Pouch salvage. Long-term outcome

Salvage surgery for pouch-related complication after ileal pouch-anal anastomosis: a report of two cases

BACKGROUND

Pouch-related complications (PRCs), such as pelvic abscesses and perianal complex fistulas, can occur after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). They are often difficult to treat and require salvage surgery. We report two cases of PRC associated with fistulas.

CASE PRESENTATION

First case: A 38-year-old man was diagnosed with UC at age 26 years. Four months after the diagnosis of UC, the patient underwent hand-assisted laparoscopic restorative proctocolectomy, IPAA, and ileostomy for acute fulminant UC. Two years after the closure of the ileostomy, the patient developed a perianal abscess and underwent ileostomy reconstruction. He was referred to our department at 35 years of age, because his symptoms did not improve despite repeated seton drainage of a complicated perineal fistula. We diagnosed PRC with a pelvic abscess and complicated pouch fistula and performed salvage surgery. This diagnosis was revised to Crohn's disease.

SECOND CASE

A 50-year-old man was diagnosed with UC at age 18 years and was administered high doses of steroids; however, his symptoms did not improve. He underwent restorative proctocolectomy, IPAA, and ileostomy at another hospital. The ileostomy was closed, and his condition stabilized thereafter. At 35 years of age, perianal pain developed, and he was diagnosed with a complicated pouch-perineal fistula. A fistula was observed near the staple line of the ileal end closure on the head side of the pouch. Reconstruction of the ileostomy and seton drainage were performed; however, his symptoms did not improve, and he was referred to our hospital. We diagnosed PRC with a pelvic abscess and a complicated pouch fistula and performed salvage surgery. The resected specimen showed strictures in two locations: at the oral site of the afferent limb (at the pouch) and at the IPAA. Both patients returned to society and are currently outpatients.

CONCLUSIONS

We encountered two cases of PRC after IPAA that did not improve with seton drainage or ileostomy. Pouch resection was performed after considering the patient's quality of life and reintegration into society.

The Surgical Management of Ileal Pouch Strictures

BACKGROUND

Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn's disease. Pouch stricture is a common complication after IPAA.

OBJECTIVE

This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm.

DATA SOURCES

A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed.

STUDY SELECTION

Randomized controlled trials, cohort studies, observational studies, and case reports were considered.

INTERVENTIONS

Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included.

MAIN OUTCOMES

Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques' including resection and reconnection, strictureplasty, or bypass.

RESULTS

Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection' or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience.

LIMITATIONS

Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.

[Complications and corrective surgery after ileal pouch-anal reconstruction?]

Proctocolectomy with ileal J‑pouch-anal and rectal reconstruction is the standard surgical treatment for ulcerative colitis, selected cases of Crohn's disease, FAP and multilocular colon carcinoma. Although this treatment has been continuously developed over the last 40 years, the long-term success rate is 80-90% of the treated patients. The reasons for this are manifold: chronic pouchitis, incontinence, secondary diagnosis of Crohn's disease, fistulas, severe surgical complications, rectal stump left for too long, chronic abscess and surgical technical errors. This article deals with the control of acute complications and with the management of long-term complications. Some of the triggering complications for pouch failure do not generally imply failure of the method. A correction, closure of the fistula and in individual cases also a completely new pouch creation can restore a good pouch function in about 75% of cases. Various indications, techniques and results are presented.

Revisional ileoanal pouch surgery: a systematic literature review assessing outcomes over the last 40 years

AIM

Failure of primary ileal pouch-anal anastomosis (IPAA) occurs in up to 15% of patients. Revision surgery may be offered to patients wishing to maintain gastrointestinal continuity. This paper explores the literature relating to IPAA revision surgery, focusing on pouch function after revision and factors associated with pouch failure.

