Pelvic Pouch Research Articles

Long-term functional outcome after ileal pouch anal anastomosis in 191 patients with ulcerative colitis

BackgroundA long-lasting good functional outcome of the pelvic pouch and a subsequent satisfying quality of life (QoL) are mandatory. Long-term functional outcome and QoL in a single-center cohort were assessed. Patients and methodsA questionnaire was sent to all patients with an IPAA for UC, operated between 1990 and 2010 in our department. Pouch function was assessed using the Öresland Score (OS) and the ‘Pouch Functional Score’ (PFS). QoL was assessed using a Visual Analogue Score (VAS). Results250 patients (42% females) with a median age at surgery of 38years (interquartile range (IQR): 29–48years) underwent restorative proctocolectomy. Median follow‐up was 11years (IQR: 6–17years). Response rate was 81% (n=191). Overall pouch function was satisfactory with a median OS of 6/15 (IQR: 4–8) and a median PFS of 6/30 (IQR: 3–11). 24-hour bowel movement is limited to 8 times in 68% of patients (n=129), while 55 patients (29%) had less than 6 bowel movements. 12 patients (6.5%) were regularly incontinent for stools, while 154 patients (82%) reported a good fecal continence. Fecal incontinence during nighttime was more common (n=72, 39%). Pouch function had little impact on social activity (4/10; IQR: 2–6) and on professional activity (3/10; IQR: 1–6). 172 patients (90%) reported to experience an overall better health condition since their operation. The OS and the PFS correlated well (Pearson's correlation coefficient=0.83). Overall pouch function was stable over time. ConclusionMajority of patients report a good pouch function on the long-term with limited impact on QoL.

FAST ULTRASOUND

Objective: Fast ultrasound is a basic tool to evaluate the blunt abdominal traumapatient and help to decision making for emergency surgery. Study design: Observational study.Place and duration of study: The King Fahad Hospital Madina Munawara, over a periodbetween 2010 and 2011. Methodology: This study consisted of 765 patients came in Emergencydepartment The King Fahad Hospital Madina Munawara Level II, or Regional Resource TraumaCenter Saudi Arabia. Detailed History was taken from all the patients with special regard to blandabdominal trauma. All patients were brought to a trauma resuscitation area where a trauma teamconducted a primary survey, after an airway and adequate oxygenation/ventilation wereestablished. The FAST examinations were performed using 4 windows: subxiphoid, right upperquadrant, left upper quadrant, and suprapubic. The critical areas for intra-abdominal bleedingwere the hepatorenal space (Morrison’s pouch), the spleno-renal space, and the pelvic pouch ofDouglas. The FAST examinations were interpreted on the spot and results Recorded. Resultswere prepared with help of tables and graphs. Data was analyzed through SPSS software.Results: 73 out of 765 patients who underwent FAST ultrasound in the Emergency Room. 40(54.79%) cases were road traffic accident (RTA) injuries followed by injury due to fall were in33(45.20%) cases. Findings are fast ultrasound observed 49 out of 73 patients (67.12%) wereconsidered positive FAST who had fluid (blood) in the peritoneal cavity and these patients shift toOperative Room for surgery. While 24(32.87%) patients with no evidence of intraperitoneal fluidwere considered negative for FAST and these patient underwent CT scans for evidence of solidorgan injury(Chart No.2). 5 out of 24 cases of solid visceral trauma found on CT scan abdomen,but had not been detected by FAST then shift to operative room after resuscitation. Conclusions:We conclude that FAST ultrasound is very helpful to assessment of blunt abdominal trauma andto detect intraabdominal fluid. Fast ultrasound can help in the quick decision for surgicalintervention within minutes of a patient's arrival at emergency department.

Recurrent volvulus of an ileal pouch requiring repeat pouchopexy: a lesson learnt.

Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed.

