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285
20 Failing Pouch
32.3 months, of 85 patients who were included in pouch survival analysis, 70 had a
functioning pouch. Patients with Crohn’s disease were more likely to develop pouch
failure after redo IPAA. Indication for redo IPAA (septic versus nonseptic) or type of
pouch (old versus new pouch) was not associated with failure following redo IPAA.
A study of 51 patients with ulcerative colitis [
13 ] reported outcomes after major
reconstructive surgery due to complications after primary IPAA. Diagnosis subse-
quently changed to Crohn’s disease in 22 patients. In 65% of the study patients, indi-
cation for revision was infectious/infl ammatory complications. The median time
between original IPAA and reconstruction was 2.3 years. Fifty-seven percent of
patients had a partial pouch reconstruction. Risk factors for complications after revi-
sion were Crohn’s disease and partial reconstruction. Pouch survival after revision
was 93% at 1 year and 89% at 5 years. Development of a pelvic abscess was the prog-
nostic factor for pouch failure after reconstructive surgery. Meanwhile, Tekkis et al.
[ 14 ] identifi ed 112 patients undergoing abdominal reconstruction. The most common
pathologic diagnosis was ulcerative colitis ( n = 86), and the most common indication
for surgery was intra-abdominal sepsis ( n = 45). Most patients underwent pouch revi-
sion/augmentation. After a median follow-up of 46 months, 21% of study patients
had failure. Septic indications were associated with failure at 5 years. Shawki et al. [ 7 ]
also reported 23 patients undergoing pouch reconstruction or revision via an abdomi-
nal approach with a 69% success rate.
Most recently, we reported our experience in 241 patients undergoing redo pouch
surgery [ 15 ] . One hundred and sixty-two (67%) patients were referred from other
institutions. Pathologic diagnosis was ulcerative colitis in 172 patients, familial ade-
nomatous polyposis in 22, Crohn’s disease in 31, indeterminate colitis in 13, and
other diagnosis in 3 patients. The most common indication for repeat pouch surgery
included chronic fi stula ( n = 67), leak ( n = 65), anastomotic stricture ( n = 42), and
pouch dysfunction ( n = 40). In 71 patients, the old pouch was excised, and a new
pouch created during repeat surgery. In 170 patients, the original pouch was used
(pouch repair/revision in 141, pouch augmentation/advancement/mobilization in 28,
and pouchopexy in 1). In a patient with chronic anastomotic leak/sinus, we believe
that the key to success is the excision of the chronic phlegmon/abscess cavity
(Fig. 20.5 ). After a median follow-up of 5 years, pouch survival rate following repeat
pouch surgery was 85%. Pouch survival rate was 84% in patients who underwent
repeat pouch surgery due to a septic complication and 87% in those with a nonseptic
indication. Of 31 patients with Crohn’s disease, 7 (22.6%) had pouch failure. Pouch
salvage patients had a mean number of 7.9 bowel movements per 24 h. Ninety-nine
percent stated that they would have repeat pouch surgery again, while 98% would
recommend it to others. Study patients were compared to those with primary IPAA
for functional outcomes and QOL. A smaller proportion of patients undergoing pri-
mary IPAA described pad usage during daytime and seepage episodes during day
and nighttime than those undergoing repeat pouch surgery; however, other pouch
function and QOL outcomes were comparable in both groups.
It is our experience that some patients [ 16 ] with technical complications after
primary IPAA may be mislabeled as having Crohn’s disease. Thus, of 33 patients
referred to the Cleveland Clinic with a diagnosis of CD after a primary IPAA, after
286
H.T. Kirat and F.H. Remzi
a.
b.
c.
d.
Fig. 20.5 Steps to a redo pouch. ( a ) Pouch with associated abscess cavity. ( b ) Mobilisation of the
puch and excision of the cavity. ( c and d ) handsewn placement of the new pouch
287
20 Failing Pouch
further evaluation showed that the indications for repeat pouch surgery were pouch
fi stula ( n = 20), anastomotic leak or pelvic sepsis ( n = 17), stricture ( n = 4), refractory
pouchitis ( n = 2), long exit conduit ( n = 1), and retained rectal stump ( n = 1). Repeat
pouch surgery included laparotomy with construction of a new pouch or revision of
existing pouch with redo IPAA. After a median follow-up of 1.7 years, pouch sur-
vival rate was 84.8%. Study patients were compared with those undergoing primary
IPAA for functional outcomes and QOL. All parameters of pouch function and
QOL were similar between the groups. In our view, careful evaluation of patients
who are referred with a diagnosis of pouch complications due to Crohn’s disease is
always necessary before accepting this label.
