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Quality of
Quality of Life
evidence
Moderate
6.5 vs 8.1 (P=0.005)
6.4 vs 7.9 (P=0.008)
5.6 vs 7.1 (P=0.026)
0.6 vs 0.8 (P=0.005)
38.8 vs 48.8
Measure Results IS vs PE
QOL
QOH
Energy level
CGQL score
SF-12 MCS
(P=0.004)
38.4 vs 46.6
(P=0.014)
No signicant
SF-12 PCS
Urinary function
Sexual function
difference
No signicant
difference
Moderate
No signicant
difference
No signicant
difference
Stoma retraction 7% vs
SF-36
CCF QoL
Stoma function
Bladder function
Sexual function
W. Alexander and S. Eisenstein
47% (P=0.003).
No signicant
difference
Ability to maintain
erection worse in male
patients after PE
(P=0.05).
Follow up (median
years, range)
Reason for pouch failure
(IS vs PE)
Type of Study Study size (N)
Table 8.2 Direct comparison of Pouch Excision to Diversion
IS: 9.9 (2.3–21.5)
PE: 9.8 (1.3–24.8)
Septic event: 48.4% vs
37.1%
Outlet obstruction:
19.4% vs 13.3%
Pouchitis: 12.9% vs
21.9%
PE: 105
Retrospective IS: 31
Kiran
etal.
(2012)
[5]
IS: 6 (1–20)
PE: 4 (0–15)
Poor function: 9.7% vs
14.3%
Other: 9.7% vs 13.3%
Sepsis (including
stula): 64% vs 68%
PE: 31
Retrospective IS: 22
Das
etal.
Poor function: 32% vs
26%
Pouchitis: 4% vs 6%
(2006)
[7]
Outcomes after direct comparison of pouch excision to diversion
IS Pouch left in-situ, PE Pouch excision, QoL quality of life, QoH quality of health, CGQL Cleveland Clinic Global Quality of Life score, SF-12 MCS San
Francisco Mental Component Summary, SF-12 PCS San Francisco Physical Component Summary, SF-36 San Francisco-36 Survey
8 Ileal Pouch–Anal Anastomosis Failure: What toDo?
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Creation ofDiverting Loop Ileostomy withPouch Left In-Situ
As mentioned previously, creation of a diverting loop ileostomy is the least invasive management approach for pouch failure. While a diverting loop ileostomy
may be created with the intent of permanent defunctioning diversion, it allows for
continued possibility of restoration of continuity while also allowing for pouch
excision based on resulting clinical outcomes. When considering the potential
downfalls of leaving the pouch in-situ at the time of initial operation of failed
pouch management, patient quality of life and concerns for potential malignant
transformation of the remnant mucosa have been considered. Prior studies have
suggested that chronic inammation of the ileal pouch following IPAA may result
in dysplasia with potential progression to adenocarcinoma with other studies
reporting rare cases of malignancy developing following IPAA [8–12].
Patient Satisfaction ofPouch Left In-Situ
In their series of 460 patients, Foley etal. report 21 cases requiring defunctioning
ileostomy creations [13]. Of these 21 patients, 5 ultimately went on to have successful restoration of continuity, all in the absence of Crohn’s disease. It should be
noted that all 5 of the successfully restored patients required additional procedures prior to ileostomy takedown as diversion alone was not sufcient to eradicate the underlying complications. Of the remaining 16 patients who had pouch
failure, 7 underwent pouch excision; 5 for extensive stulation related to Crohn’s
disease, 1 for infarcted pouch related to mesenteric injury, and 1 with persistent
anal incontinence despite re-diversion. The remaining 9 patients were adequately
treated with permeant ileostomy diversion alone with good patient satisfaction.
Of 620 patients who underwent IPAA, Bengtsson etal. identied 56 pouch failures including 23 pouch excisions, 22 defunctioned pouches in-situ, and 11 pouches
converted to continent ileostomy [14]. Of the 22 defunctioning procedures with
pouch in-situ, patients had a median follow up time of 3.5years with twenty patients
reporting minor mucous discharge peranus and two patients reporting anal pain. Of
note, no patients requested further operative management and a majority were
reported to have had “satisfactory ileostomy function”.
The available literature highlights the comparable patient satisfaction of
defucntioning ileostomy without pouch excision while maintaining a theoretical
possibility of restoring intestinal continuity. These conclusions, however, are limited by the lack of standardized quality of life measures such as the Short-Form
36-item quality-of-life questionnaire and lack of comparison to alternative forms of
management. While maintaining patient satisfaction, fecal diversion with pouch left
in-situ mitigates the considerable morbidity associated with pouch excision [15–
17]. However, when considering the risks and benets of primary defunctioning
ileostomy, ndings by Foley etal. highlight the need for consideration of the underlying disease process (e.g. Crohn’s disease) when counseling patients on best initial
management approach and likelihood of need for future procedures and/or pouchexcision [13] (Table8.3).