METHODS

Search of PubMed database was carried out for 'ileal pouch anal anastomoses', 'ileoanal pouch', 'restorative proctocolectomy', 'revision surgery', 'redo surgery', 'failure', 'refashion surgery', 'reconstruction surgery' and 'salvage surgery'. Papers were screened using the PRISMA literature review strategy. Studies of adults published after 1980 in English with an available abstract were included. Case reports and studies that were superseded using the same data were excluded.

RESULTS

Nineteen papers (1424 patients) were identified. Bowel motion frequency doubled following revision surgery compared to primary IPAA although the increase was not always statistically significant. In patients failing primary IPAA, frequency of daytime bowel motions improved following revision in three studies but only reached significance in one (12.1 vs. 6.9, P = 0.021). Risk of pouch failure is increased in patients who develop pelvic sepsis after the primary procedure with the largest study demonstrating a four-fold increased risk (hazard ratio 3.691, P < 0.0001). A final diagnosis of Crohn's causes a four-fold increased risk of pouch failure (n = 81; OR 3.92, 95% CI 1.1-15.9, P = 0.04).

CONCLUSIONS

In patients undergoing revisional surgery, improved outcomes are observed but are inferior compared to primary IPAA patients. Pelvic sepsis after primary IPAA and a final diagnosis of Crohn's are associated with increased risk of pouch failure.

Current surgical practice in pediatric ulcerative colitis: A systematic review

BACKGROUND

Surgical management of adult ulcerative colitis (UC) is well-studied, but not readily applicable to children. Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA), performed as one-, two-, or three-stage procedure, is preferred in pediatric patients with adequate anal sphincter function.

PURPOSE

METHODS: Systematic review of Cochrane Register of Controlled Trials, PubMed, and EMBASE databases was conducted (January 1987-December 2016), in accordance with PRISMA.

RESULTS

Twelve retrospective studies were identified (568 patients total); 31, 334, and 203 patients underwent one-, two-, and three-stage procedures, respectively. Median study size was 31 patients (range 10-202), median age was 13 years (range 2-21), median follow-up was 4 years (range 0.08-16). Postoperative complications included pouchitis, bowel obstruction, stricture, fistula, pouch failure, anastomotic leak, and wound infections. Calcineurin inhibitor usage improved pediatric ulcerative colitis activity index (PUCAI) score. Higher PUCAI scores correlated with likelihood of staged procedures. Number of stages did not restrict quality of life.

CONCLUSIONS

Paucity of data exists, comparing preoperative factors leading to staged procedures in pediatric UC. This systematic review identifies an area for future studies.

LEVEL OF EVIDENCE

II.

Surgical solutions for refractory J-pouch inlet obstruction

AIM

Many surgeons consider total proctectomy with ileal pouch-anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients.

METHODS

A retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal-pouch anastomosis for J-pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra-operative findings, type of surgical intervention and postoperative outcomes.

RESULTS

Surgical interventions were performed on eight patients with J-pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarily anastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow-up of 36.5 months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred.

DISCUSSION

J-pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J-pouches being performed, awareness of novel surgical techniques is important.

Ileal pouch revision vs excision: short-term (30-day) outcomes from the National Surgical Quality Improvement Program

AIM

Ileal pouch-anal anastomosis (IPAA) failure occurs in approximately 5%-10% of patients. We aimed to compare short-term (30-day) postoperative outcomes associated with pouch revision and pouch excision using a large international database. Our null hypothesis was that there is no statistically significant difference in overall postoperative complications between patients selected for pouch revision vs pouch excision.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 we identified patients who underwent either IPAA revision via the combined abdominoperineal approach [Current Procedural Terminology (CPT) 46712] or IPAA excision (CPT 45136). Differences in baseline characteristics and short-term outcomes between groups were assessed with univariate and matched analyses.

