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

Operative Approaches to re-do Pouch Surgery

Before embarking on any re-do procedure, local control of sepsis is mandatory. Depending on the cause, the preferred method of drainage (when possible) is typically a transanal mushroom catheter. When this is not possible, a 12 Fr pigtail catheter may be placed by CT guidance transgluteally or transabdominally and left behind in the abscess cavity. Complete healing of the leak must be confirmed with a combination of examination under anesthesia, pouchscopy to confirm closure of the sinus tract leading from the pouch, and an abscessogram or fistulagram with contrast injected directly into the catheter. The latter will also confirm closure of the tract prior to drain removal. Setons may also be needed for patients with a concomitant anal fistula and sepsis control.

Strong consideration is given to stoma placement, which is often required for up to 6 months or more prior to re-do pouch surgery. This enables the patient to regain his/her health while being evaluated. When creating a loop stoma, it is paramount to think ahead and place the stoma where the apex of the re-do pouch may need to be constructed (Figure 2b) if a new pelvic pouch is required. Despite drainage procedures and a stoma, some patients will continue to have presacral low-grade sepsis and require continual antibiotics. In this case, bactrim is a good option to reduce symptoms while waiting for the 6 months to pass. Waiting also gives an opportunity to optimize nutrition and muscle strength. The possibility that a re-do pouch cannot be performed and a permanent end ileostomy is required must be clearly discussed in the preoperative consent visit.

Perineal Approach

In the minority of cases, a perineal approach may be sufficient to address the problem. This would include dysplasia in a short ATZ or when addressing a low fistula where a pouch advancement can be done. It may also be effective in those patients with 'cuffitis' where inflammation in the area between the dentate line and the pouch anal anastomosis persists despite stripping or fulguration. The perineal approach involves a circumferential mobilization of the pouch starting at the level of the anastomosis taking care not to injure the underlying sphincter muscles. For PVF, this could involve a transanal, transperineal or trans-vaginal approach. Although the technical details of these procedures are beyond the scope of this article, a key point to note is that when advancing the pouch, there should be no tension on the neo-IPAA. If unable to achieve a tension-free anastomosis with this approach, a full abdominal approach and mobilization must be combined at the same setting. As such, it is critical to discuss this with the patient ahead of time and have the operating room team prepared for this event.

Abdominal Approach

Re-do pouches are long and, at times, somewhat tedious procedures. Therefore, an early start is advisable with bilateral placement of ureteric stents. A full laparotomy (usually midline) is typically preferable over a minimally invasive approach, though the latter has been described. The small bowel is mobilized out of the pelvis and most if not all adhesions divided from the duodenal jejunal junction to the pouch. If there is any difficultly in accessing the pelvis, the ileostomy is taken down. In women, the ovaries are pexied to the lateral sidewall. If needed, the uterus is transiently sewn to the anterior abdominal wall to provide improved exposure. In men (and women after a hysterectomy), the bladder wall may fall back and adhere to the pouch, therefore, the surgeon needs to constantly be mindful of the possibility of this aberrant position. For some patients with a tip of the J leak, full mobilization may not be needed, and re-excising the tip and excising the fistula is enough. This is typically not the case; however, and mobilization and disconnection of the IPAA is required. Every effort should be made to excise the remnant phlegmon and all foci of infection. (Figure 2) A mucosectomy and careful verification that all mucosa is excised completes this step. The pouch is examined, and if feasible, reused. In prior Cleveland Clinic experience, this is possible in over 50%.[5] When not possible, another J pouch can typically be constructed and only rarely is an S pouch required for length. Alternatively, when it will not reach, we may consider closing over the open distal end at the ileostomy site and tacking the pouch as far possible in the pelvis and coming back in a year and attempt anastomosis again. This keeps the area free from pelvic organ prolapse or other bowel adhering into the pelvis. If there is a fibrotic ring in the mid or distal pelvis, radial slits posteriorly are needed to ensure enough diameter to allow the pouch to reach the pelvic floor. Also, as the pouch is advanced down, it often has resistance from the undersurface of the bladder/prostate or vagina, and it must be angled steeply beneath these structures before coming out the anal canal. Almost all re-do pouches require a mucosectomy and hand sewn anastomosis. A drain is placed in the pelvis and an upstream stoma created.

Postoperatively, the drain is removed when the output is more than 30 ml in 24 h, though this often varies by individual surgeon. Between 8 and 12 weeks, an examination and pouchoscopy is performed, and if all looks healthy (Figure 4), a water-soluble enema is obtained to rule out a missed leak. If there are any concerns, an MRI is obtained to also look at the surrounding anatomy. When all studies are acceptable, stoma closure is performed at ~12 weeks.

Figure 4.

Endoscopic appearance of a healthy J pouch. The top of a J pouch has an appearance of owl's eyes created from the afferent limb and tip of J limb with a narrow wall (beak) between them on pouchscopy.

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