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Quality of
evidence
Poor
Quality of life
measure Results IS vs PE
Follow up
(median years,
range)
Unspecied Not included Pouch excision
selectively
reserved for
patients with
extensive
perianal sepsis
or stulization
persisting after
re-diversion.
Unable to make
meaningful
comparisons
Poor
given population
differences
results of PE
Not included No functional
c
14 (0.5–22)
W. Alexander and S. Eisenstein
reported for
comparison
Etiology of
pouch failure (IS
vs PE)
Pouch stula:
57%
Pouchitis: 19%
a
PE: 7
Type of study Study size (N)
Prospective IS: 14
Foley etal.
Table 8.3 Outcomes after Pouch Diversion
(1995) [13]
Anastomotic
stricture: 14%
Anastomotic
separation: 14%
b
Miscellaneous:
9.5%
Pelvic sepsis:
41% vs 39%
Poor function:
36% vs 48%
Pouchitis: 4.5%
PE: 23
Prospective IS: 22
Bengtsson etal.
(2007) [14]
vs 22%
Fissure: 4.5% vs
4.3%
Outcomes after pouch diversion when not compared directly to pouch excision
Etiology of pouch failure not subdivided to IS vs PE
Continuity restored in 5 of 14
IS Pouch left in-situ, PE Pouch excision
Median follow up data provided for IS only
a
b
c
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Morbidity ofPouch Left In-Situ
Bengtsson etal. report that of the 22 patients with defunctioning ileostomy with
pouch left in-situ, thirteen completed endoscopic evaluation of the retained pouch
(mean pouch age 13.8 years, mean time after diversion 8.2years) [14]. Of this
group, no cases of dysplasia or carcinoma was found. One patient was seen to have
atypia however this was interpreted as reactive due to severe inammation. The
authors concluded that a retained pouch results in high patient satisfaction and carries little malignant potential without need of additional routine surveillance. These
ndings are further supported by Kiran etal. who found that none of 18 patients
with pouch in situ and long term follow up developed pouch dysplasia or cancer [5].
Ileostomy Creation withPouch Excision
Patient Satisfaction ofPouch Excision
In their relatively small study, Tan etal. investigated the differences in quality of life
between patients who underwent proctocolectomy with initial conventional ileostomy creation and IPAA failure requiring ileostomy creation with pouch excision
[18]. Utilizing the Short-Form 36-item quality-of-life questionnaire, Tan etal. conclude that the two groups demonstrate comparable quality of life with the pouch
excision group only reporting increased troublesome bowel symptoms (though no
signicant difference in systemic symptoms, functional impairment, social impairment, emotional impairment, or global score). Lepisto etal. expanded on this body
of data by comparing Short-Form 36-item quality-of-life questionnaire scores
between pouch excision, intact IPAA, and the healthy population [19]. The group
conclude that the pouch excision group had signicantly decreased physical function (P<0.003), energy (P<0.01), and social function (P<0.05) when compared
to intact IPAA control group. This data should be taken with careful consideration
as it is generally accepted that patients with pouch failure have increased morbidity
due to the underlying pathology (including Crohn’s) related to pouch failure; this
observed difference may be a product of this morbidity over the morbidity related to
ileostomy creation and pouch excision. While the available data on patient satisfaction following IPAA failure with pouch excision is invaluable in setting patients’
expectations, it provides little guidance in directly management of pouch failure
given the absence of comparison to defunctioning ileostomy with pouch left in situ
and continent ileostomy creation (Table8.4).
Recommendations Based ontheData
1. Permanent diversion of ileal pouch carries minimal risk of pouch-related neopla-
sia. (Strong Recommendation based upon low-quality of evidence)
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Quality of
evidence
Health- related
quality of life
(HRQOL): PE
vs control
Quality of life
measure
Follow up
(median years,
range)
Weak
5.64 vs 6.13
(P=0.03)
Weak
Otherwise no
signicant
difference
2–16years SF-36 Physical
function 73 vs
93 (P=0.003)
Energy 51 vs 65
(P=0.01)
Role function
W. Alexander and S. Eisenstein
(physical) 55 vs
83 (P=0.05)
No signicant
difference in
remaining
domains
Reason for
pouch failure (IS
Table 8.4 Outcomes after Pouch Excision
vs PE)
– – SF-36 Bowel function:
Control
(proctocolectomy
Type of study Study size (N)
Retrospective PE: 9
Tan etal.
