The ABC's of Re-do Ileoanal Pouches, What Every Gastroenterologist Should Know

Christopher Mascarenhas; Scott R. Steele; Tracy Hull

Disclosures

Curr Opin Gastroenterol. 2019;35(4):321-329. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: To describe the development of re-do pouch surgery, what it entails, its indications and role in the management of patients with inflammatory bowel disease.

Recent findings: Re-do pouch surgery has very good outcomes and excellent patient satisfaction when performed on carefully selected patients in specialized centers.

Summary: The ileal pouch anal anastomosis (IPAA) procedure, which was developed 40 years ago, is a mainstay in the reconstruction of patients who undergo a proctoclectomy for ulcerative colitis and familial adenomatous polyposis (FAP). It allows these patients to avoid a permanent ileostomy, with the majority having a very good quality of life and functional outcomes. Unfortunately, a small but not insignificant number of patients will develop technical complications that may severely affect their quality of life and function of the pouch. In the past, pouch excision with permanent diversion or Koch pouch were the only option available to these patients. Recent advances have resulted in the development of corrective surgical measures to restore pouch function. We will discuss strategies to evaluate and select the right patients for a re-do pouch surgery, how to surgically optimize them, and describe the proper technique of ileal pouch revision and reconstruction.

Introduction

The ileal pouch anal anastomosis (IPAA) is the operation of choice in patients with ulcerative colitis not amenable to medical management, as well those with familial adenomatous polyposis who require or desire a proctocolectomy. Parks and Nicholls[1] initially described an IPAA in their seminal article 'Proctoclectomy without ileostomy for ulcerative colitis' published in 1978. Parks et al., initially used an S pouch, but in an effort to improve outcomes, various configurations of the pouch were tried (Figure 1). Utsunamiya perfected the J pouch, which has now become the configuration of choice because of ease of construction and a general lack of issues with outlet obstruction. The S pouch, somewhat hampered by the former problems, is now reserved for instances when reach of the pouch into the pelvis is problematic.[2] Other advances have been the double-staple technique, in contrast to the traditional method of stripping the mucosa from the distal rectum and anal canal (mucosectomy) and hand-sewing the pouch to the anal canal skin (Figure 2). In 1995, Fazio et al.[3] at the Cleveland Clinic reported their experience over an 11-year period including 1000 patients undergoing IPAA. Looking at patients who had the traditional hand-sewn versus the newer double-staple technique, there were more early septic complications (9.4 versus 4.9%) and lower postoperative mean maximal resting sphincter pressures (50 versus 81.3 mmHg) in the hand-sewn group.[3,4] These findings combined with reduced leakage, particularly during REM sleep at night, have made the double-staple technique the preferred method of constructing the anastomosis.

Figure 1.

Pouch configurations. (a), (b) and (c) are J, S, and W pouches, respectively. I, II, III, and IV are the limbs of small bowel used in constructing the pouch with their length. Used with permission of the Cleveland Clinic Foundation. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography 1998–2019. All rights reserved.

Figure 2.

Operative steps. When a pouch has a presacral infection, after mobilization and disconnection of the pouch anal anastomosis, the infective rind must be removed. Then a mucosectomy and handsewn anastomosis can be performed. The decision to use the initial pouch or construct a new pouch is mostly influenced by the degree of pouch damage that occurs during the mobilization. Used with permission of the Cleveland Clinic Foundation. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography 1998–2019. All Rights Reserved.

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