Redo Ileal Pouch-anal Anastomosis Research Articles

Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease.

BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2cm long to avoid subsequent complications. We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4cm. Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.

Third Time's the Charm? Indications and Outcomes for Redo-Redo IPAA.

Up to 20% to 40% cases of redo IPAA procedures will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision. To report our institutional experience of second redo IPAA procedures. This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redo procedures and those undergoing first redo procedures using propensity score matching to balance the 2 cohorts. Tertiary referral center. Patients who underwent second redo IPAA procedures between 2004 and 2021 were included in this study. Second redo IPAA. Pouch survival and patient-reported outcomes were measured using the Cleveland Global Quality of Life survey. Twenty-three patients were included (65% women), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. The final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo procedures in 21 (91%) cases: 20 (87%) patients had both redo IPAAs for septic complications. After a median follow-up of 39 months (interquartile range, 18.5-95.5 months), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of whom 3 never had their stoma closed, and 1 case due to poor function); all patients who experienced pouch failure underwent the second redo procedure due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with a final diagnosis of Crohn's disease versus 82.5% in patients with ulcerative/indeterminate colitis ( p = 0.09). Overall quality-of-life score (0-1) was 0.6 (0.5-0.8). Quality of life and functional outcomes were comparable between first and second redo procedures, except incontinence, which was higher in second redo procedures. Single-center retrospective review. A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract . ANTECEDENTES:Hasta un 20-40% de los casos de rehacer anastomosis anal con bolsa ileal (IPAA) resultarán en falla de la bolsa. La posibilidad de ofrecer un segundo procedimiento para mantener la continuidad intestinal sigue siendo una decisión controvertida.OBJETIVO:Reportar nuestra experiencia institucional de una segunda re-confección de la anastomosis anal con bolsa ileal.DISEÑO:Revisión retrospectiva; los resultados informados por los pacientes se compararon entre los pacientes que se sometieron a una segunda re-confeccion con los de los pacientes que se sometieron a una la primera re-confeccion utilizando el puntaje de propensión para equilibrar las dos cohortes.AJUSTES ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes que se sometieron a una segunda re-confeccion de de la anastomosis anal con bolsa ileal entre 2004 y 2021.INTERVENCIONES:Segunda re-confeccion de la anastomosis anal con bolsa ileal.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia de la bolsa, resultados informados por los pacientes medidos mediante la encuesta Cleveland Global Quality of Life.RESULTADOS:Se incluyeron veintitrés pacientes (65% mujeres), 20 (87%) con diagnóstico inicial de colitis ulcerosa y 3 (13%) con colitis indeterminada. El diagnóstico final se cambió a enfermedad de Crohn en ocho (35%) casos. La indicación para el rescate de la bolsa fue la misma para la primera y segunda re-confeccion en 21 (91%) casos: 20 (87%) pacientes tuvieron ambas re-confecciones de la anastomosis anal con bolsa ileal por complicaciones sépticas. Después de una mediana de seguimiento de 39 meses (RIC 18,5 - 95,5), se produjo falla de la bolsa en 8 (30%) casos (7 casos debido a sepsis, de los cuales 3 nunca cerraron el estoma y 1 caso debido a una mala función); todos los pacientes que experimentaron falla de la bolsa se sometieron a una segunda re-confeccion debido a complicaciones sépticas. La supervivencia global de la bolsa a los 3 años fue del 76%: 62,5% en pacientes con diagnóstico final de enfermedad de Crohn, versus 82,5% en colitis ulcerativa/indeterminada ( p = 0,09). La puntuación general de calidad de vida (0 -1) fue 0,6 (0,5 - 0,8). La calidad de vida y los resultados funcionales fueron comparables entre la primera y la segunda re-confeccion, excepto la incontinencia, que fue mayor en la segunda re-confeccion.LIMITACIONES:Revisión retrospectiva de un solo centro.CONCLUSIONES:Se puede ofrecer un segundo procedimiento de rescate de la bolsa con resultados aceptables a pacientes seleccionados con alta motivación para mantener la continuidad intestinal. (Traducción- Dr. Francisco M. Abarca-Rendon ).

