstructive surgery,” he began. “The current gold standard reconstructive operation worldwide is the ileoanal pouch, although two additional procedures – the ileorectal anastomosis and the Kock pouch are alternative options. We know that from long-term Swedish data the risk of having to remove the pouch is the same for ileoanal pouch and ileorectal anastomosis procedure, although less is known about the Kock pouch. We have some data from our hospital in Sweden and there are several ongoing trials that are looking at long-term outcomes from the Kock pouch and we should have the results in about 12 months’ time.”

Dr Myrelid said that the major consideration before reconstructive surgery should be the view of the patient. He emphasised that the consequences of surgery must be fully explained to patient so that they can make an informed decision. For example, those patients who opt for an ileorectal anastomosis are usually very concerned with fertility issues or the function of the pelvic pouch, compared to possibly better function from an ileorectal anastomosis.

“It is so important that the patient is provided with as much information about each procedure, the advantages and disadvantages, because it is the patient that has to manage their condition after the procedure. No matter which surgical option the patient chooses, it is important that we try to offer them some form of reconstruction, especially when you consider the amount of young people who are living with an Ileostomy or colostomy, and I believe reconstructive surgery can improve the quality of life for this groups of patients.”

Dr Myrelid emphasised the important role the multidisciplinary team (MDT) plays in all aspects patient care not only educating the patient about the procedure, managing complications, but also the MDT’s post-operative role, such as the role of a stoma or pouch nurse.

“We know that approximately half of patients who undergo reconstructive surgery will develop some form of post-operative complication, so all MDTs in all units should be educated on how to identify and treat complications.”

He noted recent research from the USA2 that looked at the role of patient-centred, multidisciplinary care concepts (defined by IBD experts and care organisations) that resulted in better compliance with quality care standards. For example, patients were referred from the gastroenterologist to the surgical team in a timely manner, improving the long-term disease outcomes.

During his presentation in Bournemouth, Dr Myrelid will discuss the benefits of the ileoanal (pelvic) pouch, the different approaches that can be utilised and the technical and anatomical concerns that should be considered before, during and after the procedure.

“I believe the presentations in Bournemouth will show the advantages of the procedures, when and when not to perform them, as well as the technical considerations that should be undertaken by the multidisciplinary team,” he explained. “What will also be revealed is how clinical practice differs between countries such as Denmark, Sweden, Norway and the UK.”

For example, he said that Denmark has consolidated its pelvic pouch reconstruction programme into five national centres, and this will be reduced to three centres in 2018, because the published data shows that the outcomes are better if performed at high volume centres by high volume surgeons. Also, some Norwegian surgeons have excellent outcomes from the Kock pouch. In this aspect, Dr Myrelid believes that Denmark is ahead of other countries and stressed that more surgeons should be trained so they can perform all of the different reconstructions.

In contrast, about half of Swedish patients receive the pelvic pouch and about half undergo an ileorectal anastomosis, this is quite different from the UK, he added.

“I am looking forward to the meeting in July and look forward to debating the merits of the different surgical options for reconstructive IBD surgery,” he concluded. “I believe following the debate, there will be some very interesting discussions and some differing views between the UK, Norwegian, Swedish and Danish specialists.”

References

  1. Nilsson et al, Probability, rate and timing of reconstructive surgery following colectomy for inflammatory bowel disease in Sweden: a population-based cohort study. Colorectal Dis. 2015 Oct;17(10):882-90.
  2. Koltun, Better together: improved care of the IBD patient using the multi-disciplinary IBD center. Expert Review of Gastroenterology & Hepatology 2017 March 28:1-3