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40. Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy
for ulcerative colitis. N Engl J Med. 2005;353:2462–76.
41. Selvasekar CR, Cima RR, Larson DW, et al. Effect of infliximab on short-term complications
in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg. 2007;204:956–
62; discussion 62–3.
42. Mor IJ, Vogel JD, da Luz MA, Shen B, Hammel J, Remzi FH. Infliximab in ulcerative colitis
is associated with an increased risk of postoperative complications after restorative procto-
colectomy. Dis Colon Rectum. 2008;51:1202–7; discussion 7–10.
43. Marchal L, D’Haens G, Van Assche G, et al. The risk of post-operative complications associ-
ated with infliximab therapy for Crohn’s disease: a controlled cohort study. Aliment Pharmacol
Ther. 2004;19:749–54.
44. Schluender SJ, Ippoliti A, Dubinsky M, et al. Does infliximab influence surgical morbidity of
ileal pouch-anal anastomosis in patients with ulcerative colitis? Dis Colon Rectum.
2007;50:1747–53.
45. Colombel JF, Loftus EV, Tremaine WJ, et al. Early postoperative complications are not
increased in patients with Crohn’s disease treated perioperatively with infliximab or immuno-
suppressive therapy. Am J Gastroenterol. 2004;99:878–83.
46. Krane MK, Allaix ME, Zoccali M, et al. Preoperative infliximab therapy does not increase
morbidity and mortality after laparoscopic resection for inflammatory bowel disease. Dis
Colon Rectum. 2013;56:449–57.
47. Kunitake H, Hodin R, Shellito PC, Sands BE, Korzenik J, Bordeianou L. Perioperative treat-
ment with infliximab in patients with Crohn’s disease and ulcerative colitis is not associated
with an increased rate of postoperative complications. J Gastrointest Surg. 2008;12:1730–6;
discussion 6–7.
48. Sewell JL, Mahadevan U. Infliximab and surgical complications: truth or perception?
Gastroenterology. 2009;136:354–5.
49. Ferrante M, D’Hoore A, Vermeire S, et al. Corticosteroids but not infliximab increase short-
term postoperative infectious complications in patients with ulcerative colitis. Inflamm Bowel
Dis. 2009;15:1062–70.
50. Gu J, Remzi FH, Shen B, Vogel JD, Kiran RP. Operative strategy modifies risk of pouch-
related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α
therapy. Dis Colon Rectum. 2013;56:1243–52.
51. Geltzeiler CB, Lu KC, Diggs BS, et al. Initial surgical management of ulcerative colitis in the
biologic era. Dis Colon Rectum. 2014;57:1358–63.
52. Pellino G, Sciaudone G, Canonico S, Selvaggi F. Role of ileostomy in restorative proctocolec-
tomy. World J Gastroenterol. 2012;18:1703–7.
53. Ross H, Steele SR, Varma M, et al. Practice parameters for the surgical treatment of ulcerative
colitis. Dis Colon Rectum. 2014;57:5–22.
54. de Montbrun SL, Johnson PM. Proximal diversion at the time of ileal pouch-anal anastomosis
for ulcerative colitis: current practices of North American colorectal surgeons. Dis Colon
Rectum. 2009;52:1178–83.
55. Gu J, Stocchi L, Remzi FH, Kiran RP. Total abdominal colectomy for severe ulcerative colitis:
does the laparoscopic approach really have benefit? Surg Endosc. 2014;28:617–25.
R.D. Hurst
www.ebook3000.com
45© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_6
Chapter 6
Which Ulcerative Colitis Patients Should Not
Have Ileal Pouch-Anal Anastomosis
Scott A. Strong
Approximately 10–15 % of patients diagnosed with ulcerative colitis will ultimately
require operative management of their disease [1, 2], and proctocolectomy with ileal
pouch-anal anastomosis (IPAA) has evolved into the most commonly performed
procedure [3, 4]. However, not all patients are best managed by a proctocolectomy
and ileal pouch-anal anastomosis, and some are better served by undergoing another
operation such as proctocolectomy with end ileostomy. The most appropriate choice
of operation is largely predicated upon multiple patient- dependent variables that
may impact long-term outcome best measured as health- related quality of life.