P270 Male Genitourinary Dysfunction after Primary and Reoperative Ileoanal Pouch Surgery

Abstract Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with IBD or FAP. As these diseases often manifest during adolescence or early adulthood, treatment effects on genitourinary function (GU) and sexual function are of paramount importance. However, the reoperative IPAA (R-IPAA) effects on male GU function and sexual function compared to primary IPAA (P-IPAA) are not known. Therefore, we conducted an observational survey to compare the long-term GU functionality of P-IPAA and R-IPAA long-term GU functionality male patients. We hypothesized that R-IPAA is associated with higher GU-dysfunction compared to R-IPAA. Methods All adult male patients who underwent IPAA at a single tertiary hospital between 1983 and 2022 were identified and demographics and clinical data were obtained from our prospectively maintained pouch registry. Patients were surveyed using validated questionnaires (Table 1). The primary outcome was composite survey scores. Patients were stratified into P-IPAA or R-IPAA groups; R-IPAA was defined as IPAA excision, reconstruction, or revision. Patients status-post prostatectomy were excluded. Results A total of 1,836 male patients were surveyed, and 457 (24.9%) submitted a response. After exclusion criteria, 339 responses were analyzed:296 (87.3%) P-IPAA and 38 (11.2%) R-IPAA, which included 22 redo IPAA, 9 excisions, and 7 revisions. In both groups, most patients had ulcerative colitis (89 vs. 90%). P-IPAA compared to R-IPAA had a similar age at surgery (40.8 vs. 42, p=0.59), similar age at survey (56.2 vs. 56.4, p=0.94), and a similar interval between surgery and survey (15.4 vs. 14.4, p=0.51). The P-IPAA group had less severe sexual dysfunction than the R-IPAA group (IBD-MSDS, 2.0 vs. 7.0, p=0.002). No significant difference was observed between P-IPAA and R-IPAA in erectile dysfunction (SHIM score 21 vs. 18.5, p=0.24), urinary tract symptoms (CLLS, 5.5 vs. 8.0, p=0.06), use of therapeutic aids for sexual activity (6 vs. 7, p=0.29), or orgasm ability (4 vs. 4, p=0.3). Patients with P-IPAA had a higher CGQoL (0.83 vs. 0.7, p=0.02). There were no differences between patients who had difficulty conceiving a child (4 vs. 7, p=0.5) and those who experienced infertility (3 vs. 1, p=0.43). In patients with fertility problems, no quality-of-life differences were observed between the groups (FertiQoL, 85.9 vs. 88.5, p=0.62). Conclusion Primary-IPAA was associated with increased sexual function and overall higher global quality of life compared to R-IPAA. No difference in erectile function, LUTS, and the need for therapeutic aids for sexual function, orgasm ability, or fertility were observed.

Long-term quality-of-life and functional outcomes after redo ileal pouch-anal anastomosis.

Long-term quality-of-life and functional outcomes after redo ileal pouch-anal anastomosis.

