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

Early Pouch Failure

The most common cause of pouch failure is sepsis, which ranges from 5 to 25%.[8] Constructing a pelvic pouch requires many suture and staple lines, and a leak from any one of them can lead to sepsis. Figure 3 shows the most common sites of leak.

Figure 3.

Sites of pouch leaks. In the noted order, these are the most common sites of pouch leaks. Used with permission of the Cleveland Clinic Foundation. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography 1998–2019. All Rights Reserved.

The recognition of a problem in the postoperative period may be an opportunity to prevent long-term sequalae. Therefore, patients with low-grade fevers, tachycardia, unusual perianal pain, prolonged ileus, and bleeding per rectum should be evaluated for a leak. Our procedure of choice is a computed tomography (CT) scan of the abdomen and pelvis with oral, intravenous and rectal contrast (rectal water-soluble contrast is crucial). We also may combine this with a water-soluble enema, which may further add valuable information. In addition, an examination under anesthesia and pouchoscopy may help identify a sinus or anastomotic dehiscence that may be silent in the setting of a proximal diversion. If identified, prompt drainage, preferably via the transanal route for an IPAA, is then performed. Avoidance of percutaneous drainage of an IPAA leak is important to prevent an extrasphincteric fistula. In those who develop a chronic sinus, endoscopic sinusotomy (or simply a minimally invasive way of unroofing the sinus and allowing the area to heal from the bottom upward) has been found to achieve complete healing in over 50% of patients.[9]

Pouch vaginal fistulas (PVF) are an especially devastating complication of IPAA. The risk of development of a PVF is ~3.9 to 15.8%, with 21 to 33% of these patients going on to develop pouch failure.[10,11] Early (<6 months after use of the anus) PVF is typically from a surgical technique problem, whereas late occurrence is associated with Crohn's disease or cryptoglandular infections. The first step in managing a PVF is complete sepsis drainage with or without a stoma. Evaluation under anesthesia with endoscopy and imaging will assist in planning the next step in treatment. This may require medical therapy when associated when Crohn's disease. In addition, it is important to ensure there was no iatrogenic cause (e.g. staple incorporation of the vaginal cuff). After optimization of all factors (including eradicating any pus, optimizing nutrition, elimination of inflammation, and improving fragility and stamina) repair from the perineal or abdominal approach can be planned.

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