Search Strategy
A comprehensive literature search of Cochrane Database of Collected Research,
EMBASE, MEDLINE, and PubMed was performed to identify all of the English-
language publications related to ulcerative colitis, colectomy, and ileal pouch-anal
S.A. Strong, MD, FACS, FASCRS
Chief, Gastrointestinal and Oncologic Surgery, Surgical Director, Digestive Health Center,
Northwestern Medicine James R. Professor of Surgery,
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
e-mail: sstrong2@nm.org
PICO table
Patients Intervention Comparator Outcome
Patients with
ulcerative colitis
requiring
operation
Proctocolectomy with ileal
pouch-anal anastomosis
Proctocolectomy with
end ileostomy
Health-related
quality of life
(HRQOL)
46
anastomosis and quality of life (QOL) outcomes from 1985 to 2015. Key search
terms included the following: “colectomy,” “colitis,” “ileal pouch-anal anastomo-
sis,” “inflammatory bowel disease,” “proctocolectomy,” and “ulcerative colitis.”
Studies were excluded if they did not directly contrast proctocolectomy with ileal
pouch-anal anastomosis to proctocolectomy with ileostomy, failed to measure any
component of health-related quality of life, included patients with Crohn’s disease
or familial adenomatous polyposis, included only patients with ulcerative colitis
plus specific conditions (e.g., primary sclerosing cholangitis), or included pediatric
patients. Only the most recent study was included if similar studies from the same
institution were encountered. The references of the included studies were reviewed
to identify additional studies that were incorporated as appropriate.
Results
Over the past three decades, only a few studies have reported health-related quality of
life outcomes in patients with ulcerative colitis undergoing proctocolectomy and ileal
pouch-anal anastomosis or ileostomy. Some of the initial studies were plagued by
poor methodology using quality of life metrics that had not been validated. However,
reports published in past 15 years have tended to use validated global, generic, or
disease-specific instruments to measure health-related quality of life [5–12].
Studies that employed global instruments to contrast health-related quality of life
between patients who underwent proctocolectomy and ileal pouch-anal anastomosis
or ileostomy reported conflicting results. Emblem and associates [5] used a non-
validated questionnaire that showed patients managed by an ileostomy were mark-
edly more likely to experience social restrictions. While McLeod et al. [6] found no
differences in several global measures, Kuruvilla and colleagues [11] reported the
Cleveland Global QOL was significantly better for patients with an ileal pouch-anal
anastomosis, particularly related to current energy level and current quality of health.
Of the studies using a generic measure, no difference in scores was found
between the two patient groups regardless whether the non-validated “lifestyle sat-
isfaction score,” [7] validated EuroQol Group’s EQ-5D-3 L questionnaire [11], or
validated Short Form (SF)-36 Health Survey [9, 10] was used. However, O’Bichere
and associates [8] used a questionnaire developed in-house to specifically measure
seven selected items, and they found patients with an ileostomy were significantly
less bothered by altered bowel emptying and diet.
A disease-specific instrument, the Inflammatory Bowel Disease Questionnaire
(IBDQ), was employed in three studies [9, 10, 12] and an abbreviated version, the
short (S) IBDQ, was used in another report [11]. No differences in scores were
found between the two groups in any of the studies [9–12], but van der Kalk et al.
[12] did report ileal pouch-anal anastomosis patients had higher quality-adjusted
life years compared to ileostomy patients.
S.A. Strong
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47
Health-related quality of life is obviously a different outcome measure than mor-
bidity. But, it is interesting that the morbidity rate of ileostomy patients was higher
in three of the four studies that reported this outcome parameter [5, 6, 10, 12].
