the failing pouch

Oxford

Colorectal

Restorative Proctocolectomy

The Failing PouchThe Failing Pouch

Neil Mortensen MD FRCS Neil Mortensen MD FRCS Department of Colorectal Surgery Department of Colorectal Surgery

Radcliffe Hospital, OxfordRadcliffe Hospital, Oxford

M62 Course 2006

Oxford

Colorectal


Parks and Nicholls

Proctocolectomy without ileostomy for ulcerative colitis

BMJ 1978;2:65-8

Oxford

Colorectal


Pouches around the World 2000USA 7600

UK 2500

Sweden 2500

Canada 1500

Germany 1100

France 250

Australia 200

Estimated Total 15650

Oxford

Colorectal


Pouch surgery – the ecstasy

Oxford

Colorectal


Pouch surgery – the agony

Oxford

Colorectal


Pouch Failure

Oxford

Colorectal


Bleeding

Infarction

Peritonitis

Anastomotic leak

Pouch cutaneous fistula

Pouch vaginal fistula

Stricture

Small bowel stricture

Pouch complications

Oxford

Colorectal


Oxford Pouch Excision

408 IPAA

30 Pouch excisions, 7 immediate

27 (6.6%) in house

3 elsewhere

Oxford

Colorectal


Oxford Pouch Excision

Reasons for excision

8 pouchitis

6 ischaemia

6 sepsis

5 Crohns

3 incontinence

1 bleeding

1 desmoid

Oxford

Colorectal


Timing of pouch excision

0

1

2

3

4

5

6

7

8

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

number

Oxford

Colorectal


Indications for Pouch Excision at St Mark’s

St Mark’s n=996

Referred n=245 Total

No patients 58(5.6%) 10(4%) 68Pelvic sepsis 28 5 33(48.5%)Pouch fistula 24 4Crohns 3 2Poor function 21 3 24(35.2%)Pouchitis 4 1other 5 1

Karoui, Cohen, and Nicholls DCR 2004

Oxford

Colorectal


Long Term Failure Rates from St Mark’s

Karoui Cohen and Nicholls DCR 2004

Oxford

Colorectal


Please don’t let it

leak

Oxford

Colorectal


Causes of Pouch Failure

49 (8.8%) of 551 pouches failed9 (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

Oxford

Colorectal


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

Oxford

Colorectal


Patient Selection : Patient Selection : Steroids

• 671 patients

• 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

Oxford

Colorectal


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

Oxford

Colorectal


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

Oxford

Colorectal


Long Term Results of IPAA in Patients with Crohn’s Disease

37 patients

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

Oxford

Colorectal


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

Oxford

Colorectal


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

Oxford

Colorectal


Fistula at Anastomosis

Oxford

Colorectal


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

Oxford

Colorectal


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

Oxford

Colorectal


Try Local Repair First if:

• gross sepsis absent

• granulation tissue minimal

• fistulas close to anal verge

• strictures are short

Oxford

Colorectal


Repeat IPAA - indications

• mechanical outlet obstruction

• lack of reservoir capacity

• sepsis

Oxford

Colorectal


Pouch Revision for septic complications35 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

Oxford

Colorectal


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 16Good function 11Pouch excision 6

Sagar et al 1996 BJS

Oxford

Colorectal


Long Term Results of Abdominal SalvageLong 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

Oxford

Colorectal

Restorative Proctocolectomy Cumulative Pouch SurvivalCumulative Pouch Survival

Tekkis et al BJS 2006

Oxford

Colorectal


Restorative Proctocolectomy - Technique

Get it right first timeGet it right first time

Oxford

Colorectal


Oxford

Colorectal


The risks of maintaining Columnar Cuff

- Some 6-10% of the total anorectal mucosa is retained

- risk of malignancy

- risk of inflammation

Oxford

Colorectal


Cuffitis - symptoms

• urgency

• frequency

• leakage

• bleeding

• anal irritation or burning discomfort

Oxford

Colorectal


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

Oxford

Colorectal


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

Oxford

Colorectal


Pouch Vaginal Fistula

• avoid catching vagina with stapler

• repair by endo vaginal advancement flap

• defunction ?

Oxford

Colorectal


Oxford

Colorectal


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%)

Oxford

Colorectal


Pouches Misbehaving Badly - the 3 problem areas

Upstream Small bowel Within the

pouch

Pouch outlet

Oxford

Colorectal


0.5

0.4

0.3

0.2

0.1

0.00 20 40 60 80 100 120 140

overall

chronic

Follow up (m)

Prop

ortio

n of

risk

Keranen et al Dis Col Rect 1997

Cumulative Risk of Pouchitis

Oxford

Colorectal


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?

Oxford

Colorectal


Summary

10% lose pouch

10% have poor function but prefer to keep their pouch

80% report an excellent quality of life

Oxford

Colorectal


But….. Some worries

Increasing numbers of patients needing chronic

ciproxin dosingPerianal disease

being treated with infliximab

the failing pouch

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