Results from pouch salvage

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes

BACKGROUND

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

AIMS

To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

METHODS

A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

RESULTS

34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

CONCLUSION

PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis

Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.

Endoscopic Treatment of Acute and Chronic Anastomotic Leaks from Inflammatory Bowel Disease Surgery

Acute or chronic anastomotic leak is a common complication after any gastrointestinal surgery in inflammatory bowel disease (IBD). The underlying disease of the bowel, comorbidities, malnutrition, anemia, and concurrent use of corticosteroids increase the risk for the development of anastomotic leaks. Anastomotic leak is traditionally managed with surgery. However, recent innovation has allowed the use of endoscopic methods in the management of some anastomotic leaks and their consequences. This article discusses a variety of endoscopic techniques that have either been established or are under current evaluation, for the management of anastomotic leaks in patients with IBD.

Therapeutic Endoscopy in Postoperative Pouch Complications

Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.

Systematic review on the management of ileoanal pouch-vaginal fistulas after restorative proctocolectomy in the treatment of ulcerative colitis

AIM

Ileoanal pouch-vaginal fistula (PVF) is a relatively common complication of restorative proctocolectomy with ileal pouch-anal anastomosis. There are several operative approaches in the management of PVF. There is currently no consensus as to which approach is the most effective or which should be attempted first.

METHOD

A systematic review was undertaken following a publicly available protocol registered with PROSPERO (CRD42019133750) in accordance with PRISMA guidelines. Online searches of databases MEDLINE and Embase, Cochrane Library, ClinicalTrials.gov, EU Clinical Trials and ISRCTN registry were performed.

RESULTS

Twenty-seven articles met the criteria for inclusion in the study: 13 retrospective cohort studies, two prospective cohort studies, eight case series, three case reports and a case-control study. A narrative synthesis was performed due to heterogeneity between included articles. Our study included 577 PVFs, and the incidence rate was 2.1%-17.1%. Both local and abdominal approaches were used in the management of PVF. The overall success of local and abdominal procedures was 44.9% and 60.2% respectively. ROBINS-I assessment revealed a critical risk of bias. GRADE assessment indicated a very low certainty in effect size and evidence quality.

CONCLUSION

Local interventions and abdominal approaches have a high failure rate. The results of this review will aid the counselling of patients with this condition. Furthermore, we provide an algorithm for discussion on the management of PVF based on experience at our local centre. The studies available on the management of PVF are low quality; a large prospective registry and Delphi consensus are required to further this area of research.

Endoscopic Sinusotomy Using Needle Knife Technique for Treatment of H-Pouch With Leak and Sinus

A 62-year-old patient with a history of ulcerative colitis and total colectomy with ileal pouch-anal anastomosis was referred to our pouch center for rectal pain, loose stool, and perianal swelling. He was diagnosed with chronic fistula and anastomotic stricture for which he had excision of J-pouch and creation of H-pouch. Surveillance workup after surgery revealed pouch sinus, which was treated with needle-knife sinusotomy (NKSi). This is the first case in the literature of an H-pouch complicated with anastomotic sinus successfully treated with NKSi. We propose using NKSi as the preferred technique for pouch sinuses.

Anastomotic Sinus That Developed From Leakage After a Rectal Cancer Resection: Should We Wait for Closure of the Stoma Until the Complete Resolution of the Sinus?

Purpose

The aims of this study were to identify the clinical characteristics of an anastomotic sinus and to assess the validity of delaying stoma closure in patients until the complete resolution of an anastomotic sinus.

Methods

The subject patients are those who had undergone a resection of rectal cancer from 2011 to 2017, who had a diversion ileostomy protectively or therapeutically and who developed a sinus as a sequelae of anastomotic leakage. The primary outcomes that were measured were the incidence, management and outcomes of an anastomotic sinus.

