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the transanal approach, decreased risk of damage to the anal sphincters, and less
tension on the repair. The procedure can be repeated if necessary and yields satisfactory results with relatively less morbidity. The repair can also be augmented by
placement of a biologic mesh between the pouch and the vagina. Possible complications include bleeding and hematoma development due to the vascularity of the
vagina. However, this risk can be minimized with meticulous technique, drainage,
and use of a vaginal packing [13, 18]. Dyspareunia is another possible
complication.
The largest series published by Mallick etal. reported results for transvaginal
approach in 32 patients. The healing rate was 55.5% (15 of 27 patients) when done
as a primary procedure and 40% (2 of 5 patients) when performed after a failure of
another approach. Authors noted that postoperative diagnosis of Crohn’s disease
was the only factor associated with failure of the repair [10]. Sagar et al. [35]
reported the results of transvaginal repair for PVF in 11 patients, each of whom had
previously undergone an attempt to close the stula with a collagen button plug.
Nine (81%) were successful at a median follow-up of 14 (6–56) months and the
remaining two patients described symptomatic improvement. Sapci etal. reported a
success rate in 1 of 4 patients (25%) [46].
Burke etal. [36] published the St. Mark’s Hospital experience with transvaginal repair for PVF in 14 patients. They reported total success in 11/14 patients
(78%), although 8 required multiple attempts to achieve long-term success.
O’Kelly et al. [13] reported successful repair in 5/7 patients (71%) with this
approach, and once again some patients in this series required more than one
attempt before complete healing was achieved. Others have reported success rates
of 0% (0/1) [18, 31], 27% (3/11) [15], and 100% (1/1) [12, 14]. A systematic
review published in 2020 by Machin etal. included 13 retrospective cohort studies, 2 prospective cohort studies, eight case series, three case reports and a casecontrol study. 143 patients in this review underwent a transvaginal approach with
a success rate of 51% [47]. The meta-analysis by Pellino etal. found an overall
recurrence rate of 52.3% [46].
M. E. Stack and M. A. Krezalek
Muscle Interposition Flap
Muscle interposition aps are particularly useful after previously failed repairs, in
setting of poor quality of native tissues, as well as when abdominal procedures are
contraindicated. The expected perioperative morbidity is 33–50% and includes perineal wound infection, urethral stricture, fever, urinary retention, and perineal bleeding [38, 40]. Perhaps because of the technical challenge, the procedure seems to
have been underused. This procedure should be preceded by fecal diversion. At
present, the low reported numbers and the relative complexity of the procedure
prevent it from being strongly recommended as a rst-line treatment. Another form
of ap used for treating rectovaginal stulas is the martius ap; however, results
with treating PVF have not been published.
Gorenstein etal. [37] reported successful repair in two women with PVF.Previous
attempts at local repair had failed in both patients and a simultaneous diverting loop
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ileostomy was constructed. Anterior sphincteroplasty was performed in one patient
for associated incontinence. Wexner et al. [15] reported results of a multicenter
study including treatment of PVF in 26 patients, 4 of whom underwent gracilis
interposition ap with a 50% success rate. In a later publication, Wexner etal. [38]
published results of gracilis ap in 53 patients, two of whom for the indication of
PVF.One patient had complete healing and the patient who did not heal was eventually diagnosed with CD and opted to have a permanent ileostomy. Zmora etal. [39]
published their experience with the gracilis interposition ap in 9 patients. Only one
patient had a PVF and the stula ultimately completely healed.
Another report by Tsujinaka etal. [31] described one patient with a failed gracilis interposition. Hull et al. reported on two patients undergoing gracilis muscle
interposition as a subsequent repair following prior unsuccessful attempts. Both
patients were diverted ahead of time and both healed successfully, however both
also developed surgical site infections [49]. Machin etal. in their systematic review
included 13 patients treated with various muscle transposition procedures (majority
of which used gracilis muscle) with a success rate of 76.9% [48]. Yellinek etal.
reviewed 11 cases of PVF repair with gracilis muscle transposition as part of a bigger cohort of complex perianal stula repairs [50]. Although the authors do not
report the success rate for these 11 patients separately, one interesting nding is that
bed rest of >3days was associated with ap failure. Frontali etal. had an overall
success rate of 7 out of 10 (70%) patients with gracilis muscle interposition for PVF,
and interestingly found that found that failure in PVF and RVF patients was signicantly associated with lack of postoperative antibiotics prophylaxis [51].