The natural history of anal transition zone inflammation and possible relationship to pouchitis: a long-term longitudinal study

Reservoir ileitis (pouchitis) is the most common complication after pelvic pouch surgery for ulcerative colitis and the aetiology remains largely unknown. The anal transition zone (ATZ) contains the only remaining colonic epithelium after ileal pouch anal anastomosis (IPAA) and may provide important clues as to whether ulcerative colitis and pouchitis share a common pathogenesis. The aim of this study was to evaluate longitudinally the long-term histological changes in the ATZ and their relationship to the incidence of pouchitis. Patients with a double-stapled IPAA for ulcerative colitis at an academic medical centre with at least 10years of clinical and histological follow-up were identified from a prospective database. Annual ATZ and pouch biopsies were taken and interpreted by two expert gastrointestinal pathologists. ATZ histological variability score, the incidence of pouchitis, and function were correlated over time. ATZ biopsies were scored from one to three based on the extent of inflammation. Sixteen of the 114 patients having IPAA fulfilled the criteria for admission to the study. There were 179 biopsies of the ATZ. All exhibited variability in ATZ histology over time and 81% had a 2-unit change in their inflammatory score. There was no correlation between pouchitis and histological severity score of the ATZ. Similarly, function over time did not vary with the intensity of ATZ inflammation. ATZ inflammation varies substantially over time in most patients. But these changes from year to year did not correlate with function or the occurrence of pouchitis.

Quantification of Risk for Early Unplanned Readmission after Rectal Resection: A Single-Center Study

Several factors predictive of readmission after colorectal surgery have been identified. Although often grouped together in readmission studies, colon and rectal resections differ in many ways. The aim of this study was to identify factors associated with readmission after rectal resection. We performed a retrospective, single-center cohort study of 565 patients who underwent rectal resections at a tertiary referral center in 2010 and 2011. The main outcomes measure was readmission within 30 days. Univariate comparison between readmitted and nonreadmitted patients was followed by a stepwise logistic regression to identify independent risk factors for readmission. There were 105 patients (18.6%) readmitted. Indication (inflammatory bowel disease [IBD], p = 0.008), type of operation (pelvic pouch surgery, p = 0.02), use of laparoscopy (readmission 27.8% vs 14%, p < 0.001), and length of operation (p < 0.001) were associated with a higher readmission rate on univariate analysis. Neither preoperative chemoradiation (p = 0.89) nor American Society of Anesthesiologists class (p = 0.09) was associated with readmission. Logistic regression showed use of laparoscopy (odds ratio [OR] 1.94, 95% CI 1.23 to 3.07), initial diagnosis of IBD (OR 1.84, 95% CI 1.17 to 2.93), and length of operation (OR 1.09, 95% CI 1.03 to 1.16 per 30 minutes) to be independent risk factors. Risks of readmission were 6.7%, 13.4%, 27.4%, and 27.4% with 0, 1, 2, or 3 positive risk factors, respectively. Readmission after rectal resection is associated with the indication for surgery and the operative technique used. Optimization of factors related to the underlying pathology and careful appraisal of the operative technique may result in decreased readmission after proctectomy.

Fate of the Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis is considered the procedure of choice for patients requiring elective surgery for ulcerative colitis, but some patients undergoing subtotal colectomy with end ileostomy are satisfied with an ileostomy and do not choose to undergo later pelvic pouch surgery. The need and timing for completion proctectomy in this setting are uncertain. To assess the long-term fate of the retained rectum compared with the morbidity associated with completion proctectomy in patients who underwent subtotal colectomy for ulcerative colitis. Retrospective review of a prospective database in an academic medical center. Patients who underwent subtotal colectomy with ileostomy for ulcerative colitis from July 1, 1990, to December 31, 2010. Proctectomy, surgical complications, and symptoms from the retained rectum. One hundred eight patients underwent subtotal colectomy for ulcerative colitis during the study period: 73 for acute disease, 18 for advanced age and/or comorbidities, and 17 to avoid the risk of sexual dysfunction or infertility. Of these patients, 71 (65.7%) underwent subsequent ileal pouch-anal anastomosis, 2 died of other causes, and 3 were lost to follow-up. Of the remaining 32 patients, 20 chose rectal stump surveillance and 12 underwent elective proctectomy. Median follow-up was 13.8 years. No difference was noted in age, sex, surgical complications, pad use, or urinary dysfunction between the 2 groups. Only 8 of 20 patients in the surveillance group were compliant with follow-up endoscopy, and 13 were able to maintain their rectum; 2 required proctectomy at 11 and 16 years, respectively, for rectal cancer; neither has developed recurrent disease. One patient in each group reported erectile dysfunction. Management of the retained rectum after subtotal colectomy remains an important issue even in the era of ileal pouch-anal anastomosis. Considering the risk of rectal cancer, the low success rate of long-term rectal preservation, and the safety of surgery, a more aggressive approach to early completion proctectomy seems justified in this situation.