RESULTS

We identified 593 reoperative IPAA procedures: revision group 78 (13%) and excision group 515 (86%). The groups had similar age and body mass index (kg/m² ), but the revision group had more women (65.4% vs 51.8%, P = 0.02) and fewer were on chronic steroids (3.9% vs 17.9%, P = 0.0008) relative to the excision group. Revision IPAA patients were more likely to have received a preoperative transfusion (5.1% vs 0.97%, P = 0.02). Revision and excision were associated with similar postoperative length of stay (9.3 vs 8.6 days, 0.44), mortality (nil vs 0.58%, respectively; P = 0.99) and short-term morbidity (34.6% vs 40.2%, respectively; P = 0.88) at 30 days.

CONCLUSIONS

Pouch revision and excision have comparable short-term postoperative outcomes, but pouch excision appears to be more commonly utilized. Increased awareness of the indications for pouch revision or referral to specialized centres may improve pouch revision rates.

The usefulness of the H-pouch configuration in salvage surgery for failed ileal pouches

AIM

Abdominal salvage surgery for a failed ileal pouch-anal anastomosis (5) is safe and feasible in experienced hands. When salvaging an ileal pouch or creating a new J, S or W pouch may not be feasible, construction of an H-pouch may be the final option. This study reports a single colorectal surgeon's experience on H-pouch anal anastomosis in patients referred with a failed ileal pouch.

METHOD

Patients undergoing transabdominal salvage surgery with H-pouch formation for a failed pouch from February 2012 to May 2016 were evaluated.

RESULTS

Five patients were identified with a mean age of 46 (22-63) years. The pathological diagnosis was mucosal ulcerative colitis in all patients. Three patients had an initial traditional two-stage J-pouch creation and two patients had an initial three-stage approach. The median time to redo pouch surgery after the index IPAA creation was 99 (11-158) months. One patient required excision of the pouch and two patients had a complication within 30 days of surgery.

CONCLUSION

The H-pouch is a good alternative for a failed IPAA when another type of reservoir is not an option.

[Surgical strategy to save ileoanal pouch reconstruction]

Restorative proctocolectomy under formation of an ileoanal/ileorectal J‑pouch has become the procedure of choice in the therapy of ulcerative colitis. Although patients experience a dramatic improvement of their quality of life, surgery is not successful in about 5-10% of all treated patients. The reasons for failure are chronic pouchitis, incontinence, delayed diagnosis of Crohn's disease, fistula, surgical complications, too long remnant rectal stump, chronic abscess, and surgical technical errors. Some of the reasons do not always prevent the loss of a well-functioning ileoanal pouch. In many cases, correction, closure of fistulas or even a complete reconstruction of the ileoanal pouch are possible. Based on a review of the literature and our own experience, we show in 887 patients a success rate of 75% with acceptable pouch function. Indications, technics, and results are presented.

Outcomes of salvage surgery for ileal pouch complications and dysfunctions. the experience of a referral centre and review of literature

BACKGROUND AND AIMS

Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction.

METHODS

We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre- and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3).

RESULTS

Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003).

CONCLUSIONS

Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction.

[Special surgical complications in chronic inflammatory bowel diseases]

After colorectal and anorectal interventions for chronic inflammatory bowel diseases, specific complications can occur.In Crohn's disease these complications mainly occur after proctocolectomy. Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis. A persisting sepsis of the sacral cavity can be treated primarily by dissection of the anal sphincter which ensures better drainage. In cases of chronic sacral sepsis, transposition of the gracilis muscle is a further effective option. Early recurrence of a transsphincteric anal fistula should be treated by reinsertion of a silicon seton drainage.Complications after restorative proctocolectomy are frequent and manifold (35%). The main acute complications are anastomotic leakage and pelvic sepsis. Therapy consists of transperineal drainage of the abscess with simultaneous transanal drainage. Late complications due to technical and septic reasons are still a relevant problem even 36 years after introduction of this operative technique. A consistent approach with detailed diagnostic and surgical therapy results in a 75% rescue rate of ileoanal pouches.

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

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.

What are the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery?

PURPOSE

Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery.

