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262
R.P. Kiran and V.W. Fazio
Fig. 17.2 Ileal J-pouch-anal anastomosis with defunctioning loop ileostomy (Reprinted with permission, Cleveland Clinic Center for
Medical Art & Photography © 2012. All Rights Reserved)
Intraoperative Challenges During Ileoanal Pouch Creation and Anastomosis
Key Concept : Several potential technical challenges , ranging from achieving a tension - free anastomosis to inducing an
iatrogenic fi stula , are present during pouch construction that
you need to be aware of and have a plan to overcome or
avoid altogether .
Commonly employed options with regard to pouch confi guration and anastomosis include a J or S pouch and a stapled or
hand-sewn anastomosis (Fig. 17.3 ). Our current preference for
a primary ileoanal pouch is a J pouch 20 cm long with a stapled
IPAA. The option of mucosectomy with a hand-sewn anastomosis is in general reserved for specifi c circumstances such as
for a redo IPAA, colitis with high- grade dysplasia or cancer
involving the distal rectum, or when patients with FAP have
extensive carpeting of the distal rectum with polyps. During
IPAA creation, close attention needs to be directed towards the
avoidance of anastomotic tension, maintenance of appropriate
orientation and blood supply of the pouch and the residual anorectum, and the avoidance of the incorporation of the vagina/
prostate and seminal vesicles in the staple line.
Problems with Reach of the Pouch
Key Concept : Prior to transecting the rectum , evaluate for
potential problems with length , and when there is an issue ,
proceed through a series of maneuvers to ensure a tension free anastomosis .
The length and orientation of the small bowel and the anatomy of the pelvis and mesentery are variable in different
patients. Thus, diffi culty with reach of the pouch to the anal
canal for an anastomosis is expected in some circumstances.
Tall patients and those with a high BMI are particularly at risk.
Thus, weight loss before surgery may be helpful. In the operating room, various maneuvers may be employed to facilitate
reach. High ligation of the ileocolic vessels, release of the
small bowel mesentery from the retroperitoneum, mobilization of the duodenum, excision of the redundant mesenteric
tissue lateral to the superior mesenteric vessels (“jib-sail”),
and performing releasing incisions along the mesenteric edge
of the small intestine also facilitate reach of the pouch to the
anal canal. Although ligation of some of the branches of the
SMA (or the main trunk of the SMA) has also been described,
we rarely employ this maneuver due to the risk for compromise of blood supply to the entire small intestine.
Diffi culty with reach of the pouch to the anal canal can be
anticipated before rectal transection during proctectomy and
the operation accordingly modifi ed to promote the chance
for a successful IPAA. Prior to transaction of the rectum, an
the pouch held in a Babcock forceps that is delivered into the
pelvis. A bimanual palpation with the gloved fi nger passed
into anal canal prior to IPAA helps confi rm reach of the
Babcock to the intended level of division of the rectum
17.4 ). In certain circumstances, such as patients with a
(Fig.
high BMI, diffi culties with reach of the pouch to the anal
canal may persist. In this, and other similar instances, the
rectal stump may be intentionally left slightly long to minimize tension on the IPAA. Orienting the pouch in such a way
as to direct the mesentery to lie in an anterior location during
anastomosis may also allow for the release of tension that
may be present with a pouch with a posteriorly oriented mesentery. When these efforts fail, consideration may be given
to the creation of an “S” instead of a “J” pouch since this
provides an extra 2 cm of reach of the pouch for anastomosis
to the anal canal when compared to the other pouch confi gurations (Fig. 17.5 ). In the rare circumstance where the pouch
has been created and cannot be anastomosed to the anal
canal, leaving the closed pouch hitched to the pelvis with a
proximal defunctioning ostomy has been described as a
maneuver that allows the pouch to lengthen with time.
Ischemia of the Pouch
Key Concept : Avoid overaggressive dissection of the pouch
blood supply or inadvertent pouch rotation that may result in
devascularization or kinking of the arterial infl ow to the
pouch and resultant ischemia .