Study Patients (N)
IPAA vs
Ileostomy
QOL measure Results
IPAA vs
Ileostomy
Quality of
evidence
Emblem [5] 19 vs 35 Social restriction 0 % vs 67 %
(P < 0.05)
Low
McLeod [6] 37 vs 28 Direct questioning of
objections
Sickness-Impact
Profile Time
trade-off
Comparable
Comparable
Comparable
Moderate
Liddell [7] 25 vs 10 Lifestyle satisfaction Comparable Low
O’Birchere [8] 30 vs 30 SF-36
Altered bowel
emptying
Body image
Clothes
Diet
Noise
Odor
Sexual relationship
Comparable
8 vs 5 (P = 0.01)
Comparable
Comparable
5.5 vs 2
(P = 0.02)
Comparable
Comparable
Comparable
Moderate
Nordin [9] 56 vs 42 IBDQ
SF-36
Comparable
Comparable
Moderate
Camilleri-
Brennan [10]
19 vs 19 IBDQ
SF-36
Comparable
Comparable
High
Kuruvilla [11] 35 vs 24 EQ-5D-3 L
Cleveland QOL
FIQL
SIBDQ
Comparable
0.9 vs 0.8
(P = 0.03)
Comparable
Comparable
Moderate
van der Valk
[12]
81 vs 48 IBDQ
Quality-adjusted life
years
Comparable
0.9 vs 0.84
(P < 0.01)
High
Recommendations
Patients requiring an operation for ulcerative colitis can undergo proctocolectomy
and ileostomy rather than proctocolectomy and ileal pouch-anal anastomosis with-
out compromising their health-related quality of life. (Evidence: moderate;
Recommendation: strong)
6 Which Ulcerative Colitis Patients Should Not Have Ileal Pouch-Anal Anastomosis
48
Patients needing surgery for ulcerative colitis are typically offered a proctocolec-
tomy and ileal pouch-anal anastomosis in one, two, or three stages with the two-
stage approach most often employed in elective scenarios. However, this restorative
procedure is occasionally contraindicated because of disease-related complications,
unachievable for technical reasons, or ill-advised due to excessive risk for operative
morbidity or impaired quality of life. In these selected settings, proctocolectomy
and ileostomy may be offered, and the patient can be reassured that her/his health-
related quality of life will be comparable to that associated with a sphincter-sparing
procedure.
Personal View
Patients with colorectal adenocarcinoma complicating their ulcerative colitis need
to undergo a sound oncologic operation. If the tumor encroaches upon the sphincter
mechanism, excision of the levators and anal canal is usually required, and a
sphincter- sparing procedure such as an ileal pouch-anal anastomosis is contraindi-
cated. Colorectal cancers that have metastasized to distant sites are commonly man-
aged with chemotherapy unless bleeding or obstruction mandates resection or
diversion. Regardless, a restorative proctocolectomy and ileal pouch-anal anasto-
mosis would be generally contraindicated because it would potentially delay the
more important systemic therapy.
Management of adenocarcinomas of the mid or lower rectum penetrating the
muscularis propria or involving one or more mesorectal lymph nodes without dis-
tant metastases usually entails a combination of chemotherapy, radiotherapy, and
resection. If the tumor is situated above the anorectal ring, a sphincter-sparing oper-
ation can be performed. However, patients receiving pre-operative external beam
radiotherapy are at increased risk for ileal pouch failure secondary to pouch dys-
function [13] despite no significant increase in operative morbidity [14]. Pouch fail-
ure also occurs more frequently in patients receiving post-operative radiotherapy
[15]. Accordingly, an ileal pouch-anal anastomosis should be likely avoided in
many patients with ulcerative colitis and rectal cancer when management requires
external beam radiotherapy.
Successful restoration of bowel continuity after proctocolectomy warrants con-
struction of a tension-free ileal pouch-anal anastomosis. Patients with visceral obe-
sity may have a shortened mesentery that physically precludes reach of the ileal
pouch to the anal canal. In those where reach can be achieved, the risk for pouch-
related complications (e.g., anastomotic separation, anastomotic/pouch stricture,
pouch fistula) is generally increased [16–18].
Proctocolectomy and diverted ileal pouch-anal anastomosis is an operation asso-
ciated with a relative high risk for operative morbidity. Specifically, stricture, pelvic
sepsis, and fistula occur in 10.7 %, 7.5 %, and 4.5 % of patients, respectively [19],
and hemorrhage complicates 3.6 % of the operations [20]. Patients with cardiac dis-
ease, pulmonary disorder, or renal impairment can expect an even greater likelihood
S.A. Strong
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49
of experiencing a post-operative complication. These co-morbidities in isolation or
combination can introduce prohibitive risk that serves as a relative contraindication
to proctocolectomy and ileal pouch-anal anastomosis.
Patients with primary sclerosis cholangitis complicating their ulcerative colitis
represent a special group of patients because some are at greater risk for compro-
mised outcomes following proctocolectomy with ileal pouch-anal anastomosis.
An ileal pouch operation in a cirrhotic with primary sclerosis cholangitis is associ-
ated with a high incidence of early post-operative complications such as bleeding
(44 %), worsening liver function (31 %), and pelvic abscess (19 %) [21]. Pelvic
sepsis is a particular concern in this population because of its link with patient
death [21].
Regardless of the degree of liver dysfunction, patients with primary sclerosis
cholangitis and ulcerative colitis are at significantly greater risk for acute pouchitis
and tend to have worse ileal pouch function compared to those without primary
sclerosis cholangitis [22]. Moreover, patients with large duct primary sclerosis chol-
angitis experience even worse pouch function and a significantly compromised
quality of life [22].