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Transanal Pouch Advancement
The technique of transanal disconnection of the ileal pouch from the IPAA, advancement of the pouch, and re-suture at the dentate line can be employed in patients with
PVF, especially in slimmer patients with demonstrable mobility of the pouch above
the level of the anastomosis. The advantage of this procedure is that it allows healthy,
full thickness tissue to be delivered to the perineum. This operation should be offered
after creation of a diverting ostomy. Both Fazio et al. [41] and Heriot et al. [19]
showed that this procedure was successful in 50% of their patients. Sapci et al.
reported success in 14/23 patients (61%), including 4 out of 5 patients having successful closure of a stula above the anastomosis [46]. Machin etal. in their systematic review included 64 pouch advancement procedures with an overall success rate
of 48.4% [48].
Abdominoperineal Approach
A “high” PVF that arises from the mid-body of the ileal pouch requires a transabdominal approach. This approach may also be selected after failed local repairs and
in patients with ongoing pelvic sepsis due to abscess cavities with granulation tissue
that cannot be completely removed using a local approach. The pouch needs to be
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carefully mobilized down to the level of the pelvic oor with attention given to the
anterior wall of the pouch and the posterior wall of the vagina.
There are basically three surgical options: pouch advancement, pouch redo with
a new handsewn IPAA, and pouch excision. The reported overall success rates for
treating a PVF via the abdominoperineal approach are approximately 50–75% [10,
15, 16, 18, 19, 31, 42–44, 46]. Machin etal. in their systematic review included 161
transabdominal approaches with an overall success rate of 60.2% [48] The authors
note that excision and reconstruction of the pouch was used in 107 patients with a
65.4% success rate. Sapci etal. demonstrated a simultaneous transabdominal and
transperineal approach with pouch reconstruction and closure of the PVF had the
highest success rate of closure at 69% overall and 71% for PVFs located distal to the
anastomosis [46]. The authors specically believe that if the tissue of stula origin
is retained at the rectum/ anal transition zone, removal should be considered for a
successful outcome. The authors caution that due to complexity of the operation,
these should be undertaken by experts with high volume of pouch redo surgeries.
This is precisely why it should be noted that transabdominal revision of the pouch
is technically demanding and carries a signicant risk of loss of the pouch [10, 16,
18]. In addition, failed attempt at pouch revision may result in signicant loss of
small bowel with the risk of short gut syndrome. The patient needs to be fully counseled about these risks and preferably referred to a center of excellence in this eld.
M. E. Stack and M. A. Krezalek
Diversion
A diverting ileostomy is commonly used in patients with PVF to control pelvic
sepsis, relieve symptoms, or to divert fecal material away from the repair. Some
authors have reported healing with the ileostomy alone [15, 31]. However, most
authors describe construction of a diverting ileostomy either before or at the time of
PVF repair [10, 18, 23]. Lee etal. [23] found higher success rates (60% vs. 45%)
when a diverting ileostomy was performed before a transanal pouch advancement.
Sapci etal. also showed improved success of PVF closure procedures with a diverting stoma in place (65.3% versus 27.7%), favoring diversion of all patients when
operating to close PVFs [46]. However, much of the data is mixed in showing that a
diverting ileostomy improves the chance of PVF healing. A permanent diversion,
with or without pouch excision, is recommended when all other attempts have failed.
Recommendations
As noted above, all studies provide low quality data, providing weak
recommendations.
1. Patients presenting with pelvic sepsis should undergo EUA and seton drainage.
2. A diverting ileostomy should be considered for all patients before or at the time
of repair.
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PVF
83
Redo pouch
Seton drain
Diversion
Pouch excision
Crohn’s disease
Medical treatment
failure
Success
Consider local repair
Fistula below IPAA
(cryptoglandular origin)
Local repair:
seton, fistulotomy,
advancement flap
Non-Crohn’s disease
Low PVF High PVF
Local repair:
transanal advancement flap,
transvaginal repair,
Gracilis interposition,
transanal pouch advancement
Control Sepsis and Symptoms
Evaluation
Abdominoperineal approach:
laparotomy vs. laparoscopy
Pouch
advancement
Review pathology
EUA
Imaging (perineogram, pouchogram, MRI, CT, endo-anal US)
Physiology (anal manometry, PNTML)
Fig. 7.1 Suggested treatment algorithm
3. Local repair should be attempted rst for low PVFs.
4. An abdominoperineal approach should be reserved for “high” PVF and failed
attempts at local repair.