This is a rare occurrence and is usually related to an overzealous skeletonization of the blood vessels that supply the
17 Ileal Pouch Complications
263
Fig. 17.3 ( a , b ) Commonly used pouch confi gurations and anastomoses (Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2012. All Rights Reserved)
pouch or damage to the blood supply of the pouch by direct
injury or traction due to tension. Additionally, inadvertent
twisting of the pouch as it is brought down into the pelvis
can block arterial blood fl ow to the pouch. When ischemia
occurs, pouch excision with the creation of a new pouch
with an additional length of small intestine proximal to the
pouch can be undertaken. This, however, may sometimes be
associated with diffi culty of reach of the pouch to the anal
canal.
the careful monitoring of volume of output and fl uid and
electrolyte balance with the concomitant use of bowel stoppers until ostomy closure. While in many cases this may be
unavoidable, anticipating diversion diffi culties and discussing potential strategies to alleviate them with the patient
will allow for realistic expectations. This may include mandating weight loss prior to surgery, trading off the ideal
location of the stoma for one that is functionally better,
using an end-loop versus a loop stoma, or instituting a medical regimen early to slow effl uent and improve
absorption.
Problems with Stoma Creation
Key Concept : Certain patients may be expected to have diffi culties with diversion and you should have a plan ahead of
time to deal with this situation .
The defunctioning ileostomy can be diffi cult to create in
patients who have had diffi culty with reach of the pouch or
those with a high BMI. Creation of the ostomy in a more
proximal portion of the small intestine in these circumstances minimizes tension on the IPAA. This can, however,
be associated with a high ostomy output and thus requires
Problems with the Anastomosis
and Stapler Misfi re
Key Concept : Mechanical diffi culties with a stapler may be
managed with a redo stapled or conversion to a hand - sewn
anastomosis . You must ensure adequate length is available
to avoid tension at the anastomosis .
Problems associated with the anastomosis and stapler
misfi re that occur in the operating room can be disheartening;
264
R.P. Kiran and V.W. Fazio
Fig. 17.4 Evaluating reach of the pouch to the anorectal stump
(Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2012. All Rights Reserved)
however, the situation is usually salvageable. The surgeon
needs to ensure adequate assistance to facilitate retraction
and exposure so as to allow access to both the abdomen and
perineum. The specifi c management depends upon the type
and severity of the problem encountered. For a small anastomotic dehiscence that is identifi ed on air testing, the creation of a defunctioning ostomy either alone or in addition
to suture approximation of the defect by the abdominal or
perineal approach may be all that is required. On the other
hand, for a major breach of the anastomosis, when nonfunction or malfunction of the stapler occurs or when the anal
cuff staple line is breached by the inserted stapler, the anastomosis may have to be redone. In these circumstances, disconnection of the IPAA followed by an assessment of the
structure and reach of the pouch, as well as the length and
condition of the residual anal canal, is performed. Provided
there is an adequate length of the rectal cuff remaining
above the anorectal ring, a purse-string suture can be manually placed on the cuff and is then tied around the stapler
that is introduced transanally. This allows for the stapled
anastomosis to be redone. This is often very diffi cult and, in
many cases, impossible to do. Therefore, when this is not
feasible, a hand-sewn anastomosis should be performed
between the pouch and the residual anal canal, often after
the incorporation of additional maneuvers to mobilize the
pouch to ensure adequate length.
ab c
Fig. 17.5 Confi guration of the pouch. The S pouch provides an extra 2 cm of reach to the anal canal (Reprinted with permission, Cleveland Clinic
Center for Medical Art & Photography © 2012. All Rights Reserved)
17 Ileal Pouch Complications
265
Management of Surgical Complications Related to the Pouch
Early Complications
As previously discussed, some of the complications, especially those related to the anastomosis and pelvic sepsis, may
affect the long-term function of the pouch. Thus, the prompt
identifi cation of these complications and their management
is required so as to preserve a functional pouch.
Anastomotic Disruption and Pelvic Abscess
Key Concept : Whether through a transanal , transabdominal ,
or trans - anastomotic route , prompt drainage of pelvic
abscesses ( often along with appropriate diversion ) is crucial
to preserving pouch function .
These conditions are often interrelated. An anastomotic
disruption may be isolated or associated with sepsis and
may be silent or present with pelvis sepsis and abscess.