MP78-15 MANAGEMENT AND OUTCOMES OF ILEAL POUCH-URETHRAL FISTULAS

You have accessJournal of UrologyCME1 Apr 2023MP78-15 MANAGEMENT AND OUTCOMES OF ILEAL POUCH-URETHRAL FISTULAS João Pedro Emrich Accioly, Marianna Maspero, Hanson Zhao, Roger K. Khouri, Olga Lavryk, Kenneth W. Angermeier, Tracy Hull, and Hadley M. Wood João Pedro Emrich AcciolyJoão Pedro Emrich Accioly More articles by this author , Marianna MasperoMarianna Maspero More articles by this author , Hanson ZhaoHanson Zhao More articles by this author , Roger K. KhouriRoger K. Khouri More articles by this author , Olga LavrykOlga Lavryk More articles by this author , Kenneth W. AngermeierKenneth W. Angermeier More articles by this author , Tracy HullTracy Hull More articles by this author , and Hadley M. WoodHadley M. Wood More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fistulas may develop following ileal pouch anal anastomosis (IPAA), but urinary tract involvement in this setting is rare. We thus aim to describe our experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with IPAA. METHODS: We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort through keywords and procedure codes. In a retrospective medical record review, we obtained demographic, clinical and operative data, including diagnostic methods, individual management strategies and outcomes and described our findings. RESULTS: We identified thirteen patients with a diagnosis of IPUF managed from 2005–2022. Median age at IPAA was 29 years (range 11–53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Interval events included IPAA dilations (n=5) and dual radiation therapy for prostate cancer (n=2). Median time from IPAA to fistula diagnosis was 15 years (range 0.5–38.5). Initial management consisted of urinary diversion with either suprapubic tube (n=6) or Foley catheter (n=1) and fecal diversion with either loop (n=8) or end ileostomy (n=3); five had dual urinary/fecal diversion. Four patients experienced resolution with either urinary (n=2) or fecal (n=2) diversion alone. Eight patients eventually required pouch excision and end ileostomy, of which seven underwent concomitant urethral repair. Gracilis muscle interposition was employed in addition to primary closure in five patients. Only one patient successfully underwent re-do IPAA. With a median follow-up of 4 years (range 0.3–13 years), all patients had resolution of their fistulas without recurrence. CONCLUSIONS: IPUFs are an uncommon complication of IPAA. In this cohort, all patients had urinary tract preservation, but in most instances, permanent fecal diversion was necessary. These results can help guide management of this complex issue. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1137 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information João Pedro Emrich Accioly More articles by this author Marianna Maspero More articles by this author Hanson Zhao More articles by this author Roger K. Khouri More articles by this author Olga Lavryk More articles by this author Kenneth W. Angermeier More articles by this author Tracy Hull More articles by this author Hadley M. Wood More articles by this author Expand All Advertisement PDF downloadLoading ...

THIRD TIME’S THE CHARM? INDICATIONS AND LONG-TERM OUTCOMES AFTER REDO-REDO ILEAL POUCH ANAL ANASTOMOSIS

Pouch failure after redo ileal pouch anal anastomosis (IPAA) occurs in 20-40% of cases. The decision to offer a second redo procedure to maintain intestinal continuity is controversial, and scarce evidence exists regarding long-term pouch survival and functional outcomes after redo-redo IPAA.

LONG RECTAL CUFF SYNDROME AFTER ILEOANAL POUCH FOR INFLAMMATORY BOWEL DISEASE

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) removes the entire rectum to the anal canal, but is technically challenging, especially with minimally invasive (MIS) approaches. Pouches are most commonly double-stapled, leaving a 1-2 cm “rectal cuff”. If the cuff is longer, patients may develop recurrent ulcerative proctitis (UP) or rectal stricture (RS) of the retained rectum. The aim of this study is to describe long rectal cuff syndrome (LRCS) and its outcomes after redo IPAA performed for long rectal cuffs.