Liver transplantation prior to proctocolectomy and ileal pouch-anal anastomosis
can ameliorate some problems, and these patients can expect an acceptable risk for
operative morbidity and reasonable pouch function [23].
Another cohort of patients who may experience impaired ileal pouch function
and diminished quality of life are those with low (<40 mmHg) pre- and post-
operative anal sphincter resting pressures. These reduced pressures are associated
with an increased incidence of pad usage, seepage, and incontinence as well as
reduced quality of life and satisfaction with surgery that do not improve over time
[24]. Similarly, patients with pre-operative fecal incontinence unrelated to urgency
are not good candidates for an ileal pouch-anal anastomosis because of the same
reasons. However, a patient with pre-operative continence despite an anterior
sphincter defect does not usually experience a similar outcome [25].
Selected patients with absent proctitis, adequate rectal compliance, and reason-
able sphincter strength are potential candidates for colectomy and ileoproctostomy
[26]. In these cases, the benefits of less operative morbidity, preserved female
fecundity, and reasonable function must be weighed against the risk of neoplasia
and recurrent disease. The likelihood of the patient requiring a proctectomy is
16–26 % at 10 years and 31–54 % at 20 years [4].
References
1. Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults: American College of
Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010;105:501–23.
2. Dignass A, Lindsay JO, Sturm A, Windsor A, Colombel JF, Allez M, D’Haens G, D’Hoore A,
Mantzaris G, Novacek G, Oresland T, Reinisch W, Sans M, Stange E, Vermeire S, Travis S,
Van Assche G. Second European evidence-based consensus on the diagnosis and management
of ulcerative colitis part 2: current management. J Crohns Colitis. 2012;6:991–1030.
6 Which Ulcerative Colitis Patients Should Not Have Ileal Pouch-Anal Anastomosis
50
3. Ross H, Steele SR, Varma M, Dykes S, Cima R, Buie WD, Rafferty J, Standards Practice Task
Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the
surgical treatment of ulcerative colitis. Dis Colon Rectum. 2014;57:5–22.
4. Øresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, Marteau P,
Zmora O, Kotze PG, Espin-Basany E, Tiret E, Sica G, Panis Y, Faerden AE, Biancone L,
Angriman I, Serclova Z, de Buck van Overstraeten A, Gionchetti P, Stassen L, Warusavitarne
J, Adamina M, Dignass A, Eliakim R, Magro F, D’Hoore A, European Crohn’s Colitis
Organisation (ECCO). European evidence based consensus on surgery for ulcerative colitis.
J Crohns Colitis. 2015;9:4–25.
5. Emblem R, Larsen S, Torvet SH, Bergan A. Operative treatment of ulcerative colitis: conven-
tional proctectomy with Brooke ileostomy versus mucosal proctectomy with ileoanal anasto-
mosis. Scand J Gastroenterol. 1988;23:493–500.
6. McLeod RS, Churchill DN, Lock AM, Vanderburgh S, Cohen Z. Quality of life of patients
with ulcerative colitis preoperatively and postoperatively. Gastroenterology. 1991;101:
1307–13.
7. Liddell A, Pollett WG, MacKenzie DS. Comparison of postoperative satisfaction between
ulcerative colitis patients who chose to undergo either a pouch or an ileostomy operation. Int
J Rehabil Heal. 1995;1:89–96.
8. O’Bichere A, Wilkinson K, Rumbles S, Norton C, Green C, Phillips RK. Functional outcome
after restorative panproctocolectomy for ulcerative colitis decreases an otherwise enhanced
quality of life. Br J Surg. 2000;87:802–7.
9. Nordin K, Påhlman L, Larsson K, Sundberg-Hjelm M, Lööf L. Health-related quality of life
and psychological distress in a population-based sample of Swedish patients with inflamma-
tory bowel disease. Scand J Gastroenterol. 2002;37:450–7.
10. Camilleri-Brennan J, Munro A, Steele RJ. Does an ileoanal pouch offer a better quality of life
than a permanent ileostomy for patients with ulcerative colitis? J Gastrointest Surg. 2003;7:
814–9.
11. Kuruvilla K, Osler T, Hyman NH. A comparison of the quality of life of ulcerative colitis
patients after IPAA vs ileostomy. Dis Colon Rectum. 2012;55:1131–7.