Patients with a pelvic abscess usually present with fever,
leukocytosis, and other signs of infection or sepsis. However,
the fi ndings may sometimes be indolent and manifest as a
persistent ileus or prolonged recovery in the postoperative
period. A CT scan of the abdomen and pelvis with oral,
intravenous, and rectal contrast helps delineate the presence
and location of any abscess and any associated anastomotic
leak. Hemodynamic instability and peritonitis mandate an
exploratory laparotomy with peritoneal washout and the
creation of an ostomy when the pouch was not defunctioned
at IPAA. Conversion of a loop ileostomy above a pouch to
an end ostomy allows for complete diversion of enteric contents from the pouch and may occasionally be required. In
stable patients, the prompt institution of percutaneous drainage of any identifi ed abscesses and treatment with intravenous antibiotics allows for the control of sepsis and may
minimize long-term ill-effects on the pouch due to persistent sepsis.
When a pelvic abscess or presacral collection is detected
after IPAA, prompt surgical drainage of the abscess with
eradication of sepsis may help conserve the pouch. When
such abscesses are associated with an anastomotic leak
detected on CT scan, whether drainage should be by the
transanal route or by percutaneous CT-guided drainage is
often a dilemma. A transanal/trans-anastomotic drainage of
the abscess through the breached suture or staple line may be
more comfortable for the patient and takes advantage of the
conditions already present. However, whether a transanastomotic drain interferes with anastomotic healing and,
consequently, pouch retention is a potential concern. In contrast, CT-guided drainage may be more uncomfortable and
be associated with concerns for the development of an
extrasphincteric fi stula. The results of a review of our experi-
9 ] with 71 patients suggest that pouch failure is high
ence [
for patients with pelvic abscess associated with an anasto-
motic leak, but the success rates for the transanal and percutaneous drainage procedures in terms of long-term pouch
retention (75.5 and 83 % respectively) and pouch function
are similar. Thus, management of the patients needs to be
individualized based on a determination of the relative ease
and effi cacy of the two procedures and the comfort of the
patient based on the location and size of the abscess and the
anastomotic defect.
Postoperative Bleeding from the Pouch
Key Concept : Identify staple line bleeding during pouch construction . For those manifesting in the postoperative setting ,
endoscopic control is diagnostic and therapeutic .
This complication can be minimized by inspecting the
back row of staples aligned along the mesentery of the small
bowel after the pouch has been created. Our practice is to
oversew any bleeding areas that are identifi ed in the staple
line with interrupted sutures placed in a fi gure-of-eight fashion. When bleeding occurs postoperatively, this may manifest as bleeding through the anal canal or into the ileostomy.
Pouch endoscopy with cauterization of any identifi ed bleeding points or the application of hemostatic clips or injection
of epinephrine usually controls bleeding. When there is diffuse oozing, the instillation of ice-cold saline with epinephrine into the pouch facilitates control of bleeding [ 10 ].
Late Complications
Many of these late complications manifest following takedown
of the ileostomy and restoration of stool through the pouch.
Pouch-Vaginal Fistula (PVF)
Key Concept : While investigative studies are available to
help guide treatment , EUA is the gold standard for evaluating PVF . Management options range from local options with
or without diversion to redo IPAA .
This complication is potentially disabling and can cause
signifi cant impingement on quality of life. However, its presentation and the extent of its effect vary among patients.
Common symptoms include discomfort, irritation, incontinence, as well as recurrent vaginal and urinary infections.
Investigations
These are chosen so as to assess the size, nature, and location of the fi stula; state of the anoperineum and sphincter
mechanism; confi guration, size, and state of the pouch; and
the presence or absence of any associated disease of the
small intestine. The potential diagnosis of Crohn’s disease
needs to be considered in any patient who develops fi stulous
and septic complications after IPAA, since this determines
the management and also the eventual outcomes.
Differentiating septic complications related to IPAA creation from Crohn’s disease is important; however, this is
266
R.P. Kiran and V.W. Fazio
Fig. 17.6 Gastrografi n study demonstrating a pouch-vaginal fi stula
with contrast fi lling both structures
often easier said than done. It is especially diffi cult when
distinct clinical and histopathological features of Crohn’s
disease are absent. In general, septic complications that
occur within 1 year of IPAA creation or closure of a defunctioning ostomy are likely to be due to perioperative IPAA
complications. On the other hand, their occurrence after
1 year of IPAA construction suggests the possibility of a
diagnosis change to Crohn’s disease when the initial diagnosis was ulcerative or indeterminate colitis.