METHODS

The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence.

RESULTS

Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohn's disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohn's disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohn's disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent.

CONCLUSION

Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeon's preference and patient-related factors such as diagnosis.

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.

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.

Repeat pouch surgery by the abdominal approach safely salvages failed ileal pelvic pouch

PURPOSE

: This study evaluated outcomes of patients with abdominal salvage operations for failed ileal pouch-anal anastomosis.

METHODS

: Patients undergoing laparotomy for ileoanal pouch salvage were reviewed from a prospectively maintained pouch database and records.

RESULTS

: From 1983 to 2007, 241 abdominal reconstructions were performed. The median follow-up was 5 years (range, 0.04-20.8). Diagnoses before primary ileal pouch-anal anastomosis were ulcerative colitis in 187, familial adenomatous polyposis in 22, indeterminate colitis in 20, Crohn's disease in 9, and other in 3. The most common indications for salvage were fistula (n = 67), leak (n = 65), stricture (n = 42) pouch dysfunction (n = 40), pelvic abscess (n = 25). Seventy-one cases had a new pouch constructed. One hundred and seventy cases had the original pouch salvaged. Twenty-nine cases had either pouch excision or ileostomy without pouch excision the result of failure after reconstruction. To assess functional results and quality of life, patients with reconstruction were matched to those with a primary ileal pouch-anal anastomosis. Significantly higher proportions of patients with reconstruction reported seepage during daytime (P = 0.002), at night (P = 0.015), and daytime pad usage (P = 0.02). Other parameters and quality of life were similar between groups.

CONCLUSIONS

: Repeat abdominal surgery was a good alternative for pouch failure. Functional and quality of life outcomes were encouraging.

Ileal pouch dysfunction: diagnosis and management

Restorative proctocol ectomy is the elective surgical procedure of choice for most patients who have ulcerative colitis or familial adenomatous polyposis. This major advance has offered an alternative to permanent ileostomy in these patients.

Routine contrast imaging of low pelvic anastomosis prior to closure of defunctioning ileostomy: is it necessary?

PURPOSE

The purpose of the study was to determine the utility of routine contrast enema prior to ileostomy closure and its impact on patient management in patients with a low pelvic anastomosis.

MATERIAL AND METHODS

Two hundred eleven patients had a temporary loop ileostomy constructed to protect a low colorectal or coloanal anastomosis following low anterior resection for cancer (57%) or other disease (12%) or to protect an ileal pouch-anal anastomosis following restorative proctocolectomy (31%). All patients were evaluated by physical examination, proctoscopy, and water-soluble contrast enema prior to ileostomy closure. Imaging results were correlated with the clinical situation to determine the effects on patient management.

RESULTS

The mean time from ileostomy creation to closure was 15.6 weeks. Overall, 203 patients (96%) had an uncomplicated course. Eight patients (4%) developed an anastomotic leak, seven of which were diagnosed clinically and confirmed radiographically before planned ileostomy closure. Resolution of the leak was confirmed by follow-up contrast enema. One patient, whose pouchogram revealed a normal anastomosis, clinically developed a leak after ileostomy closure. It is important to note that routine contrast enema examination did not reveal an anastomotic leak or stricture that was not already suspected clinically.

CONCLUSIONS

All patients who developed an anastomotic leak in this study were diagnosed clinically, and the diagnosis was confirmed by selective use of radiographic tests. Routine contrast enema evaluation of low pelvic anastomoses before loop ileostomy closure did not provide any additional information that changed patient management. The utility of this routine practice should be questioned.

Intermittent torsion of a megapouch: report of a case

We report an unusual presentation of pouch dysfunction because of excessive pouch enlargement or "mega pouch" and probable torsion. The patient presented with abdominal pain that was positional. Contrast-enhanced computerized tomography showed pouch anastomotic staples extending into the right upper quadrant. At operation, gross pouch enlargement with dilation of the afferent ileum was confirmed. Reduction pouch-plasty resulted in pain resolution and maintenance of satisfactory function.