12. van der Valk ME, Mangen MJ, Severs M, van der Have M, Dijkstra G, van Bodegraven AA,
Fidder HH, de Jong DJ, Pierik M, van der Woude CJ, Romberg-Camps MJ, Clemens CH,
Jansen JM, van de Meeberg PC, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY,
Bolwerk C, Vermeijden JR, Siersema PD, Leenders M, Oldenburg B, COIN study group,
Dutch Initiative on Crohn and Colitis. Comparison of costs and quality of life in ulcerative
colitis patients with an ileal pouch-anal anastomosis, ileostomy and anti-TNF therapy. J Crohns
Colitis. 2015;9:1016–23.
13. Wu XR, Kiran RP, Remzi FH, Katz S, Mukewar S, Shen B. Preoperative pelvic radiation
increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer.
J Crohns Colitis. 2013;7:e419–26.
14. Wertzberger BE, Sherman SK, Byrn JC. Differences in short-term outcomes among patients
undergoing IPAA with or without preoperative radiation: a National Surgical Quality
Improvement Program analysis. Dis Colon Rectum. 2014;57:1188–94.
15. Radice E, Nelson H, Devine RM, Dozois RR, Nivatvongs S, Pemberton JH, Wolff BG, Fozard
BJ, Ilstrup D. Ileal pouch-anal anastomosis in patients with colorectal cancer: long-term func-
tional and oncologic outcomes. Dis Colon Rectum. 1998;41:11–7.
16. Kiran RP, Remzi FH, Fazio VW, Lavery IC, Church JM, Strong SA, Hull TL. Complications
and functional results after ileoanal pouch formation in obese patients. J Gastrointest Surg.
2008;12:668–74.
17. Canedo JA, Pinto RA, McLemore EC, Rosen L, Wexner SD. Restorative proctectomy with
ileal pouch-anal anastomosis in obese patients. Dis Colon Rectum. 2010;53:1030–4.
18. Klos CL, Safar B, Jamal N, Hunt SR, Wise PE, Birnbaum EH, Fleshman JW, Mutch MG,
Dharmarajan S. Obesity increases risk for pouch-related complications following restorative
S.A. Strong
www.ebook3000.com
51
proctocolectomy with ileal pouch-anal anastomosis (IPAA). J Gastrointest Surg. 2014;18:
573–9.
19. de Zeeuw S, Ahmed Ali U, Donders RA, Hueting WE, Keus F, van Laarhoven CJ. Update of
complications and functional outcome of the ileo-pouch anal anastomosis: overview of evi-
dence and meta-analysis of 96 observational studies. Int J Colorectal Dis. 2012;27:843–53.
20. Fazio VW, Kiran RP, Remzi FH, Coffey JC, Heneghan HM, Kirat HT, Manilich E, Shen B,
Martin ST. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707
patients. Ann Surg. 2013;257:679–85.
21. Lian L, Menon KV, Shen B, Remzi F, Kiran RP. Inflammatory bowel disease complicated by
primary sclerosing cholangitis and cirrhosis: is restorative proctocolectomy safe? Dis Colon
Rectum. 2012;55:79–84.
22. Pavlides M, Cleland J, Rahman M, Christian A, Doyle J, Gaunt R, Travis S, Mortensen N,
Chapman R. Outcomes after ileal pouch anal anastomosis in patients with primary sclerosing
cholangitis. J Crohns Colitis. 2014;8:662–70.
23. Cho CS, Dayton MT, Thompson JS, Koltun WA, Heise CP, Harms BA. Proctocolectomy-ileal
pouch-anal anastomosis for ulcerative colitis after liver transplantation for primary sclerosing
cholangitis: a multi-institutional analysis. J Gastrointest Surg. 2008;12:1221–6.
24. Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW. Perioperative resting
pressure predicts long-term postoperative function after ileal pouch-anal anastomosis.
J Gastrointest Surg. 2002;6:316–20.
25. Gearhart SL, Hull TL, Schroeder T, Church J, Floruta C. Sphincter defects are not associated
with long-term incontinence following ileal pouch-anal anastomosis. Dis Colon Rectum.
2005;48:1410–5.
26. Scoglio D, Ahmed Ali U, Fichera A. Surgical treatment of ulcerative colitis: ileorectal vs ileal
pouch-anal anastomosis. World J Gastroenterol. 2014;20:13211–8.