Although leak from the tip of the J-pouch is less frequent than anastomotic leak,
it is known to be associated with pouch failure. A recent study from our institution
[ 17 ] included 27 patients with a leak from the tip of the J-pouch following IPAA.
The fi nal pathologic diagnosis was ulcerative colitis in 22 patients, familial adenom-
atous polyposis in 3, and Crohn’s disease in 2. One patient underwent pouch exci-
sion and end ileostomy, and another patient healed after CT-guided drainage of a
pelvic abscess. Other 25 patients underwent salvage surgery to repair the leak
(Figs.
20.6 and 20.7 ). After a mean follow-up of 3.2 years, 24 patients had a func-
tioning pouch. Pouch function and QOL outcomes were compared between the
study patients and those with primary IPAA and were found to be similar. It was
concluded that although tip of the J-pouch has an indolent course, salvage surgery
is required and often associated with good outcomes.
Fig. 20.6 Stapled repair of
leak from the tip of the
J-pouch
288
H.T. Kirat and F.H. Remzi
20.4 Pouch Excision Versus Permanent Diversion
In patients with pouch failure for whom restoration of intestinal continuity is not
pursued, pouch excision can be performed [ 18, 19 ] . QOL scores after pouch excision
are reported to be similar to those following standard proctocolectomy and ileostomy,
despite more liquid ileostomy loss in patients undergoing pouch excision [ 18 ] .
However, when compared to healthy population, those with pouch excision had worse
QOL parameters for physical, social, energy, and physical role function . Moreover,
patients with pouch excision had signifi cantly lower physical, energy and physical
role function scores than a control group of patients with a functioning pouch [ 19 ] .
Permanent ileostomy without pouch excision may be an alternative to pouch
excision. In a study [ 20 ] which compared outcomes after pouch excision with divert-
ing ileostomy without excision, no difference was found in stoma-related complica-
tions and urinary symptoms. However, male sexual function was signifi cantly worse
in patients undergoing pouch excision. Despite higher QOL scores in patients with
pouch excision than those with permanent stoma without excision, the difference
was not statistically signifi cant (Box
20.4 ).
In 18 patients with available histopathology, no dysplasia or cancer was found.
Similarly, in a study including 22 patients with permanent diversion without excision,
Fig. 20.7 Hand-sewn repair
of leak from the tip of the
J-pouch
289
20 Failing Pouch
13 patients underwent an endoscopic examination with pouch biopsy, and no case of
dysplasia or cancer was seen [ 21 ] . Although outcomes seem to be similar between
these two approaches, further studies with larger number of patients were needed for
defi nitive conclusions.
20.5 Summary
Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the
procedure of choice for patients with ulcerative colitis and selected patients with
familial adenomatous polyposis. Early postoperative complications after IPAA
include anastomotic leak, pelvic sepsis, stricture, and fi stula, while late complica-
tions are pouchitis, obstruction, and pouch dysfunction. Pouch failure rates range
from 0.5% to 24%. If local procedures fail to salvage the pouch, abdominoperineal
reconstructive surgery with/without redo IPAA can be performed. Reconstructive
procedures have been reported to be associated with good outcomes and high sal-
vage rates in patients with a failed pouch. A delayed diagnosis of Crohn’s disease
might be associated with adverse outcomes following salvage surgery. Sepsis has
been shown to be one of the most common reasons for failure and also a contraindi-
cation for pouch salvage surgery by some authors. In contrast, others reported that if
sepsis is controlled, salvage surgery can be carried out with good functional results.
If the failed pouch is not salvageable, permanent ileostomy with or without excision
of pouch is an alternative.
