How do you treat refractory pouchitis and when do you decide to remove the pouch?

Abstract

From every textbook page and lecture platform, we are offered the clichC that surgery is a “cure” for ulcerative colitis. To be sure, after a total proctocolectomy, there is no longer a colon or a rectum to serve as the target for this particular disease, but often the operation has simply substituted a different disease for the original one. In the case of a total proctocolectomy and Brooke ileostomy, the spectrum of “new” diseases is limited primarily to surgical complications such as prolapse, retraction, or intestinal obstruction. The roster of complications, however, is more extensive after ileal pouch-anal anastomosis. These postoperative problems may be minimized by enthusiastic surgeons or exaggerated by skeptical gastroenterologists, while the patients are left confused or suffering. Let us therefore try to take a dispassionate look at the facts. First, the bad news. Those centers with the largest experience and the longest follow-up are reporting the cumulative incidence of pouchitis to be at or above 50%, with two-thirds of these patients experiencing multiple attacks (1-4). Next, the good news. The vast majority of cases of acute pouchitis-up to 96% in a representative