Ileal pouch-anal anastomosis

BACKGROUND

Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application.

METHODS AND RESULTS

Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

CONCLUSION

The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

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.

Complications of ileal pouch anal anastomosis

Ileal pouch anal anastomosis (IPAA) is associated with complications in a significant number of patients, including ileal-anal separation, anal stricture, pouchitis, pelvic sepsis, and small bowel obstruction. In most cases, these complications may be successfully treated using either medical or surgical therapy and do not result in long-term pouch dysfunction. Important preventative measures include accrual of experience or creation of a team with experienced surgical leadership and scrupulous selection of patients who have no features of Crohn's disease. Despite these precautions, 5% to 15% of patients will develop chronic pouch dysfunction and pouch failure requiring diversion with or without excision of the pouch. Medical measures, such as antibiotics, immunomodulators, and biologic agents, and surgical measures such as advancement flap anoplasty may be attempted to salvage pouch function and are successful in more than 50% of cases. Indeterminate colitis does not preclude IPAA; however, Crohn's colitis is absolute contraindication for same. Patients who require colectomy and are suspected for any reason to have CD may undergo ileorectal anastomosis with preservation of anorectal continence and excellent functional results.

Effect of infliximab on short-term complications in patients undergoing operation for chronic ulcerative colitis

BACKGROUND

Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the preferred operation for patients with chronic ulcerative colitis (CUC) refractory to medical therapy. Infliximab (IFX), an antitumor necrosis factor-alpha antibody, has demonstrated efficacy in medical management of CUC. The aim of this study is to determine if IFX before IPAA impacts short-term outcomes.

STUDY DESIGN

A prospective institutional database was retrospectively reviewed for short-term complications after IPAA for CUC. Postoperative outcomes were compared between patients who received pre-IPAA IFX and those who did not.

RESULTS

Between 2002 and 2005, 47 patients received IFX before IPAA, and 254 patients received none. There were no gender (p = 0.16) or body mass index (p = 0.07) differences between groups. IFX patients were younger than non-IFX patients (mean age 28.1 to 39.3 years) (p < 0.001). In IFX patients, 70% were receiving preoperative IFX, azathioprine, and corticosteroids. Mortality was nil. Overall surgical morbidity was similar: 61.7% and 48.8%, IFX and non-IFX, respectively (p = 0.10). Anastomotic leaks (p = 0.02), pouch-specific (p = 0.01) and infectious (p < 0.01) complications were more common in IFX patients. Multivariable analysis revealed IFX as the only factor independently associated with infectious complications (odds ratio [OR] = 3.5; CI, 1.6-7.5). In a separate analysis, incorporating age, high-dose corticosteroids, azathioprine, and severity of colitis, IFX remained significantly associated with infectious complications (OR = 2.7; CI, 1.1-6.7).

CONCLUSIONS

CUC patients treated with IFX before IPAA have substantially increased the odds of postoperative pouch-related and infectious complications. Additional prospective studies are required to determine if IFX alone or other factors contribute to the observed increases in infectious complications.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

Long-term results of abdominal salvage surgery following restorative proctocolectomy

BACKGROUND

This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy.

METHODS

Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine.

RESULTS

One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32).

CONCLUSION

Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.

Revolution and evolution: 30 years of ileoanal pouch surgery

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND

Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis.

METHODS

Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients.

RESULTS

A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent.

CONCLUSION

Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Current concepts and controversies in surgery for IBD

Surgery improves the quality of life in patients with Crohn's disease (CD) and cures patients with chronic ulcerative colitis (CUC). There are several surgical controversies primarily involving techniques and long-term outcomes. Some debates are long standing; whether to perform a double-stapled ileal pouch-anal anastomosis (IPAA) or a mucosectomy and hand-sewn anastomosis, and whether to divert or not to divert in patients with CUC undergoing an IPAA. Other issues are more recent, such as the effects of age, pregnancy, pouch salvage, and laparoscopic IPAA. In patients with Crohn's disease the anastomosis technique, the management of perianal disease, and the role of laparoscopic surgery are topics of debate. This review shows the current concepts and controversies in the surgical management of patients with CUC or CD.