LONG RECTAL CUFF SYNDROME AFTER ILEOANAL POUCH FOR INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) removes the entire rectum to the anal canal, but is technically challenging, especially with minimally invasive (MIS) approaches. Pouches are most commonly double-stapled, leaving a 1-2 cm “rectal cuff”. If the cuff is longer, patients may develop recurrent ulcerative proctitis (UP) or rectal stricture (RS) of the retained rectum. The aim of this study is to describe long rectal cuff syndrome (LRCS) and its outcomes after redo IPAA performed for long rectal cuffs. METHODS We defined LRCS as a constellation of UP or RS symptoms related to a long (≥ 4 cm) rectal cuff. We retrospectively reviewed our prospectively maintained Pouch Registry to identify patients whose indication for redo pouch was LRCS. We report their presentation and outcomes after redo IPAA for LRCS. Figures are frequency (percentage) and median (interquartile range). RESULTS LRCS was the primary indication for redo IPAA in 40 patients (7% of the redo IPAA cases at our Center); median age at redo surgery, 42.5 (29 – 49 years); 18 (42%) were females; 36 (90%) patients were referral cases. Diagnosis at index IPAA was ulcerative colitis in 39 (97.5%), and Crohn’s in 1 (2.5%) case. The index pouch was performed MIS in 14 (35%). The median rectal cuff length was 6 (5 – 8) cm, with 13 (32.5%) patients having a cuff ≥ 8 cm. After a median of 21 (16 – 68) months, patients most commonly presented (31, 77.5%) with UP-symptoms (urge-incontinence, frequency, abdominopelvic or rectal pain) or with obstructive (9, 22.5%) symptoms (crampy abdominopelvic pain, outlet obstruction). Preoperative pouchoscopy was available in 32 (80%) cases: pouchoscopy findings included proctitis (18, 56%), rectal stricture (16, 50%), and/or dilated pouch (7, 22%). The median interval between the index pouch and redo pouch was 31 months (16 – 67.5). The pouch was disconnected and re-anastomosed to anus in 16 (40%), while excised with neo-pouch construction in 24 (60%) of cases. The anastomosis was stapled vs. handsewn 25 (62.5%) vs. 15 (27.5%). Pathologic exam revealed chronic active proctitis in 38 (90%) cases; the remained showed other pathologic changes. In terms of long-term outcomes, two (5%) patients never had their stoma closed after redo due to Crohn’s-related pouch complication, and fistulae development, respectively. After a median follow up of 34.5 (12 – 109) months, pouch failure occurred in 9 (22.5%) cases. The median interval between redo IPAA and pouch failure was 10 (4 – 34) months. Pouch survival at 3-, 5- and 10-years was 78%, 72%, and 63%. CONCLUSION Long rectal cuff syndrome is a potentially avoidable complication which presents with symptoms from either ulcerative proctitis or stricture. Redo IPAA can be offered as treatment to maintain intestinal continuity and may allow long-term pouch salvage in many cases.

THIRD TIME’S THE CHARM? INDICATIONS AND LONG-TERM OUTCOMES AFTER REDO-REDO ILEAL POUCH ANAL ANASTOMOSIS

Abstract BACKGROUND Pouch failure after redo ileal pouch anal anastomosis (IPAA) occurs in 20-40% of cases. The decision to offer a second redo procedure to maintain intestinal continuity is controversial, and scarce evidence exists regarding long-term pouch survival and functional outcomes after redo-redo IPAA. METHODS We retrospectively analyzed our prospectively collected pouch registry for redo IPAA procedures and identified all patients who underwent a second redo IPAA procedure from 2004 to 2021. Our primary outcome was pouch survival, defined as no pouch excision or rediversion. Figures are frequency (percentage) and median (interquartile range). RESULTS Twenty-three patients met inclusion criteria (65% female, 4% of all redo IPAAs). The index diagnosis was ulcerative colitis in 20 (87%) cases and indeterminate colitis in 3 (13%). The median interval between the index pouch and the second redo was 36 (24 – 90) months, while the median time between the first and second redo was 16 (9 – 36.5) months. Only 8 (35%) of patients had their stoma closed between the first and second redo. In 15 (65%) cases both redo procedures were done at our center. The indication for pouch salvage was the same for the first and second redo in 21 (91%) cases (Figure 1): 20 (87%) patients both redo for septic complications. Second redos were done transabdominally in 21 (91%) of cases, and 14 (61%) involved pouch excision and construction of a neo-pouch. All were handsewn, and the final pouch configuration was “J” in 18 (78%) and “S” in 5 (22%) cases (Figure 2). Twenty (87%) had their stoma closed after the second redo. After a median follow up of 39 months (18.5 – 95.5), 10 (44%) patients experienced pouch failure (due to sepsis in 9 cases of which 3 never had their stoma closed, and poor function in 1). Pouch survival was 81% at 1-year, and 76% at 3-years. The median interval between second redo and pouch failure was 12 months (3 – 50.5). Postoperative Cleveland Global Quality of Life surveys were available for 17 (74%) patients. After a median interval of 14 (6 – 40) months, the overall quality of life score (0 -1) was 0.6 (0.5 – 0.8). The median number of bowel movements was 6 (5 – 8) during daytime, 2 (2 – 4) at night, for a total of 8 (6.5 – 12.5) per 24 hours. Urgency occurring most days of the week was reported by 30%, frequency by 14%, seepage during the day by 71% and at night by 86%. Dietary restrictions were reported by 50% of patients, social restrictions by 44%, work restrictions by 62.5%, and sexual restrictions by 50%. CONCLUSION A second redo pouch procedure may be offered with acceptable outcomes to a very select group of patients who are highly motivated to maintain intestinal continuity.

