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337
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_37
A. Feinberg · T. Hull (*)
Cleveland Clinic Foundation, Cleveland, OH, USA
e-mail: hullt@ccf.org
37
Use ofAntiadhesive Barriers inPouch
Surgery
AdinaFeinberg andTracyHull
Introduction
Ileal-pouch anal anastomosis (IPAA) is a desired option for many ulcerative colitis
(UC) patients since it provides the opportunity for restoration of intestinal continu-
ity. Nonetheless, there is no difference in the overall quality of life between patients
who undergo IPAA versus permanent ileostomy as both groups report signicant
improvement [1]. IPAA reconstruction is associated with a variety of complications
which may impact quality of life. Postsurgical adhesions create a signicant amount
of morbidity for patients after IPAA.Over 20% of patients who undergo IPAA may
develop small bowel obstruction (SBO) [2]. Decreased fertility after IPAA has been
well-established with approximately 40–50% of female patients in the child- bearing
years reporting inability to conceive within 12months [3–5]. There is great interest
in surgical approaches that can minimize the formation of these adhesions.
Numerous commercial barrier agents have been designed to reduce intraabdominal
adhesions after surgery [6]. These products prevent contact between raw peritoneal or
serosal surfaces. 0.5% Ferric Hyaluronate Gel (Intergel; Lifecore Biomedical Inc.,
Chaska, MN) was designed to be instilled into the peritoneal cavity following surgery
to minimize tissue apposition. This product was subsequently withdrawn due to adverse
events. Oxidised regenerated cellulose (Interceed
®
; Ethicon, Sommervile, NJ, USA) is
an absorbable product. Interceed
®
is not often used due to the requirement for total
hemostasis prior to application, as the combination of blood and oxidized cellulose in
the peritoneal cavity may promote increased adhesion formation; this is antithetical to
the intended purpose. Polytetrauorethylene (Gore-Tex
®
, W.L. Gore Corporation,
Flagstaff, AZ, USA) is a permanent material that requires suture xation. Justiable
concerns about leaving permanent material in the intraperitoneal position have
decreased enthusiasm for Gore-Tex
®
as an antiadhesive product. Sodium hyaluronic
338
acid and carboxymethylcellulose membrane (Sepralm
®
; Genzyme Corporation,
Cambridge, MA, USA) is an absorbable product that can be used without xation and
without a requirement for absolute hemostasis, making it a more popular choice.
This chapter will discuss the role of antiadhesive barriers in IPAA surgery
(Table37.1).
Search Strategy
A comprehensive literature search was performed in MEDLINE, EMBASE and
PubMed from inception to June 2018, without language restriction, for any human
clinical study assessing the effect of antiadhesive barriers in colorectal surgery with
regards to intraabdominal adhesions, small bowel obstruction, or fertility. MeSH
descriptors were used that included: “proctocolectomy, restorative” or “colonic
pouches” or “surgery, colorectal” or “digestive system surgical procedures” com-
bined with “biocompatible materials” or “membranes, articial” or “carboxymeth-
ylcellulose sodium” or “hyaluronic acid” combined with “tissue adhesions” or
“intestinal obstruction” or “fertility”. Given the paucity of studies investigating
IPAA patients, the search was expanded to include all colorectal surgical patients.
Citation tracking was used to identify any additional relevant studies.
Results
Becker [7] was the rst to assess the effects of Sepralm
®
in a randomized controlled
trial. In this study, patients with ulcerative colitis or familial adenomatous polyposis
undergoing restorative proctocolectomy with loop ileostomy were randomized to
receive Sepralm
®
placed under the midline incision or not (n= 85 Sepralm
®
vs.
n=90 control). The degree and severity of subsequent adhesions were assessed at the
time of ileostomy closure with laparoscopy 8–12weeks later. Sepralm
®
decreased
both the incidence (49% vs. 94%, p< 0.001) and severity (15% vs. 58% grade 3
severity, p<0.001) of adhesions. There was no signicant difference in the incidence
of complications, including intraabdominal abscess, between the groups.
