Pouch Function Research Articles

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.

Functional outcomes of transanal versus transabdominal restorative proctectomy with ileal pouch-anal anastomosis in ulcerative colitis-a monocentric retrospective comparative study.

Ileal pouch-anal anastomosis (IPAA) ensures satisfactory gastro-intestinal function and quality of life (QoL) in patients with refractory ulcerative colitis (UC). The transanal approach to proctectomy and IPAA (Ta-IPAA) has been developed to address the technical shortfalls of the traditional transabdominal approach (Tabd-IPAA). Ta-IPAA has proven to be safe but there is lack of reported functional outcomes. Aim of this study is to compare functional outcomes and QoL after Ta- or Tabd-IPAA for UC. This is a retrospective study of consecutive UC patients who underwent IPAA between 2011 and 2017, operated according to a modified 2- or 3-stage approach. Close rectal dissection was performed in Ta-IPAA as opposed to total mesorectal excision in Tabd-IPAA. A propensity score weighting was performed. Functional outcomes were assessed using the pouch functional score (PFS) and the Öresland score (OS). The global quality of life scale (GQOL) was used for patients' perspective on QoL. Follow-up was scheduled at 1, 3, 6, and 12months, postoperatively. One hundred and eight patients were included: 38 patients had Ta-IPAA. At 12months follow-up, mean OS and PFS were 4.6 (CI 3.2-6.0) vs 6.2 (CI 5.0-7.3), p = 0.025 and 6.1 (CI 3.5-8.8) vs 7.4 (CI 5.4-9.5), p = 0.32, for Ta and Tabd-IPAA, respectively. Mean GQOL for Ta-IPAA was 82.5 (CI 74.8-90.1) vs 75.5 (69.4-81.7) for Tabd-IPAA (p = 0.045). At 12months postoperatively, pouch function and QoL of Ta-IPAA are probably as good as those of Tabd-IPAA. Limitations include retrospectivity, differences in the surgical technique, and lack of validated scores for QoL.

TU2.13 Laparoscopic/robotic restorative proctectomy in the District General Hospital setting

Abstract Aims Ileal pouch anal anastomosis/restorative proctectomy is a standard surgical treatment for ulcerative colitis performed in a few specialist centres. We report the evolution of the service at our trust which originally carried out open pouch surgery but has moved practice towards laparoscopic and robotic-assisted pouch surgery. The aim of this study was to assess the surgical and functional outcomes of patients undergoing laparoscopic/robotic-assisted IPAA. Methods Data were prospectively collected from consecutive laparoscopic/robotic IPAA cases from 2014 to 2021. Patient demographics, operative details, postoperative complications, functional outcomes were collected. Patients were selected by IBD specialized surgeons and reviewed by a pouch nurse. Follow-up consisted of clinical examination and assessment of pouch function. Results 18 patients underwent laparoscopic or robotic IPAA during the study period, 13 (72.23%) were males. Median age was 28 years. Indication for surgery was ulcerative colitis. Median duration of surgery was 7 hours. Four patients (22.23%) developed postoperative intra-abdominal collection, managed conservatively in all except one, who required laparoscopic washout. The median duration of stay was 8 days. The rate of severe complications, Grade 3 and 4 on Clavien-Dindo classification was 11.12%. During a median follow up of 75 months, there were no pouch failures. The median stool frequency was 6 daily. Conclusion Our data suggests that with good patient selection and guidance from an experienced pouch nurse, laparoscopic/robotic IPAA is safe and feasible. Good perioperative outcomes and acceptable pouch function can be achieved in a DGH setting with a team to ensure consistent care of patients.

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 40years, 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. Acorrection, closure of the fistula and in individual cases also acompletely new pouch creation can restore agood pouch function in about 75% of cases. Various indications, techniques and results are presented.

