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K. E. Chuquin and B. L. Bello
included “ileal pouch-anal anastomosis”, “ileal pouch”, “IPAA”, “anastomotic
leak” and “sinus”.
PICO table
Patient population
Patients with ileal pouch-anal
anastomosis who developed a
posterior sinus
Intervention Comparator
Observation Operative
intervention
Outcome
Sinus tract healing,
pouch retention
Results
Overall, there is no high-quality literature on pouch sinus management, and the
studies that exist are small and observational or descriptive in nature. Most of the
literature focuses on the treatment of asymptomatic sinus tracts. Reported treatment
methods include watchful observation, sinus tract debridement, tract unroong,
brin glue, and revising or creating a new pouch. Many patients need more than one
treatment to achieve healing. Ultimately, if these methods fail, this may lead to the
need for pouch excision or permanent fecal diversion. Although there is literature
reporting the success rates of various interventions, little exists in the way of guidance on choosing one particular intervention over another.
Delay Ostomy Closure/Watchful Observation
Delay of ostomy closure and observation alone have been shown to have a reasonable healing rate, particularly in the setting of an asymptomatic sinus. If a contained
sinus is detected on pouchogram, observation is usually recommended as the initial
strategy. In the series reported by Ahmed Ali [2], observation alone with delay of
ostomy closure was successful in achieving sinus healing in 65% of patients,
although this was higher in asymptomatic sinus (79%) versus symptomatic sinus
(44%). Slightly lower rates of sinus healing were reported by Akbari [4] who found
that 52.6% of patients treated with delay in ostomy closure and observation alone
ultimately achieved sinus healing without the need for further procedures.
When considering ileostomy reversal and pouch retention, Nyam et al [5]
reported a series of 41 patients with pouch sinuses who were observed for 3- to
6-month periods before repeat pouchogram. All 41 patients eventually had their
ileostomy reversed, although 2 patients required repeat diversion for recurrent sinus
prior to ultimately having their second ileostomy closed. Of the 41 patients in this
series, only one patient ultimately had pouch failure requiring pouch excision.
Debridement
After watchful observation, approximately 62% of patients require additional treatment [2]. Exam under anesthesia with irrigation and debridement can be done safely
6 Persistent Posterior Sinus After Ileal Pouch-Anal Anastomosis
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with mechanical debridement usually with curettage. The success of tract debridement is reported by Akbari [4]. Of 6 patients who underwent EUA with tract
debridement, 4 patients subsequently underwent successful ileostomy closure.
Debridement may also be used in conjunction with other interventions at the time of
operative intervention including during the use of brin glue6 and during tract
unroong [7].
71
Fibrin Glue
Swain and Ellis [6] published a series of 7 patients with persistent low pelvic
anastomotic sinuses including both patients with IPAA and patients with low
colorectal anastomosis done for rectal cancer. All patients were asymptomatic.
After mechanical debridement of the sinus, brin glue was injected to obliterate
the sinus tract. At 11months, 100% of the patients had achieved complete healing
of the sinus.
The series reported by Ahmed Ali [2] included 3 patients treated with brin glue,
although use of glue was employed only as the second or third intervention. Of
these 3 patients, 2 achieved sinus healing. No comment is made on which patients
ultimately received treatment with brin glue and whether or not they were
symptomatic.
Unroofing
Unroong of a sinus involves dividing the common wall of the sinus and adjacent
pouch. Sinus tract unroong has success rates varying from 50% to 100% [7–10],
with multiple techniques for sinus tract unroong have been described.
Whitlow [7] reported outcomes of a cohort of 6 patients with sinuses including
both patients with IPAA and with low colorectal anastomosis. In all patients, the
sinus tract was unroofed using laparoscopic scissors to divide the septum between
the sinus and the bowel. All six patients achieved sinus tract healing at 1year, with
5 of those patients achieving healing at 1month.
Use of a laparoscopic stapler to divide the septum between the bowel and the
sinus tract has also been described. Although not specic to IPAA, Alsanea &
Alabbad [8] report 100% healing of sinus tract using this method in 4 patients with
sinus after low colorectal anastomosis.
Treatment using endoscopic sinusotomy has also been described by Lan [9] in a
series that included 109 patients with IPAA sinus tracts. This is performed using an
endoscopic needle knife to divide the septum before placing endoscopic clips along
the edges of the opened sinus to marsupialize the sinus. Additionally, the sinus tract
is treated with topical doxycycline +/−50% dextrose to encourage brosis. Using
this technique, complete healing was achieved in 49.5% of these patients, and partial healing was reported in 18.3%. The majority of patients did require more than 1
treatment, and sinus recurrence was found in 15% of patients treated with endoscopic sinusotomy alone.
