Oxford Colorectal People, Pouches and Places:The Generation Game - Pouch Salvage and Reconstruction Prof Neil Mortensen MA, MB ChB, MD, FRCS Eng hon FRCS Glas, hon FRCS Edin Kangaroo Club October 2016

Oxford Colorectal

Parks and Nicholls Proctocolectomy without ileostomy for ulcerative colitis BMJ 1978;2:65-8

Oxford Colorectal Pouches around the World 2014 USA UK 5500 Sweden 2000 Canada 4500 Germany 3000 France 1750 Australia 750 Estimated Total 40,000

Oxford Colorectal Pouch surgery – the ecstasy

Oxford Colorectal

Disparity in experience ACPGBI Pouch Registry 2012

Oxford Colorectal W and J inversion

Oxford Colorectal The Rise of the use of Biologics

Oxford Colorectal 2383 IPAA in ACPGBI Pouch Registry

Oxford Colorectal Redo are 7% total ACPGBI Pouch Registry 2012

Oxford Colorectal Oxford IPAA Redo increased from 0% to 20%

Oxford Colorectal Bleeding Infarction Peritonitis Leak Pouch anal fistula Pouch vaginal fistula Stricture Small bowel stricture Pouch complications

Oxford Colorectal Septic complications 20% ACPGBI Pouch Registry 2012

Oxford Colorectal Please don’t let it leak

Oxford Colorectal n% leaks single stage22 32 previous colectomy49 12* steroids > 15mg15 33 no steroids56 14* under 40 yrs54 13 over 40 yrs17 35* Pemberton et al 1994 Restorative protocolectomy – anastomotic leakage

Oxford Colorectal Site of pouch sepsis After Fazio

Oxford Colorectal Pelvic Sepsis after Pouch Surgery 200 of 3234 pouch patients had septic complications within 3 months Higher rate of pouch failure 19.5% v 4% Incontinence worse Lower CGQoL score Kiely et al DCR 2012

Oxford Colorectal Pouch Failure Pouch excision or defunction for more than 6 months

Oxford Colorectal Two Peaks ACPGBI Pouch Registry 2012

Oxford Colorectal Indications for Pouch Excision at St Mark’s St Mark’s n=996 Referred n=245 Total No patients 58(5.6%)10(4%)68 Pelvic sepsis 28533(48.5%) Pouch fistula 244 Crohns32 Poor function 21324(35.2%) Pouchitis41 other51 Karoui, Cohen, and Nicholls DCR 2004

Oxford Colorectal Long Term Failure Rates from St Mark’s Karoui Cohen and Nicholls DCR 2004

Oxford Colorectal Salvage early and late

Oxford Colorectal Make an early diagnosis High index of suspicion Contrast enema or CT with rectal contrast EUA or digital rectal exam Leakage comes like a thief in the night

Oxford Colorectal Endo sponge – vacuum assisted healing

Oxford Colorectal The Healing Cavity

Oxford Colorectal Indications for Pouch Reconstruction - Mechanical Long efferent limb Small pouch Long blind limb Twisted pouch Intra pouch prolapse or hour glassing Anastomotic stricture

Oxford Colorectal Indications for Pouch Reconstruction - sepsis Partial anastomotic separation Anastomotic sinus Anastomotic stenosis

Oxford Colorectal local abdominal salvage

Oxford Colorectal Local repairs Endoanal pouch advancement Endovaginal repair of pouch vaginal fistula Repeated repairs often necessary Overall 50% success Heriot et al DCR 2005

Oxford Colorectal Pouch reconstruction Cleveland Clinic 241 abdominal reconstructions Indications: Fistula 67, leak 65, stricture 42, pouch dysfunction 40, pelvic abscess new pouch, 170 original pouch refurbished 29 failures Functionally more minor incontinence Remzi et al DCR 2009

Oxford Colorectal Pouch Revision Mayo 51 pouch revisions 65% for septic causes, 35% mechanical Function median 5 pouch emptyings per day Pouch survival 93% 1yr, 89% 5yr Mathis et al Ann Surg 2009

Oxford Colorectal Long Term Results of Abdominal Salvage St Marks 112 underwent 117 pouch salvage procedures Common indications - sepsis 45, stricture 13, retained stump 35 21% pouch failure Associated with Crohn’s, sepsis Tekkis et al BJS 2006

Oxford Colorectal Cumulative Pouch Survival Tekkis et al BJS 2006 overallsepsis

Oxford Colorectal Leaks after IPAA – improved outcomes – 1981/4 v 2001/3 141 of 1424 IPAA 10% leaks 118 from anast and 23 from pouch Non op treatment initially in 100 with 80% success 59 had an operative intervention 34 transanal - 66% success Lap and suture repair in % success Combined AP repair in % success Overall 84% functioning pouch Pouch salvage after leak up from 67% to 88% Raval et al Ann Surg 2007

Oxford Colorectal Most promising candidates - mechanical outflow obstruction Distal segment of an S pouch Ileoanal anastomotic stricture Long retained rectal remnant

Oxford Colorectal Oxford Salvage abdominal redo – one later failure all others closure stoma 1 attempted but thick mesentery and no reach 6 excision 1 excision and conversion to K pouch 11 indefinite diversion

Oxford Colorectal 70% OVERALL SALVAGE INCONTINENCE UNCOMMON The take home message

Oxford Colorectal Complications after redo surgery ACPGBI Pouch Registry 2012

Oxford Colorectal Failure is 3 x worse after redo ACPGBI Pouch Registry 2012

Oxford Colorectal Summary of Treatment Options After Sagar and Pemberton BJS 2012

Oxford Colorectal What if it is not possible to reconstruct ? Excise pouch Convert to a Koch Pouch

Oxford Colorectal Pouch Excision Not for the feint hearted Usually follows sepsis and local destructive effects Must take anus, but healing may be delayed Consider do you really need to take it out? Why not indefinite diversion? Kiran et al DCR 2012

Oxford Colorectal Leaving the Pouch as is –Indefinite Diversion No evidence for mucosal deterioration a median 12 years after IPAA and 3.6yrs after defunction in 20 patients, 5 developed type C villous atrophy, no cancer or dysplasia even in anastomosis biopsies 22 indefinite diversion median 10yrs no cancer or dysplasia and clinically fine Das et al Colorectal Dis 2008 Bengtsson et al Colorectal Dis 2007

Oxford Colorectal Conversion of failed pouch to continent ileostomy 64 patients at Cleveland Clinic 5 yr FU Main indication septic complications in 56% Previous pouch used in 25% Complications in 30% Long term dysfunction 50%, complications 61%, revision 45% Durability 95%, median revision free interval 2.8yrs Lian et al DCR 2009

Oxford Colorectal Pouch Failure Options Local repairAbdominal repair Leave in place Indefinite defunction Repair old pouch Make new pouch Convert to Kock pouch 70% success

Oxford Colorectal Restorative Proctocolectomy - Technique Get it right first time Spend quality time with your anastomosis !

Oxford Colorectal Within a generation we have seen The creation of pouch surgery Technical refinement Advances in medical therapy Now the age of redo surgery

Oxford Colorectal A big thank you for your support