A suggested algorithm based on results and recommendations is presented in
Fig.7.1.
Personal View oftheData
The management of pouch complications such as pouch perineal and pouch vaginal
stula presents a major challenge for the surgeon and the patient. It is our view that
these patients should ideally be referred to large volume experienced centers for a
more optimal outcome. It is essential for the surgeon to review all of the patients’
prior relevant history including pathology and operative reports, as well as physiologic and imaging studies. In reviewing the data of multiple management strategies,
it is clear that one’s approach should be tailored to each individual patient. It is
important to counsel patients that successful treatment often requires several operations over a long time period in order to achieve healing. Most studies had an average over 2.5 operations per patient prior to success. In addition, patients with CD
should also be aware of the higher rate of pouch failure.
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M. E. Stack and M. A. Krezalek
Local repair via the perineal approach should be considered when dealing with a
low PVF, with the transanal ileal advancement ap, gracilis interposition, and pouch
advancement all viable options. The abdominoperineal approach should be used for
high stulas and those that have failed previous local attempts. A diverting loop
ileostomy before or at the time of repair offers the patient symptom relief, better
sepsis control, and in our view an increased chance of successful healing. It seems
that no single procedure is optimal for all cases of PVF.Therefore, the surgeon
should be familiar with the existing armamentarium of treatment options and be
continually updated on their success rates.
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32. Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R.Assessment of the efcacy of the
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34. Ozuner G, Hull T, Lee P, Fazio VW.What happens to a pelvic pouch when a stula develops?
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36. Burke D, van Laarhoven CJ, Herbst F, Nicholls RJ.Transvaginal repair of pouch-vaginal stula. Br J Surg. 2001;88(2):241–5. Blackwell Science Ltd
37. Gorenstein L, Boyd JB, Ross TM.Gracilis muscle repair of rectovaginal stula after restorative proctocolectomy. Report of two cases. Dis Colon Rectum. 1988;31(9):730–4.
38. Wexner SD, Ruiz DE, Genua J, Nogueras JJ, Weiss EG, Zmora O.Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal stulas: results in 53
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40. Zmora O, Potenti FM, Wexner SD, Pikarsky AJ, Efron JE, Nogueras JJ, etal. Gracilis muscle
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M. E. Stack and M. A. Krezalek
Ileal Pouch–Anal Anastomosis Failure:
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What toDo?
WyethAlexander andSamuelEisenstein
Introduction
First described by Parks and Nicholls in 1978 [1], restorative proctocolectomy with
ileal pouch-anal anastomosis (IPAA) has been widely adopted as the treatment of
choice for management of Familial Adenomatous Polyposis (FAP), medically
refractory Ulcerative Colitis (UC), and more recently adopted for management of
highly selected patients with medically refractory Crohn’s disease. Over four
decades of development, the creation of a double loop stapled “J-shaped” pouch
with anastomosis between the apex of the pouch and the anus has become the standardized approach with an abundance of literature demonstrating low mortality and
excellent patient satisfaction when compared to creation of an end ileostomy.
Despite these promising end results, high rates of post-operative complications
have plagued the IPAA with morbidity ranging between 15% and 70% [2–4].
Furthermore, “pouch failure” has been reported to occur in roughly 3.5–18% with
the broad range of occurrence largely owing to difference in follow up time [2–4].
While exact terminology varies between studies, for the purpose of this chapter,
pouch failure will be broadly dened as need for indenite de-functioning fecal
diversion in the presence of IPAA with or without pouch excision.