Results

Of the 876 patients who had undergone a low anterior resection, 14 (1.6%) were found to have had an anastomotic sinus on sigmoidoscopy or a gastrografin enema before their ileostomy closure. In the 14 patients with a sinus, 7 underwent ileostomy closure as scheduled, with a mean closure time of 4.1 months. The remaining 7 patients underwent ileostomy repair, but it was delayed until after the follow-up for the widening of the sinus opening by using digital dilation, with a mean closure time of 6.9 months. Four of those remaining seven patients underwent stoma closure even though their sinus condition had not yet been completely resolved. No pelvic septic complications occurred after closure in any of the 14 patients with an anastomotic sinus, but 2 of the 14 needed a rediversion due to a severe anastomotic stricture.

Conclusion

Patients with an anastomotic sinus who had been carefully selected underwent successful ileostomy closure without delay.

Endoscopic sinusotomy versus redo surgery for the treatment of chronic pouch anastomotic sinus in ulcerative colitis patients

BACKGROUND AND AIMS

Pouch sinus may be a serious adverse event in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to compare endoscopic sinusotomy (ESi) and redo pouch surgery in the management of pouch sinus.

METHODS

All consecutive ulcerative colitis patients with chronic pouch sinuses treated with ESi versus redo surgery from 2006 to 2016 were identified. The primary outcomes were recurrence-free and surgery-free survivals. The secondary outcome was postprocedural adverse events.

RESULTS

This historical cohort study included 226 patients (ESi, n = 141; redo surgery, n = 85). Complete healing of the sinus was achieved in 75 patients (53.2%) and partial healing in 23 patients (16.3%) with ESi, and an initial complete healing (ie, no anastomotic leak before ileostomy closure) was obtained in 80 patients (94.1%) receiving redo surgery. Sinus recurrence after complete healing was seen in 17 patients (22.7%) treated with ESi and 28 patients (32.9%) treated with surgery (P = .15). Subsequent surgery was needed in 34 patients (24.1%) with ESi therapy and 18 patients (21.2%) with initial redo surgery (P = .70). Kaplan-Meier recurrence-free and surgery-free survivals after initial procedures showed no statistical difference between the 2 groups (P = .42 and P = .65, respectively). The rate of adverse events in the ESi group was significantly lower than that in the surgery group (2.5% vs 43.5%, P < .0001).

CONCLUSIONS

Recurrence-free and surgery-free survivals were comparable between patients treated with ESi and redo surgery, whereas pouch redo surgery was found to be associated with a higher immediate complete healing rate yet a higher morbidity.

Endoscopic Treatment of Ileal Pouch Sinus

BACKGROUND AND AIMS

Pouch sinus is a serious complication in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to verify the efficacy and safety of endoscopic needle knife sinusotomy (NKSi) in the management of pouch sinus.

METHODS

All consecutive patients with a pouch sinus treated with NKSi from 2008 to 2016 were identified. The primary outcomes were complete healing of the sinus and pouch survival.

RESULTS

A total of 109 patients were included. During a median follow-up of 2.1 years (interquartile range: 0.7-4.4), 54 (49.5%) patients achieved complete healing and 20 (18.3%) patients had partial healing, Twenty-two (20.2%) patients developed sinus-related pouch failure. In multivariable analysis for the sinus healing, Crohn's disease of the pouch was a risk factor [odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8), whereas a longer interval between NKSi (OR: 1.1, 95%CI: 1.0-1.1) and high body mass index (OR: 1.2, 95%CI: 1.0-1.3) were protective factors. In the multivariable analysis for surgery-free survival, previously documented acute anastomotic leak (OR:3.5, 95%CI: 1.2-10.4), toxic megacolon (OR: 7.4, 95%CI: 1.9-29.1), an increased length of sinus (OR: 1.4, 95%CI: 1.0-2.0), and increased duration from sinus diagnosis to NKSi (OR: 2.6, 95%CI: 1.1-6.2) were risk factors; and a longer interval between NKSis (OR: 0.9, 95%CI: 0.9-0.99), and concurrent use of dextrose 50% (OR: 0.2, 95%CI: 0.04-0.6) and doxycycline during the NKSi procedure (OR: 0.2, 95%CI: 0.04-0.7) were protective factors. NKSi-associated complications were reported in 6 (1.8% per procedure) cases.