Current trends regarding protective ileostomy after restorative proctocolectomy

The decision to perform a protective ileostomy after ileoanal-pouch anastomosis is controversial, and most of the discussion is based on its advantages and disadvantages. Although a temporary intestinal diversion has been routinely indicated in most patients, this choice is also associated with complications. The present work aims to review the outcomes after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes. Most papers emphasize that diversion protects against anastomosis leaks; consequently, it may prevent pelvic sepsis and pouch failure. Otherwise, a defunctioning ileostomy may cause morbidity such as dehydration, electrolyte imbalance, psychological problems, skin irritation, anastomosis strictures and intestinal obstruction, among others. There are those who believe that the omission of an ileostomy after the confection of ileal pouches should be reserved for selected patients, with quite acceptable results. The selection criteria should include surgeon, patient and procedure features to ensure a good outcome

Current trends regarding protective ileostomy after restorative proctocolectomy

The decision to perform a protective ileostomy after ileoanal-pouch anastomosis is con- troversial, and most of the discussion is based on its advantages and disadvantages. Al- though a temporary intestinal diversion has been routinely indicated in most patients, this choice is also associated with complications. The present work aims to review the outcomes after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes. Most papers emphasize that di- version protects against anastomosis leaks; consequently, it may prevent pelvic sepsis and pouch failure. Otherwise, a defunctioning ileostomy may cause morbidity such as dehydra- tion, electrolyte imbalance, psychological problems, skin irritation, anastomosis strictures and intestinal obstruction, among others. There are those who believe that the omission of an ileostomy after the confection of ileal pouches should be reserved for selected patients, with quite acceptable results. The selection criteria should include surgeon, patient and procedure features to ensure a good outcome.

Adenoma Formation and Malignancy After Restorative Proctocolectomy With or Without Mucosectomy in Patients With Familial Adenomatous Polyposis

There is controversy concerning whether or not to perform mucosectomy after IPAA in patients with familial adenomatous polyposis. Although more frequent adenoma formation at the anastomotic site in patients without a mucosectomy is documented, the interpretation of the theoretical reflections and empirical findings are ambiguous. The aim of this study was to assess the differences in adenoma formation at the anastomotic site and in the ileal pouch among patients with familial adenomatous polyposis after IPAA with or without mucosectomy. Data were gathered from The Norwegian Polyposis Registry and The Cancer Registry of Norway. Sixty-one patients with familial adenomatous polyposis who had IPAA were included in the Norwegian Polyposis Registry. The frequency of adenoma development in the pouch or at the anastomotic site was measured. Thirty-nine patients had a pelvic pouch performed with mucosectomy and 22 patients without. The observational time was 15.5 and 13.7 years. Adenoma formation at the anastomotic site was 4 in 39 and 14 in 22, and the estimated rate was 17% vs 75% (p = 0.0001). One patient without mucosectomy had a cancer (Dukes A) at the anastomotic site. There was no estimated long-term difference in adenoma formation in the ileal pouches between the 2 surgical procedures (38%) (p = 0.10). The study is retrospective, in part, and relies on data from registries. There is a limited number of cases, and selection bias because of surgeon preference may exist. In patients with familial adenomatous polyposis who undergo IPAA, adenoma formation at the anastomotic site is significantly reduced after mucosectomy. Mucosectomy may be the preferable procedure to prevent adenomas at the anastomotic site.