Box 20.4: Permanent Excision or Indefi nite Diversion
SF36 QOL scores same for both groups •
No signifi cant difference in urinary symptoms •
Male sexual function was signifi cantly better with indefi nite diversion •
when compared to permanent excision
Key Points
Long Term IPAA problems
18.8% pouchitis, •
9.5% pelvic sepsis, •
9.2% stricture •
5.5% fi stula•
Pouch failure Independent predictors of pouch survival
Diagnosis (Crohns), anal pathology, abnormal anal manometry, patient
comorbidity, pouch-perineal or pouch-vaginal fi stula, pelvic sepsis, anasto-
motic stricture and separation
290
H.T. Kirat and F.H. Remzi
References
1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J.
1978;2:85–8.
2. Fazio VW, O’Riordain MG, Lavery IC, et al. Long-term functional outcome and quality of life
after stapled restorative proctocolectomy. Ann Surg. 1999;230:575–84; discussion 584–6.
3. Kirat HT, Remzi FH, Kiran RP, Fazio VW. Comparison of outcomes after hand-sewn versus
stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009;146:723–9.
4. Hueting WE, Buskens E, van der Tweel I, Gooszen HG, van Laarhoven CJ. Results and com-
plications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies com-
prising 9,317 patients. Dig Surg. 2005;22:69–79.
Case Scenario Answer
(d) In diverted patients with anastomotic leak following IPAA, we perform an
examination under anesthesia (EUA) and transanal/transanastomotic drainage
of pelvic abscess through the defect using a small mushroom catheter. We
subsequently do EUA and gastrographin enema every 8–10 weeks during the
next 6–12 months to check the healing of anastomotic leak and pelvic abscess.
The mushroom catheter is usually removed after the acute episode subsides or
where the cavity shrinks to the size that no further transanastomotic drainage
is necessary. After this 6–12 months period if the pathology heals, we close
ileostomy. In case of incomplete healing, if there is a small presacral sinus, we
proceed with ileostomy closure after explaining the possibility of recurrence
of infection to the patient. On the other hand, if there is a persistent large cav-
ity and a large presacral sinus with drainage of pus after 9–12 months, as in
this patient, our approach is disconnection of IPAA and excision of the chronic
pelvic abscess cavity during abdominal reoperative surgery.
Pouch failure decreases with time
Salvage Strategies Transanal Reoperative Surgery
Abdominoperineal Reoperative Surgery
Chronic anastomotic leak/sinus, - excision of the chronic phlegmon/ abscess
cavity
Pouch survival rate - 84% in patients who underwent repeat pouch surgery
due to a septic complication; 87% in those with a non-septic indication
Permanent Diversion or Pouch Excision? QOL scores after pouch excision
are reported to be similar to those following standard proctocolectomy and
ileostomy
Male sexual function was signifi cantly in patients undergoing pouch
excision
291
20 Failing Pouch
5. Fazio VW, Tekkis PP, Remzi F, Lavery IC, Manilich E, Connor J, Preen M, Delaney CP.
Quantifi cation of risk for pouch failure after ileal pouch anal anastomosis surgery. Ann Surg.
2003;238:605–14; discussion 614–7.
6. Dehni N, Remacle G, Dozois RR, Banchini F, Tiret E, Parc R. Salvage reoperation for compli-
cations after ileal pouch-anal anastomosis. Br J Surg. 2005;92:748–53.
7. Shawki S, Belizon A, Person B, Weiss EG, Sands DR, Wexner SD. What are the outcomes of
reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery? Dis Colon
Rectum. 2009;52:884–90.
8. Shah NS, Remzi FH, Massmann A, Baixauli J, Fazio VW. Management and treatment out-
come of pouch-vaginal fi stulas following restorative proctocolectomy. Dis Colon Rectum.
2003;46:911–7.
9. MacLean AR, O’Connor B, Parkes R, Cohen Z, McLeod RS. Reconstructive surgery for failed
ileal pouch-anal anastomosis: a viable surgical option with acceptable results. Dis Colon
Rectum. 2002;45:880–6.
10. Fonkalsrud EW, Bustorff-Silva J. Reconstruction for chronic dysfunction of ileoanal pouches.
Ann Surg. 1999;229:197–204.