Salum [8] conducted a retrospective matched cohort study comparing patients
who underwent colorectal surgery and had Sepralm
®
placed under the incision
(n=259) to those that did not have Sepralm
®
placed (n=179). Chart review and
telephone interviews were used to assess for SBO and complications. There was no
signicant difference between the Sepralm
®
and control group in terms of rate of
SBO (4.6% vs. 6.7%, p=NS) or rate of surgery for SBO (1.5% vs. 2.8%, p=NS).
Table 37.1 PICO table
Patients
Intervention Comparator
Outcome
Patients with UC undergoing
IPAA
Anti-adhesion
barriers
Standard
care
Adhesions
Small bowel
obstruction
Fertility
A. Feinberg and T. Hull
339
Vrijland [9] performed a randomized controlled trial (RCT) to evaluate the effect
of Sepralm
®
on patients undergoing Hartmann procedure for diverticulitis or can-
cer. They randomized 71 patients, but were only able to assess 42 patients undergo-
ing a second operation for anastomosis (21 Sepralm
®
vs. 21 control). There was no
difference in the incidence of adhesions found at subsequent surgery. They did nd a
reduction in the severity of adhesions in the group that received Sepralm
®
(mean
severity score 18 vs. 50, p=0.002). They published a follow-up study assessing the
long-term incidence of SBO.They did not nd any signicant difference between the
groups, but the study was underpowered with only 35 patients in this analysis [10].
Fazio [11] performed an RCT to evaluate the effect of Sepralm
®
on patients
undergoing intestinal resection. This international, multicenter study randomized
1701 patients (840 Sepralm
®
vs. 861 control) to receive between 3 and 10 sheets
of Sepralm
®
at the time of abdominal closure. There was no difference in the pri-
mary outcome of overall SBO (12% vs. 12%). However, a subgroup analysis was
done for patients who underwent surgery for SBO and were conrmed to have an
adhesive cause at the time of operation. There was a lower rate of operatively diag-
nosed adhesive disease for patients who received Sepralm
®
(1.8% vs. 3.4%,
p<0.05). It is important to note that the overall rate of surgery for SBO did not
differ between the two groups. They also analysed the rate of adverse events and
found that patients who received Sepralm
®
had higher rates of anastomotic leak
(4% vs. 2%, p<0.05), peritonitis (3% vs. 1%, p<0.05) and stula (2% vs. <1%,
p<0.05) [12]. They found that these complications occurred in association with
wrapping Sepralm
®
around the anastomosis. This has led to a recommendation
against placing Sepralm
®
in contact with enteric suture lines.
Cohen [13] performed a RCT using sodium hyaluronic acid and carboxymethyl-
cellulose that was chemically modied with glycerol to form G-HA/CMC. This
modication aimed to improve membrane exibility and handling. In this RCT,
patients with ulcerative colitis or familial adenomatous polyposis undergoing restor-
ative proctocolectomy with loop ileostomy were randomized to receive G-HA/
CMC placed under the midline incision (n=59G-HA/CMC vs. n=61 control). As
in prior studies, the degree and severity of subsequent adhesions were assessed at
the time of laparoscopic ileostomy closure. G-HA/CMC decreased both the inci-
dence (67% vs. 90%, p = 0.002) and severity (6% vs. 33% grade 3 severity,
p<0.001) of adhesions. Of note, there was a trend towards increased intraabdomi-
nal abscess in patients who received G-HA/CMC (15% vs. 4.9%, p=0.07). After
this trial, G-HA/CMC was never brought to the market.
Tang [14] performed an RCT to evaluate the effect of Intergel
®
instillation on
patients undergoing colorectal resection. They initially aimed to recruit 200 patients
but the trial was suspended after 32 patients had been recruited due to high morbid-
ity in the treatment group (65% vs. 27%, p=0.031).
Tsuruta [15] retrospectively analyzed all patients who had undergone laparo-
scopic colorectal surgery (n=167) at their institution between 2007 and 2012. The
primary outcome was short-term postoperative SBO or ileus diagnosed by X-ray or
computed tomography (CT). The rate of postoperative SBO was 9.7% (6/62) in the
group without any adhesion barrier, 5.0% (1/19) in the group with single layer
Sepralm
®
and 0% (0/86) in the group with multi-layer Sepralm
®
(p<0.05). This
37 Use ofAntiadhesive Barriers inPouch Surgery
340
retrospective study has signicant limitations with no adjustment in the analysis for
possible confounders such as type of surgical procedure or history of previous sur-
gery (Table37.2).