CONCLUSIONS

NKSi is an effective and safe procedure for treating pouch sinus.

Endoscopic needle-knife therapy for ileal pouch sinus: a novel approach for the surgical adverse event (with video)

BACKGROUND

Pouch sinus is an adverse event in patients undergoing ileal pouch surgery.

OBJECTIVE

To evaluate the efficacy of needle-knife therapy in managing pouch sinus and to assess factors associated with the healing of pouch sinus.

DESIGN

An historical cohort study from a prospectively collected database.

SETTING

A high-volume specialized pouch center.

PATIENTS

From tertiary-care pouch center.

INTERVENTIONS

Endoscopic needle-knife therapy.

RESULTS

This cohort consisted of 65 patients. Men accounted for 76.9% (n = 50). The median interval from colectomy to the diagnosis of pouch sinus was 4.0 years (interquartile range [IQR]: 2.0-7.5). Pouch sinus was located at the anastomosis in 59 patients (90.8%), at the mid pouch suture line in 4 patients (6.2%), and at the tip of "J" in 2 patients (3.1%). The mean depth of the pouch sinus was 4.4 ± 1.8 cm. Twenty patients (30.8%) had complex pouch sinuses. After a median of 2.0 needle-knife therapies (IQR: 1.5-3.5) during a follow-up period of 1.1 years (IQR: 0.4-2.8), 28 patients (43.1%) with pouch sinus experienced a complete response, 27 (41.5%) had a partial response, and 10 (15.4%) had persistent sinus. Fifty-three patients (81.5%) maintained a functional pouch at the last follow-up. Multivariate analysis showed that a longer duration from colectomy to diagnosis of pouch sinus (odds ratio: 0.85; 95% confidence interval: 0.73-0.99; P = .033) and complex sinuses (odds ratio: 0.17; 95% confidence interval: 0.04-0.70; P = .014) were inversely associated with the healing of pouch sinuses, whereas the increased sessions of needle-knife therapy (odds ratio: 1.36; 95% confidence interval: 1.01-1.81; P = .041) improved the healing of the pouch sinuses.

LIMITATIONS

Single-center study with a relatively small number of patients.

CONCLUSION

In experienced hands, endoscopic needle-knife therapy is an efficacious and safe procedure for pouch sinuses. A longer duration from colectomy to diagnosis of pouch sinus and complex pouch sinuses appeared to be associated with a higher risk for nonhealing of the sinus, suggesting that early diagnosis and intervention have an impact on outcomes.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

Robotic-assisted laparoscopic "salvage" rectopexy for recurrent ileoanal J-pouch prolapse

Total restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) has become the standard of care for the surgical treatment of ulcerative colitis. Despite its correlation with an excellent quality of life and favorable long-term outcomes, RP/IPAA has been associated with several complications. Prolapse of the ileoanal pouch is a rare and debilitating complication that should be considered in the differential diagnosis of pouch failure. Limited data exist regarding the prevalence and treatment of pouch prolapse. We present the case of a recurrent J-pouch prolapse treated with a novel minimally invasive “salvage” approach involving a robotic-assisted laparoscopic rectopexy with mesh.

Outcomes in patients with ulcerative colitis undergoing partial or complete reconstructive surgery for failing ileal pouch-anal anastomosis

OBJECTIVE

Evaluate outcomes of patients with an original diagnosis of ulcerative colitis (UC) who required partial or complete ileal pouch reconstruction due to poor function or infectious complications.

METHODS

A prospectively collected ileal pouch-anal anastomosis (IPAA) database was reviewed retrospectively to identify UC patients undergoing major reconstructive revisions of their IPAA at our institution between 1981 and 2005. Functional results were derived from continued surveys of patients.