A thorough review of the history and medical records
relating to the IPAA surgery and the postoperative course is
required since this may provide insight into the potential differential diagnoses that may have caused the fi stula. A review
of pathology relating to the biopsies, even prior to surgery
and of the colectomy or proctocolectomy specimen, additionally helps assess the possibility of Crohn’s disease as the
correct diagnosis. General, abdominal, and perineal examination for clinical harbingers of Crohn’s disease and evaluation of the tone of the sphincter at rest and with squeeze
provide useful information. Vaginoscopy and pouchoscopy
may allow for the identifi cation of the fi stula and an assessment of the location, number, nature, and size of any fi stula
as well as the physical state of the pouch, anal canal, and
vagina. Examination under anesthesia provides excellent
information and is currently the gold standard test in the
evaluation of a pouch-vaginal fi stula. As stated previously,
other tests that should be considered include gastrografi n
enema, vaginogram, and MRI of the pelvis since these help
to further characterize the anatomy of the fi stula. CT or MR
enterography also helps delineate the anatomy of the pouch
and the state of the small bowel above the pouch (Fig. 17.6 ).
The fi nal decision relating to the management of the
pouch-vaginal fi stula depends upon the severity of the
symptoms and their effect on the patient’s quality of life
(QOL). Examination under anesthesia allows for a better
assessment of the fi stula tract and the state of the associated
tissues. If there is evidence of active infl ammation, sepsis,
and induration in the tract or adjoining abscess cavity and
surrounding tissues, the placement of a seton allows for the
reduction in the ongoing sequestration of infection and further damage of tissues. The seton also allows for the normalization of the tissues so that a better assessment of the
area may subsequently be feasible. Adequate drainage also
allows for the tissues surrounding the fi stula to become
healthy, with an improvement in the elasticity and tensile
strength of anorectal and pouch-related tissues that may be
utilized in the defi nitive repair of the pouch-vaginal fi stula.
The additional use of medical treatment with antibiotics,
anti-infl ammatory agents, and anti-Crohn’s disease medication may be required to reduce infl ammation before the consideration of repair, especially for those involving local
procedures.
Some patients with pouch-vaginal fi stulae are candidates
for perineal procedures. A redo IPAA is an option when
repair by the perineal approach is unlikely to be successful or
when local procedures have failed. Although there is a relatively high risk for pouch failure for patients with a pouchvaginal fi stula, up to 85 % of pouch-vaginal fi stulae can be
healed using these approaches [ 11 – 14 ].
Treatment Options for PVF
Local Procedures
These include pouch or vaginal advancement fl ap repairs,
perineal pouch advancement, fi stula plugs, and gracilis fl ap
repair. Local repair may be considered for low, simple fi stulae that are not associated with fl orid infl ammation.
Advancement Flap Repair
Technique: We prefer the prone jackknife position in the
operating room, with the patient under general anesthesia and
skeletal muscle relaxation to provide the best exposure to the
area. The procedure is covered with intravenous antibiotics,
and a Foley catheter is placed into the bladder. Although the
Lone Star Retractor System TM (CooperSurgical Inc, Trumbull,
CT) is an option for anoperineal exposure, our preference is
the placement of effacement sutures in the four quadrants of
the perineum, which provide equivalent exposure to the anal
verge and canal. A Hill-Ferguson retractor introduced into
both the vagina and anal canal facilitates exposure of the fi stula tract. A malleable probe such as a lacrimal probe or
instead a Lockhart-Mummery probe facilitates identifi cation
17 Ileal Pouch Complications
267
of the tract. If there is no evidence of festering sepsis and the
surrounding tissues are supple and noninfl amed, consideration may be given to the creation of a fl ap for repair. The os
of the fi stula on the side of the pouch is circumscribed, and a
U-shaped curvilinear broad-based fl ap incorporating the
mucosa and submucosa of the pouch wall is raised with the os
at its apex. The fi stula tract is dissected into the pouch-vaginal
septum and excised. The tissue surrounding the excised fi stula tract is approximated using #2-0 Vicryl sutures with
sutures that incorporate the sphincter mechanism. The fl ap is
developed upwards and sutured to the pouch-anal mucosa,
the sutures placed in such a way as to incorporate the adjoining sphincter mechanism on their deep aspect, ensuring a
tension-free repair. Our preference is to keep patients on strict
bed rest in the hospital for the fi rst 24 h after the procedure.