(1998) [18]
Fistula: 21% [5]
Pouchitis: 12.5%
with initial end
ileostomy): 14
Control:
Retrospective PE: 18
Lepiesto etal.
(2002) [19]
[3]
Pouchitis with
stula: 8.3% [2]
Incontinences:
(successfull
IPAA): 18
21% [5]
Crohns: 17% [4]
Other: 21% [5]
Outcomes after pouch excision when not compared directly to pouch diversion
PE pouch excision
8 Ileal Pouch–Anal Anastomosis Failure: What toDo?
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2. Pouch excision carries a greater risk of operative morbidity than diversion alone.
(Weak Recommendation based upon low-quality of evidence)
3. Pouch excision may impart better long-term quality of life than diversion alone
for patients who experience QoL limiting symptoms from their diverted pouch.
(Weak Recommendation based upon low-quality of evidence)
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Personal View
Patients who are experiencing pouch failure have often suffered a signicant insult
by the time they are prepared to undergo denitive intervention. The patients are
often malnourished, anemic, on immunosuppressive medications, and experiencing
signicant pain as well as other systemic symptoms. The goal will always be to
maximize the patient’s quality of life while exposing them to a surgery with an
acceptable risk prole. While pouch revision may be an option for some patients,
we have chosen to omit that population for the purpose of this chapter understanding that the question being asked is whether to divert or excise the pouch once a
patient has exhausted their other options. Often times the answer is yes to both of
these options.
Pouch excision in and of itself can be an incredibly morbid procedure in a sick
patient and thus the denitive options is often a step-wise process where the pouch
is diverted rst and the patient is allowed to recover. Pouch diversion can be seen as
a bridge to allow the patient to both recover their health and to remember that an
ileostomy can impart an improvement in the quality of life while allowing time for
making important decisions about what their future will hold. The potential for
reversibility is often important when a patient makes the decision to undergo diversion from a poorly functioning pouch. When diverting the pouch, it is important to
ensure that the surgeon leaves themselves maximal exibility for a patient’s future
needs and depending on the etiology of the pouch failure. If there is a possibility for
a redo IPAA, it is important to construct the ileostomy in such a way that it can be
used in a future pouch, about 20cm proximal to the pouch inlet [20].
Ultimately, many patients will either opt not to restore continence or will not
have the option to restore continence given the etiology of their pouch failure. For
these patients the question is whether it is in their best interest to have their pouch
excised. Generally, in this patient population there is no imperative to ultimately go
on to pouch excision as it has been demonstrated that there is no increased risk of
neoplasia in the diverted pouch [5, 7, 14] and the decision to move beyond simple
diversion is made to improve quality of life when the patient has problems with
either their pouch or their diversion.
There are several issues to consider when making the decision about denitive
management including the quality of the patient’s ileostomy, the amount of drainage
the patient is experiencing from their anus, and potential pelvic inammation from
a diseased pouch or cuff, all weighed against the risks of the surgery including nonhealing perineal wounds and the myriad of other complications which spring up
around redo pelvic surgery.
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W. Alexander and S. Eisenstein
The loop ileostomy in the setting of an IPAA is often imperfect. Tension along
the mesentery pulls in 2 directions with the origin of the blood supply being tethered
cephalad and the pouch being tethered caudally. This can lead to problems getting
an adequate stoma eversion for effective pouching, particularly in those patients
who have short mesenteries or thick abdominal walls. In a truly sick patient, it is
sometimes unavoidable to make an imperfect stoma with an understanding that
either revision or pouch excision may ultimately be necessary once the patient
recovers. In those patients who are unlikely to have restoration of intestinal continuity in the future, an end ileostomy is the best option, dividing the ileum as close to
the pouch as possible preserve proximal ileum length. Another option may be separating the proximal and distal ends of the stoma or considering an end-loop conguration. This maneuver, however should not be employed in patients with distal
strictures as they could dehisce the distal suture line. Ultimately to obtain a highquality end ileostomy it is often necessary to perform a pouch excision, freeing up
the caudal tension and allowing a stoma to come up more easily.
A common complaint of the diverted pouch patient is anal mucus drainage. This
can be uncomfortable, leading to signicant anal pruritus, as well as embarrassment
in social situations necessitating use of a pad or disposable undergarment. While
this may seem trivial, it was a signicant complaint in the largest comparative series,
with 12/31 (38.7%) of patients who were diverted complaining of problematic seepage or anal pain [6]. It is certainly reasonable to consider pouch excision in acceptable risk patients for this indication as the QoL does seem to be better for those
patients whose pouches are excised [5].