Prospective analysis of surgical and functional outcomes after total proctocolectomy with ileal pouch-anal anastomosis in 86 patients with ulcerative colitis

Proctocolectomy with an ileal pouch‑anal anastomosis is currently considered the procedure of choice for the majority of patients with ulcerative colitis. Certain controversies about pouch design and pouch‑anal anastomosis technique remain a matter of debate, and possible advantages of laparoscopic approach are still being discussed.
 Objective — to investigate short‑term and long‑term outcomes of laparoscopic and open restorative proctocolectomy for UC in terms of postoperative morbidity and pouch function depending on the three types of construction of a neorectum described in our research.
 Materials and methods. 86 patients with inflammatory bowel disease underwent one‑stage or two‑stage restorative proctocolectomy. The two ileal pouch configurations were used: S‑pouch — in 16 patients and J‑pouch — in 70 patients. Removal of the distal rectum and ileal pouch‑anal anastomosis were performed using transanal distal rectum mucosectomy followed by a handsewn pouch‑anal anastomosis (n = 45) or a double‑stapled technique (n = 31). Laparoscopic approach was applied in 39 patients, and open surgery — in 47 patients. The short‑term (30 days after surgery) and long‑term surgical outcomes were prospectively studied. The analysis of functional outcomes was based on the number of bowel movements a day, episodes of fecal incontinence, seepage, and urgency. Instrumental investigation included measurement of the anal sphincter pressures and ileal pouch threshold volume as well as the study of its residual volume. Statistical analysis was performed using SPSS statistical software.
 Results. There was no postoperative mortality. In the laparoscopic group, 4 (10.3 %) patients had early postoperative complications compared with 13 (27.7 %) patients in the open surgery group, but the difference was not statistically significant (Fisher exact test value is 0.0579 at p < 0.05). Pouch failure occurred in 4 patients. The second‑stage laparoscopic restorative procedure revealed the abdominal cavity almost free of adhesions in 19 (86.4 %) patients after laparoscopic total colectomy. The total number of early and late mucosectomy complications was significantly higher, 12 (75.0 %) vs. 10 (26.0 %) (p = 0.0018), in patients managed with a handsewn S pouch‑anal anastomosis than in patients treated with a J‑pouch‑anal anastomosis. Good functional outcomes were observed in 44 (51.0 %) patients. A strong negative correlation was found between the pouch threshold volume and the number of bowel movements per 24 hours (r = –0.7347, p < 0.0001). The seepage episodes were detected in 30 (34.8 %) patients. The resting anal sphincter pressure was the only measured parameter which correlated accurately with the number of day and night seepage episodes (r = –074, p < 0.0001).
 Conclusions. Good functional outcomes of construction of a neorectum were associated with the resting anal sphincter pressure (≥ 30 mm Hg) and ileal pouch threshold volume (150 — 250 ml). The S‑shaped and J‑shaped pouches demonstrated the same functional outcomes and posed similar risks. The S‑pouch was associated with a higher postoperative morbidity (p = 0.0018). There was no significant difference between laparoscopic and open surgery groups in terms of morbidity rate and functional outcomes. However, it was much easier to perform the second‑stage surgery after laparoscopy due to less adhesion formation.

Restorative proctocolectomy with ileal pouch-anal anastomosis in elderly patients - is advanced age a contraindication?

AimWe aimed to determine pouch function and retention rate for restorative proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for ulcerative colitis (UC) in elderly patients.MethodsWe identified patients over 50 years old subjected to IPAA for confirmed pathological UC from 1980 until 2016. Patients were grouped according to age: 50–59, 60–69 and 70+ years. Short and long‐term outcomes and quality of life (QOL) were compared among the groups.ResultsSix hundred and one patients were identified (399 (66.4%) between 50–59 181 (30.1%) between 60–69, and 21 (3.5%) over 70 years of age). More males were in the 70+ arm, and more two‐stage procedures were performed in this group. Wound infection increased with age (P = 0.023). There was a trend of more fistula and pouchitis in the 70+ patients (P = 0.052 and P = 0.055, respectively). Pouch failure rate increased with age, and it was statistically significant in the 70+ cohort (P = 0.015). Multivariate stepwise logistic regression showed that pelvic sepsis (HR 4.8 (95% CI 1.5–15.4), P = 0.009), fistula (HR 6.0 (95% CI 1.7–21.5), and mucosectomy with handsewn anastomosis (HR 4.5 (95% CI 1.4–14.7)), were independently associated with pouch failure. No difference was observed in the QOL among the groups, but pouch function was better for patients younger than 60 years.ConclusionIn elderly patients with UC, IPAA may be offered with reasonable functional outcomes, and ileal pouch retention rates, as an alternative to the permanent stoma. Stapled anastomosis increases the chance of pouch retention and should be recommended as long as the distal rectum does not carry dysplasia.

Defining normal pouch function in patients with ileal pouch-anal anastomosis: a pilot study.

