Failed Ileal Pouch-anal Anastomosis Research Articles

Risk factors for failure of ileal pouch-anal anastomosis in patients with refractory ulcerative colitis

BackgroundProctocolectomy with ileal pouch-anal anastomosis is the standard surgical procedure for ulcerative colitis refractory to medical treatment. In a few cases, ileal pouch-anal anastomosis cannot be completed due to intraoperative technical problems. The aim of this single-center study was to identify risk factors for a technically failed ileal pouch-anal anastomosis. MethodsIn total, 391 patients with ulcerative colitis who received ileal pouch-anal anastomosis were identified. Clinical and perioperative data from patients with successful ileal pouch-anal anastomosis (IPAA+) were compared to data from failed ileal pouch-anal anastomosis (IPAA-). Definition of failed ileal pouch-anal anastomosis was intraoperative failure to perform ileal pouch-anal anastomosis. Risk factors for failed ileal pouch-anal anastomosis were assessed by logistic regression. Cut-off values were calculated on the basis of receiver operating characteristic curves and the Youden Index. ResultsThe rate of failed ileal pouch-anal anastomosis was 26 of 391 (6.6%). In 22 of 26 cases (84.6%), there was an insufficient length of the small intestinal mesentery. Patients with failed ileal pouch-anal anastomosis were more often male (80.8% vs 54.5%, P = .009), older (47.1 ± 14.1 vs 39.2 ± 12.8 years, P = .007), had a higher body mass index 27.2 ± 4.5 vs 23.7 ± 4.3 kg/m2, P < .001), and had extraintestinal manifestations more frequently (65.4% vs 26.3%, P < .001). Further risk factors for failed ileal pouch-anal anastomosis were hypertension and Cushing’s syndrome. ConclusionTechnical failure of ileal pouch-anal anastomosis is elevated in patients with higher body mass index, with refractory ulcerative colitis, and/or extended immunosuppressive medication. Three-staged ileal pouch-anal anastomosis and optimizing preoperative conditions may help to elevate the rate of successful ileoanal pouch construction in these patients.

Transabdominal re-do pouch surgery in pediatric patients for failed ileal pouch anal anastomosis: a case matched study.

Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. 60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

Tu1823 Is Conversion of a Failed Ileal Pouch-Anal Anastomosis to a Continent Ileostomy a Predictor of Failure in Long-Term?

Tu1823 Is Conversion of a Failed Ileal Pouch-Anal Anastomosis to a Continent Ileostomy a Predictor of Failure in Long-Term?

Risk Factors Associated with Refractory Pouchitis Following Ileal Pouch Anal-Anastomosis

Purpose: Patients with severe medically refractory ulcerative colitis commonly undergo total proctocolectomy with ileal pouch-anal anastomosis (IPAA). This surgery occurs in 1, 2 or 3 stages. Up to 50% of patients develop pouchitis, diagnosed based on various clinical, endoscopic, and histological findings. Multiple risk factors for pouchitis have been suggested, including bacterial dysbiosis, presence of pANCA titers, extra-intestinal manifestations of ulcerative colitis, use of preoperative steroids and NSAIDs. While many different therapies have been studied, antibiotics are the mainstay of treatment. Approximately 10% of patients with pouchitis develop antibiotic refractory pouchitis and require immunomodulators, biologics, and/or surgery. There are no randomized trials in the literature and maintenance of remission in refractory pouchitis remains a challenge. The aim of this study was to identify risk factors leading to the development of refractory pouchitis. Methods: A retrospective analysis was performed of patients who underwent IPAA from 2003-2010 at a single tertiary care center. The variables of pre-operative diagnosis, age, gender, Charlson comorbidity index score, and diagnosis and treatment of pouchitis were assessed. Patients were excluded if they had less than one year follow-up documented in the chart or a surgical complication leading to diagnosis of failed IPAA. Results: A total of 112 patients were included in the study (91 UC, 1 CD, 9 IC, 11 FAP). The mean age at diagnosis was 26.8 years, 59 patients were male (52.7%), and the mean Charlson score was 0.69. Pouchitis was diagnosed in 67 patients (59.8%) and all received antibiotics for initial management. Of those patients with pouchitis, 46 (68.7%) were also given probiotics, 4 (5.9%) received immunomodulators (azathioprine, methotrexate, or 6-mercaptopurine), and 8 (11.9%) received biologics (infliximab, adalimumab, or certolizumab). A total of 6 patients (8.9%) required management with pouch excision or revision. Univariate analysis identified a trend towards significance for number of stages (p=0.08) and post-operative diagnosis change to Crohn's Disease (p=0.08) for predicting such refractory disease. Conclusion: We hypothesized that certain patients may be predisposed to refractory pouchitis. While more data is needed to prove significance, the patients with more aggressive distal disease necessitating a 3 stage procedure may be at higher risk for subsequent pouchitis. This also may influence the conversion to phenotypically identified Crohn's disease. Additionally, operative techniques for the IPAA itself need to be investigated. Given the difficulties of management, further studies are needed to identify patients at risk for development of refractory pouchitis.