While QoL is likely higher after pouch excision if things go well, there is signicant risk of morbidity from these procedures with morbidity rates from excision
ranging from 44% to 62% in larger series [2, 15, 16, 21]. While postoperative ileus
and pelvic abscesses are recoverable, perineal nerve injury can lead to signicant
sexual and urinary dysfunction. Perineal wound complications are likely the most
signicant issues faced by this population. Kiran, etal. reported 51% delayed perineal wound healing and 39.8% persistent pouch sinus [22]. These are important
issues to counsel your patient on prior to undertaking such a signicant procedure,
particularly when the patients have already experienced signicant morbidity
because of their pouch failure.
Unfortunately for our patients the quality of data on this issue is not the highest.
Most studies are retrospective in nature and demonstrate a signicant selection bias.
That being said, having a thoughtful approach based on a variety of patient factors
is key to maximizing QoL.Generally, when we see patients with pouch failure it is
important to understand their current QoL, what their long-term goals for continence are, and what their risk factors are for surgical intervention. If restoration of
continuity is a priority in the future, then a loop ileostomy is often a good rst step
for improving both the health and satisfaction of the patient. This should be done in
such a way that pouch revision is possible, but also with the understanding that
many patients will not ultimately seek out pouch revision once their QoL is restored.
Once the patients have recovered and resumed their usual life, the decision to excise
the pouch should be made on symptoms alone. If the patient is satised there is no
8 Ileal Pouch–Anal Anastomosis Failure: What toDo?
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97
imperative to expose them to a potentially morbid procedure. If the pouch or stoma
related symptoms dictate that there is a possibility that pouch excision will improve
their QoL, then this approach is reasonable after counseling the patient on the potential risks of the procedure, understanding that there is data support a higher QoL
after pouch excision in symptomatic patients.
References
1. Nicholls RJ, Pescatori M, Motson RW, Pezim ME.Restorative proctocolectomy with a threeloop ileal reservoir for ulcerative colitis and familial adenomatous polyposis. Ann Surg.
1984;199:383–8.
2. Hueting WE, Buskens E, van der Tweel I, etal. Results and complications after ileal pouch
anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients. Dig
Surg. 2005;22:69–79.
3. de Zeeuw S, Ali UA, Donders RART, etal. Update of complications and functional outcome of
the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational
studies. Int J Color Dis. 2012;27:843–53. https://doi.org/10.1007/s00384- 011- 1402- 6.
4. Heuthorst L, Wasmann KATGM, Reijntjes MA, Hompes R, Buskens CJ, Bemelman WA. ileal
pouch-anal anastomosis complications and pouch failure: a systematic review and meta- analysis.
Ann Surg Open. 2021 June;2(2):e074. https://doi.org/10.1097/AS9.0000000000000074.
5. Kiran RP, Delaney CP, Senagore AJ, O’Brien-Ermlich B, Mascha E, Thornton J, Fazio
VW. Prospective assessment of Cleveland Global Quality of Life (CGQL) as a novel
marker of quality of life and disease activity in Crohn’s disease. Am J Gastroenterol. 2003
Aug;98(8):1783–9. https://doi.org/10.1111/j.1572- 0241.2003.07592.x. PMID: 12907333.
6. Lins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of
life: scoping review. SAGE Open Med. 2016 Oct 4;4:2050312116671725. https://doi.
org/10.1177/2050312116671725. PMID: 27757230; PMCID: PMC5052926.
7. Das P, Smith JJ, Tekkis PP, Heriot AG, Antropoli M, John NR.Quality of life after indenite
diversion/pouch excision in ileal pouch failure patients. Color Dis. 2007 Oct;9(8):718–24.
https://doi.org/10.1111/j.1463- 1318.2007.01216.x. Epub 2007 Aug 31. PMID: 17764535.
8. Hultén L, Willén R, Nilsson O, Safarani N, Haboubi N.Mucosal assessment for dysplasia
and cancer in the ileal pouch mucosa in patients operated on for ulcerative colitis–a 30-year
follow-up study. Dis Colon Rectum. 2002 Apr;45(4):448–52. https://doi.org/10.1007/
s10350- 004- 6218- 9. PMID: 12006923.