Most patients experience good functional outcomes following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. We aimed to determine if asymptomatic patients with an IPAA had findings consistent with normal defecation on standard objective anorectal tests. Patients 18-65years old with IPAA and self-reported healthy pouch function were recruited. Patients with chronic pouchitis, Crohn's disease, anastomotic stricture, or indication for IPAA other than ulcerative or indeterminate colitis were excluded. Patients underwent an interview with an abbreviated Rome Questionnaire followed by high-resolution ano-pouch manometry, balloon expulsion test, pouch barostat, and magnetic resonance (MR) defecography. Twenty patients completed all testing. Six patients were excluded from the final analysis due to symptoms suggestive of pouch evacuation disorder on the abbreviated Rome Questionnaire (n=2), structural abnormality on MR imaging (n=3), or both (n=1). Of the remaining 14 patients, mean anal resting pressure during high-resolution manometry was 72±16mmHg, mean anal squeeze pressure was 247±69mmHg, and mean pouch-anal gradient during the simulated evacuation was -27±37mmHg. The meantime to balloon expulsion was 54seconds. During dynamic MR defecography, the mean descent of ano-pouch junction was 2.6cm, and mean pouch evacuation was 44.5% and 74.2% pre- and posttoilet phase, respectively. A substantial proportion of patients with IPAA and self-reported healthy pouch function have anatomic and/or functional abnormalities of the pouch. In asymptomatic IPAA patients with an anatomically normal pouch, we have proposed normal parameters for high-resolution ano-pouch manometry, time to balloon expulsion, pouch barostat, and MR defecography.

P108 Identifying Patient-Centered Future Research Priorities: A Report from the Patient Reported Outcomes after Pouch Surgery (PROPS) Delphi Consensus Study

Abstract Background The Patient Reported Outcomes after Pouch Surgery (PROPS) Delphi Consensus Study recently described Ileoanal Pouch Syndome – the constellation of functional outcomes that should be the focus of future research. Importantly, several additional items not related to bowel function were identified by patients as critical to their quality of life. The aim of this abstract is to highlight these additional items. Methods Three panels of expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients: (A) patients, (B) colorectal surgeons, (C) gastroenterologists/other clinicians. IPAA patients were recruited by advertisements on the social media pages of a national patient advocacy groups. Clinicians were recruited by a 14 member scientific committee with the aim of selecting experts in inflammatory bowel disease and IPAAs. A starting list of items was generated by systematic literature review. Three rounds of Delphi surveys were employed to select high priority items based on an a priori threshold. Participants had the opportunity to suggest additional symptoms not included in the starting list. A final online consensus meeting with representation from all three expert panels was held to finalize a consensus statement. Results After three rounds of voting, 195 patients, 62 colorectal surgeons, and 48 gastroenterologists/other specialists completed all three rounds. In the patient group, 95% had UC and J-pouch anatomy. In the early Delphi rounds, approximately 74% of patients identified impact on sexual function/intimacy as a high priority outcomes, while 70% of patients identified impact on ability to conceive as a high priority. Similarly, 78% of patients believed that risk of pouchitis was a high priority, compared to 47% of surgeons and 66% of gastroenterologists. Furthermore, patients participating in the subsequent online focus groups and final consensus meeting felt strongly that future research on delivery of care, long term follow up, and proper consent before surgery (including accurate counseling on function and perception of being “cured”) were critical areas for future research. Conclusion PROPS was the first study to identify key functional outcomes after pouch surgery with direct input from a large panel of IPAA patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function. In addition to the identification of key bowel function outcomes, the study highlighted additional patient-centered core outcomes that clinicians should focus future research efforts on.

P182 Twisted Pouch Syndrome: A Rare, Difficult to Diagnose Mechanical Complication of Ileal Pouch-Anal Anastomosis Amenable to Redo Pouch Salvage Surgery