Sexual function after failed ileal pouch-anal anastomosis

Background and AimsFailure of ileal pouch-anal anastomosis (IPAA) occurs in around 10% of the patients. Compared to patients with functioning pouches, health related quality of life is deteriorated after failure. Sexual function in patients with pouch failure is however poorly studied.The aim was to study sexual function in patients with pelvic pouch failure; patients with functioning pouches were used as controls. The hypothesis was that patients with pouch failure have worse sexual function. Methods36 patients with pouch failure were compared with 72 age and sex-matched controls with ulcerative colitis and functioning pouches. The patients answered a set of questionnaires concerning sexual function (Female Sexual Function Index [FSFI] and International Index of Erectile Function [IIEF]), body image (BIS-scale) and health-related quality of life (SF-36). ResultsBoth women and men with pouch failure scored lower than controls in the FSFI and IIEF questionnaires. However, none of the observations were statistically significant. The scores in the failure group (for both sexes) were below the cut-off level for sexual dysfunction. Scores for the BIS instrument were significantly lower for both sexes in the failure group. Women and men in the failure group scored lower than the controls in all domains of the SF-36, however statistically significant only for the social function domain in men. ConclusionsThe hypothesis, that a failed IPAA is associated with worse sexual function, was not confirmed. Compared to patients with functioning pouches, patients with pouch failure have inferior body image.

Failed pelvic pouch substituted by continent ileostomy

The long-term failure rate of ileal pouch-anal anastomosis (IPAA) is 10-15%. When salvage surgery is unsuccessful, most surgeons prefer pouch excision with conventional ileostomy, thus sacrificing 40-50 cm of ileum. Conversion of a pelvic pouch to a continent ileostomy (CI, Kock pouch) is an alternative that preserves both the ileal surface and pouch properties. The aim of the study was to evaluate clinical outcome after the construction of a CI following a failed IPAA. During 1984-2007, 317 patients were operated with IPAA at St Olavs Hospital and evaluated for failure, treatment and outcome. Seven patients with IPAA failure had CI. Four patients with IPAA failure referred from other hospitals underwent conversion to CI and are included in the final analysis. Seven patients had a CI constructed from the transposing pelvic pouch and four had the pelvic pouch removed and a new continent pouch constructed from the distal ileum. Median follow up after conversion to CI was 7 years (0-17 years). Two CI had to be removed due to fistulae. One patient needed a revision of the nipple valve due to pouch loosening. At the end of follow-up, 8 of the 11 patients were fully continent. One patient with Crohn's disease had minor leakage. In patients with pelvic pouch failure, the possibility of conversion to CI should be presented to the patient as an alternative to pouch excision and permanent ileostomy. The advantage is the continence and possibly a better body image. Construction of a CI on a new ileal segment may be considered, but the consequences of additional small bowel loss and risk of malnutrition if the Kock pouch fails should be appraised.

Outcomes for Patients Undergoing Continent Ileostomy After a Failed Ileal Pouch-Anal Anastomosis

Continent ileostomy is considered an alternative for patients with a failed ileal pouch-anal anastomosis. The aim of this study is to investigate outcomes for patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis at our institution. Patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis were identified from a prospectively maintained pouch database. Quality-of-life scores were obtained by telephone follow-up or office visit and were determined by the Cleveland Global Quality of Life Score. Sixty-four patients were identified between 1982 and 2007. Forty-two percent were male. The median age was 36.5 (range, 14-61) years. Most common diagnoses included ulcerative colitis (n = 44, 68.8%) and Crohn's disease (n = 13, 20.3%). The indication for continent ileostomy was septic pouch complications in 56.3% patients. The previous pelvic pouch was used in 16 (25%) patients. The 30-day complication rate was 31.3%. There were no perioperative deaths. Median follow-up was five years. The long-term dysfunction rate was 50%, the complication rate was 60.9%, and the revision rate 45.3%. The median revision-free interval was 2.8 years (range, 3 months to 19 years) and the retention rate of continent ileostomy was 95.3% (61 of 64). Median continent ileostomy survival time was 4.2 (range, 1-19) years. The median quality-of-life score was 0.77. Continent ileostomy is possible in patients wishing to avoid an external appliance after pelvic pouch failure. Despite the associated morbidity, most of this select group of highly motivated patients retain their continent ileostomy long-term and are highly satisfied with their choice of continent ileostomy.