The Foley catheter is discontinued on the second postoperative day and limited mobility of the patient to the bathroom
allowed until the return of bowel function. The use of preoperative bowel preparation delays the return of bowel function.
Patients are usually discharged on oral antibiotics.
Fibrin Glue, Fistula Plug, Biologic Mesh Repair, and Gracilis Muscle Interposition
These perineal procedures [ 15 – 17 ] have been described for
the management of pouch-vaginal fi stulae. Considering the
variable success reported with these procedures, we do not
routinely use these techniques.
Failure of Flap Repair
Redo fl ap procedures may be considered in some patients
who have had failure with a fl ap repair provided the basic
principles of avoidance of sepsis, maintenance of tensile
strength, and control of ongoing infl ammation can be
ensured. Repeat fl ap procedures facilitate healing of some
fi stulae which initially failed repair and thus improve the
cumulative success of the fl ap procedure [ 12 , 13 ].
Perineal Pouch Advancement
This can be accomplished by the perineal route, whereby the
anterior half of the pouch is disconnected from the anal canal
and the pouch mobilized transanally and approximated to the
anal canal.
Redo IPAA
This is the most defi nitive option in patients with a pouchvaginal fi stula who have previously had failure of local procedures. The procedure can be considered in patients who
otherwise have a healthy pouch, anoperineum, and sphincter
mechanism. Details of the redo pouch procedure per se are
discussed elsewhere in the text. The technique, as it pertains
to a pouch-vaginal fi stula, is slightly modifi ed depending
upon the location of the fi stula. When the fi stula involves the
IPAA or is proximal to the IPAA, abdominoperineal discon-
nection of the pouch, followed by revision of the pouch after
excision and debridement of the portion involved in the fi stula
tract, is completed. The defect in the rectovaginal septum is
repaired, followed by the performance of mucosectomy with
a hand-sewn anastomosis at the anal verge. The previous
pouch may be utilized if it’s noted to be healthy and of adequate capacity, or augmented or refashioned prior to anastomosis, if required. A neoileal pouch creation after excision of
the previous pouch may be required if the pouch is damaged
or infl amed. Additionally, the use of an omental pedicle fl ap,
when feasible, to separate the pouch from the vagina allows
for extra protection between the pouch and the vagina. When
the pouch-vaginal fi stula is located below the IPAA, either at
the dentate line or in the anal canal, mucosectomy with
pouch-anal anastomosis of the previously revised, or a new,
pouch to the perianal skin allows the use of the full thickness
of the pouch wall as a natural fl ap over the vaginal opening.
Loop Ileostomy
A defunctioning ileostomy can be considered as a temporizing maneuver to divert the fecal stream either prior to or
concomitantly with the local repair of a pouch-vaginal fi stula. This may also be a suitable option as a fi rst step to
improve quality of life that is affected by the irritating and
infectious effects of the chronic fecal drainage into the
vagina and perineum. Finally, pouch excision with end ileostomy and conversion of the J pouch to a K pouch are other
options that can be considered in the individual patient.
Pouch-Perineal Fistula (PPF)
The evaluation, management, and surgical options for pouchperineal fi stulae are similar to those for pouch-vaginal fi stulae. Figure 17.7 demonstrates the steps of an advancement
fl ap repair as it pertains to a pouch-perineal fi stula.
Pouch Sinus
Key Concept : Pouch sinus presentation varies widely , helps
dictate therapy , and is the best predictor of outcome .