What is the best surgical option after failure of graciloplasty in patients with recurrent rectovaginal fistula? A study of 19 consecutive patients.

Management of recurrent rectovaginal fistula (rRVF) remains challenging despite the good results of graciloplasty reported in the literature. However, little is known about how to avoid a permanent stoma if graciloplasty fails. The aim of our study was to report the management of rRVF after failure of graciloplasty. A retrospective study was performed on consecutive patients with rRVF after failure of graciloplasty treated at our institution in January 2005-December 2021. There were 19 patients, with a median age at graciloplasty of 39years (range 25-64years). Etiologies of RVF were Crohn's disease (CD) (n = 10), postoperative (n = 5), post-obstetrical (n = 3), and unknown (n = 1). After failure of graciloplasty, 45 new procedures were performed, all of them with a covering stoma: trans-anal repairs (n = 31), delayed colo-anal anastomosis (DCAA) (n = 4), biological mesh interposition (n = 3), second graciloplasty (n = 3), stoma only (n = 2) and redo ileal pouch-anal anastomosis (IPAA) (n = 2). One patient was not re-operated on and instead treated medically for CD. After a mean follow-up of 63 ± 49months, success (i.e., absence of stoma or RVF) was obtained in 11 patients (58%): 4/4 DCAA (100%), 5/31 after local repair (16%), 1 after stoma creation alone (50%) and 1 after redo IPAA (50%). Second graciloplasty and biologic mesh interposition all failed. All 8 patients with failed intervention had CD. In cases of rRVF after failed graciloplasty, reoperation is possible, although the chance of success is relatively low. The best results were obtained with DCAA. CD is a predictor of poor outcome.

Management and Outcomes of Ileal Pouch-Urethral Fistulas

To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases. Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences. IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.

S77 Redo Ileal Pouch Anal Anastomosis for Dysplasia or Cancer at the Anal Transition Zone

Background: Presence of dysplasia or cancer at the anal transition zone (ATZ) is considered an indication to pouch excision with permanent ileostomy, while redo ileal pouch anal anastomosis (IPAA) is contraindicated. These recommendations are however based on anecdotal evidence due to the rarity of this occurrence. Methods: We retrospectively analyzed our prospectively collected database on redo IPAA. Among patients who underwent redo IPAA between 1988 and 2020, those whose primary indication was dysplasia/cancer in the ATZ were included in this study. Results: Out of 542 total patients, 8 patients underwent redo IPAA for either dysplasia or cancer at the ATZ. Of the 8 patients who underwent redo IPAA for dysplasia/cancer, 5 had ulcerative colitis, 2 had familial adenomatous polyposis (FAP), and one had hereditary non-polypoid colon cancer. Preoperative pathology of ATZ showed adenocarcinoma in 2 cases, low grade dysplasia in 3 and high grade dysplasia in 3. Final pathology was consistent with preoperative biopsy in 6 cases, while 2 cases of preoperative dysplasia showed no evidence of dysplasia at final pathology. The 2 cases of cancer were, respectively, a pT4N0 and a pT1N0 rectal cancer. The patient with pT4N0 adenocarcinoma had an early recurrence 4 months after redo IPAA with peritoneal carcinomatosis and pelvic lymph nodal metastases. She died 23 months after redo IPAA of cancer-related causes. The remaining 7 patients had no recurrence and are alive at a median follow up of 77 months (range 27–144). Pouch failure occurred in only one case due to severe pouch dysfunction with incontinence and poor quality of life requiring permanent diversion 38 months after redo IPAA. Conclusion(s): Redo ileal pouch anal anastomosis appears to be an acceptable option with good long-term outcomes in case of dysplasia or cancer at the anal transition zone.