Table 37.2 Summary of literature search
Study
Population Intervention
Study
design N Outcome
Quality
of
evidence
Becker
(1996)
[7]
Beck
(1997)
[16]
Patients
undergoing
restorative
proctocolectomy
with IPAA
Sepralm
®
placed
under the
midline
incision
RCT 90 control
vs.
85
Sepralm
®
Reduced
incidence of
adhesions in
Sepralm
®
group (49%
vs. 94%,
p<0.001)
Decreased
severity of
adhesions in
Sepralm
®
group (15%
vs. 58% grade
3 severity,
p<0.001)
High
Salum
(2001)
[8]
Patients who
underwent
colorectal
surgery
Sepralm
®
placed
under the
midline
incision and
around
stoma sites
R 259
Sepralm
®
vs.
179
control
No difference
in the
incidence of
SBO
(4.6% vs.
6.7%, p=NS)
No difference
in the rate of
surgery for
SBO
(1.5% vs.
3.9%, p=NS)
Low
Vrijland
(2002)
[9]
Van der
Wal
(2011)
[10]
Patients
undergoing
Hartmann
procedure for
diverticulitis or
obstructing
cancer
Sepralm
®
placed
under the
midline
incision and
in the pelvis
RCT 21 control
vs.
21
Sepralm
®
No difference
in the
incidence of
adhesions
Severity of
adhesions
decreased in
Sepralm
®
group (mean
severity score
18 vs. 50,
p=0.002)
No signicant
difference in
long term
SBO
incidence
Moderate
A. Feinberg and T. Hull
341
Table 37.2 (continued)
Study
Population Intervention
Study
design N Outcome
Quality
of
evidence
Beck
(2003)
[12]
Fazio
(2006)
[11]
Patients
undergoing
intestinal
resection
Sepralm
®
placed in
3–10 sheets
at the
surgeon’s
discretion
RCT 861
control
vs.
840
Sepralm
®
No difference
in incidence
of SBO (12%
vs. 12%)
High
Cohen
(2005)
[13]
Patients
undergoing
restorative
proctocolectomy
with IPAA
G-HA/CMC
placed in
2–4 sheets
under the
midline
incision
RCT 61 control
vs.
59G-HA/
CMC
Reduced
incidence of
adhesions in
G-HA/CMC
group (67%
vs. 90%,
p=0.002)
Decreased
severity of
adhesions in
Sepralm
®
group (6% vs.
33% grade 3
severity,
p<0.001)
High
Tang
(2006)
[14]
Patients
undergoing
colorectal
resection
Intergel
®
instillation
RCT 15 control
vs.
17
Intergel
®
Terminated
early due to
high
morbidity
(anastomotic
dehiscence
and ileus) in
treatment
group
Moderate
Tsuruta
(2015)
[15]
Patients
undergoing
laparoscopic
colorectal
surgery
Sepralm
®
placed in a
single or
multi-layer
R 62 control
vs.
19 single
layer
vs.
86
multi-
layer
Postoperative
bowel
obstruction or
ileus within
3months:
9.7% with no
adhesion
barrier
vs.
5% with
single layer
vs.
0% with
multi-layer
Very low
N number, R retrospective, RCT randomized controlled trial, NS not signicant
37 Use ofAntiadhesive Barriers inPouch Surgery
342
Recommendations Based onData
While multiple RCTs have demonstrated that antiadhesive barriers (specically
Sepralm
®
) reduce both the incidence and severity of adhesions after IPAA and
other intestinal surgery, this has not translated into a decreased incidence of
SBO.There was no data in our patient population regarding antiadhesive barriers
and future fertility. Antiadhesive barriers have also been associated with increased
risk of abscess in colorectal surgery, particularly when placed in contact with an
anastomosis. However, the question remains as to whether patients who later
require reoperative surgery benet from decreased intraabdominal adhesions.
The clinical benet of antiadhesive barriers in patients with UC undergoing
IPAA is uncertain and its use may be evaluated on a case by case basis.
(Evidence: moderate; Recommendation: moderate).
