M62 Course 2006 The Failing Pouch Neil Mortensen MD FRCS Department of Colorectal Surgery Radcliffe Hospital, Oxford

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

Pouches around the World 2000 USA 7600 UK 2500 Sweden 2500 Canada 1500 Germany 1100 France 250 Australia 200 Estimated Total 15650

Pouch surgery – the ecstasy

Pouch surgery – the agony

Pouch Failure

Pouch cutaneous fistula Pouch complications Pouch cutaneous fistula Pouch vaginal fistula Stricture Small bowel stricture Bleeding Infarction Peritonitis Anastomotic leak

Oxford Pouch Excision 408 IPAA 30 Pouch excisions, 7 immediate 27 (6.6%) in house 3 elsewhere

Oxford Pouch Excision Reasons for excision 8 pouchitis 6 ischaemia 6 sepsis 5 Crohns 3 incontinence 1 bleeding 1 desmoid

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

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

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

Please don’t let it leak

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

Restorative Proctocolectomy - Anastomotic Leakage n % leaks single stage 22 32 previous colectomy 49 12* steroids > 15mg 15 33 no steroids 56 14* under 40 yrs 54 13 over 40 yrs 17 35* Pemberton et al 1994

Patient Selection : Steroids 20 mg Prednisolone threshold no differences in septic complications IPAA without diversion, 50% complication on high dose steriods Ziv et al Dis Col Rect 1996

Incidence and Impact Pelvic Abscess after IPAA 73 of 1508 pelvic abscess pouch failure 26% 55% need transabdominal salvage 8% local surgery 37% non surgical functional outcome poorer Farouk et al Dis Col Rect 1998

Patient Selection - indeterminate colitis 71 indeterminate v. 1232 UC no difference in frequency, continence or pouchitis failure rate 19% v. 8% McIntyre et al Dis Col Rect 1995

Long Term Results of IPAA in Patients with Crohn’s Disease Original diagnosis UC (22), indeterminate (9), Crohn’s (6), Complex fistulas in 11 Site of Crohn’s pouch (20), anal (4), both (10) Failure in 17 Sagar et al Dis Col Rect 1996

Pouch Failure & Crohn’s - Cleveland Clinic Overall failure 3.4%, 1.1% non function Of 34 failures - 17 had Crohn’s 25% Crohn’s fail Fazio et al Ann Surg 1995

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

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

Pouch Related Fistula after Restorative Proctocolectomy 21 patients, in 6 > 5 m after ileostomy closure Site : anastomosis 14 vertical staple line 2 efferent limb end 5 Adverse factors : late fisutula enterocutaneous pouch vaginal suspect Crohn’s Paye et al 1996 BJS

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

Pouch Revision by Disconnection - Reconnection 23 patients 9 long efferent 4 sepsis fistula 3 redundant blind limb 3 twisted pouch 3 anastomotic problem Pouch Salvaged in 16 Good function 11 Pouch excision 6 Sagar et al 1996 BJS

Long Term Results of Abdominal Salvage 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

Cumulative Pouch Survival Tekkis et al BJS 2006

Restorative Proctocolectomy - Technique Get it right first time

The risks of maintaining Columnar Cuff - Some 6-10% of the total anorectal mucosa is retained - risk of malignancy - risk of inflammation

Cuffitis - symptoms urgency frequency leakage bleeding anal irritation or burning discomfort

Cuffitis and Inflammatory Changes 113 patients, 715 biopsies acute inflammation in columnar cuff in 13% in 9% symptomatic with endoscopic inflammation no relationship with pouchitis, pouch frequency or anastomotic height Thompson-Fawcett, Warren, Mortensen Dis Col Rect 1999

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

Pouch Vaginal Fistula avoid catching vagina with stapler repair by endo vaginal advancement flap defunction ?

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

Pouches Misbehaving Badly - the 3 problem areas Upstream Small bowel Within the pouch Pouch outlet

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

Refractory Pouchitis Review the previous histology Is there a pelvic abscess? Is there partial obstruction to ileum? Is there a small bowel motility disturbance Is there dietary intolerance?

Summary 10% lose pouch 10% have poor function but prefer to keep their pouch 80% report an excellent quality of life

But….. Some worries Increasing numbers of patients needing chronic ciproxin dosing Perianal disease being treated with infliximab