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K. E. Chuquin and B. L. Bello
Ileostomy Closure withPersistent Sinus
In some instances, ileostomy closure has been reported despite the presence of a
persistent asymptomatic sinus. In the series published by Nyam [5], 6 patients ultimately had their ileostomies reversed despite a persistent sinus after a prolonged
period of expectant management. All of these patients were asymptomatic, and at
the time of ileostomy closure, the sinus tract was either stable in size or smaller than
at the time of initial diagnosis. None of these 6 patients developed symptoms after
ileostomy closure, and pouch function was not different than in patients who had
demonstrated sinus healing prior to ileostomy closure.
Redo Pouch
In the absence of sinus healing after more conservative measures, pouch redo may
offer a chance at pouch retention. In the series by Ahmed Ali [2], 3 patients were
ultimately treated with pouch redo with 2 of 3 patients achieving sinus healing and
the remaining patient eventually requiring pouch excision.
In a series by Lan [10] comparing endoscopic sinusotomy to redo pouch surgery,
redo pouch had an initial healing rate of 94.1%, however, there was a 32.5% sinus
recurrence rate. Of the patients that had a sinus recurrence, 73% went on to demonstrate complete healing after additional treatments for an overall healing rate in the
redo pouch group of 85.9%. Although the healing rate was high in the redo pouch
group, the authors point out that the rate of postoperative morbidity was high in the
redo pouch group at 43.5%.
Number of
patients
Study
Ali etal [2] 45 Observation,
Akbari etal [4] 22 Observation,
Alsanea &
Alabbad [8]
Lan etal [10] 226 Unroong
Lan & Shen [9] 109 Unroong
Nyam etal [5] 41 Observation Pouch
Swain etal [6] 7 Fibrin glue Sinus
included Intervention Outcome
4 Unroong
drainage,
unroong,
Closure,
Diversion
Debridement
(stapler)
(endoscopic),
Redo pouch
(endoscopic)
Sinus
healing
Ileostomy
reversal
Sinus
healing
Sinus
healing
Sinus
healing
retention
healing
Success
rate
60% Low
95.5% Low
100% Low
53.2%,
94.1%
49.5% Low
97.6% Low
100% Low
Quality of
evidence
Low
6 Persistent Posterior Sinus After Ileal Pouch-Anal Anastomosis
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Number of
patients
Study
Whitlow etal [7] 6 Sinus unroong
Zhuo [3] 20 Observation,
included Intervention Outcome
Sinus
(scissors)
Debridement,
Unroong
healing
Sinus
healing,
Ileostomy
reversal
Success
rate
100% Low
80%,
80%
Quality of
evidence
Low
73
Recommendations
All reported evidence quality is low given that all data regarding pouch-sinus management comes from small observational studies. Given this, all recommendations
based on that data are weak recommendations.
1. Management of pouch sinus should be individualized based on symptoms, pres-
ence of diverting ileostomy, and prior interventions.
2. Observation with delay of ileostomy reversal is an acceptable initial manage-
ment of an asymptomatic pouch sinus.
Personal View oftheData
Anastomotic complications can lengthen the path to recovery after complex surgery. A pouch sinus from a contained leak demands a measured approach to avoid
any future failures. Most of the literature regarding this topic is focused on the treatment of the asymptomatic sinus and is limited to observational studies and case
series. Thus, the recommendations should be interpreted with caution. The initial
approach should be watchful waiting and delaying three to sixmonths for a repeat
pouchogram since a signicant amount of these tracts resolve or get smaller [2, 4,
5]. Debridement, brin glue, and unroong can then be considered with not any
single approach showing any distinct advantage. Decision on approach is individualized and based on sinus characteristics and surgeon expertise. If a persistent sinus
is still present after initial treatment and remains asymptomatic despite the above
strategy, ileostomy closure can be considered. A redo pouch can also be carefully
considered depending on level of expertise as repeat pouch creation may be more
problematic due to adhesions, inherent difculty in operating in a redo pelvis, and
dealing with possible reach issues. A redo pouch has good success, yet recurrent
sinus is a possibility [10]. Pouch excision and redo also comes with a higher morbidity rate than the index procedure. Further comparative studies are needed to elucidate success rates of these different approaches. Unfortunately, up to 33% patients
ultimately have pouch failure despite above treatments and require permanent diversion [2].
