Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course 2011 The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford

Pouch surgery – the agony

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

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 28 5 33(48.5%) Pouch fistula 24 4 Crohns 3 2 Poor function 21 24(35.2%) Pouchitis 1 other Karoui, Cohen, and Nicholls DCR 2004

Causes of Pouch Failure 49 (8.8%) of 551 pouches failed 9 (1.6%) defunctioned - 21 (39%) anastomotic leak - 13 (23%) poor function - 7 (12%) pouchitis - 7 (12%) pouch leakage - 7 (12%) perianal disease - 3 (5%) various MacRae et al Dis Col Rect 1997

Timing of pouch excision number 1 2 3 4 5 6 7 8 9 10 <20 years after pouch construction

Initial Assessment of Poor Pouch Function History of poor function Always bad Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy

Common problems Pouchitis Pouch-anal anastomotic stricture Cuffitis Metronidazole ciprofloxacin Pouch-anal anastomotic stricture EUA + gentle dilatation Cuffitis topical steroids or mesalazine

Persisting poor function Look: In the pouch Outside the pouch Below the pouch Above the pouch

Problems Arising in the Pouch Pouchitis Inadequate pouch volume (n = 200 - 450 ml) Abnormal motility

Problems outside the pouch: Pelvic abscess

Problems below the pouch Pouch anal anastomotic stenosis (9-19%) Pouch vaginal fistulas (4-10%) Poor sphincter function Cuffitis Paradoxical puborectalis contraction

Small Bowel Problems above the pouch Adhesions 15-30% symptomatic 5-10% need re-operation Functional obstruction - ileal brake Small bowel bacterial overgrowth Crohn’s disease (5-7%)

Assessment of persistent poor pouch function Inside Flexible pouchoscopy + biopsy Outside CT or MR pelvis Below Sphincter physiology and ultrasound Pouchogram Defaecating pouchogram EUA, pouch and cuff biopsies Above Small bowel enema

Cuffitis - Treatment medical - largely empirical - steroids, per anal or oral - 5ASA compounds, per anal or oral - lignocaine jelly, per anal surgery - mucosectomy Curran & Hill 1992 - mucosectomy & pouch advancement Fazio & Tjandra 1994

Treating the early abscess or anastomotic dehiscence EUA assessment Abscess – drain mushroom catheter, CT drain Dehiscence – drain, early resuture or advancement Wait, pouchogram, consider re operation

Cumulative Risk of Pouchitis 0.5 0.4 0.3 overall Proportion of risk 0.2 0.1 chronic 0.0 20 40 60 80 100 120 140 Follow up (m) Keranen et al Dis Col Rect 1997

Fistula at Anastomosis

Pouch related fistula 59 of 1040 IPAA 24 pouch vaginal 11 pouch cutaneous 16 pouch perineal 8 pouch presacral 32% eventually excised Ozuner et al Dis Col Rect 1997

Try Local Repair First if: gross sepsis absent granulation tissue minimal fistulas close to anal verge strictures are short

Repeat IPAA - indications mechanical outlet obstruction lack of reservoir capacity sepsis

Pouch Revision for septic complications 35 patients repeat IPAA Outcome 86% functioning pouches, 4 excised Function 57% good, 43% fair or poor, Pad usage and seepage 60-70% Fazio et al Ann Surg 1998

Summary Initial Assessment of Poor Pouch Function History of poor function Always bad Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy

Summary Assessment of persistent poor pouch function Inside Flexible pouchoscopy + biopsy Outside CT or MR pelvis Below Sphincter physiology and ultrasound Pouchogram Defaecating pouchogram EUA, pouch and cuff biopsies Above Small bowel enema