The Problem Pouch

1. M25 Course 2011 The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford

2. Pouch surgery – the agony

3. Long Term Failure Rates from St Mark’s Karoui Cohen and Nicholls DCR 2004

4. Indications for Pouch Excision at St Mark’s Karoui, Cohen, and Nicholls DCR 2004

5. Causes of Pouch Failure 49 (8.8%) of 551 pouches failed 9 (1.6%) defunctioned - 21 (39%) anastomotic leak - 13 (23%) poor function - 7 (12%) pouchitis - 7 (12%) pouch leakage - 7 (12%) perianal disease - 3 (5%) various MacRae et al Dis Col Rect 1997

6. Timing of pouch excision number 1 2 3 4 5 6 7 8 9 10 <20 years after pouch construction

7. History of poor function Always bad Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy Initial Assessment of Poor Pouch Function

8. Pouchitis Metronidazole ciprofloxacin Pouch-anal anastomotic stricture EUA + gentle dilatation Cuffitis topical steroids or mesalazine Common problems

9. Look: In the pouch Outside the pouch Below the pouch Above the pouch Persisting poor function

10. Problems Arising in the Pouch Pouchitis Inadequate pouch volume (n = 200 - 450 ml) Abnormal motility

11. Problems outside the pouch: Pelvic abscess

12. Problems below the pouch Pouch anal anastomotic stenosis (9-19%) Pouch vaginal fistulas (4-10%) Poor sphincter function Cuffitis Paradoxical puborectalis contraction

13. Small Bowel Problems above the pouch Adhesions 15-30% symptomatic 5-10% need re-operation Functional obstruction - ileal brake Small bowel bacterial overgrowth Crohn’s disease (5-7%)

14. Inside Flexible pouchoscopy + biopsy Outside CT or MR pelvis Below Sphincter physiology and ultrasound Pouchogram Defaecating pouchogram EUA, pouch and cuff biopsies Above Small bowel enema Assessment of persistent poor pouch function

15. Cuffitis - Treatment • medical - largely empirical • - steroids, per anal or oral • - 5ASA compounds, per anal or oral • - lignocaine jelly, per anal • surgery - mucosectomy Curran & Hill 1992 • - mucosectomy & pouch advancement • Fazio & Tjandra 1994

16. EUA assessment Abscess – drain mushroom catheter, CT drain Dehiscence – drain, early resuture or advancement Wait, pouchogram, consider re operation Treating the early abscess or anastomotic dehiscence

17. Cumulative Risk of Pouchitis 0.5 0.4 0.3 overall Proportion of risk 0.2 0.1 chronic 0.0 0 20 40 60 80 100 120 140 Follow up (m) Keranen et al Dis Col Rect 1997

18. Fistula at Anastomosis

19. Pouch related fistula • 59 of 1040 IPAA • 24 pouch vaginal • 11 pouch cutaneous • 16 pouch perineal • 8 pouch presacral • 32% eventually excised Ozuner et al Dis Col Rect 1997

20. Try Local Repair First if: • gross sepsis absent • granulation tissue minimal • fistulas close to anal verge • strictures are short

21. Repeat IPAA - indications • mechanical outlet obstruction • lack of reservoir capacity • sepsis

22. Pouch Revision for septic complications 35 patients repeat IPAA Outcome 86% functioning pouches, 4 excised Function 57% good, 43% fair or poor, Pad usage and seepage 60-70% Fazio et al Ann Surg 1998

23. History of poor function Always bad Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy SummaryInitial Assessment of Poor Pouch Function

24. Inside Flexible pouchoscopy + biopsy Outside CT or MR pelvis Below Sphincter physiology and ultrasound Pouchogram Defaecating pouchogram EUA, pouch and cuff biopsies Above Small bowel enema SummaryAssessment of persistent poor pouch function