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K. E. Chuquin and B. L. Bello
References
1. Kiely JM, Kiran RP.Leak, stula, sepsis, sinus, portal vein thrombosis. Semin Colon Rectal
Surg. 2019;30(1):7–9. https://doi.org/10.1053/j.scrs.2019.01.003.
2. Ali UA, Shen B, Remzi FH, Kiran RP. The management of anastomotic pouch sinus after
IPAA.Dis Colon Rectum. 2012;55(5):541–8. https://doi.org/10.1097/dcr.0b013e318244087c.
3. Zhuo C, Trencheva K, Maggiori L, Milsom JW, Sonoda T, Shukla PJ, Vitellaro M, Makino T,
Lee SW.Experience of a specialist centre in the management of Anastomotic sinus following leaks after low rectal or ileal pouch-anal anastomosis with diverting stoma. Color Dis.
2013;15(11):1429–35. https://doi.org/10.1111/codi.12436.
4. Akbari RP, Madoff RD, Parker SC, Hagerman G, Minami S, Bullard Dunn KM, Mellgren
AF.Anastomotic sinuses after ileoanal pouch construction: incidence, management, and outcome. Dis Colon Rectum. 2009;52(3):452–5. https://doi.org/10.1007/dcr.0b013e31819a20e0.
5. Nyam D.Does the presence of a pre-ileostomy closure asymptomatic pouch-anastomotic sinus
tract affect the success of ileal pouch-anal anastomosis? J Gastrointest Surg. 1997;1(3):274–7.
https://doi.org/10.1016/s1091- 255x(97)80120- 5.
6. Swain BT, Ellis CN.Fibrin glue treatment of low rectal and pouch-anal anastomotic sinuses.
Dis Colon Rectum. 2004;47(2):253–5. https://doi.org/10.1007/s10350- 003- 0040- 7.
7. Whitlow CB, Opelka FG, Gathright BJ, Beck DE.Treatment of colorectal and ileoanal anastomotic sinuses. Dis Colon Rectum. 1997;40(7):760–3. https://doi.org/10.1007/bf02055427.
8. Alsanea N, Alabbad S.Use of the endostapler for the treatment of non-healing sinus secondary to a dehisced colorectal anastomosis. Tech Coloproctol. 2010;14(3):249–51. https://doi.
org/10.1007/s10151- 010- 0600- 5.
9. Lan N, Shen B. Endoscopic treatment of ileal pouch sinus. Inamm Bowel Dis.
2018;24(7):1510–9. https://doi.org/10.1093/ibd/izy029.
10. Lan N, Hull TL, Shen B. Endoscopic sinusotomy versus redo surgery for the treatment
of chronic pouch anastomotic sinus in ulcerative colitis patients. Gastrointest Endosc.
2019;89(1):144–56. https://doi.org/10.1016/j.gie.2018.08.004.
How toManage Pouch-Perineal
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andPouch-Vaginal Fistula After Ileal
Pouch–Anal Anastomosis
MelindaE.Stack andMonikaA.Krezalek
Introduction
Total proctocolectomy with ileoanal pouch anastomosis is the main surgical treatment for patients who require surgery with a history of ulcerative colitis or those
with familial adenomatous polyposis [1–6]. While many patients who have undergone IPAA have a high quality of life, some patients will develop complications,
such as pouch vaginal or perineal stulae. While an uncommon problem with incidence rates ranging from 2.9–16.7% [7–19], PVF is a source of considerable morbidity for the patient and a technical challenge for the surgeon. Patients who develop
a PVF face high pouch failure rates of 21–30% [7].
PVFs typically present in the rst year after surgery; however, a late presentation
might occur even after 10years from surgery. Due to the relative paucity of published data, optimal management is still debated. However, most agree the management strategy needs to take into account factors related to the etiology of the stula
(surgical related, disease related, or sepsis related), as well as the location of the
stula in relation to the anastomosis. For example, it is important to note that a stapled anastomosis is going to be more cephalad, therefore making a pouch advancement ap to the dentate line a more viable remedial option when PVF complicates
a stapled anastomosis. Conversely, following an index handsewn anastomosis,
pouch advancement may not be a viable option. As for pouch type, Wexner etal.
found no difference in the incidence of PVF for different pouch types [15].