An anastomotic sinus of the pouch is a condition about
which there is minimal information in the literature. It is
known to occur in 2.8–8 % of patients after an IPAA procedure and is related to the development of an anastomotic leak
that is confi ned to a blind-ending track. The problem can be
puzzling since presentation and outcomes may vary. The sinus
tract may be asymptomatic and incidentally detected on imaging studies or cause symptoms, which may extend from minor
to more major including sepsis, pelvic pain, pouch dysfunction, and pouch failure. Its occurrence is also associated with
widely differing outcomes-from a condition without any consequence in some patients to pouch failure in others. Several
therapies including debridement, unroofi ng, occlusive treatment with fi brin glue, pouch revision, and redo pouch [ 18 – 20 ]
have been described. A recent review of the presentation,
268
R.P. Kiran and V.W. Fazio
Fig. 17.7 Advancement fl ap repair of pouch-perineal fi stula (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography
© 2012. All Rights Reserved)
management, and outcomes for 45 (2 %) patients who developed a pouch sinus after IPAA [ 21 ] suggests that diagnosis is
usually established at pouchoscopy, gastrografi n enema, CT
scan, or MRI of the pelvis. Symptomatic presentation is a signifi cant predictor for low healing rates and is associated with a
high risk of pouch failure. Management depends upon the presentation, size, location, and presence of other associated factors such as whether or not the patient is defunctioned.
Observation and watchful monitoring is the initial treatment of
choice when permitted by the patient’s condition. The overall
healing rate for the 45 patients in this study was about 60 %,
with a healing rate of 84 % for asymptomatic patients.
Unroofi ng of the sinus was helpful in asymptomatic sinuses
(81 % healed) but less so in symptomatic patients (18 %
healed). Fibrin glue, used in three patients, resulted in complete healing in two (66 %) patients. With transanal drainage
of the sinuses, 66 % patients eventually healed. Again, healing
rate in asymptomatic patients was much higher (100 %) compared to symptomatic patients (20 %). When other measures
fail, a redo pouch is an option for these patients. Of three
patients who underwent a redo pouch, two (66 %) achieved
successful healing with a functional pouch.
Based on these results, an algorithm was proposed for the
management of pouch sinuses, which is discussed below.
Incidentally detected sinus : Sinuses detected in patients
without an ostomy who are asymptomatic are best left alone
without intervention.
Sinus detected on routine Gastrografi n enema prior to
stoma closure after IPAA : In such patients, delaying ileostomy closure for a few months until healing of the sinus is
demonstrated is the best strategy.
Symptomatic and persistent sinus : Symptomatic sinuses
and those that are defunctioned, but nonhealing on watchful
waiting alone, may be managed by transanal drain placement, unroofi ng of the sinus, or injection of fi brin glue to
facilitate healing. Simple closure of the ileostomy may be
considered in selected asymptomatic patients with a small
persistent sinus. When eventual healing of the sinus is
17 Ileal Pouch Complications
269
expected, a loop ileostomy with further local procedures to
facilitate closure is an option in patients who are not
defunctioned. When there is failure of healing, especially in
symptomatic patients, a redo IPAA or the alternatives of a
conventional or continent ileostomy may be considered.
Crohn’s Disease of the Pouch
Key Concept : The ultimate diagnosis of Crohn ’ s disease in
pouch patients can present in a variety of locations and manifestations . In addition to endoscopic and surgical therapy ,
aggressive medical therapy should be instituted .
Crohn’s disease may affect the body, afferent limb, or IPAA
of the pouch, perineum, or small intestine proximal to the
pouch. Management depends upon the phenotype, whether
infl ammatory, fi brostenotic, or fi stulous, and the resultant
symptoms. Medical management includes medical treatment
with steroids, immunosuppressive medication, and/or biologics. Endoscopic intervention including dilatation may be used
for isolated short-segment strictures of the IPAA, pouch body,
or afferent limb. Surgical treatment is required for strictures
not amenable to endoscopic therapy and when there is failure
of endoscopic therapy. When surgery is performed, preservation of intestinal continuity is feasible in the majority of
patients with localized fi brostenosing disease. Strictures of the
afferent limb may require small bowel resection or stricturoplasty or rarely a side-to- side anastomosis between the strictured segment and the top of the pouch. Strictures of the pouch
body can similarly be managed with stricturoplasty. Such
treatment is usually combined with a defunctioning ostomy
above the pouch and medical treatment of the Crohn’s disease.