11. Fazio VW, Wu JS, Lavery IC. Repeat ileal pouch-anal anastomosis to salvage septic complica-
tions of pelvic pouches: clinical outcome and quality of life assessment. Ann Surg.
1998;228:588–97.
12. Baixauli J, Delaney CP, Wu JS, Remzi FH, Lavery IC, Fazio VW. Functional outcome and
quality of life after repeat ileal pouch-anal anastomosis for complications of ileoanal surgery.
Dis Colon Rectum. 2004;47:2–11.
13. Mathis KL, Dozois EJ, Larson DW, Cima RR, Wolff BG, Pemberton JH. Outcomes in patients
with ulcerative colitis undergoing partial or complete reconstructive surgery for failing ileal
pouch-anal anastomosis. Ann Surg. 2009;249:409–13.
14. Tekkis PP, Heriot AG, Smith JJ, Das P, Canero A, Nicholls RJ. Long-term results of abdominal
salvage surgery following restorative proctocolectomy. Br J Surg. 2006;93:231–7.
15. Remzi FH, Fazio VW, Kirat HT, Wu JS, Lavery IC, Kiran RP. Repeat pouch surgery by the
abdominal approach safely salvages failed ileal pelvic pouch. Dis Colon Rectum.
2009;52:198–204.
16. Garrett KA, Remzi FH, Kirat HT, Fazio VW, Shen B, Kiran RP. Outcome of salvage surgery
for ileal pouches referred with a diagnosis of Crohn’s disease. Dis Colon Rectum.
2009;52:1967–74.
17. Kirat HT, Kiran RP, Oncel M, Shen B, Fazio VW, Remzi FH. Management of leak from the tip
of the “j” in ileal pouch-anal anastomosis. Dis Colon Rectum. 2011;54:454–9.
18. Tan HT, Morton D, Connolly AB, Pringle W, White M, Keighley MR. Quality of life after
pouch excision. Br J Surg. 1998;85:249–51.
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;45:1289–94.
20. Das P, Smith JJ, Tekkis PP, Heriot AG, Antropoli M, John Nicholls R. Quality of life after
indefi nite diversion/pouch excision in ileal pouch failure patients. Colorectal Dis.
2007;9:718–24.
21. Bengtsson J, Börjesson L, Willén R, Oresland T, Hultén L. Can a failed ileal pouch anal anas-
tomosis be left in situ? Colorectal Dis. 2007;9:503–8.
293
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_21, © Springer-Verlag London Limited 2012
21.1 Introduction
Surgery cannot “cure” Crohn’s disease but should be about best managing the compli-
cations of the disease. It is the transmural infl ammation that is typical of Crohn’s dis-
ease which gives rise to the complications of stricture, abscess, and fi stulation.
Symptoms may include abdominal pain, diarrhea, malaise, fever, anorexia, weight loss,
or anemia and will vary depending upon the underlying nature and distribution of the
disease. In an individual patient, the disease tends to be either stricturing or fi stulating,
and recurrent disease after surgical resection tends to recur in a similar pattern [ 1 ] .
Crohn’s disease most commonly affects the terminal ileum (when it was fi rst reported,
it was termed “terminal ileitis” [ 2 ] ) with ileocolic disease present in approximately
40% of patients, ileal disease in 30%, and colonic/anal disease in less than 30% [ 3 ] .
21.2 Investigations
Approximately a fi fth of patients with Crohn’s disease will present as an emergency
[ 4 ] . In the patients presenting acutely with complications of the disease and in whom
medical management is not possible, CT scanning is the most useful imaging modal-
ity. It can demonstrate obstruction, fi stulation, or abscess formation and will fre-
quently allow radiologically guided percutaneous drainage of collections. For those
patients who present less acutely, there are other imaging modalities available.