7
M. E. Stack (*)
Colon and Rectal Surgery Associates, Minneapolis, MN, USA
M. A. Krezalek
Department of Surgery, Division of Colon and Rectal Surgery, NorthShore University
HealthSystem, Evanston, IL, USA
e-mail: mkrezalek@northshore.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_7
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M. E. Stack and M. A. Krezalek
Clearly, surgical technique and post operative sepsis are major contributors to the
development of PVF, reemphasizing the need for appropriate technique at the index
operation [18, 20–25]. As inammation often plays a role in the pathogenesis of PVF,
careful review of appropriate histopathologic materials by an expert gastrointestinal
pathologist may be crucial to future management options. This step is especially true
for the 2–3% of patients who undergo IPAA for UC only to nd the long-term diagnosis is Crohn’s disease (CD). Lee etal. [23] found a high correlation between PVF
and CD, with 12 of the 23 women (52%) with a preoperative diagnosis of UC eventually diagnosed with CD.It is worth noting that the average time to development of a
PVF is typically longer in patients with CD, and these patients suffer from a signicantly higher rate of pouch failure and ultimately excision. Often biologics with TNFalpha inhibitors may be considered in those patients with Crohn’s disease [45]. In
addition, patients who undergo IPAA for indeterminate colitis also have a high rate of
pouch complications including PVF and pouch failure [26]. However, patients whose
indication for surgery is familial adenomatous polyposis present with a signicantly
lower rate of PVF when compared to IBD patients [27, 28].
Patients with PVF may be asymptomatic or present with minor symptoms. They
may also present with severe symptoms such as vaginal discharge of fecal material
or gas, recurrent vaginitis, and vulvar irritation. Some cases of asymptomatic PVF
are found on routine pouchography prior to ileostomy closure. Once PVF is suspected, further investigation is needed to conrm the diagnosis and establish its
nature. This will also be important in helping to decide the next course of action. As
noted above, the surgeon should request the pathology slides for expert pathology
review. If not clinically evident, a perineogram and a water-soluble contrast pouchogram may help to diagnose the presence and the level of the stula tract.
Imaging with computed tomography (CT) scan, ideally with contrast enema, may
also help to identify stulous tracts, although magnetic resonance imaging (MRI) T1
weighted with fat suppression and IV gadolinium is preferable. In expert hands, endoanal ultrasound is also helpful in detecting sphincter deformity, especially in women
with a history of vaginal delivery. However, the reliability of endoanal ultrasound is
poor for stula detection because the stulous tracts in PVF are short and wide.
Although clinical examination in the ofce will often conrm the diagnosis,
careful examination under anesthesia (EUA) may be preferable. EUA allows access
to the stula and excludes associated sepsis while overcoming the potential limitations of patient discomfort. It also allows identication of the level of the internal
opening, its relation to the anastomosis (usually the staple line), the direction of the
tract, and the location of the external orice in relation to the vaginal wall, vaginal
fourchette, labia, or perineum. While most tracts are short and straight, they can be
complex and branched, and a low PVF can mask the presence of a higher stula
from the pouch-body to the mid-body of the vagina. If necessary, introduction of
dye such as methylene blue into the pouch, with white swabs placed in the vagina to
identify staining, is useful. Alternatively, for low stulae, hydrogen peroxide gently
instilled into the anus may demonstrate bubbles as they emerge from the vaginal
opening. Lastly, patients should typically undergo anal manometry to assess the
sphincter pressures, and a pudendal nerve terminal motor latency study to assess for
neural impairment, especially in women after childbirth.
7 How to Manage Pouch-Perineal and Pouch-Vaginal Fistula After Ileal Pouch–Anal…
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Table 7.1 Search strategy
P (patients)
Patient who underwent restorative
proctocolectomy with ileal pouch anal
anastomosis and developed a pouchvaginal or pouch-perineal stula
I (Intervention) C (comparator)
See Table1 Not applicable Fistula healing,
O (outcomes)
pouch retention
77
Search Strategy (See Table7.1)
A literature search was carried out to identify articles on PVF.The search was done
on the electronic databases PubMed, Embase, and Medline, from 1980 to December
2022. The main search terms used were ‘pouch-vaginal stula’, ‘ileoanal pouchvaginal stula,’ ‘anal pouch-vaginal stula,’ ‘ileoanal pouch stula’ OR ‘anal pouch
stula.’
Results
Many procedures have been proposed for the treatment of PVF, most of them
adopted from rectovaginal stula repairs [29, 30]. The procedures can be divided
into those performed via a perineal approach or via an abdominal approach. All
studies provide level IV evidence, with small numbers of patients and signicant
heterogeneity. There are no randomized controlled trials and only three systematic
reviews with one meta-analysis on the management of PVF.Pooled results for the
different types of PVF repair are presented in Table7.2.
