Which factors are considered when determining the ileal pouch size and type in the surgical treatment of ulcerative colitis (UC)?

Updated: Apr 01, 2019
  • Author: E Stanton Adkins, III, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Answer

Answer

The creation of an IPAA involves total proctocolectomy, with folding of the distal ileum into a J, S, or W formation to create a fecal reservoir. The anastomosis to the anus preserves continence function involving the internal and external anal sphincters. The S and W configurations have been associated with a failure rate as high as 66% and a need for revision; however, the J configuration is associated with a need for revision in only 1-2% of cases. [9]

Reasons for failure with S and W pouches include dilation of the reservoir, leading to stasis, and elongation of the spout at the anal anastomosis, leading to stenosis. [10] These technical points are all but alleviated with the current technique of J pouch construction. Transanal defecation is restored in 88% of children with J pouches, whereas 32% of those with S pouches and 32% of those undergoing straight ileoanal pull-through procedures require revision. [11]

Although most surgeons do not use the S pouch as the first option (because of its pouchitis rate), the spout created in its construction provides an additional 3-5 cm in length to the entire ileal reservoir, as compared with the length of a J pouch.

Some still advocate straight ileoanal pull-through anastomosis without reservoir construction. Straight endorectal pull-through causes dilatation and compensation over time so that the pouch develops a reservoir function. In addition, length is generally not a problem with a straight pull-through. Thus, many pediatric surgeons perform this as their primary procedure. Good long-term outcomes and patient satisfaction are reported. [12]

However, others have noted a need for revision of the straight pull-through configuration in 70% of cases. [13] Construction of the ileal J pouch–anal anastomosis is described below. One should keep in mind that the straight ileoanal pull-through is performed in essentially the same manner and uses less total length of small bowel.

In summary, the choice of pouch size and type involves a balance between increasing reservoir function to decrease stool frequency and the risk of developing pouchitis. All reservoirs have a tendency to enlarge over time. Consequently, most surgeons have opted for a smaller initial reservoir that depends on reservoir enlargement to gradually decrease stooling frequency while avoiding pouchitis.


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