Social Media Influences Redo Pouch Surgery Referral More Than Index Surgeons

Introduction: Redo ileal pouch anal anastomosis (IPAA), the procedure of choice for IPAA, is mainly attempted in specialized centers but referral patterns for redo IPAA are not well known. Social media may be a valuable tool for patients to find surgeons. In our study we evaluated referral patterns of redo IPAA. Methods: All redo IPAA procedures performed at our center for IPAA failure between 09/2016 and 02/2022 were included. Patient demographics, disease characteristics and referral patterns were reported. Results: A total of 141 patients with IPAA failure who had redo IPAA surgery were included. The median age was 40 years. The median time between the index surgery and the redo surgery was 5 years (interquartile range: 2-11). There were 108 ulcerative colitis, 25 indeterminate colitis and 8 familial adenomatous polyposis patients. Referrals for 49 patients were via social media or word of mouth (33.1%), 48 were referred by gastroenterologists (32.4%), 33 by colorectal surgeons (22.3%) and 1 by an oncologist (0.7%). The index case was done by our team in 11 patients (7.4%). A significant majority of patients, 30%, were from outside of our center’s tristate area. Conclusion: Social media and patient-patient interaction was the number one referral source, followed closely by the gastroenterologists. The small number of referrals by the primary surgeon is a source of concern since the majority of redo IPAAs are done to fix surgical failures.

Management, Functional Outcomes, and Quality of Life After Development of Pelvic Sepsis in Patients Undergoing Re-Do Ileal Pouch Anal Anastomosis

The data on management and outcomes of pelvic sepsis after re-do IPAA are scarce. The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do IPAA and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no sepsis control group. This is a retrospective cohort study. This investigation is based on a single academic practice group experience on re-do IPAA. Patients who underwent re-do IPAA for ileal pouch failure between September 2016 and September 2020 were included in the study. Management of pelvic sepsis was reported. Functional outcomes, restrictions, and quality-of-life scores were compared between the sepsis and no sepsis groups. One-hundred ten patients were included in our study, of whom 25 (22.7%) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure, and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included interventional radiology abscess drainage (n = 7), IV antibiotics alone (n = 5), interventional radiology drainage and mushroom catheter placement (n = 1), mushroom catheter placement (n = 1), and endoluminal vacuum-assisted closure (n = 1). Average number of bowel movements, urgency, incontinence, pad use, and seepage were comparable between the pelvic sepsis and no pelvic sepsis groups ( p > 0.05). Lifestyle alterations, Cleveland Global Quality of Life scores, and happiness with the results of the surgery were similar ( p > 0.05). This study is limited by its low study power and limited follow-up time. Pelvic sepsis is common after re-do IPAA, and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823 . ANTECEDENTES:Los datos sobre el tratamiento y los resultados de la sepsis pélvica después de reconfección de anastomosis anal, de la bolsa ileal son escasos.OBJETIVO:El objetivo de este estudio es informar nuestro algoritmo de manejo de la sepsis pélvica en el contexto de reconfección de anastomosis anal de la bolsa ileal y comparar los resultados funcionales y la calidad de vida después del manejo exitoso de la sepsis pélvica con un grupo de control sin sepsis.DISEÑO:Este es un estudio de cohorte retrospectivo.AJUSTES:Esta investigación se basa en una experiencia de un solo grupo de práctica académica sobre reconfección de IPAA.PACIENTES:Se incluyeron en el estudio pacientes que se sometieron a una nueva anastomosis anal, del reservorio ileal por falla del reservorio ileal entre el 09/2016 y el 09/2020.PRINCIPALES MEDIDAS DE RESULTADO:Se informó el manejo de la sepsis pélvica. Los resultados funcionales, las restricciones y las puntuaciones de calidad de vida, se compararon entre los grupos con sepsis y sin sepsis.RESULTADOS:Se incluyeron 110 pacientes en nuestro estudio, de los cuales 25 (22,7) desarrollaron sepsis pélvica. Veintitrés pacientes presentaron sepsis pélvica antes del cierre de la ileostomía y 2 pacientes presentaron sepsis pélvica después del cierre de la ileostomía. Hubo 6 fallas de la bolsa en el período de estudio debido a sepsis pélvica. Nuestro manejo fue exitoso en el 79% de los pacientes con una mediana de seguimiento de 26 meses. Los tratamientos incluyeron drenaje de abscesos IR (n = 7), antibióticos intravenosos solos (n = 5), drenaje IR y colocación de catéter en forma de hongo (n = 1), colocación de catéter en forma de hongo (n = 1) y cierre endoluminal asistido por vacío (n = 1). El número promedio de evacuaciones intestinales, urgencia, incontinencia, uso de almohadillas y filtraciones fueron comparables entre los grupos con sepsis pélvica y sin sepsis pélvica ( p > 0,05). Las alteraciones del estilo de vida, las puntuaciones de la Calidad de vida global de Cleveland y la felicidad con los resultados de la cirugía fueron similares ( p > 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:La sepsis pélvica es común después de la reconfección de anastomosis anal de la bolsa ileal y el manejo varía según la ubicación y el tamaño del absceso / seno. Si se detecta temprano, nuestra estrategia de manejo se asoció con altas tasas de recuperación de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/B823 . (Traducción-Dr. Mauricio Santamaria ).