6 Which Ulcerative Colitis Patients Should Not Have Ileal Pouch-Anal Anastomosis
53© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_7
Chapter 7
Management of Pouch-Vaginal Fistulas
Ido Mizrahi and Steven D. Wexner
Introduction
Since the initial description of restorative proctocolectomy in 1978 by Parks and
Nicholls [1], the stapled ileal-pouch anal anastomosis (IPAA) has evolved into the
mainstay surgical treatment for most patients who require surgery for ulcerative
colitis (UC) and many others with familial adenomatous polyposis (FAP) [2–5].
Pouch vaginal fistula (PVF) is a specific complication after IPAA, first reported by
Wong et al. in 1985 [6]. Though not a common problem, with reported incidence
rates ranging from 2.9 to 16.7 % [7–19], PVF is a source of considerable morbidity
for the patient and a technical challenge for the surgeon. PVF typically presents in
the first year after surgery; however, a late presentation might occur even after 10
years from surgery. The optimal management of PVF is not yet determined due to
the relative paucity of published data. Most authors agree that the management
depends on four basic etiologic/clinical factors: surgery related, sepsis related, dis-
ease related, and the location of the fistula.
Surgical technique in any operation is important for successful clinical results,
especially in complex procedures such as IPAA. In fact, increased experience has
been shown to decrease complications after IPAA [20, 21]. Tissue ischemia at the
anastomosis must strictly be avoided and therefore a tension-free anastomosis with
good blood supply should be obtained. It is crucial not to damage the rectovaginal
septum or “button hole” the vagina when dissecting the rectum, and to avoid incor-
poration of the posterior vaginal wall when firing the stapler. If identified at the time
of surgery, the anastomosis can be disconnected, the vagina repaired, and a hand-
sewn anastomosis re-constructed.
I. Mizrahi, MD • S.D. Wexner, MD, PhD (Hon) (*)
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
e-mail: wexners@ccf.org
www.ebook3000.com
54
Despite this specific mechanism of injury associated with the double stapled
technique, large scale studies have shown no difference in the incidence of PVF
after stapled and hand-sewn anastomosis [18, 22–25]. Further, it is important to
note that a stapled anastomosis is likely to be more cephalad. Therefore pouch
advancement to the dentate line is more likely to be a good remedial option when
PVF complicates a stapled anastomosis. Conversely, following an index hand-
sewn anastomosis, pouch advancement may not be a viable option. As for pouch
type, Wexner et al. found no difference in the incidence of PVF for different pouch
types [15].
Pelvic sepsis remains a major determinant in the development of PVF, as high-
lighted by the high rate of this complication in patients with PVF. Groom et al. [14]
found that 65 % of patients with PVF had pelvic sepsis compared with 16 % without
PVF. Wexner et al. [15] reported pelvic sepsis in 35 % of their PVF patients. Lee
et al. [23] found a significantly greater incidence of pelvic sepsis in patients with a
PVF than in those without (26.3 % vs. 6.3 %; p = 0.003). Pelvic sepsis can either be
ascending – originating from a disrupted anastomosis, or descending – resulting
from an intraoperative contamination or a pelvic hematoma [15, 23]. These mecha-
nisms further emphasize the importance of meticulous technique with attention to
hemostasis, contamination, and a tension-free anastomosis with adequate blood
supply. Furthermore, pelvic sepsis might be caused by cryptoglandular perianal dis-
ease, which is more common in patients with colitis and may lead to an anovaginal
fistula [8]. Typically, PVF of cryptoglandular origin is associated with an internal
opening of the fistula below the IPAA. A series from St Mark’s Hospital reported 2
out of 17 PVFs arising below the IPAA and most likely independent of the original
pouch procedure [14].
Careful review of appropriate histopathologic materials by an expert gastrointes-
tinal pathologist may be crucial to future management options. This step is espe-
cially true for the small percentage of patients, approximately 2–3 %, who undergo
IPAA for UC only to find the long-term diagnosis is Crohn’s disease (CD). Lee et al.
[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. Other
studies have shown similar results. The average time to development of a PVF is
typically longer in patients with CD. Importantly, these patients suffer from a sig-
nificantly higher rate of pouch failure and ultimately excision. Patients who undergo
IPAA for indeterminate colitis also have a high rate of pouch complications includ-
ing PVF and pouch failure [26]. However, patients whose indication for surgery is
familial adenomatous polypos present with a significantly low rate of PVF when
compared to IBD patients [27, 28], implying inflammation plays a role in the patho-
genesis of PVF.
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 ileotomy closure. Once PVF is
I. Mizrahi and S.D. Wexner