Discussion
IPAA, bowel movements, proctitis, UC, UC [Failure, pouchitis, IBD
STILL, DISEASE, PROCTITIS, COMPLICATION, POUCHITIS, RECTAL CANCER, COMPLICATIONS
Reconstruction after colectomy is a morbidity-associated as well as a resource-intensive activity with the sole purpose of enhancing function, QoL and patient satisfaction. The actual disease has already been treated with the colectomy. Hence it is crucial to provide patients and care givers with the best possible information on the risks and benefits of each reconstructive treatment. They should be informed of what to expect if they choose to keep their end ileostomy permanently. There are no prospective head-to-head comparisons between IRA and IPAA in UC patients published.The aspects to consider when evaluating a reconstruction after colectomy are early as well as late complications of the reconstruction, bowel function as well as urogenital and sexual function, quality of life (QoL), patient satisfaction as well as risk of failure and/or rectal cancer. There are also patient preferences which must be considered.The IRA is easier to perform and does not require pelvic dissection, but instead the preserved rectum demands continuous topical medication and the risk for rectal cancer remains [Early complications generally refers to complications within 30 days of surgery and they are most often graded according to the Clavien-Dindo scale [Considering late complications, pouchitis for IPAA is reported in between 36–48% of cases [Regarding bowel function, the main issues are continence, number of bowel movements, need to evacuate the bowel during nighttime and urgency to evacuate the bowel. For IRA, between three and six bowel movements per 24 h have been reported [The pelvic dissection associated with IPAA constitutes a risk for impaired sexual function and impaired fecundity. Sexual function is described and compared in different ways in IPAA studies and the results are difficult to compare [In reconstructive surgery, the goal is to improve quality of life (QoL). Still, it is not obvious how to assess and compare QoL in surgery for UC [Failure, defined as excisions or permanent deviation, is reported in between 4–9% of IPAA cases at 5 years and 7–19% at 10 years [The obvious limitation with our study design is the lack of randomization. As mentioned in the introduction we have made an attempt to randomize between IRA and IPAA but after receiving detailed information, patients decline randomization and insist on choosing a reconstructive method themselves, with similar numbers opting for IRA and IPAA. We do not consider it a risk, but a fact, that some degree of selection bias will occur as some patients are more concerned regarding pelvic surgery, and its possible consequences, while others are more concerned by the need of anti-inflammatory medication, endoscopic surveillance and the risk of rectal cancer. We aim to minimize such effects with the provision of standardized information whenever possible. Because this is a multicenter study the same consultant cannot present the oral information to every patient. Instead, all patients will be shown the same information video by the consultant IBD Surgeon.We do, however, see an upside to the lack of randomization. It is of interest to see what patients choose when presented with standardized information and if there are any demographic patterns in the choice of reconstructive method. Furthermore, we do not think that IRA will necessarily be a better choice than IPAA but rather it will be equally good in the selected cohorts eligible for either restorative procedure. Patient involvement may also increase the chance of a favorable outcome.Another question that we hope to address is if there are any differences in the outcome of IPAA between the patients that were eligible for both IRA and IPAA and the patients that had IPAA as their only restorative option, i.e. will the level of proctitis affect the outcome of IPAA.The multinational setting of the study will also allow for detection of possible differences in the attitude towards functional outcomes and complication patterns between the Swedish and English UC population. It will also improve the external validity of our study.