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.

Pouch reconstruction in the pelvis

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.

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.

Reoperative abdominal and perineal surgery in ileoanal pouch patients

PURPOSE

Complications of the ileal pouch with ileoanal anastomosis are associated with poor function and diminished quality of life; often, these complications may require surgery to salvage the pouch. The aims of this study were to review our experience with reoperative ileoanal pouch surgery and to define any predictors of pouch salvage surgery.

METHODS

Between 1991 and 1999, the medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision were reviewed; any minor local procedures were excluded. Successful ileoanal pouch salvage was considered to be an intact and functioning pouch, with acceptable patient satisfaction and good control.

RESULTS

Thirty-two patients underwent reoperative ileoanal pouch surgery, 25 for attempted pouch salvage and 10 for pouch excision (3 patients were included in both groups). Five patients (20 percent) had pouch reconstruction, 1 of which was successful; 8 (32 percent) had pouch advancement, with a 62 percent success rate; and 16 (64 percent) had local perianal procedures for control of perianal sepsis, with a 75 percent success rate (4 of these required further surgery). The overall success rate of ileoanal pouch salvage surgery was 84 percent, with 64 percent of patients having acceptable function. There was no correlation between the number of ileoanal pouch salvage procedures and failure. Four (40 percent) of the 10 patients who had pouch excision were ultimately diagnosed with Crohn's disease.

CONCLUSIONS

Ileoanal pouch salvage surgery is often successful and, in motivated patients without Crohn's disease, is worthwhile. Pouch advancement or local perianal repair yielded better results than did pouch reconstruction. Patients diagnosed with Crohn's disease after ileoanal pouch construction may be best suited for pouch excision when complications occur.

Redo ileal pouch-anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy?

BACKGROUND

Pouch complications after ileal pouch-anal anastomosis (IPAA) can result in morbidity and pouch loss. Recent reports describe success with redo IPAA. This study was conducted to assess the outcome of malfunctioning pouches treated by redo IPAA.

METHODS

All patients undergoing redo IPAA between 1983 and 1999 were identified and clinical records studied. Redo IPAA was defined as an operation for malfunctioning pouch with pelvic dissection and disconnection, pouch revision, and reanastomosis. Analyzed were etiology, presentation, diagnostic modalities, surgical management, pouch loss, and outcome. Follow-up was obtained by telephone or mailed survey.

RESULTS

Between 1983 and 1999, 650 IPAA procedures were performed, 6 (0.9%) of which required redo IPAA. Ten referred patients required redo IPAA. These 16 cases included 7 anastomotic disruptions, 3 pouch-vaginal fistulae, 2 recurrent polyps after stapled IPAA, 2 megapouches, 1 cuff abscess, and 1 straight pullthrough. All patients underwent redo IPAA with pouch salvage 100% in this series. Twelve had the original pouch repaired and 4 new pouches. Six patients (37%) had complications and outcome was acceptable with 7.8 stools per day and nighttime incontinence "rarely" or "never" in 7 patients. Eight described results as "good," 6 as "fair.".

CONCLUSION

Redo IPAA can be performed with few complications, an acceptable outcome, and should result in low pouch loss.

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.

Functional results after perineal complications of ileal pouch-anal anastomosis

PURPOSE

This study investigated the functional significance of perineal complications after ileal pouch-anal anastomosis.

METHODS

Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi-squared and Fisher's exact probability tests.

RESULTS

Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications.

CONCLUSIONS

An appreciable number of perineal complications occur after ileal pouch-anal anastomosis. Pouch-perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch-anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.