Abstract Background Ileal pouch-anal anastomosis (IPAA) is a technically demanding procedure. Intraoperatively, great care must be taken to assure a straight superior mesenteric axis. Rarely, twisted pouches are inadvertently constructed, resulting in deviations of expected pouch function. Herein we describe our quaternary pouch referral center experience with twisted pouch syndrome (TPS). Methods We performed a retrospective review of our prospectively maintained pouch registry from 1995 – 2020. Patients were identified using free-text search of redo IPAA operative reports for variations of the term “twist”. We defined twisted pouch syndrome as intraoperative findings of twisting of the pouch around its mesenteric axis which could not be reduced without disconnection from the anus. Data represent frequency (proportion) or median (range). Results Over 25-years, we identified 31 patients with confirmed TPS who underwent a redo pouch procedure by 11 surgeons: 67% were female, median BMI 21.2 (16.9 – 29.5) kg/m2. The duration from the index IPAA to redo procedure was 5 (0.5 – 21) years; all (100%) were referral cases constructed elsewhere. Original diagnoses included: ulcerative colitis 28 (90%), FAP 2 (6.5%). All patients presented with symptoms of pouch dysfunction including erratic bowel habits 28 (93%) with urgency and frequency, abdominal/pelvic/rectal pain 26 (87%), and obstructive symptoms 28 (93%) i.e. obstructed defecation and incomplete evacuation. Most had (75%) been treated for chronic pouchitis with medical therapy, and 48% had undergone previous surgery. Prior to redo IPAA procedure patients underwent a thorough workup: 100% pouchoscopy, 94% pouchogram, 87% underwent EUA, 87% MRI/CT, 71% manometry, and 39% defecography. TPS was diagnosed in 16% by pouchoscopy, in 13% by imaging, and in 71% was diagnosed intra-operatively at re-diversion (20%) or revision/redo IPAA (51%). In terms of surgical intervention, 81% were initially re-diverted. A total of 18 (60%) underwent pouch revision, and 12 (40%) required neo-IPAA. Short-term outcomes: LOS 8 (3 – 32) days, any complication 48%, readmission 11%, reoperation 3.4%, zero mortalities. After a median follow-up 52.5 (1 – 206) months, there were 4 failures: 2 never had loop ileostomy closure, 1 pouch excision, 1 Kock pouch, yielding an overall pouch survival rate of 87%. Conclusion Twisted pouch syndrome presents with pouch dysfunction manifest by the triad of erratic bowel habits, unexplained pain, and obstructive (defecation) symptoms. This syndrome may also mimic chronic pouchitis. Despite a thorough workup suggesting a mechanical problem, many patient are not diagnosed until time of redo pouch surgery. Redo surgery for twisted pouch syndrome results in long-term pouch survival for the majority.

Pouch Function Over Time and With Advancing Age.