9. Börjesson L, Willén R, Haboubi N, Duff SE, Hultén L.The risk of dysplasia and cancer in
the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low:
a long-term term follow-up study. Color Dis. 2004 Nov;6(6):494–8. https://doi.org/10.1111/
j.1463- 1318.2004.00716.x. PMID: 15521942.
10. Veress B, Reinholt FP, Lindquist K, Löfberg R, Liljeqvist L. Long-term histomorphological surveillance of the pelvic ileal pouch: dysplasia develops in a subgroup of patients.
Gastroenterology. 1995;109(4):1090–7, ISSN 0016-5085
11. Setti Carraro P, Talbot IC, Nicholls RJ.Longterm appraisal of the histological appearances
of the ileal reservoir mucosa after restorative proctocolectomy for ulcerative colitis. Gut.
1994 Dec;35(12):1721–7. https://doi.org/10.1136/gut.35.12.1721. PMID: 7829009; PMCID:
PMC1375260.
12. Gullberg K, Ståhlberg D, Liljeqvist L, Tribukait B, Reinholt FP, Veress B, Löfberg R.Neoplastic
transformation of the pelvic pouch mucosa in patients with ulcerative colitis. Gastroenterology.
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13. Foley EF, Schoetz DJ Jr, Roberts PL, Marcello PW, Murray JJ, Coller JA, Veidenheimer
MC.Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of sub-
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sequent pouch salvage. Dis Colon Rectum. 1995 Aug;38(8):793–8. https://doi.org/10.1007/
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14. Bengtsson J, Börjesson L, Willén R, Oresland T, Hultén L. Can a failed ileal pouch anal
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j.1463- 1318.2007.01308.x. PMID: 17573744.
15. Karoui M, Cohen R, Nicholls J.Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum. 2004 Jun;47(6):869–75. https://doi.org/10.1007/
s10350- 004- 0536- 9. Epub 2004 Apr 19. PMID: 15108024.
16. Prudhomme M, Dehni N, Dozois RR, Tiret E, Parc R.Causes and outcomes of pouch excision
after restorative proctocolectomy. Br J Surg. 2006 Jan;93(1):82–6. https://doi.org/10.1002/
bjs.5147. PMID: 16288450.
17. Lightner AL, Dattani S, Dozois EJ, Moncrief SB, Pemberton JH, Mathis KL.Pouch excision: indications and outcomes. Color Dis. 2017 Oct;19(10):912–6. https://doi.org/10.1111/
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19. Lepistö A, Luukkonen P, Järvinen HJ.Cumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure. Dis Colon Rectum. 2002 Oct;45(10):1289–94. https://doi.
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HT, Remzi FH.Management, functional outcomes, and quality of life after development of
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22. Nisar PJ, Turina M, Lavery IC, Kiran RP.Perineal wound healing following ileoanal pouch excision. J Gastrointest Surg. 2014 Jan;18(1):200–7. https://doi.org/10.1007/s11605- 013- 2340- 0.
Epub 2013 Oct 22. PMID: 24146336.
W. Alexander and S. Eisenstein
Perioperative Steroid Management
https://t.me/medicina_free
inIBD Patients Undergoing Colorectal
Surgery
EvanD.Adams andKarenZaghiyan
Introduction
Perioperative management of patients with inammatory bowel disease (IBD) is
paramount to surgical success. Steroids, as potent anti-inammatory agents, play a
central role in the management of IBD symptoms and disease progression. However,
chronic steroid use may suppress the hypothalamic-pituitary adrenal (HPA) axis,
thereby hindering the natural physiologic stress response to surgery. This has led
physicians to be wary of surgery-induced adrenal insufciency (AI). Colorectal surgeons, therefore, must be familiar and condent with perioperative steroid management in this complex patient population.
The concept of prophylactic administration of supra-physiologic doses of glucocorticoids to prevent an Addisonian crisis arose from case reports of rapid postoperative death after uneventful surgeries in the 1950s [1, 2]. The initial cases were
young patients with long term corticosteroid use for rheumatologic conditions who
underwent orthopedic procedures, and subsequently developed unexplained cardiovascular collapse. At no point did these patients receive basic aspects of modern
critical care including aggressive uid resuscitation, vasoactive support, and invasive hemodynamic monitoring. At least one had their cortisone abruptly halted two
days prior to operation. While no serum cortisol was drawn, the observation on
autopsy of atrophied adrenal glands and/or large adrenal hemorrhages was concluded to represent a need for supra-physiologic “stress-dose” steroids to compensate for adrenal insufciency induced by surgical stress. This practice became
9
E. D. Adams (*)
Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
e-mail: Evan.Adams@cshs.org
K. Zaghiyan (*)
Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
© 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_9
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