Colonoscopy with terminal ileal intubation may diagnose the disease, provide the
opportunity to obtain biopsies, and allow for therapeutic balloon dilatation of fi brotic
strictures, including anastamotic strictures. MRI enteroclysis, where the bowel is
P. Rooney, FRCS (*) • N. Eardley
Department of Surgery , Royal Liverpool University Hospital ,
Prescot St , Liverpool , L7 8XP , UK
e-mail: paul.rooney@rlbuht.nhs.uk
Chapter 21
Surgery for Small Bowel Crohn’s Disease
Paul Rooney and Nicola Eardley
294
P. Rooney and N. Eardley
deliberately distended with fl uid prior to imaging, results in good demonstration of
the bowel without the radiation dose associated with CT scans. Although previously
used extensively, small bowel contrast studies can be low in sensitivity and are being
superceded by MRI enteroclysis. Contrast studies via fi stulae are often helpful in
defi ning anatomy in order to plan surgery. Capsule endoscopy may occasionally be
useful in obtaining an elusive diagnosis, but there is a theoretical risk of the capsule
becoming stuck and causing obstruction if there is any associated stricturing.
21.3 Medical Management (See Chap. 17 )
The majority of patients with small bowel disease will present electively to the col-
orectal surgeon after a period of medical management. The general principle of med-
ical management of active disease is induction and then maintenance of remission [ 5 ]
(Table 21.1 ). Traditionally, patients have been started on steroid therapy and then
worked up towards biologic therapy if other measures were failing, the so-called
step-up approach. The SUTD (Step-Up Top-Down) trial demonstrated that early
treatment with immunosuppression (infl iximab and azathioprine), the “top-down”
approach, was more effective in maintaining remission and preventing relapse [ 29 ] ,
and we should fi nd that the use of steroids in Crohn’s disease is decreasing.
21.3.1 Smoking Cessation
One of the most important factors in maintenance of remission and also prevention
of recurrence after surgery is cessation of smoking [ 30– 32 ] . An interventional study
using a smoking cessation program for smokers with Crohn’s disease was able to
demonstrate that smoking cessation resulted in reduced requirements for steroids
and immunosuppressants [ 33 ] . This should be strongly emphasized to patients and
help offered to them to aid them in their efforts, e.g., referral to a smoking cessation
service and prescription of nicotine patches.
21.4 Surgery for Small Bowel Crohn’s Disease
21.4.1 Do I Need to Operate?
Sometimes the decision to operate is easy, and the surgeon has no choice but to
operate, e.g., generalized peritonitis or acute obstruction. This is the minority of
cases, and usually, the decision of when to operate and what to do is not an easy one.
295
21 Surgery for Small Bowel Crohn’s Disease
Table 21.1 Medical treatment of small bowel Crohn’s disease
Treatment Induction of remission? Maintenance of remission?
Prevention of recurrence after
surgery?
Side effects/complications
5-Aminosalicylic acid
(5-ASA)
Yes. Mesalazine may be used in mild
ileocolonic disease [
5 ] , but the
clinical effects are minimal [ 6 ]
No [
7 ] Yes. Mesalazine may prevent
recurrence [
8– 10 ]
Nausea, diarrhea, headaches.
Rarely, pancreatitis,
hepatitis, myocarditis
Steroids Yes [
5 ] . Exclude alternative causes
for symptoms, e.g., bile salt
malabsorption, bacterial
overgrowth, or short bowel
syndrome
No. Limit use to minimum
period required to
induce remission
No Sepsis, diabetes mellitus,
hypertension, osteoporosis,
mood change. Increased risk
of anastamotic leak [ 11 ]
Enteral feeding Yes [ 5 ] . Remission rates approxi-
mately 60% with enteral feeding
as compared to 80% with steroid
therapy [ 12– 15 ]
Yes. Useful in pediatrics
where effects of
prolonged steroid usage
are particularly
important
No May be unpalatable
Thiopurines (azathio-
prine and
6-mercaptopurine)
No. Onset of action is slow. Often
used as maintenance therapy
after induction of remission with
steroids
Yes. Azathioprine may
maintain remission for
up to 4 years [ 16 ]
Yes [ 17 ] Nausea, vomiting, pancreatitis,
hepatitis, myelosuppression.
Risk of lymphoma with
long-term therapy (although
absolute risk small) [ 18 ]
Methotrexate Yes. Delayed onset of action but
combined with early steroids can
be used to induce and then
maintain remission [ 19, 20 ]
Yes [ 9, 10 ] No Nausea, stomatitis, and diarrhea
are common. Serious side
effects of myelosuppression,
hepatotoxicity, and
pneumonitis are less so.
Teratogenic [ 21 ]
(continued)
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