No long-term pouch studies have included follow-up >30 years or an analysis in patients >80 years old. This study aimed to investigate pouch function and pouch failure in patients with a pouch in situ >30 years and in patients >80 years old. This is a retrospective review. This study was conducted at an IBD referral center. Adult patients with ulcerative colitis who underwent an IPAA between 1983 and 1990 were selected. The primary outcomes measured were pouch function and pouch failure rates. Data collection included diagnosis, age at IPAA, indication for IPAA, medications at IPAA, pathology at the time of IPAA, postoperative morbidity, functional outcomes, quality of life, pouch excision or ileostomy and indication, and date of last follow-up. All living patients were contacted in April 2020 to retrieve functional data and pouch failure rates. A total of 566 patients had a pouch constructed between 1983 and 1990; of the 145 at most recent contact, 75 had their pouch in situ ≥30 years and 14 were ≥80 years old. Mean age at diagnosis was 25.8 years (10.6 SD), age at surgery was 34.7 years (11.3 SD), and age at last follow-up was 60.5 years (13.2 SD). At a median of 30 years (IQR, 21-32), 145 patients responded to the functional survey. Significantly increased rates of urgency (always, mostly, sometimes: 71.5% vs 23.5%) and seepage during the day (71.4% vs 22.4%) were observed in patients ≥80 years. In patients ≥80 years with a pouch in situ ≥30 years, urgency and incontinence were sometimes experienced by nearly 50% and pouch failure occurred in one third of patients. The overall rate of pouch failure was 19.4% (n = 110) at a median follow-up of 15 years; risk factors were female sex, 3-stage approach, and pelvic sepsis. A retrospective database was used. Patients with IPAA maintain good pouch function even after 30 years and in patients over the age of 80 years. Pouch function declines with time and failure rates increase over time. See Video Abstract at http://links.lww.com/DCR/B684.Función De La Bolsa Ileal En El Tiempo Y En Pacientes De Edad Avanzada. No se han efectuado estudios en pacientes con bolsa a largo plazo que incluyan un seguimiento por treinta años o más y en pacientes mayores de 80 años. Investigar la funcionalidad o la falla de la bolsa en pacientes bolsa in situ por mas de treinta años y en pacientes mayors de 80 años. Revisión retrospective. Centro de referencia de Enfermedad Inflamatoria Intestinal. Pacientes adultos con diagnóstico de colitis ulcerative sometidos a anastomosis bolsa ileal anal (IPAA) entre 1983 y 1990. Indices de efectividad y disfunción de la bolsa ileal. Recopilación de la información incluyendo diagnóstico, edad del procedimiento (IPAA), indicaciones para IPAA, medicamentos para IPAA, patología en el transcurso del IPAA, morbilidad postoperatoria, resultados funcionales, calidad de vida, excisión de la bolsa o ileostomía y su indicación y fecha de seguimiento mas reciente. Se contactaron a todos los pacientes vivos en abril de 202 para recuperar la información de los índices de funcionalidad o disfunción de la bolsa. Se les construyó una bolsa a un total de 566 pacientes entre 1983 y 1990; de los 145 mas recientemente contactados, 75 permanecían con su bolsa in situ ≥ 30 años y 14 eran mayores de 80 años. La edad media en el momento de diagnóstico fue de 25.8 años (con desviación estándar de 10.6, sd), edad al momento de la cirugía fue de 34.7 años (11.3sd), y la edad en el último seguimiento de 60.5 años (13.2,sd). A una media de 30 años (IQR: 21,32), 145 pacientes respondieron al cuestionario de funcionalidad. En pacientes mayores de 80 años se observaron tasas aumentadas de urgencia (siempre, la mayor parte de las veces, algunas veces: 71.5% vs 23.5%) y fuga durante el día (71.4% versus 22.4%). En pacientes mayores de 80 años con una bolsa in situ durante 30 años o más, experimentaron urgencia e incontinencia en cerca del 50% y disfunción de la bolsa en un tercio de los pacientes. La tasa global de fallo de la bolsa fue de 19.4% (n = 110) en un seguimiento a 15 años; los factores de riesgo asociados fueron: sexo femenino, abordaje de tres tiempos y sepsis pélvica. Información retrospective. Los pacientes con IPAA continúan con una función adecuada de la bolsa aún después de 30 años de efectuada así como en pacientes mayores de 80 años. La funcionalidad de la bolsa disminuye con el tiempo y las tasa de falla aumentan de igual forma con el tiempo. Consulte Video Resumen en http://links.lww.com/DCR/B684. (Traducción- Dr. Miguel Esquivel-Herrera).

Functional outcomes, quality of life, sexual function, and fertility of adult patients undergoing ileo‐anal pouch anastomosis in childhood

BackgroundWe conducted a questionnaire-based study of pouch function, quality of life, sexual function, and fertility among patients who had undergone ileal pouch anal anastomosis (IPAA) in childhood and who are now more than 18 years old. MethodsA consecutive series of patients were asked to complete the following questionnaires: Pouch function score (PFS), short form 36 (SF-36), International index of erectile function (IIEF) (males), and Female sexual function index (FSFI) (females). Fertility in females was also assessed. Data are quoted as a median (SD). ResultsOf 144 patients who had IPAA, 101 were eligible, and 70 responded. Mean age at surgery was 14 years, and mean current age is 26 years. Most patients had either ulcerative colitis or familial adenomatous polyposis. The questionnaire was completed by 38/70 (54%). Median PFS score was 6 (5). SF-36 were lower than previous reports. Median FSFI was 30 (7.6), 84% of possible maximum. Median IIEF was 69, 92% of possible maximum. Successful conception was reported in 5/7 women who had tried. However, there were several miscarriages and two surgical emergencies during pregnancies. ConclusionsIPAA can be performed in childhood with similar pouch function to reported adult series. Quality of life appears poorer, but sexual function is maintained. There may be an association with adverse events in pregnancy. Level of evidenceIV.