Personal View oftheData
The senior author was a blind participant in the Becker [7] study where laparos-
copy was done at the time of stoma closure to evaluate the presence adhesions to
the midline incision. The senior author could correctly guess which patient received
Sepralm
®
and which patient did not in every case, based on viewing the extent of
adhesions, which impressed her. Our institution has not experienced issues with
increased anastomotic leaks, but we do not wrap anastomoses in this product. We
have seen rare cases of “sterile peritonitis” [17]. That is, the patient presents with
an acute abdomen and, upon reoperation, has generalized erythema throughout the
abdomen with neither bowel perforation nor abscess. We have not used anti-
adhesive barriers with the laparoscopic approach in our practice. Laparoscopic
IPAA surgery has been shown to cause fewer intraabdominal adhesions as well as
adnexal adhesions [18]. Small retrospective series have reported on improved
pregnancy rates with laparoscopic IPAA [19, 20]. However, when there is reopera-
tive surgery with an open approach, we strongly consider the use of antiadhesive
barriers, particularly if we suspect that there will be further open operations in the
future [21].
References
1. Murphy PB, Khot Z, Vogt KN, Ott M, Dubois L.Quality of life after total proctocolectomy
with ileostomy or IPAA: a systematic review. Dis Colon Rectum. 2015;58(9):899–908.
2. MacLean AR, Cohen Z, MacRae HM, etal. Risk of small bowel obstruction after the ileal
pouch-anal anastomosis. Ann Surg. 2002;235(2):200–6.
3. Johnson P, Richard C, Ravid A, etal. Female infertility after ileal pouch-anal anastomosis for
ulcerative colitis. Dis Colon Rectum. 2004;47(7):1119–26.
A. Feinberg and T. Hull
343
4. Waljee A, Waljee J, Morris AM, Higgins PD. Threefold increased risk of infertility: a
meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Gut.
2006;55(11):1575–80.
5. Gorgun E, Remzi FH, Goldberg JM, etal. Fertility is reduced after restorative proctocolectomy
with ileal pouch anal anastomosis: a study of 300 patients. Surgery. 2004;136(4):795–803.
6. Ahmad G, O’Flynn H, Hindocha A, Watson A.Barrier agents for adhesion prevention after
gynaecological surgery. Cochrane Database Syst Rev. 2015;(4):CD000475.
7. Becker JM, Dayton MT, Fazio VW, etal. Prevention of postoperative abdominal adhesions
by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-
blind multicenter study. J Am Coll Surg. 1996;183(4):297–306.
8. Salum MR, Lam DT, Wexner SD, etal. Does limited placement of bioresorbable membrane
of modied sodium hyaluronate and carboxymethylcellulose (Sepralm) have possible short-
term benecial impact? Dis Colon Rectum. 2001;44(5):706–12.
9. Vrijland WW, Tseng LN, Eijkman HJ, et al. Fewer intraperitoneal adhesions with use of
hyaluronic acid-carboxymethylcellulose membrane: a randomized clinical trial. Ann Surg.
2002;235(2):193–9.
10. van der Wal JB, Iordens GI, Vrijland WW, van Veen RN, Lange J, Jeekel J.Adhesion pre-
vention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg.
2011;253(6):1118–21.
11. Fazio VW, Cohen Z, Fleshman JW, etal. Reduction in adhesive small-bowel obstruction by
Sepralm adhesion barrier after intestinal resection. Dis Colon Rectum. 2006;49(1):1–11.
12. Beck DE, Cohen Z, Fleshman JW, etal. A prospective, randomized, multicenter, controlled
study of the safety of Sepralm adhesion barrier in abdominopelvic surgery of the intestine.
Dis Colon Rectum. 2003;46(10):1310–9.
13. Cohen Z, Senagore AJ, Dayton MT, et al. Prevention of postoperative abdominal adhesions
by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable mem-
brane: a prospective, randomized, evaluator-blinded multicenter study. Dis Colon Rectum.
2005;48(6):1130–9.
14. Tang CL, Jayne DG, Seow-Choen F, Ng YY, Eu KW, Mustapha N.A randomized controlled
trial of 0.5% ferric hyaluronate gel (Intergel) in the prevention of adhesions following abdomi-
nal surgery. Ann Surg. 2006;243(4):449–55.