Preoperative pelvic radiation increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer

Background and aimsTo evaluate the impact of preoperative radiation on pouch outcomes in patients with colitis-associated cancer (CAC). MethodsCAC patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1984 to 2009 were identified from our registry. The impact of preoperative pelvic radiation for CAC or other pelvic cancer on pouch related outcomes was evaluated. ResultsSixty-three pouch patients with confirmed CAC were included (37 male, 58.7%). The mean age at pouch construction was 46.9±10.6years. Seven patients were excluded due to the presence of persistent diverting ileostomy (n=2) or no follow-up (n=5). The remaining 56 patients were analyzed, including 9 who received pelvic radiation prior to IPAA creation for CRC or other cancers. Preoperative pelvic radiation was significantly associated with chronic pouchitis (P=0.024). There was, however, no correlation between pelvic radiation and pouch/anal transitional zone neoplasia, pouch stricture, pelvic abscess and pouch fistula/sinus. Pouch failure occurred in 13 patients after a median follow-up of 66.4 (range: 2.7–322.2) months. Although a simple statistical analysis based on the number of patients with pouch failure did not achieve significance (4/9 vs. 9/47, P=0.19), Kaplan–Meier analysis showed a strong association between preoperative pelvic radiation and the risk for pouch failure (P<0.001). A subgroup analysis of rectal cancer patients revealed that 3/7 patients (42.9%) with radiation and 3/17 (17.6%) without had pouch failure (P=0.31). Again, the association between pelvic radiation and pouch failure was confirmed using Kaplan–Meier analysis (P=0.02). ConclusionsPelvic radiation administered prior to IPAA creation appears to be associated with poor pouch outcomes. Oncological benefits and pouch functional outcomes should be carefully balanced before pelvic radiation is considered prior to restorative proctocolectomy.

A Comparison of the Quality of Life of Ulcerative Colitis Patients after IPAA vs Ileostomy

Total proctocolectomy with IPAA is frequently considered the procedure of choice for surgical patients with ulcerative colitis, presumably owing to an expectation of improved quality of life in comparison with an ileostomy. The goal of our study was to determine whether long-term quality of life among patients with a pelvic pouch is better than those who chose a permanent stoma. This investigation is a cross-sectional observational study using a prospective database. This study was conducted at an academic medical center. Consecutive patients who had undergone IPAA or a permanent ileostomy for ulcerative colitis by a single surgeon, presenting for their annual follow-up visit from July through September 2011, were offered participation in the study. A randomly chosen group of subjects who did not have scheduled appointments during the study period were sent a letter inviting them to participate in the study. The primary outcome measures used were EQ-5D-3L, the Short Quality of Life in Inflammatory Bowel Disease questionnaire, the Cleveland Global Quality of Life instrument, the Fecal Incontinence Quality of Life scale, and the Stoma Quality of Life scale. Thirty-five patients with a pelvic pouch and 24 ostomates were accrued and comprehensively studied. Global quality-of-life scores were virtually identical for the 2 groups. Patients with a pelvic pouch had better subscores in current quality of health and energy level, Fazio score, sexuality/body image, and work/social function. This study was limited by its small sample size, and some of our patients were enrolled through mailed surveys and, hence, nonresponse bias may be present. The follow-up time since surgery was longer in the pelvic pouch group than in the ileostomy group. Informed patients with ulcerative colitis choosing an ileostomy have a health-related global quality of life very similar to patients with a pelvic pouch. Better outcomes in patients with an ileal pouch were most evident in the areas of sexuality/body image and work/social function.

Invited comment on Selvaggi et al.: Is omitting pouchography before ileostomy takedown safe after negative clinical examination in asymptomatic patients with pelvic ileal pouch? An observational study