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Table 7.2 Pooled results for the different types of PVF repair
Type of repair Success rate
Perineal approach
Seton 5/15 (33%)
Fistulectomy 3/22 (14%)
Biological
Collagen plug [33, 46]
Fibrin glue [31, 42]
Transanal ileal advancement ap [9, 10, 14, 15, 18, 23, 31, 34, 46] 95/196 (48%)
Transvaginal [10, 12–15, 18, 35, 36, 46] 49/83 (58%)
Gracilis muscle interposition [15, 31, 37–39, 49, 51] 57/91 (62%)
Transanal pouch advancement [19, 41] 2/4 (50%)
Abdominoperineal approach
(a) Abdominoperinal approach [10, 15, 16, 18, 19, 31, 42–44, 46] Overall success 50–75%
Pouch advancement 8/16 (50%)
Redo pouch 38/65 (58%)
(b) Pouch excision 60/401 (15%) 100%
(a) Some studies not indicating different success rates for pouch advancement vs redo pouch
(b) Number represents percentage of patients eventually requiring pouch excision
M. E. Stack and M. A. Krezalek
1/14 (7%)
2/6 (33%)
Perineal Approach
Seton Drain
A draining seton is mainly used for controlling pelvic sepsis and for dening the
stula tract. One study [12] reported a success rate of 25% in patients with the use
of a seton as denitive treatment. However, Wexner etal. (0/2) [15], Mallick etal.
(0/3) [10] and Shah etal. (0/5) [18] all reported 100% failure rates. Tsujinaka etal.
[31] showed complete healing in one patient with an asymptomatic stula. To date,
there is no evidence to support seton use except for initial control of sepsis before
denitive repair. Most studies chose not to include patients treated with setons in
their nal analysis, instead focusing on patients undergoing procedures with a clear
intent to close the stula. Despite the widespread use of seton drain placement
before attempting a denitive repair of PVF, there are no studies showing denitive
data impacting the outcome.
Fistulectomy
The coring out of the stula tract with repair of the internal opening at the pouch
level has been described with disappointing results [12, 14, 15]. With little evidence
available to support its use in the management of PVF, more recent studies have not
included it as an option in their approach.
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Biological Therapy
The use of a collagen plug to treat PVF was rst reported by Gonsalves etal. [32].
While initial healing rates of 57% at 16weeks (4/7) were promising, long term results
showed 0/11 PVF successfully healed at 2years [33]. Early success was probably
related to the persistence of the collagen plug within the tract, but failure of local tissue in-growth coupled with the relatively short length of PVF led to long- term failure.
Sapci etal. had success in 1/3 (33%) patients with use of a stula plug, though this
was limited to patients with a stula distal to the anastomosis [46]. Tsujinaka etal.
[31] reported the instillation of brin glue in the stula tract with complete healing in
one patient with a minimally symptomatic stula and failure in 2/3 symptomatic
patients who eventually required pouch advancement and a redo pouch.
Transanal Ileal Advancement Flap
An ileal pouch advancement involves mobilizing a ap of mucosa and submucosa
from the ileal pouch, excising the internal opening, and then advancing the ap
beyond the internal stula opening where it is sutured in place. Mallick etal. [10]
reported healing rates of 42% (20/48) when advancement ap was performed as a
primary procedure and 66% (4/6) when performed secondarily after a different procedure. Tsujinaka etal. [31] showed healing rates of 60% (6/10), while Shah etal.
[18] and Ozuner etal. [34] reported success rates of 44% (17/39) and 45% (15/24),
respectively. Lee etal. [23] had a slightly higher success rate of 50% (10/20), with
the rate increasing to 83% (10/12) when excluding patients with CD.Wexner etal.
[15] reported successful stula healing in 8/16 patients with this approach in a survey of North American colorectal units, whereas Groom et al. [14] reported only
one success in 10 attempts. Sapci etal. reported a success of 14/23 (61%) of patients,
with most of these stulae located below the anastomosis (18/23) [46]. Pellino etal.
performed a meta-analysis including 34 total articles with 770 total patients and
reported an overall recurrence rate with this technique at 56.9% [47].
Advantages of the ileal pouch advancement ap include the relative simplicity of
the procedure with more distal mobility of the ap [9]. The disadvantages of this
approach include the suboptimal exposure, the risk of damage to the sphincters in
patients with borderline incontinence, and the fact that the ap lies on the highpressure side of the PVF.
Transvaginal Repair
Transvaginal repair is commonly one of the rst interventions used for treatment of
low PVF.These stulas are usually the result of ileal-anal anastomotic disruption or
inclusion of the vaginal wall in the anastomosis at the time of pouch creation.
Advantages of the transvaginal approach include improved exposure compared to
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