Interposition of a gastric pouch between ileum and anus after proctocolectomy: Long-term results in 3 patients

After proctocolectomy, ileal pouch-anal anastomosis may not be feasible, especially in the case of desmoid tumor or after failed ileal pouch-anal anastomosis requiring excision of the pouch. We designed a gastric pouch interposed between the terminal ileum and the anus to avoid a permanent ileostomy for these patients. Long-term results and quality of life with this technique remain unknown. After proctocolectomy, ileal pouch-anal anastomosis was not feasible or had failed in 3 patients (2 with familial adenomatous polyposis and 1 with ulcerative colitis; 40, 49, and 50 years of age, respectively). Of these patients, 2 had undergone end ileostomy 7 and 8 years previously. A pouch was created using the left half of the gastric fundus, supplied through the right gastroepiploic vessels; the pouch was anastomosed proximally to the terminal ileum and distally to the anus. Diverting ileostomy was performed in all patients. After a mean follow-up of 6 years, all 3 patients were highly satisfied with the operation and described their quality of life as good. The median stool frequency during the day and night were 6 and 1, respectively. No patient reported incontinence or urgency. Of the 3 patients, 2 had minimal soiling with gastric juice; 1 patient had anastomotic ulcers with bleeding requiring resection with reanastomosis. All of the patients needed long-term proton pump inhibitor therapy and topical perianal treatment to prevent skin burning. Inter-ileoanal gastroplasty is a surgical salvage technique that can avoid a permanent ileostomy. The procedure provides a good quality of life for patients with unfeasible or failed ileal pouch.

Results from pouch salvage.

Over an 11-year period, 17 salvage procedures were performed on a failed ileal pouch-anal anastomosis carried out for ulcerative colitis from a series of 157 patients. Ten pouches were saved, four excised and three defunctioned. Salvage procedures included five operations for fistulas (three of five successful), six reoperations on the ileoanal anastomosis (five of six successful), three new pouches after previous pouch excision (all failed), and three miscellaneous: excision of an efferent limb (successful), pouchpexy for a pouch prolapse (successful) and postanal repair for incontinence (failed). Pouch salvage may be successful in the motivated patient who wishes to avoid a permanent ileostomy.

The failed pelvic pouch: conversion to a continent ileostomy.

Excision of the ileal pouch-anal anastomosis (IPAA) with construction of a conventional ileostomy is in general the ultimate procedure after unsuccessful salvage surgery. Conversion of the IPAA to a continent ileostomy (CI) is an alternative. The clinical outcome of 13 patients operated with conversion of IPAA into CI was evaluated. Median follow-up was 6 years. One patient was lost to follow-up. There were two failures with pouch excision. At follow-up, ten patients with intact CI were fully continent and none needed to use a stoma appliance. Revisional surgery had been required in 8 patients. Conversion of a failed IPAA into CI is a feasible procedure that may be considered an alternative to Brooke's ileostomy in motivated patients. The operation should ideally be done in specialized units.

Conversion of failed ileal pouch-anal anastomosis to continent ileostomy.

We report the results of converting 42 failed ileal pouch-anal anastomoses to a continent ileostomy (using the Barnett modification of the Kock pouch) performed in the course of 1,334 consecutive continent ostomy procedures. Results were obtained from a data registry that tracks long-term outcomes of consecutive continent ostomy procedures performed by 12 surgeons in five centers in the United States. Forty of the 42 patients with failed ileal pouch-anal anastomoses have a functioning continent ostomy. Two patients have had pouch excision. Quality of life for the patients with ileal pouch-anal anastomoses as measured by the SF-36 index improved postoperatively. Long-term outcomes for the patients with ileal pouch-anal anastomoses were similar to those for the larger population of patients who underwent the continent ostomy procedure for other reasons. Conversion of a failed ileal pouch-anal anastomosis to a continent ileostomy is a satisfactory alternative to the Brooke ileostomy in appropriate cases.