Springer-Verlag 2012 In the manuscript ‘‘Is omitting pouchography before ileostomy takedown safe after negative clinical examination in asymptomatic patients with pelvic ileal pouch? An observational study,’’ Selvaggi et al. [1] have questioned the utility of routine pouchography prior to the restoration of intestinal continuity following ileal pouch-anal anastomosis (IPAA). In their study, they identified 186 patients over a 23-year period who had undergone an IPAA with diverting ileostomy performed by a single surgeon. All patients underwent regular clinical examinations and endoscopic evaluation prior to takedown of their ileostomy and were found to have normal endoscopic examinations. Fifty-four of these patients underwent pouchography before takedown of their ileostomy, while 132 patients did not. In the pouchography group, 5 patients had abnormal findings (anastomotic sinuses) and underwent ileostomy closure without delay. In the follow-up period (12 months minimum), 2 patients presented with pouch-related fistulas: one from the pouchography group (who had a normal preoperative pouchography) and one from the clinical examination group (who had a normal preoperative clinical and endoscopic examination). Because the pouchographies performed on asymptomatic patients did not change management, the authors conclude that pouchography may be safely omitted before ileostomy takedown if there is no clinical and endoscopic evidence of pelvic sepsis or ileo– anal anastomotic complications. Selvaggi et al. have provided us with some valuable perspectives to take into consideration when evaluating patients preoperatively prior to takedown of a diverting ileostomy after IPAA. It is clear from a majority of the literature that most surgeons use a protecting stoma when performing IPAA. The rationale for this is that multiple suture lines, tension at the anastomosis, and sometimes the immunosuppressed state of the patient, increases the risk of anastomotic and peri-pouch complications. Diversion may, in fact, not prevent complications such as an anastomotic leak, but likely decreases the severity of sepsis secondary to the leak if it occurs. Given that the stoma is placed for the potential risk of anastomotic leak, and the fact that the diversion may significantly decrease clinical manifestations of occult, an evaluation of the pouch, before resto

Is omitting pouchography before ileostomy takedown safe after negative clinical examination in asymptomatic patients with pelvic ileal pouch? An observational study

When restorative proctocolectomy (RPC) is performed, a temporary diverting loop ileostomy is often fashioned and usually closed 2-3 months later. Pouchography is used to assess pouch integrity, although its benefits have been questioned and no definitive data support its routine use. Our aim was to assess the utility of pouchography before ileostomy closure in patients with a negative clinical examination. We retrospectively reviewed our database of patients who underwent ileostomy takedown between 1987 and 2010. Two hundred and thirty-two patients were identified who underwent RPC with a W- or J-pouch for ulcerative colitis or familial adenomatous polyposis. Twenty-one patients underwent RPC without diversion. Twenty-four symptomatic patients were excluded from the study. Only asymptomatic patients with a normal clinical examination were enrolled. One patient was lost at follow-up. Hence, 186 patients were considered suitable for evaluation. Patients undergoing ileostomy closure without any radiological examination were assigned to Group A (n = 132); those operated on after a preoperative pouchography to Group B (n = 54). Pouchography was normal in 49 (90.7%) Group B patients. None of the 5 (9.3%) Group B patients with an abnormal radiographic examination experienced complications. Negative pouchography did not exclude future problems. Patients of both groups experienced similar early functional impairments. Failure occurred in 3 (2.3%) Group A patients and in 2 (3.7%) patients of the pouchography group. Pouchography may be safely omitted before ileostomy takedown if there is no clinical or endoscopic evidence of pelvic sepsis or ileo-anal anastomotic complications, even in very young patients, provided clinical and endoscopic follow-up is carefully performed. All anomalies detected were already suspected clinically.

Tu1905 Interaction of IBD-Associated Genetic Polymorphisms and the Microbiome of the Pelvic Pouch

Tu1905 Interaction of IBD-Associated Genetic Polymorphisms and the Microbiome of the Pelvic Pouch