RESULTS

Fifty-one UC patients were identified but 22 subsequently proved to have Crohns disease (CD). The initial IPAA was constructed at our institution in 32 patients and elsewhere in 19 patients. Indications for revision included infectious/inflammatory complications (65%) and mechanical difficulties (35%). Pouch revision was partial in 57% of patients and complete in 43%. There were no postoperative deaths. Following reconstruction, patients reported on average 5 daytime and 1 nighttime bowel movements. Daytime incontinence was occasional in 43% and frequent in 4%. Nighttime incontinence was occasional in 54% and frequent in 7%. The probability of pouch survival after reconstruction was 93% at 1 year and 89% at 5 years. Of the pouches that subsequently failed, 75% occurred in patients with a later diagnosis of CD. Postreconstruction abscess was a significant risk factor for ultimate pouch failure.

CONCLUSIONS

In UC patients with failing IPAA, partial or complete pouch reconstruction can be done safely with good functional results, and may avoid pouch excision and permanent ileostomy in carefully selected patients, especially those with definite UC.

Anastomotic sinuses after ileoanal pouch construction: incidence, management, and outcome

PURPOSE

This study was designed to analyze the incidence, management, and outcome of pouch sinuses after ileal pouch-anal anastomosis at one institution.

METHODS

We identified 282 ileal pouch-anal anastomosis patients between 1992 and 2002 who had a pouchogram before planned ileostomy closure. The management and outcome of patients with pouchograms revealing pouch sinuses were reviewed.

RESULTS

Twenty-two patients (7.8 percent) had a pouch sinus at pouchogram. Nineteen patients were observed and underwent repeat pouchogram. Of these, ten had sinus resolution (mean, 3.6 months) and underwent successful ileostomy closure. Eight patients underwent examination under anesthesia +/- sinus debridement. Six of these patients had subsequent pouchograms with five showing sinus resolution. The patient without resolution was not reversed. Of the eight patients who underwent examination under anesthesia +/- debridement, seven underwent ileostomy closure (mean, 4.9 months), with healing in six and pelvic sepsis in one. Four patients underwent successful ileostomy takedown despite persistent sinus. Overall, 21 of the 22 pouch sinus patients underwent ileostomy closure and only 1 had postoperative pelvic sepsis.

CONCLUSIONS

Pouch sinuses after ileal pouch-anal anastomosis with ileostomy are uncommon. Most heal within six months. The majority of patients with sinuses eventually undergo successful ileostomy closure. Pelvic septic complications are rare but can occur despite sinus healing on pouchogram.

Neutrophil-related immunoinflammatory disturbance in steroid-overdosed ulcerative colitis patients

BACKGROUND

There is some evidence that large preoperative doses of steroids are a causative factor for postoperative higher morbidity in ulcerative colitis (UC) patients. This study aimed to assess steroid-related changes in functional profiles of neutrophils in UC patients to estimate the immunological changes under surgical stress.

METHODS

Neutrophils were extracted from peripheral blood of 30 UC patients and 30 healthy controls. UC patients whose neutrophils were isolated were divided into two subgroups according to their total preoperative dosage of prednisolone: group H, > or =10,000 mg; group L, <10,000 mg. Expression of neutrophil surface antigens was analyzed and neutrophil phagocytosis was evaluated. Patterns of cell death of neutrophils were evaluated by co-culturing with Escherichia coli. Production of inflammatory mediators in cultured neutrophils was assessed.

RESULTS

There were no significant differences in the expression rates of TLR4, CD11b, and CD16b on neutrophils (CD15(+) cells) between the two patient groups and controls. There was also no significant difference in neutrophil phagocytosis between the two patient groups and controls. The neutrophil necrosis rate in group H was higher than that in group L and the controls 3 h after exposure to E. coli. Neutrophils from group H released the highest levels of proinflammatory cytokines following interleukin-1beta or lipopolysaccharide stimulation. Neutrophils from group H also released the highest levels of proteolytic enzymes.

CONCLUSIONS

Steroid-overdosed UC patients may have a functional deficit in neutrophils, which may cause a postsurgical systemic "storm" of inflammatory mediators.

Factors predicting postoperative infectious complications and early induction of inflammatory mediators in ulcerative colitis patients

BACKGROUND

Positive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC).