Delivery Mode after Ileal Pouch-Anal Anastomosis among Pregnant Women with Ulcerative Colitis

Objectives: The appropriate and recommended delivery mode after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has not been sufficiently evaluated. This study was designed to compare the delivery outcomes associated with cesarean section (CS) and vaginal delivery (VD) after IPAA. Methods: We conducted a questionnaire-based survey of female patients who underwent IPAA for UC between July 1987 and May 2018. Additionally, we reviewed clinical data and collected information regarding pouch function and postpartum complications. Results: In total, 45 patients had 68 deliveries, including 64 CS deliveries and four VDs. Fecal incontinence worsened in seven patients, including six CS patients and one VD patient. The Wexner scores of these patients before and after delivery were 5.4 ± 0.4 and 14.8 ± 1.0, respectively (p = 0.005). Four patients in the CS group and one in the VD group (p = 0.32) had increased stool frequency. Bowel obstructions developed during 11/64 (17.2%) deliveries, and one patient required surgical intervention. One patient with four VDs (three before IPAA and one after IPAA) developed vaginal fistula 5 months after the final VD. Information on episiotomies could not be obtained. Conclusions: Pouch function can decline even after CS. Notably, bowel obstruction can develop after CS. However, we cannot recommend a particular delivery method after IPAA. Further analyses to elucidate the relationship between CS and postoperative complications or vaginal fistula and episiotomy in VDs should be conducted.

Sperm transport and male pregnancy in seahorses: An unusual model for reproductive science

The Syngnathidae (seahorses and pipefishes) are a group of teleost fishes in which, uniquely, developing embryos are hosted throughout pregnancy by males, using a specialized brood pouch situated on the abdomen or tail. Seahorses have evolved the most advanced form of brood pouch, whereby zygotes and embryos are intimately connected to the host's circulatory system and also bathed in pouch fluid. The pouch is closed to the external environment and has to perform functions such as gaseous exchange, removal of waste and maintenance of appropriate osmotic conditions, much like the mammalian placenta. Fertilization of the oocytes occurs within the brood pouch, but unlike the mammalian situation the sperm transport mechanism from the ejaculatory duct towards the pouch is unclear, and the sperm: egg ratio (about 5:1) is possibly the least of any vertebrate. In this review, there is highlighting of the difficulty of elucidating the sperm transport mechanism, based on studies of Hippocampus kuda. The similarities between seahorse pouch function and the mammalian placenta have led to suggestions that the pouch provides important nutritional support for the developing embryos, supplementing the nutritional functions of the yolk sac provided by the oocytes. In this review, there is a description of the recent evidence in support of this hypothesis, and also emphasis, as in mammals, that embryonic development depends on nutritional support from the placenta-like pouch at important stages of the gestational period ("critical windows").

Safety of transanal ileal pouch-anal anastomosis for ulcerative colitis: a retrospective observational cohort study

BackgroundColectomy with transanal ileal pouch-anal anastomosis (taIPAA) is a surgical technique that can be used to treat benign colorectal disease. Ulcerative colitis is the most frequent inflammatory bowel disease (IBD) and although pharmacological therapy has improved, colectomy rates reach up to 15%. The objective of this study was to determine anastomotic leakage rates and treatment after taIPAA as well as short- and long-term pouch function.MethodsWe conducted a retrospective analysis of a prospective database of all patients undergoing taIPAA at an academic tertiary referral center in Germany, between 01/03/2015 and 31/08/2019. Patients with indications other than ulcerative colitis or with adjuvant chemotherapy following colectomy for colorectal carcinoma were excluded for short- and long-term follow up due to diverging postoperative care yet considered for evaluation of anastomotic leakage.ResultsA total of 22 patients undergoing taIPAA during the study time-window were included in analysis. Median age at the time of surgery was 32 ± 12.5 (14–54) years. Two patients developed an anastomotic leakage at 11 days (early anastomotic leakage) and 9 months (late anastomotic leakage) after surgery, respectively. In both patients, pouches could be preserved with a multimodal approach. Twenty patients out of 22 met the inclusion criteria for short and long term follow-up. Data on short-term pouch function could be obtained in 14 patients and showed satisfactory pouch function with only four patients reporting intermittent incontinence at a median stool frequency of 9–10 times per day. In the long-term we observed an inflammation or “pouchitis” in 11 patients and a pouch failure in one patient.ConclusionPostoperative complication rates in patients with benign colorectal disease remain an area of concern for surgical patient safety. In this pilot study on 22 selected patients, taIPAA was associated with two patients developing anastomotic leakage. Future large-scale validation studies are required to determine the safety and feasibility of taIPAA in patients with ulcerative colitis.

Staged Approaches to Restorative Proctocolectomy with Ileoanal Pouch—When and Why?