More extensive disease involvement of the pouch may necessitate pouch excision or permanent defunction. Strictures of
the IPAA may similarly be managed with dilatation, stricturoplasty, or diversion. Perianal disease may be managed with
drains or setons for loculated abscesses or fi stulae and coupled
with medical treatment. Advancement fl ap repair may be a
suitable option for Crohn’s-related pouch-perineal or pouchvaginal fi stulae after control of sepsis and medical treatment of
infl ammation. Extensive perineal disease and recurrent
abscesses or fi stulae resistant to local measures may necessitate
a temporary or permanent ostomy. Such patients may rarely be
candidates for a continent ileostomy when the pouch and the
proximal small intestine are free of Crohn’s disease (though
caution should be exercised). Despite the potential problems
related to the nipple valve with a continent ileostomy and the
risk of reoperations relating to this complication, the procedure may be suitable for Crohn’s patients with an adequate
length of small intestine at surgery, especially when this can be
maintained, even if eventual resection of the continent reservoir were to occur. In such patients, conversion of the ileoanal
pouch to a continent ileostomy, in fact, conserves small intestinal length and absorptive capacity in contrast to pouch exci-
sion. When an ileoanal pouch is salvaged or continent
ileostomy is created in patients with Crohn’s disease, the use
of suppressive medication to reduce the risk of recrudescence
of the Crohn’s disease needs to be carefully considered.
Incontinence
Key Concept : In pouch patients with incontinence , the cause
of the incontinence determines management and outcomes .
Incontinence may be due to abnormalities of the pouch
including pouchitis, cuffi tis, presacral sinus, or chronic presacral cavity related to an anastomotic leak. Alternatively, this
can be due to weakness of the sphincter mechanism from either
patient-specifi c factors or postsurgical changes. Evaluation of
the pouch and the anal canal and sphincter mechanism reveals
potential causes. Minor degrees of incontinence and those
relating to infl ammation of the pouch or cuff may improve with
medical therapy. When incontinence occurs as a complication
of these complications, the surgical treatment of the complications corrects the incontinence. Isolated sphincter defects can
be managed with sphincter repair. However, when sphincter
compromise is severe, options include pouch excision with
permanent ileostomy or a continent ileostomy.
Outlet Dysfunction
Key Concept : Diffi culty in evacuation may be due to structural or functional disorders and can often be managed successfully by nonoperative means .
Problems with pouch evacuation may be due to a wide
range of causes such as IPAA stricture or pouch prolapse.
Strictures from scar tissue or Crohn’s disease can be managed by dilatation or stricturoplasty. For outlet dysfunction
that occurs in the absence of an anatomic cause, biofeedback
is an option. Enemas and intermittent self-intubation of the
pouch with irrigation may be useful in both organic and
functional obstructive disorders. Finally, sacral nerve stimulation may play a role in the future but has little data supporting its effi cacy.
Pouchitis and Cuffi tis
Key Concept : Bleeding , pain , and increased stool frequency
from residual infl ammation at the IPAA or in the pouch itself
should initially be approached with medical management .
Surgical options to include ablation , diversion , or excision
should be considered second - line or last - resort options for
recalcitrant disease .
These conditions relate to infl ammation of the pouch or
the lining of the residual anal canal and are diagnosed at
pouchoscopy and biopsy (Fig. 17.8 ). Treatment is primarily
270
R.P. Kiran and V.W. Fazio
Fig. 17.8 Pouchitis on fl exible sigmoidoscopy. Notice the erythematous mucosa and the watery stools present in the pouch
medical. Small areas of cuff infl ammation may be approached
through ablative or excisional means, though often require multiple attempts. A defunctioning ostomy or pouch excision with
an end ileostomy may however be required for recalcitrant pouchitis or cuffi tis unresponsive to medical treatment. Corrective
surgery or redo IPAA may also be required for the management
of pouchitis secondary to pouch-related conditions such as
chronic presacral abscess, pouch sinus, small pouch size, or
obstruction due to stricture or pouch prolapse. Redo IPAA is
also an option for persistent cuffi tis secondary to a long segment
of anal canal and rectal remnant retained at the time of IPAA.
Pouch Prolapse
Key Concept : This rare condition should be treated primarily
with dietary management and avoidance of straining . Pexy
of the pouch is reserved for severe cases .