METHODS

To determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients.

RESULTS

Postoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups.

CONCLUSIONS

Circulating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.

The impact of preoperative immunomodulation on pouch-related septic complications after ileal pouch-anal anastomosis

PURPOSE

We studied preoperative and perioperative factors with particular attention to the role of immunomodulatory medication, which may impact the incidence of pouch-related septic complications.

METHODS

A retrospective review of data from patients who underwent ileal pouch surgery during a 20-year period from 1985 to 2005 was performed. Preoperative use of immunomodulatory medication along with perioperative clinical, surgical, and disease variables were recorded. Patients were monitored for pouch-related sepsis in the early (within 30 days of surgery) and late (after 30 days of surgery) postoperative periods. Univariate and multivariate logistic regression analysis was performed.

RESULTS

There were 445 patients (206 females; 46.4 percent). Median age was 36 (interquartile range, 27-46) years. Median follow-up period was 52 (interquartile range, 26-86) months. Complete data were available for 335 patients. Early sepsis was seen in 58 patients (17.3 percent). Another 22 patients (6.5 percent) developed late sepsis. On multivariate analysis, only steroid use remained predictive of higher rates of early sepsis (odds ratio, 1.81; 95 percent confidence interval, 1.02-3.45; P=0.002). Likewise on multivariate analysis, both male gender (odds ratio, 0.24; 95 percent confidence interval, 0.09-0.71; P=0.007) and 5-aminosalicylic-acid use (odds ratio, 0.22; 95 percent confidence interval, 0.08-0.76; P=0.023) remained predictive of lower rates of sepsis.

CONCLUSIONS

Preoperative steroid use is associated with higher rates of early but not late pouch-related septic complications. We recommend that patients be weaned of steroids before ileal pouch surgery or be warned of the higher risk of postoperative sepsis.

Long-axis rotational volvulus in a W ileoanal pouch: an unusual but potentially preventable problem. Report of a case

PURPOSE

This study was designed to report long-axis rotational volvulus, an unusual long-term complication of restorative proctocolectomy.

METHODS

A MEDLINE search using the keywords, pouch volvulus, pouch complications, ileoanal pouch volvulus, restorative proctocolectomy volvulus, restorative proctocolectomy complications, W-pouch, and early and late complications, was performed and yielded no previous reports.

RESULTS

We describe pouch gangrene secondary to volvulus in a W-pouch four years after restorative proctocolectomy for ulcerative colitis. Early recognition by clinical features, pouchoscopy, and soluble contrast studies are crucial if pouch salvage by pouchpexy is to be successful.

CONCLUSIONS

Acute necrosis of the ileoanal pouch caused by long-axis rotational volvulus is an important, but uncommon, cause of life-threatening acute abdomen after restorative proctocolectomy. Prophylactic pouchpexy at the time of pouch construction or salvage pouchpexy after early diagnosis of the at-risk pouch are important considerations to avoid loss of the pouch.

Salvage surgery after restorative proctocolectomy

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. There are four causes of failure including acute and chronic sepsis, poor function for mechanical or functional reasons, mucosal inflammation (including pouchitis and retained rectal mucosa) and neoplastic transformation. Failure rates themselves range from 5% to nearly 20%. Followed over a period of 20 years, the failure rate can be summarised approximately as 5% at five years, 10% at ten years and 15% at 15 years.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results

PURPOSE

Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients.

METHODS

All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database.

RESULTS

Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent.

CONCLUSION

Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.

Outcome after septic complications in J pouch procedures

BACKGROUND

Despite the wide range of surgical approaches for pouch salvage, septic complications are among the main causes of pouch failure.

METHODS

This study analysed the mode and outcome of various therapeutic approaches for pouch salvage and the impact of time of diagnosis, localization and form of septic complications on the risk of pouch failure in 131 patients with septic complications of a total of 706 patients undergoing a J pouch procedure.

