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.

Investigations

As stated above, problems that manifest within 6 months of stool via the anus should raise suspicions of a surgical technical problem. A full evaluation of the pouch and anal region can be achieved by an examination under anesthesia. If a leak is suspected, a preoperative MRI and/or pelvic CT (with rectal contrast) may provide a road map to the exact nature of the problem. Table 3 has a list of tests we perform and the reasoning behind them.

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Table 1. Relative indications to refer a patient for pouch removal versus an attempt at revision or re-do
Patients who have any of the pouch complications listed below leading to an unacceptable quality of life and who do not wish to undergo multiple operations over the span of many months may be referred for pouch removal versus an attempt at revision or re-do
(1) Crohn's disease
(2) Fistulas and chronic pelvic abscess
(3) Fecal incontinence
(4) Chronic pelvic pain
(5) Poor pouch function
(6) Obstruction
All such patients will benefit from a comprehensive evaluation at a specialized center so that they can understand all options available to them with their risks, and thus make an educated decision.

Table 2. Causes of pouch failure
Early causes of pouch failure (<6 months after use of the anus)
Leak (IPAA anastomosis, tip of the J, staple line leaks)
Pelvic abscess
Late causes of pouch failure (>6 months after use of the anus)
Cryptoglandular infection
Crohn's disease
Neoplasia/dysplasia of the pouch
Poor function (urgency, obstructive symptoms, incontinence, chronic pouchitis)
Problems with evacuation/structural (paradoxical contraction, afferent limb and efferent limb problems, anal stricture, pouch prolapse)

Table 3. Investigative work-up of the failing pouch
Test	Objective
EUA (exam under anesthesia) and pouchoscopy (see Figure 4)	Complete evaluation of the pouch and anal region, assessing sphincter quality, extent of any stricture, length and distensibiltiy of the pouch body, size of pouch and afferent limb, afferent and efferent limb anatomy (looking for twisting, prolapse and retraction), length of the anal transition zone, quality of the mucosal lining. Location of fistulae in relation to the dentate line. Also any sepsis can be drained and a seton placed if appropriate
Vaginoscopy	To help delineate the anatomy of a pouch vaginal fistula.
MRI pelvis	Useful for delineation of anatomy when not straightforward at EUA of any anal fistula, vaginal fistulas, sinuses and chronic leaks. These tracts appear hypointense in T1-weighted images and hyperintense on T2-weighted images
CT abdomen and pelvis with oral, IV and rectal contrast	Useful for Identification of an acute leak or abscess and to delineate anatomy.
Defecating pouchogram	Performed with water-soluble contrast. It is noted if there is any unusual configuration, such as the afferent limb tucked in the presacral space or a long efferent limb/anal transitional zone. Note it also made of the ease of initiation of defecation, the pouch wall movement when defecating, and time needed to evacuate two-third of contrast from the pouch. Any unusual positions that assist in evacuation are also noted.
Anal manometry	In all patients selected for a re-do to assess of sphincter function. For patients with a history consistent with outlet obstruction, we use this test to examine paradoxical contraction during defecation.

Table 4. Indications to consider re-do/revision of a pouch versus a permanent ileostomy
Indications for re-do/revision of pouch	Indications for a permanent ileostomy
A. Adequate bowel length and sphincter function is a prerequisite	A. Inadequate bowel length and sphincter function
B. Once criteria (B) have been met, the following conditions are all indications to consider a re-do or revision of the pouch.	B. Active anal Crohn's disease and Crohn's disease of the pouch and prepouch ileum that has failed medical management
Pouch leaks/sinus/fistula
A chronic pelvic abscess	C. Severe pelvic fibrosis
Cryptoglandular infections
Dysplasia and early-stage malignancies of the pouch	D. Locally advanced cancer of the pouch involving the sphincter musculature
Structural problems of the pouch
	E. Patient preference in patients who cannot tolerate the prospect of additional major surgery

Table 5. Re-do pouch surgery outcomes
Year	Name of institution and author	Number of cases (N)	Median follow-up	Pathological diagnosis, N (%)	Indication for surgery, N (%)	Success rate (%)
Mayo Clinic
2018	Lightner et al. [8]	81	3.5 years	49 (60%) UC 32 (40%) CD	Sepsis 54 (66%) Mechanical 27 (33%) Combination 47 (58%)	65% (± 9%) 10-year survival 70% for CD versus 84% without CD
2009	Mathis et al. [19]	51	8.2 years	29 (56%) UC 22 (43%) CD	Sepsis 29 (57%) Obstruction 22 (43%)	89% at 5 years^a
Cleveland Clinic
2015	Remzi et al. [5]	502	7 years	419 (84%) UC/IC 41 (8%) FAP 32 (6%) CD 10 (2%) Neoplasia	Sepsis 263 (52%) Obstruction 116 (23%) Dysfunction 45 (10%)	90% at 5 years 82% at 10 years
2009	Garrett and Remzi [18]	33	1.7 years	33 (100%) CD referral diagnosis 7 (21%) final diagnosis of CD	Sepsis 25 (76%) Obstruction 6 (18%) Dysfunction 2 (6%)	84%
2009	Remzi et al. [7]	221	5 years	172 (71%) UC 31 (14%) CD 13 (7.5%) IC 25 (14%) other	Sepsis 25 (76%) Obstruction 6 (18%) Dysfunction 2 (6%)	85% at 5 years
Mount Sinai hospital and University of Toronto
2001	MacLean et al. [21]	57	69 months	52 (91%) UC 4 (8%) CD 1 (.01%) c	Sepsis 37 (65%) Obstruction 19 (33%) Dysfunction 1 (2%)	73.6%
Beajon Hospital, Clichy
2018	Rossi et al. [22]	39	56 months	25 (65%) UC 6 (15%) CD 8 (0.20%) FAP	Sepsis 7 (18%) Obstruction 15 (39%) Dysfunction 7 (18%) Other 10 (25%)	65%

^aSeventy-five percent of pouch failures were in those with a later diagnosis of CD but the difference in probability of pouch survival did not differ significantly between patients with UC and those with CD. CD, Crohn's disease; FAP, familial adenomatous polyposis; IC, inderterminate colitis; UC, ulcerative colitis.