15. Tsuruta A, Itoh T, Hirai T, Nakamura M.Multi-layered intra-abdominal adhesion prophylaxis
following laparoscopic colorectal surgery. Surg Endosc. 2015;29(6):1400–5.
16. Beck DE.The role of Sepralm bioresorbable membrane in adhesion prevention. Eur J Surg
Suppl 1997(577):49–55.
17. Remzi FH, Oncel M, Church JM, Senagore AJ, Delaney CP, Fazio VW.An unusual com-
plication after hyaluronate-based bioresorbable membrane (Sepralm) application. Am Surg.
2003;69(4):356–7.
18. Hull TL, Joyce MR, Geisler DP, Coffey JC. Adhesions after laparoscopic and open ileal
pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg. 2012;99(2):270–5.
19. Bartels SA, DʼHoore A, Cuesta MA, Bensdorp AJ, Lucas C, Bemelman WA.Signicantly
increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional
study. Ann Surg. 2012;256(6):1045–8.
20. Beyer-Berjot L, Maggiori L, Birnbaum D, Lefevre JH, Berdah S, Panis Y.A total laparoscopic
approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study. Ann
Surg. 2013;258(2):275–82.
21. Benlice C, Stocchi L, Costedio M, etal. Laparoscopic IPAA is not associated with decreased
rates of incisional hernia and small-bowel obstruction when compared with open technique:
long-term follow-up of a case-matched study. Dis Colon Rectum. 2015;58(3):314–20.
37 Use ofAntiadhesive Barriers inPouch Surgery
345
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_38
J. T. Saraidaridis (*) · P. W. Marcello
Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center,
Burlington, MA, USA
e-mail: Julia.T.Saraidaridis@lahey.org
38
Optimal Management ofPelvic Abscess
After Pouch Surgery
JuliaT.Saraidaridis andPeterW.Marcello
Introduction
For patients who undergo ileal pouch anal anastomosis (IPAA), pelvic sepsis is the
leading cause of pouch failure. Additionally, it is well-acknowledged that infectious
complications following pouch surgery result in worsening function [1–3]. It is esti-
mated that after a septic complication from IPAA, the chance of pouch failure is
roughly 25% [3, 4]. Depending on the denition of pelvic sepsis, most studies report
a 5–14% incidence of pelvic sepsis (4.8%—Mayo [4], 5%—Lahey [5], 8.2%—
Cleveland Clinic [6], 13.3% Mount Sinai, Toronto [3]). Pelvic sepsis is a broad term
that encompasses anastomotic leaks, anastomotic separations, pelvic cellulitis, pel-
vic abscess, and perineal stulas as the component complications. Pouch abscess,
classically, is described as a collection of purulent exudate without demonstrable
anastomotic leak [7].
However, for the purpose of this chapter, we will use the term pouch abscess
dened as a collection of purulent exudate with or without an evident anastomotic
leak. Management of pouch abscess includes a number of potential avenues towards
source control. If a patient is overtly septic, they will require operative intervention
with drainage of the abscess and fecal diversion (if not already diverted). If the
patient is hemodynamically stable, non-operative interventions including percuta-
neous drainage and trans-anastomotic drainage (including endo-sponge) can be
attempted. This chapter investigates whether there is any difference in the outcomes
of abscess eradication, pouch function, and pouch loss when comparing percutane-
ous drainage versus trans-anastomotic drainage to treat pelvic abscess after IPAA
(Table38.1).
346
Search Strategy
A comprehensive literature search was performed of the PubMed and MEDLINE
database to identify English-language publications related to ulcerative colitis,
ileal-pouch anal anastomosis, pouch abscess, and pelvic sepsis from 1980–2018.
Key search terms included “ileoanal pouch”, “ileal pouch anal anastomosis”, “pouch
abscess”, “anastomotic leak”, and “pelvic sepsis.” Studies were excluded if they did
not include patients who had treatment of a pelvic abscess with either method speci-
ed or did not reect upon the outcomes above. The reference lists of each article
were also searched to identify additional articles relating to this topic. Unfortunately,
there is a dearth of publications regarding this issue; however, the articles that do
address this topic are included in Table38.2.