RESULTS

Septic complications consisted of 76.3 per cent fistulas, 15.3 per cent anastomotic breakdowns and 8.4 per cent pelvic abscesses. A total of 107 patients (81.7 per cent) with septic complications required a mean of 2.2 surgical procedures. The frequency of permanent defunctioning and excision of the pouch in the 131 patients with septic complications was 23.7 and 6.1 per cent respectively. The estimated cumulative 3-, 5- and 10-year rate of pouch failure in patients with septic complications was 19.6, 31.1 and 39.2 per cent respectively. The risk of pouch failure was significantly affected by the site of origin of septic complications (P = 0.02). The 5-year pouch failure rate increased in a subgroup of patients with septic complications at the pouch-anal anastomosis when the anal sphincter was involved (50.1 versus 29.2 per cent; P = 0.18).

CONCLUSION

Pouch failure as a result of septic complications may occur several years after ileal pouch-anal anastomosis. For prevention of pouch failure, surgery for septic complications is required in a high percentage of patients and repeated attempts are justified. Follow-up studies are required for further analysis of pouch failure.

Surgery for ulcerative colitis

The type of surgery performed for UC varies from patient to patient and must take into account the nutritional status and health of the patient, the presence of dysplasia or cancer, the desire of the patient to maintain continence, the preoperative anorectal function, the degree of confidence in the diagnosis of UC, and the technical constraint because of certain body habituses. A total proctocolectomy is the surgical procedure of choice for UC. A restorative proctocolectomy is the preferred surgical approach that not only cures the patient of the disease and prevents the development of colorectal cancer, but also maintains continence with an improved quality of life.

A new ileal pouch salvage technique

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the surgical treatment of ulcerative colitis. Fistulas originating from the ileal pouch are uncommon but serious complications, sometimes leading to failure of the operation. We describe a technique to treat and salvage a pouch involved in a chronic fistulating ileal J-pouch-anal anastomosis by disconnecting the pouch, turning it inside out after repair, and reanastomosing it to the dentate line.

Use of a gracilis muscle flap to facilitate delayed ileal pouch-anal anastomosis

Failure of an ileal pouch-anal anastomosis may result in unsuccessful completion of the anastomosis or removal of an ischemic pouch. We report a technique for preservation of the muscular wall of the rectum after mucosal dissection, which allowed a successful delayed pull-through.

Reconstruction for chronic dysfunction of ileoanal pouches

OBJECTIVE

A retrospective review was performed to determine the results after surgical reconstruction for chronic dysfunction of ileal pouch-anal procedures for ulcerative colitis and familial colonic polyposis at a university medical center.

METHODS

During the 20-year period from 1978 to 1998, 601 patients underwent colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, familial colonic polyposis, or Hirschsprung's disease. A J pouch was used for 351 patients, a lateral pouch for 221, an S pouch for 6, and a straight pull-through for 23. Acute complications after pouch construction have been detailed in previous publications and are not included in this study. Chronic pouch stasis with diarrhea, frequency, urgency, and soiling gradually became more severe in 164 patients (27.3%), associated with pouch enlargement, an elongated efferent limb, and obstruction to pouch outflow, largely related to the pouch configuration used during the authors' early clinical experience. These patients were sufficiently symptomatic to be considered for reconstruction (mean 68 months after IPAA). Transanal resection of an elongated IPAA spout was performed on 58 patients; abdominoperineal mobilization of the pouch with resection and tapering of the lower end (AP reconstruction) and ileoanal anastomosis on 83; pouch removal and new pouch construction on 7; and conversion of a straight pull-through to a pouch on 16.

RESULTS

Good long-term results (mean 7.7 years) with improvement in symptoms occurred in 98% of transanal resections, 91.5% of AP reconstructions, 86% of new pouch constructions, and 100% of conversions of a straight pull-through to a pouch. The average number of bowel movements per 24 hours at 6 months was 4.8. Complications occurred in 11.6% of reconstructed patients. Five of the 164 patients (3.1%) required eventual pouch removal and permanent ileostomy. The high rate of pouch revision in this series of patients undergoing IPAA is due to a policy of aggressive correction when patients do not experience an optimal functional result, or have a progressive worsening of their status.