How I do it: the stapled ileal J pouch at restorative proctocolectomy

Ileal pouch-anal anastomosis (IPAA) following proctocolectomy is the preferred option for patients with medically refractory ulcerative colitis, indeterminate colitis, and familial adenomatous polyposis. However, it remains a procedure associated with morbidity and mortality. Pelvic sepsis, pouch fistulae, and anastomotic dehiscence predispose to pouch failure. We report our experience with an adaptation for the formation of the stapled ileal J pouch using the GIA™ 100 stapling device (Covidien, Mansfield, Massachusetts, USA). When creating the J pouch, we remove the bevelled plastic protector from the thin fork of the stapling device, allowing the staple line to be completed to the tip of the stapled efferent limb of the pouch, thereby minimizing potential blind ending in the efferent limb and injury to the transverse staple line. Patients undergoing elective IPAA at our institution over a 5-year period using this adapted stapling technique for creation of the ileal J pouch were reviewed. Data were collected from a prospectively maintained inflammatory bowel disease database, theater records, and patient chart review. Forty-one patients underwent IPAA using this technique at our institution during the study period. Postoperative morbidity was encountered in 11 of 41 patients including pelvic sepsis, pouch fistulae, anastomotic stricture, or leak. There was no morbidity observed related to a blind efferent limb or transverse staple line disruption. No mortality was observed in this series. Maximizing the length of the efferent fork of the GIA stapling device can reduce the length of redundant efferent J limb of the ileal J pouch. This may reduce the incidence of torsion, volvulus, distension, fistulae/sinuses, and pelvic sepsis/anastomotic leak following IPAA.

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.

Expression Changes of Xenobiotic Efflux Genes Are Associated With Ileal Inflammation in the Pelvic Pouch of Individuals With Ulcerative Colitis

Expression Changes of Xenobiotic Efflux Genes Are Associated With Ileal Inflammation in the Pelvic Pouch of Individuals With Ulcerative Colitis

Outcome After Pelvic Pouch Surgery is Associated With Differences in the Microbiome as Characterized by 16s rRNA Pyrosequencing

Outcome After Pelvic Pouch Surgery is Associated With Differences in the Microbiome as Characterized by 16s rRNA Pyrosequencing

Management of Leak From the Tip of the “J” in Ileal Pouch-Anal Anastomosis

Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. This study is a retrospective review of prospectively gathered data. Data were obtained from a prospectively maintained single-institution pelvic pouch database. Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 ± 1.9 years. : The study was limited by its retrospective nature. Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.

Oncologic Outcome in Patients With Ulcerative Colitis Associated With Dyplasia or Cancer Who Underwent Stapled or Handsewn Ileal Pouch-Anal Anastomosis

Ulcerative colitis is a risk factor for colorectal cancer. Restorative proctocolectomy with ileal pouch-anal anastomosis is a standard surgical management of patients with ulcerative colitis who have cancer or dysplasia, but the oncologic risk of stapled anastomosis vs mucosectomy with handsewn anastomosis is debated. We compare the risk of new cancer or recurrence in the pouch or rectal cuff in patients with ulcerative colitis undergoing stapled anastomosis vs mucosectomy with handsewn anastomosis. This study was performed as a retrospective analysis of the clinical database at a single center, Mount Sinai Hospital, Toronto, Canada. The patients with ulcerative colitis associated with colorectal dysplasia or cancer who underwent ileal pouch-anal anastomosis between 1981 and 2009 were evaluated. The development of dysplasia or cancer at ileoanal anastomosis or in the pelvic pouch was assessed. Eighty-one patients underwent stapled (n = 59) or handsewn (n = 22) ileal pouch-anal anastomosis; 52 had evidence of dysplasia and 29 had colorectal cancer (24 colon; 5 rectum) at the time of surgery. Median follow-up was 76.1 months. Two of 10 (20%) patients with handsewn anastomosis and 0% patients with stapled anastomosis developed metastatic cancer. One patient with a 33-year history of colitis, a previously resected right-sided colon cancer, and subsequent high-grade dysplasia in the rectum underwent a handsewn pelvic pouch and developed an unresectable adenocarcinoma at the cuff 4 years later. A second patient with a 10-year history of colitis underwent handsewn pelvic pouch and developed dysplasia in the pouch 8 years after surgery. Nine patients were dead at last follow-up (11%). Of those patients, both colorectal cancer-related deaths were in patients with handsewn anastomoses. Differences in overall 5-year survival between the groups did not reach statistical significance. This study was limited by the sample size in subgroups and the few outcome events. Performing a stapled ileal pelvic anal anastomosis does not appear to be inferior to mucosectomy and handsewn anastomosis in oncologic outcome, and it seems appropriate in patients with ulcerative colitis associated with coexisting dysplasia or cancer.