Pouch-related fistula and intraoperative tricks to prevent it.

Abstract

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the mainstay of treatment for refractory ulcerative colitis (UC) or dysplasia in chronic UC. In spite of the advances in the medical treatment for UC, up to 30 % of patients may still require surgery [1]. Irrespective of age at surgery and disease duration [2, 3], IPAA achieves optimal functional results, and this is reflected in health-related quality of life (HRQoL). Early postoperative pelvic sepsis, which is responsible for significant functional disturbances [4] and impaired HRQoL in the long term [1– 6], is the most dreaded complication of IPAA [4, 5]. Up to 25 % of IPAA patients are affected to some degree [1–7] and are at greater risk of pouch-related fistula. The risk of pelvic sepsis is inversely proportional to the surgeon’s experience with pouch surgery, suggesting that some factors responsible for pelvic sepsis and late formation of pouch-related fistulae are modifiable. Pouch-related fistulae can develop at any time, but often occur some months after IPAA, and might be related to medical factors and unidentified Crohn’s disease (CD) [7, 8], but technical faults may be responsible for this complication in a relevant number of patients. Treatment for pouch-related fistulae is difficult. The article on this type of fistula, recently published by Gaertner et al. [8] in this journal, is of great interest. The authors describe the outcomes of the treatment for pouchrelated fistula after IPAA in a retrospective series from 1989 through 2011. Twenty-five patients presented with pouch-related fistula. Each patient underwent on average 2.8 (range 1–10) procedures or repairs, consisting of seton drainage (n = 20), fibrin glue injection (n = 11), fistulotomy (n = 5), collagen plug insertion (n = 4), transperineal repair (n = 3), ileal advancement flap (n = 2), insertion of cutting seton (n = 2), Martius flap (n = 1), transabdominal repair (n = 1), and revision of ileal pouch–anal anastomosis with gracilis muscle interposition (n = 1). In 24 % of patients, a temporary loop ileostomy was fashioned, whereas some CD patients received concomitant medical treatment. Complete healing was achieved in 64 % of patients with a stepwise diagnostic and therapeutic approach. The paper includes 60 % of patients with CD of the pouch, which was the only factor associated with persistent fistulas in this series [8]. The authors provide their algorithm for managing ileal–pouch-related fistulas based on their etiology (surgical complications, cryptoglandular, or CD). However, every effort should be made to reduce the incidence of surgical complications by acting on modifiable periand intraoperative factors. We have further subdivided fistula etiology specific to ileoanal pouches in Table 1. Early pelvic sepsis [4, 5] is mainly due to breakdown of the IPAA and may determine peri-pouch abscess formation. The clinical impact of pelvic sepsis can be reduced by a temporary stoma, which is mandatory in patients with risk factors for anastomotic complications [9]. In addition, a stoma makes it possible to treat a potential peri-pouch abscess via a transperineal approach, with no need of repeated laparotomy. Early recognition of pelvic sepsis is the key. Pelvicand peri-pouch collections need timely treatment. The transperineal approach should be preferred when possible and certainly used in patients with diversion ileostomies, and the ideal drainage route is the line of the ileoanal anastomosis. The abscess can be drained by removing some sutures or staples. If there is a large F. Selvaggi (&) G. Pellino Department of General Surgery, Second University of Naples, Via F.Giordani, 42, 80122 Naples, Italy e-mail: fselvaggi@hotmail.com