Restorative proctocolectomy (RPC) with ileal pouch anal-anastomosis (IPAA) is commonly performed for patients with ulcerative colitis, familial adenomatous polyposis, and selected phenotypes of Crohn's disease (CD). Due to concerns about the effects of surgical complications on pouch functional outcomes, debate remains surrounding when and whether RPC with IPAA should be performed in a staged manner. Particularly debated are the timings of the IPAA, whether it is constructed at time of the proctocolectomy and whether to utilize temporary fecal diversion with a loop ileostomy. RPC with IPAA can be performed in one, two, or three stages, with each stage typically separated by 3-6 months. Proponents of a staged approach argue that poor pouch function, which is often a result of IPAA complications, including leak and infection, can be difficult to overcome and mandate additional, major surgeries, and that staging pouch creation and pairing with a protective ileostomy reduce those complications. However, subjecting patients to multiple surgeries and prolonging their time with an ileostomy present unique risks as well. Surgeons' experience and preference and patient characteristics need to be considered when determining operative planning. Highly selected patients with CD can be considered for RPC with IPAA, although with an acknowledgment of inherently higher pouch failure rates. Understanding the short- and long-term consequences of RPC with IPAA construction can help surgeons determine the appropriate approach.

TWISTED POUCH SYNDROME - A DIFFICULT TO DIAGNOSE MECHANICAL COMPLICATION OF ILEAL POUCH-ANAL ANASTOMOSIS: OUTCOMES AFTER REDO POUCH PROCEDURES

Ileal pouch-anal anastomosis (IPAA) is a technically demanding procedure. Intraoperatively, great care must be taken to assure a straight superior mesenteric axis. Rarely, twisted pouches are inadvertently constructed, resulting in deviations of expected pouch function, i.e. patients readily able to open their bowels on average 7x/24 hours without pain. Twisted pouches may result in symptoms classified as pouch dysfunction. Herein we describe our quaternary pouch referral center experience with twisted pouch syndrome (TPS).

TWISTED POUCH SYNDROME - A DIFFICULT TO DIAGNOSE MECHANICAL COMPLICATION OF ILEAL POUCH-ANAL ANASTOMOSIS: OUTCOMES AFTER REDO POUCH PROCEDURES

Abstract Background Ileal pouch-anal anastomosis (IPAA) is a technically demanding procedure. Intraoperatively, great care must be taken to assure a straight superior mesenteric axis. Rarely, twisted pouches are inadvertently constructed, resulting in deviations of expected pouch function, i.e. patients readily able to open their bowels on average 7x/24 hours without pain. Twisted pouches may result in symptoms classified as pouch dysfunction. Herein we describe our quaternary pouch referral center experience with twisted pouch syndrome (TPS). Methods We performed a retrospective review of our prospectively maintained pouch registry from 1995 – 2020. Patients were identified using free-text search of redo IPAA operative reports for variations of the term “twist”. We defined twisted pouch syndrome as intraoperative findings of twisting of the pouch as the primary pathology. Data are presented as frequency (proportion) or median (interquartile range). Results Over 25-years, we identified 29 patients with confirmed TPS who underwent a redo pouch procedure by 10 surgeons. Overall, 65% were female, median BMI 21.2 (19.5 – 26) kg/m2. The duration from the index IPAA to the redo procedure was 4 (2 – 8) years; all (100%) were referral cases constructed elsewhere. Original diagnoses included: ulcerative colitis (90%), FAP (10%), lack of interstitial cells of Cajal in 1 patient (10%). All patients presented with symptoms of pouch dysfunction including erratic bowel habits (96%) with urgency/frequency, abdominal/pelvic/rectal pain (92%), and obstructive symptoms (88%). Most had (75%) been treated for chronic pouchitis with antibiotics or biologics, and 46% had undergone 1 or more additional surgery. Prior to redo IPAA procedure patients underwent a thorough workup: 100% pouchoscopy, 96% GGE, 93% underwent EUA, 88% MRI, 73% manometry, and 42% defecography. TPS was diagnosed in 15% by pouchoscopy, in 10% by imaging, and in 75% was diagnosed intra-operatively at re-diversion (20%) or revision/redo IPAA (55%). In terms of surgical intervention, 85% were initially re-diverted. A total of 18 (62%) underwent pouch revision, and 10 (38%) required redo-IPAA. Short-term outcomes: LOS 7.5 (5 – 9) days, any complication 48%, readmission 11%, reoperation 3.4%, zero mortalities. After a median follow-up 50 (28 – 60) months, 2 never had loop ileostomy closure, 1 had pouch excision, and 1 a Kock pouch, yielding an overall pouch survival rate of 86%. Conclusions Twisted pouch syndrome presents with pouch dysfunction manifest by erratic bowel habits, unexplained pain, and obstructive (defecation) symptoms. This syndrome may also mimic chronic pouchitis. Despite a thorough workup which may suggest a mechanical problem, many patient may not be diagnosed until time of redo pouch surgery. Redo surgery for twisted pouch syndrome results in long-term pouch survival for the majority.