While the IPAA has been widely adopted in the modern-day colorectal surgeon’s
tool belt, little data exists to guide management of pouch failure. Additionally, existing literature lacks broad use of standardized vocabulary, protocols, or endpoint
data between institutions making comparisons difcult. Given the seemingly inevitability of practitioners to encounter IPAA pouch failure, this chapter will aim to
8
W. Alexander · S. Eisenstein (*)
Department of Surgery, Division of Colon and Rectal Surgery, UC San Diego Health,
La Jolla, CA, USA
e-mail: walexander@ucsd.edu; seisenstein@ucsd.edu
© 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_8
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Table 8.1 PICO diagram for Ileal pouch failure
Patients
Patients s/p IPAA
with subsequent
pouch failure
Intervention Comparator
Creation of defunctioning
ileostomy with pouch left
in-situ
Creation of
ileostomy with
pouch excision
W. Alexander and S. Eisenstein
Outcome
Health-related
quality of life
(HRQOL)
provide a succinct review of data driven recommendations to answer the question:
Ileal-anal pouch anastomosis failure- what to do.
PICO Diagram (Table8.1)
Search Strategy
A Medline Ovid database search was performed on publications from 1985 through
July 2022 detailing operative strategies for management of pouch failure. Search
phrases utilized: “ileal-anal anastomosis”, “ileal pouch”, “J-pouch”, “proctocolectomy”. Articles were omitted if they were not in the English language or if they
were conducted at pediatric centers. The literature search was further broadened
with review of references of resulted articles.
Results
When considering management of a failed pouch, the two common interventions
include creation of a defunctioning ileostomy with pouch left in-situ vs ileostomy
creation with pouch excision. The creation of a continent ileostomy can additionally
be considered however for simplicity, and due to the relative rarity of this procedure
in the modern era, discussion of this approach will be deferred. Despite nearly four
decades since the advent of the IPAA, few studies have analyzed the difference in
patient safety and health-related quality of life outcomes of these two approaches.
Furthermore, as previously mentioned, early studies are plagued by the absence of
common nomenclature or validated quality of life metrics. More recently, the
Cleveland Global QOL [5] and Short Form (SF)-36 [6] questionaries have been
widely adopted as validated measures of patient quality of life following IPAA.
Interestingly, the two available studies offering direct comparisons of pouch left
in-situ vs pouch excision via validated quality of life questionnaires come to conicting conclusions. In their retrospective comparison of 22 patients with pouch left
in situ compared to 31 patients with pouch excisions, Das etal. found little difference in overall health related quality of life metrics between the two groups [7]. The
study does note a trend towards higher quality of life scores among the pouchexcision group by the Cleveland Clinic Foundation QoL however this trend did not
8 Ileal Pouch–Anal Anastomosis Failure: What toDo?
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reach statistical signicance in any of the included questionnaire domains. The
group went on to include additional metrics of urinary and sexual function and
found that pouch excision was associated with higher incidence of urinary and sexual complications hypothesized to be related to pelvic nerve damage related to the
excision. They additionally included added metrics of stoma function citing
increased risk of stoma retraction in the pouch excision group which likely stems
from the creation of end ileostomies with pouch excision compared to creation of
diverting ileostomies with pouches left in situ. The group concludes that a defunctioning ileostomy with pouch left in-situ offers similar outcomes with reduced risk
of complication related to pouch excision.
In a slightly larger retrospective study, Kiran etal. compared the health-related
quality of life of 31 patients who underwent ileostomy creation with pouch left insitu to 105 patients who underwent pouch excision [5]. Despite the slightly larger
population size, the group relied on less validated measures of outcome including a
non-descript quality of life and quality of health questionnaire and an abbreviated
SF-12 questionnaire. Additionally they included the Cleveland Global QoL. In
direct disagreement with the ndings present by Das etal., Kiran etal. report signicantly higher QoL scores of the pouch excision group in all domains with the
exception of urinary function and sexual function. Kiran etal. note that anal pain
and anorectal seepage within the pouch left in-situ group were the main morbidities
driving the worse QoL scores among the population. The authors conclude that
while pouch excision adds to the operative complexity with theoretical risk of
increased morbidity, it offers increased long term health related quality of life and
should be pursued when appropriate (Table8.2).
Data for direct comparisons of pouch left in situ vs pouch excision is extremely
sparse, including only studies with small population sizes and variable outcome
metrics. In attempt to further understand the topic, additional insight can be gleaned
from literature available reporting morbidity and patient satisfaction of each
approach individually without direct comparisons.
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