This is a rare complication of the ileoanal pouch, with few
reports examining the presentation, investigation, and management of the condition. Ehsan et al. [ 22 ] conducted a sur-
vey on pouch prolapse and indicated an incidence of 0.3 %
for the condition, which was similar to our experience (11
patients, 0.3 %). Seven of the patients in our experience had
full-thickness pouch prolapse while four had mucosal prolapse. Diagnosis in ten patients was based on symptoms and
examination, while in one patient was diagnosis was made at
pouchography performed to investigate pouch dysfunction.
Our experience suggests that the fi rst line of treatment for
patients with mucosal prolapse is stool bulking agents and
biofeedback so as to avoid excessive straining. In two
patients, this was successful in relieving symptoms while the
other two patients underwent a local perineal procedure with
pouch advancement after the excision of redundant mucosal
tissue. None of these patients subsequently developed full-
thickness prolapse. Patients with full-thickness pouch prolapse were treated with defi nitive transabdominal surgery.
Pouchpexy using a transabdominal approach, with fi xation
of pouch to the sacrum using nonabsorbable sutures, was
used in the fi rst six patients, while one patient needed mesh
fi xation of the pouch for recurrent pouch prolapse.
Leak from the Tip of the “J”
Key Concept : Leaks in this location most often follow an
indolent course but may require operative therapy and can
even lead to loss of the pouch .
This is a rare and indolent complication related to the
pouch. Leaks from suture lines in the pouch itself and from
the tip of the J pouch (Fig. 17.9a ) are less likely than anas-
tomotic leaks but are also associated with pouch failure.
A review of our experience related to the diagnosis and
management of leaks from the tip of the J in 27 patients [ 23 ]
suggested that the frequency of this condition for patients
who underwent primary IPAA is very low (0.5 %). Patients
present with variable symptoms such as abdominal pain,
fever, or diarrhea—making the diagnosis diffi cult to establish. Further, in some patients, leaks may present with a fi stula rather than a pelvic abscess, a presentation usually
suggestive of an anastomotic leak or Crohn’s disease. A leak
could be detected on gastrografi n enema ( n = 4) or pouchos-
copy ( n = 4) in only 8 of the 27 patients. In one patient, an
abscess was detected during emergent laparotomy for acute
peritonitis due to leak from the tip of the J pouch. The
majority of patients had a long median time between primary IPAA and salvage surgery suggesting that a leak from
the tip of the J pouch leads to an indolent course. This is
further corroborated by the fact that in six patients (22 %),
the ultimate diagnosis could only be made at the time of
salvage surgery. These six patients underwent salvage surgery due to their symptoms and the suspicion of a septic
complication after primary IPAA. A high degree of suspicion is hence required for its diagnosis, since pouch leaks
are associated with pouch failure after IPAA. When a leak
from the tip of the J pouch is detected, management depends
upon the nature and degree of the defect and associated fi ndings in the pouch and pelvis. Salvage surgery may require
pouch repair with suture (Fig. 17.9b ) or stapled (Fig. 17.9c )
repair of the leak site with or without a redo IPAA or pouch
resection with redo IPAA.
J-Pouch to K-Pouch (Continent Ileostomy) Conversion
Key Concept : Select , highly motivated patients may undergo
conversion of their IPAA to a continent ileostomy , though
commonly associated with a higher rate of complications .
17 Ileal Pouch Complications
a
271
b
Fig. 17.9 ( a ) Leak from the tip of the J pouch (Reprinted with per-
mission, Cleveland Clinic Center for Medical Art & Photography ©
2012. All Rights Reserved). ( b ) Suture repair of a leak from the tip of
the J pouch (Reprinted with permission, Cleveland Clinic Center for
c
Medical Art & Photography © 2012. All Rights Reserved). ( c ) Stapled
repair of the tip of the J pouch (Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography © 2012. All Rights
Reserved)
For patients with pouch failure secondary to problems
with the anal canal and perineum and patients with pouch
failure who may be suitable candidates for a redo IPAA but
elect not to continue to maintain defecation by the normal
route, conversion of the J pouch to a K pouch is an option.
The procedure is complex and associated with a high frequency of complications since it incorporates the additional
technical challenges of the continent ileostomy reservoir