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

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. 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. 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). 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.

P058 Tofacitinib and Ileal Pouch Anal Anastomosis. A Single-Center Case Series.

BACKGROUND: Tofacitinib is an emerging off label option for patients with moderate to severe ulcerative colitis (UC). However, data about the postoperative complications after ileal pouch anal anastomosis (IPAA), and the long-term pouch function after using tofacitinib are scarce. This study aims to describe postoperative complications and pouch function for patients with UC who had prior exposure to tofacitinib preoperatively. METHODS: After institutional review board approval, electronic medical records were reviewed for patients with UC treated with tofacitinib and subsequently underwent IPAA. Demographics, anthropometrics, previous treatments, smoking, preoperative risk factors and comorbidities, postoperative complications, and long-term pouch function were evaluated. RESULTS: A total of 13 patients were included. Of them, 10 (76.9%) were male, 1 (7.7%) current smoker, 1 (7.7%) had primary sclerosing cholangitis (PSC), 13 (100%) had ≥ previous 3 lines of treatment for UC. The median age at diagnosis was 23 years (IQR 21.5 – 34) and the median duration of UC was 10 years (IQR 4 – 17.5). All patients had previously failed tumor necrosis factor-alpha inhibitors and steroids while 11 (85%) patients failed aminosalicylate and 7 (54%) failed thiopurines. The most common dose used for tofacitinib prior to colectomy was 10 mg twice per day 8 (62%) and most patients had three-stage operation 11 (85%). No 90-day postoperative Clavien Dindo class III or IV complications were reported, no intra-abdominal sepsis, no other infectious complications, and no mortality. At a median follow up of 4 months (IQR 3.2 – 10.3), 3 (23.1%) patients had pouchitis, of whom 1 had a prior history of PSC and liver transplantation. Only 1 out of the 3 patients who had pouchitis needed a permanent stoma, the other 2 were managed medically. One of these patients also had had clostridium difficile infection. CONCLUSION: No major postoperative complications were reported after IPAA for patients who were treated with tofacitinib. From a surgical standpoint, tofacitinib was not associated with surgical complications in our small cohort of medically refractory UC patients. Pouch function was similar to expected in this patient population. Larger scale studies with longer follow up are needed to confirm these findings.

Determinants of long-term function and general well-being in patients with an ileoanal pouch.

Background and aimFecal incontinence and/or evacuation difficulty are common after ileoanal pouch surgery. This study aimed to determine whether the development of these symptoms can be predicted so that preventive measures might be instituted.MethodsA consecutive series of 46 patients with ulcerative colitis (median age at surgery, 41 years; 50% female) and a functioning pouch for a duration ≥12 months was included. Assessment utilized medical record review and questionnaires on pre‐ and postoperative bowel function, quality of life, and psychological well‐being. Pouch function was assessed by the Colorectal Functional Outcome score (0 = no impairment, 100 = worst impairment). Good pouch function was defined as a score ≤24.ResultsFecal incontinence occurred in 67% preoperatively and 54% postoperatively; evacuation difficulty occurred in 65% and preoperatively and 85% postoperatively. The postoperative median Colorectal Functional Outcome score was 20 (range 2–74), with 44% of patients >24 (poor pouch function). Preoperative nocturnal fecal incontinence (odds ratio [OR] 4.92, 95% confidence interval [CI] 1.2–19.4, P = 0.02) and pouchitis (OR 5.41, 95% CI 1.2–23.7, P = 0.02) were associated with poor pouch function after multivariable regression analysis. Postoperative satisfaction, psychological well‐being, and quality of life were significantly better in those with good pouch function, while poor sleep, impaired work, and sexual dysfunction were independently associated with poor pouch function.ConclusionsFunctional bowel symptoms are common before and after pouch surgery and are associated with the impairment of patient‐reported outcomes. Preoperative nocturnal fecal incontinence predicts poor pouch function. Therapeutic focus on continence, bowel evacuation, psychological well‐being, and quality of life should begin before surgery.