Results
Pelvic abscess as described in the literature is a heterogeneous group of different pro-
cesses and pathologies including abscesses resulting from anastomotic leak and those
without a demonstrable anastomotic leak. Within the category of anastomotic leak, a
pelvic or pouch abscess can include abscesses from three anatomic locations: the tip of
the J-pouch, the body of the J-pouch, and the ileal pouch-anal anastomosis (Fig.38.1).
Each of these locations lends itself to different treatment paradigms. As a result, we
have grouped the studies and reported the outcomes based on the location of the pouch
leak (from the tip of the J-pouch, pouch body versus ileoanal anastomosis).
For those with a leak from the tip of the J-pouch, trans-anastomotic drainage is
not an option. If there is an associated abscess, patients should undergo an attempt
at percutaneous drainage and if unsuccessful, revisional surgery will need to be
considered. Leaks from the tip of the J were reported exclusively in a Cleveland
Clinic series of 27 patients. Only four were treated initially with percutaneous
drainage while 23 underwent immediate salvage surgery. Percutaneous drainage
was successful in one patient, while three patients required subsequent surgery.
Overall, salvage surgery was successful with eventual stoma closure in 24/26
patients, with functional outcomes similar to those with a primary IPAA.Only one
patient had pouch loss and one did not have their ileostomy reversed [8].
Mount Sinai in Toronto, Canada also reported on 23 patients with leakage from
the pouch body (not leakage from the pouch-anal anastomosis). Eleven were treated
with pouch drainage alone (rectal tube) with healing in nine (82%). Five of 23 had
percutaneous drainage, of which three (60%) healed. Seven patients underwent
laparotomy and repair of leak, of which four (57%) healed. Of the seven patients in
Table 38.1 Pico table
Patients
Interventions Comparator
Outcome
Patients with pelvic
abscess after IPAA
Percutaneous
drainage
Trans-anastomotic
drainage
Abscess eradication, pouch
function, and pouch loss
J. T. Saraidaridis and P. W. Marcello
347
Table 38.2 Studies evaluating treatment of IPAA associated abscess: percutaneous drainage versus trans-anastomotic drainage
Reference
Year published/pts
accrued
Number of
patients Intervention Abscess eradiation Pouch loss
Quality of
evidence
Farouk (Mayo)
[4]
1997 (1981–1994) 73 (pelvic
abscess)
– 40 abdominal surgery
– 6 trans-anastomotic
– 11 antibiotics alone
– 16 CT guided percutaneous drainage
– 36/40 (90%) healed
– 5/6 (83%) healed
– 9/11 (81%) healed
– 15/16 (94%) healed
19 (26%) pouch failure overall
– 14/40 immediate pouch
excision
– 1/16 prolonged ileostomy
– 1/11 prolonged ileostomy
Very low
Kirat (Cleveland
Clinic)
[8]
2011 (1983–2009) 27 (tip of
J-pouch)
– 4/27 CT-guided drainage
– 25/27 abdominal surgery
– 1/4 (25%) healed – 1/27 pouch loss
– 17/27 pouch repair
– 6/27 pouch repair with repeat
IPAA
– 2/27 new pouch with repeat
IPAA
Very low
Raval
(Mt. Sinai
Toronto) [12]
2007 (1981–2003) 29 (IAA leak
with abscess)
– 17 percutaneous drainage
– 8 trans-anastomotic
– 3 abdominal surgery
– 1 combined drainage
– 16/17 (94%) healed
– 6/8 (75%) healed
– 3/3 (100%) healed
– 1/3 pouch removal Very low
Raval
(Mt. Sinai
Toronto) [12]
2007 (1981–2003) 23 (pouch
leak—not IAA)
– 11 pouch drainage
– 5 percutaneous drainage
– 7 laparotomy
– 9/11 (81%) healed
– 3/5 (60%) healed
– 4/7 (57%) healed
– 18/23 maintained pouch
– 2/23 successful pouch
reconstruction
Very low
Kirat (Cleveland
Clinic) [9]
2011 (1984–2009) 71 (IAA leak) – 18 percutaneous drainage
– 53 trans-anastomotic
– 15/18 (83%) healed
– 40/53 (75%) healed
– 2/18 redo pouch
– 6/53 pouch excision
– 3/53 redo pouch
– 2/53 long-term stoma
Very low
38 Optimal Management ofPelvic Abscess After Pouch Surgery