1. Management of the Problem Pouch
Bruce George
Oxford University Hospitals

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. For every failed pouch, there are a few injured

7. Phase 1 assessment of poor pouch function
History of poor function
Always bad
Recent deterioration
Review histology
Review peri-operative course
Clinical examination PR
Pouchoscopy + biopsy
Stool culture

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

9. Phase 2 Assessment of persistent poor pouch function
Inside
Flexible pouchoscopy + biopsy
pouchogram
Outside
CT or MR pelvis
Below
Sphincter physiology and ultrasound
Pouchogram
EUA, pouch and cuff biopsies
Above
MRE
endoscopy
Emptying the pouch
Dynamic evacuating “proctography”

10. INSIDE THE POUCH Chronic pouchitis Irritable pouch
Small volume/non compliant pouch
Ischaemia
Cmv/c diff
Collagenous pouchitis

11. OUTSIDE THE POUCH Pelvic abscess/induration Fistula
Unrelated pathology
Fibroid, desmoid

12. Below the pouch Stenosis/induration at anastomosis
Pouch-vaginal fistula
Sphincter weakness
Cuffitis
Long rectal cuff

13. ABOVE THE POUCH Adhesions Bacterial overgrowth Crohn’s disease
Pre-pouch ileitis
NSAIDs
coeliac

14. EMPTYING THE POUCH
Intussusception/prolapse
Anismus

15. Treatment
Dependant on identification of cause of poor pouch function

16. Phase 3 the really failing pouch
Septic
Peri-pouch fistulae
Strictured, indurated pouch-anal anastomosis
Long retained rectal cuff
Severe pouchitis
Mechanical
Small pouch
Long blind end
Long efferent spout
intussusception
Suspicion of Crohn’s disease
Chronic resistant pouchitis

17. Surgical options for the failing pouch
Indefinite diversion
with pouch excision
with pouch left in-situ
Re-do pouch reconstruction
Kock pouch

18. operative procedure

19. operative procedure

20. operative procedure

21. operative procedure

22. operative procedure

23. operative procedure

24. operative procedure

25. Summary Structured approach to poor pouch function
Joint with gastroenterologists
Probably main argument for large volume units
Avoid salvage surgery if possible