Redo Ileal Pouch-anal Anastomosis Research Articles

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.

Redo ileal pouch‐anal anastomosis: outcomes from a case–controlled study by Rossi et al.

Redo ileal pouch‐anal anastomosis: outcomes from a case–controlled study by Rossi <i>et al</i>.

P644 Factors and salvage surgery for treatment of pouch failure after restorative proctocolectomy for ulcerative colitis – a single-institution study

Background: For many patients with ulcerative colitis (UC), total colectomy and pouch surgery (ileal pouch-anal canal anastomosis (IACA), ileal pouch-anal anastomosis (IAA)) are performed, improving the quality of life (QOL). However, pouch failure occurs in some patients, markedly reducing their QOL. In this study, we examined the course of patients with pouch failure. Methods: Of 1,156 patients who underwent total colectomy and pouch surgery under a preoperative diagnosis of UC between 1992 and 2015, the subjects were 26 patients (2.2%) in whom pouch-associated complications led to pouch failure (ileostomy state for 2 years or more or pouch resection). Total colectomy was indicated for 14 patients with refractory UC, 12 with severe UC, and 1 with cancer/dysplasia. Concerning techniques, IACA was selected for 21 patients, and IAA for 5. The median age at the time of pouch surgery was 31 years. The median interval from surgery until the appearance of complication-related symptoms was 19.5 months. The median follow-up period from pouch failure was 60 months. Results: Among complications causing pouch failure, fistulae from the anastomotic site accounted for 38% (10 patients), the highest percentage. In 4 of these, suture failure was noted as an early complication. In addition, anal canal-associated complications were observed in 34% (9 patients: 7 with anal fistulae, 1 with a vaginal fistula, and 1 with a pouch fistula (5%)). The final outcomes consisted of anal and pouch excision in 11 patients (after re-ileal pouch anal anastomosis in 2), pouch vacant in 14, and redo ileal pouch anal anastomosis in 1 (12%, 3/26). Of these, 1 required additional ileostomy. Finally, concerning the pouch function after stoma closure, the frequency of defecation was 10 to 15 times/day in both patients, facilitating rehabilitation. Conclusions: In UC patients with pouch failure, the incidence of complications related to fistulae from the anastomotic site was high, suggesting the possibility of early suture failure. For 92% of the subjects, permanent ileostomy was selected. However, redo ileal pouch anal anastomosis was possible in some patients, and closure was possible after temporary ileostomy in others. Treatment methods must be examined in accordance with individual patients.

Redo Ileal Pouch Anal Anastomosis after a Failed Pouch in Patients with Crohn’s Disease: Is it Worth Trying?

Redo Ileal Pouch Anal Anastomosis after a Failed Pouch in Patients with Crohn’s Disease: Is it Worth Trying?

Functional and Manometric Outcomes after Redo-Ileal Pouch Anal Anastomosis in Patients with Ulcerative Colitis

Aim: To retrospectively analyze manometric findings in patients with ulcerative colitis who underwent redo-ileo anal anastomosis for pouch-related complications. Methods: Functional and anal manometric parameters were analyzed before, immediately after, and 6 months after the procedure in 17 patients who underwent redo-ileo anal anastomosis between 2001 and 2012. Results: Of the 17 patients, 13 showed stoma closure and 9 have maintained gastrointestinal continuity with functional pouches. Manometric findings were similar before and immediately after redo-ileo anal anastomosis, including length of high-pressure zone (p = 0.11) and maximum resting and (p = 0.060) squeezing (p = 0.69) pressures, but maximum resting pressure improved significantly 6 months later (p = 0.021). Univariate analysis showed that ulcerative colitis duration <3 years before ileo anal anastomosis (p = 0.0073), interval between pouch-related complications and ileo anal anastomosis <2 years (p = 0.040), and persistent abscess before diversion ileostomy (p = 0.0024) were significant risk factors for pouch failure after redo-ileo anal anastomosis. Conclusions: Although maximum resting pressure was significantly reduced 3 months after redo-ileo anal anastomosis, it returned to preoperative levels after 6 months. The length of the high-pressure zone and the maximum squeezing pressure were not affected by this procedure.