P024 Anorectal Manometry in Patients with Fecal Incontinence After Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: A Cohort Study.

Fecal incontinence (FI) affects up to 1 in 4 patients with inflammatory bowel disease (IBD) and is associated with inflammation, surgeries, and altered rectal sensitivity. Ileal pouch-anal anastomosis (IPAA) is a surgical intervention for select IBD patients to avoid a permanent stoma. High-resolution anorectal manometry (HRAM) studies in IBD patients with FI demonstrate lower resting pressures and rectal sensory dysfunction. However, HRAM data in IBD patients with FI post-IPAA remains limited. We hypothesized patients with FI would have lower resting and squeeze pressures and rectal hypersensitivity compared to healthy controls and that these changes would be similar after IPAA. Retrospective review of prospectively collected data was conducted on patients undergoing HRAM from 2017-2021 at a single urban academic medical center. Patient characteristics (age, gender, BMI, stool frequency, diabetes, pregnancy history) and surgical history (prior perianal surgery, index vs. re-do IPAA) were obtained. HRAM variables included rectoanal inhibitory reflex (RAIR), sphincter length, resting, squeeze, cough, and push pressures, sensation thresholds (first sensation, constant sensation, desire to defecate, urgency to defecate, max tolerable volume), and balloon expulsion test (BET). HRAM outcomes in IPAA patients with FI (IPAA-FI) were compared to non-IBD patients with FI (non-IBD-FI). HRAM data for both patient cohorts were also compared to existing normative data of healthy controls. Non-IBD patients with constipation and FI were excluded from analysis. An independent samples t-test was performed (p < 0.05) for continuous variables, and chi-square test was used for categorical variables. Fifty-six patients (66% female) were in the non-IBD-FI group. Eighteen patients (67% female) were in the IPAA-FI group. Average age in the IPAA-FI cohort was 44.8 ± 13.6 vs. 66.3 ± 14.4 in the non-IBD-FI group (p< 0.01). Sphincter length in the IPAA-FI group was 2.7 ± 1.1cm vs. 3.2 ± 0.6cm in the non-IBD-FI group (p=0.03). There was no significant difference in sensation thresholds or resting, squeeze, cough, and push pressures between the two groups. Urinary incontinence was observed in 5.6% of IPAA-FI patients vs. 44.6% of non-IBD-FI patients (p < 0.01). RAIR was present in 38.5% of IPAA-FI patients vs. 100% of non-IBD-FI patients (p < 0.01). Both patient cohorts had significantly shorter sphincter length, lower squeeze and push pressures, and lower sensation thresholds compared to normative data. Resting pressures for the IPAA-FI group was not significantly different compared to healthy controls. Overall, anorectal pressures and sensation are similar between IPAA-FI and non-IBD-FI patients. However, the underlying FI mechanism seems to differ. Higher rates of urinary incontinence in the non-IBD-FI cohort suggests global pelvic floor dysfunction compared to IPAA-FI patients who are younger and have post-operative neuromuscular dysfunction, as evidenced by shorter sphincter length and absent RAIR. Though rectal hypersensitivity and lower squeeze/push pressures are observed in both patient groups compared to healthy controls, normal resting pressure in IPAA-FI suggests that potentially different normative ranges are needed for this cohort to accurately assess post-surgical changes and guide pre-operative counseling.

