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

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

3. Pouches around the World 2000
USA UK
Sweden
Canada
Germany
France
Australia
Estimated Total

4. Pouch surgery – the ecstasy

5. Pouch surgery – the agony

6. Pouch Failure

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

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

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

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

11. 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

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

13. Please don’t let it leak

14. 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

15. Restorative Proctocolectomy - Anastomotic Leakage
n % leaks
single stage
previous colectomy *
steroids > 15mg
no steroids *
under 40 yrs
over 40 yrs *
Pemberton et al 1994

16. 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

17. 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

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

19. 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

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

21. 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

22. Fistula at Anastomosis

23. 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

24. 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

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

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

27. 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

28. 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
Good function
Pouch excision
Sagar et al BJS

29. 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

30. Cumulative Pouch Survival
Tekkis et al BJS 2006

31. Restorative Proctocolectomy - Technique
Get it right first time

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

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

35. 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

36. 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

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

39. 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%)

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

41. 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

42. 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?

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

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