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

Christopher Mascarenhas; Scott R. Steele; Tracy Hull


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

In This Article

Late Pouch Failure

Outside of the postoperative period (>6 months after using the anus), pouch failure is typically from poor function or structural problems. Poor pouch function, characterized by urgency (i.e. the inability to defer defecation more than 30 min), incontinence and obstructive symptoms, can occur if the pouch is too small, has significant loss of compliance, or if there is another structural problem as described below.[12]

Chronic pouchitis is another risk factor for pouch failure.[13] For patients with chronic pouchitis, a high suspicion of Crohn's disease should be raised. Although surgery (other than ileostomy) is not the procedure of choice for chronic pouchitis, it is important to rule out other reasons (listed below) that may mimic chronic pouchitis and lead to poor pouch function, which may be amendable to surgical treatment.

Problems with abnormal pouch evacuation fall into several categories: paradoxical contraction, efferent limb problems, anal stricture, or pouch prolapse. If the anal muscles or pelvic floor muscles do not relax with defecation, there can be an inability to empty the pouch. This is treated with physical therapy re-education (i.e. biofeedback), not surgery. Efferent limb problems are characterized by a long efferent limb in an S pouch, or a long section of retained rectum in patients with a J pouch, where a true ileoanal anastomosis has not been created. This may result in outlet obstruction eventually leading to pouch failure and is amendable to surgical intervention.[14]

Anal strictures at the IPAA can also develop over time. This may require regular dilations or revision of the IPAA if severe, and other causes, such as Crohn's disease, ischemia, or malignancy should be ruled out.

Problems with the pouch inlet may require surgical intervention. The afferent limb of the pouch can kink back behind the pouch causing a sharp angulation and difficulty of stool going through this area. Also, stricture at the inlet (typically from Crohn's disease) may be amendable to surgical strictureplasty or reimplantation.[14,15]