Incidence, Management, and Long-term Outcomes of Strictures in Patients Undergoing Re-do Ileal Pouch Anal Anastomosis

Incidence, Management, and Long-term Outcomes of Strictures in Patients Undergoing Re-do Ileal Pouch Anal Anastomosis

Indications, functional and quality of life outcomes of new pouch creation during re-do ileal pouch anal anastomosis: A comparative study with existing pouch salvage

BackgroundSalvage of the existing ileal pouch is favored during re-do ileal pouch anal anastomosis if the pouch is not damaged after pelvic dissection and there are no other mechanical reasons that may necessitate construction of a new pouch. Excision of the existing pouch may be associated with some concerns for short-bowel syndrome and poor functional outcomes. This study aimed to report indications and compare functional and quality of life outcomes of new pouch creation versus salvage of the existing pouch during re-do ileal pouch anal anastomosis. MethodsPatients who underwent re-do ileal pouch anal anastomosis between September 2016 and June 2020 were included. The reasons for pouch excision and new pouch creation were reported. Perioperative, functional outcomes and quality of life were compared between patients who had creation of a new pouch versus salvage of existing pouch. ResultsA total of 105 patients with re-do ileal pouch anal anastomosis (new pouch, n = 63) were included. Most common indications for a new pouch creation were chronic pelvic infection that compromised the integrity and viability of the existing pouch (n = 32) and small pouch (n = 21). No patient developed short-bowel syndrome. The number of bowel movements, daily restrictions and Cleveland Global Quality of Life score scores were similar between 2 groups. Day-time seepage, day-time and night-time pad usage were more common after new pouch creation. Two-year pouch survival rates were comparable (new pouch: 92% versus existing pouch: 85%, P = .31). ConclusionNew pouch creation can be safely performed at the time of re-do ileal pouch anal anastomosis. It provides acceptable functional and quality of life outcomes if existing pouch salvage is not feasible.

Ileoanal Pouch: Pelvic Sepsis and Poor Function-Now What?

Pelvic sepsis is a dreadful complication after ileal pouch creation. It is mostly treated conservatively, and the ileal pouch can be salvaged if sepsis is detected and treated in a timely manner. Even under the best circumstances, pelvic sepsis is often associated with poor functional outcomes. If pelvic sepsis becomes chronic, it could lead to pouch failure. Redo ileal pouch-anal anastomosis (IPAA) is a viable option in the setting of chronic pelvic sepsis to preserve gastrointestinal continuity in motivated patients. It is associated with similar surgical morbidity, acceptable functional outcomes, and good quality of life. Patients should be involved in the decision-making process after ileal pouch failure. In the setting of ileal pouch failure, surgeons with limited experience may not be comfortable offering patients redo IPAA. Redo IPAA requires subspecialization and patients with ileal pouch failure should be treated at specialized high-volume centers.

Volvulus of the ileal pouch-anal anastomosis: a meta-narrative systematic review of frequency, diagnosis, and treatment outcomes.

BackgroundProctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA.MethodsA systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018.ResultsThe frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%).ConclusionPouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.

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.