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

2. Pouch surgery – the agony

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

4. 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

5. 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

6. Timing of pouch excision
number
< years after pouch construction

7. 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

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

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

10. Problems Arising in the Pouch
Pouchitis
Inadequate pouch volume (n = ml)
Abnormal motility

11. Problems outside the pouch:
Pelvic abscess

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

13. 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%)

14. 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

15. 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

16. 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

17. 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

18. Fistula at Anastomosis

19. 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

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

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

22. 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

23. 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

24. 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