CONCLUSIONS

Although occasionally a major undertaking, reconstruction of ileoanal pouches with progressive dysfunction due to large size or a long efferent limb has resulted in marked improvement in intestinal function in >93% of patients and has reduced the need for late pouch removal.

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment

OBJECTIVE

To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery.

SUMMARY BACKGROUND DATA

Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications.

METHODS

The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey.

RESULTS

Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit.

CONCLUSIONS

Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.

Quality of life after pouch excision

BACKGROUND

Pouch excision is a devastating experience for patients having restorative proctocolectomy for ulcerative colitis.

METHODS

The quality of life among patients having pouch excision for ulcerative colitis was compared with that in those having proctocolectomy and ileostomy for ulcerative colitis using a validated standardized self-administered questionnaire.

RESULTS

After pouch excision patients (n = 9) had more troublesome bowel symptoms (mainly from liquid stoma output) than those in the proctocolectomy group (n = 14) (mean(s.d.) score 5.64(0.92) versus 6.13(0.37), P = 0.03). However, the mean scores for the other parameters (systemic symptoms, functional, social and emotional impairment) did not differ significantly.

CONCLUSION

Patients having pouch excision for ulcerative colitis have more liquid ileostomy loss but a comparable quality of life to those treated by standard proctocolectomy and ileostomy.

Treatment of colorectal and ileoanal anastomotic sinuses

PURPOSE

This study is designed to describe a technique and report results for treating low anastomotic sinuses.

METHODS

Restorative proctocolectomy and complicated low anterior resections were protected with diverting loop ileostomy. Contrast enemas identified anastomotic problems before ileostomy closure. Pouch-anal or colorectal anastomotic sinuses that failed to resolve with observation were treated before intestinal continuity was restored. With the patient receiving regional or general anesthesia, a rigid proctoscope or anoscope was used to identify the sinus opening. The common wall between the sinus and the bowel lumen was divided under direct vision with laparoscopic cautery scissors, and the sinus cavity was debrided with a suction cautery wand placed through the scope.

RESULTS

Six patients with anastomotic sinuses have received outpatient treatment in the described manner during the past two years. Four patients had restorative proctocolectomies for ulcerative colitis, and two had low anastomosis for rectal cancer. Three patients presented with pelvic sepsis before the contrast study; the remainder were asymptomatic. Division of anastomotic sinus was performed one to eight months after diagnosis of the sinus. Following division, anastomotic cavities resolved in five patients by 1 month and in one patient by 12 months. In these six patients, there was one dilatable anastomotic stricture but no other anastomotic complications at follow-up 5 to 16 (mean, 9.2) months after sinus division.

CONCLUSION

When used in conjunction with fecal diversion, sinus unroofing by division of the common wall between the sinus and bowel lumen treats low pelvic sinuses.

Pouch salvage. Long-term outcome

PURPOSE

The aim of this study was to determine the outcome of pouch salvage operations and the factors that may influence successful reconstructions.

METHODS

This retrospective review includes data from 198 patients who had undergone restorative proctocolectomy at a single institution during an 11-year period. All patients who had undergone attempted pouch salvage and who still had a pouch in situ were reviewed by both postal questionnaire and at interview in the outpatients clinic.

RESULTS

Of 198 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis, 27 (13.6 percent) presented with pouch-specific complications requiring pouch salvage. A further five patients requiring pouch salvage were referred from other centers. Of 32 patients who underwent attempted pouch salvage, 16 (50 percent) had a successful outcome, 12 (37.5 percent) had pouch excision, and 3 (9 percent) are still defunctioned. There was one death (3 percent) in this series. Pelvic sepsis was a major cause of pouch failure, being present in 50 percent (8/16) of failed salvage procedures, and accounting for 58 percent (7/12) of pouch excisions.

CONCLUSIONS

Salvage surgery for major complications following ileoanal pouch construction is worthwhile in the absence of major pelvic sepsis. Overall success rate is 50 percent, and these results may be acceptable to highly motivated patients.