Redo Ileal pouch-anal anastomosis combined with anti-TNF-α maintenance therapy for Crohn’s disease with pelvic fistula: report of two cases

Pouch failure has been reported to occur after ileal pouch-anal anastomosis for Crohn's disease. We report two cases of patients with Crohn's disease, who underwent redo ileal pouch-anal anastomosis (redo-IPAA) combined with anti-TNF-α maintenance therapy, with good functional results. The first patient, a man with presumed ulcerative colitis, suffered pelvic fistula recurrence and anastomotic dehiscence. He underwent redo-IPAA, at which time longitudinal ulcers were found. Infliximab was started 4 days postoperatively and continued. The second patient, a woman treated for ulcerative colitis, underwent laparoscopic IPAA 8 years later. After the development of a pelvic fistula, twisted mesentery of the ileal pouch was found intraoperatively and Crohn's disease was diagnosed. Adalimumab therapy resulted in fistula closure. Redo-IPAA was performed to normalize the twisted mesentery of the ileal pouch. No complications have been observed in either patient, both of whom have experienced good functional results after closure of the covering stomas.

Prevalence and risk factors for adenomas in the ileal pouch and the afferent loop after restorative proctocolectomy for patients with familial adenomatous polyposis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the treatment of choice in familial adenomatous polyposis (FAP) to prevent the risk of colorectal cancer. However, it currently is recognized that adenomas may develop in the ileal pouch. The risk of adenoma occurring in the afferent ileal loop above the pouch is less clearly identified. This study aimed to evaluate the difference in prevalence of adenomas between the ileal pouch and the afferent ileum after IPAA in FAP. The study analyzed 442 endoscopies performed between 2003 and 2008 for 139 FAP patients. The patients had undergone an IPAA in 118 cases, an ileorectal anastomosis in 13 cases, or an ileostomy in 8 cases. Among the 118 IPAA patients, 57 (48.3%) had pouch adenomas a median of 15years after surgery. The risk factors for pouch adenomas were delay since pouch construction [odds ratio (OR), 1.11; p=0.016] and presence of advanced duodenal adenomas (OR, 4.35; p=0.011). Seven patients had pouch adenomas with high-grade dysplasia. Only nine patients had afferent ileal loop adenomas (6.5%). The only significant risk factor for ileal adenomas was the presence of pouch adenomas (OR, 2.16; p=0.007). After restorative proctocolectomy in FAP, adenoma recurrence is frequent in the pouch, with a higher risk for patients with advanced duodenal adenomas and an increasing risk over time, whereas adenomas are rarely found in the afferent ileal loop. This finding may help to propose redo ileal pouch anal anastomosis if required.

Outcome of Salvage Surgery for Ileal Pouches Referred with a Diagnosis of Crohn's Disease

Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis. We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate. Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8-4.9). Median follow-up was 1.7 years (interquartile range, 1.0-3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

Redo ileal pouch–anal anastomosis for malfunctioning pouches–acceptable alternative to permanent ileostomy?

Background: Pouch complications after ileal pouch–anal anastomosis (IPAA) can result in morbidity and pouch loss. Recent reports describe success with redo IPAA. This study was conducted to assess the outcome of malfunctioning pouches treated by redo IPAA. Methods: All patients undergoing redo IPAA between 1983 and 1999 were identified and clinical records studied. Redo IPAA was defined as an operation for malfunctioning pouch with pelvic dissection and disconnection, pouch revision, and reanastomosis. Analyzed were etiology, presentation, diagnostic modalities, surgical management, pouch loss, and outcome. Follow-up was obtained by telephone or mailed survey. Results: Between 1983 and 1999, 650 IPAA procedures were performed, 6 (0.9%) of which required redo IPAA. Ten referred patients required redo IPAA. These 16 cases included 7 anastomotic disruptions, 3 pouch-vaginal fistulae, 2 recurrent polyps after stapled IPAA, 2 megapouches, 1 cuff abscess, and 1 straight pullthrough. All patients underwent redo IPAA with pouch salvage 100% in this series. Twelve had the original pouch repaired and 4 new pouches. Six patients (37%) had complications and outcome was acceptable with 7.8 stools per day and nighttime incontinence “rarely” or “never” in 7 patients. Eight described results as “good,” 6 as “fair.” Conclusions: Redo IPAA can be performed with few complications, an acceptable outcome, and should result in low pouch loss.