1 / 44

The Failing Pouch

M62 Course 2006. The Failing Pouch. Neil Mortensen MD FRCS Department of Colorectal Surgery Radcliffe Hospital, Oxford. Parks and Nicholls Proctocolectomy without ileostomy for ulcerative colitis BMJ 1978;2:65-8. Pouches around the World 2000. USA 7600 UK 2500 Sweden 2500

rudolf
Download Presentation

The Failing Pouch

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. M62 Course 2006 The Failing Pouch Neil Mortensen MD FRCS Department of Colorectal Surgery Radcliffe Hospital, Oxford

  2. Parks and Nicholls Proctocolectomy without ileostomy for ulcerative colitis BMJ 1978;2:65-8

  3. Pouches around the World 2000 USA 7600 UK 2500 Sweden 2500 Canada 1500 Germany 1100 France 250 Australia 200 Estimated Total 15650

  4. Pouch surgery – the ecstasy

  5. Pouch surgery – the agony

  6. Pouch Failure

  7. Pouch complications Pouch cutaneous fistula Pouch vaginal fistula Stricture Small bowel stricture Bleeding Infarction Peritonitis Anastomotic leak

  8. Oxford Pouch Excision 408 IPAA 30 Pouch excisions, 7 immediate 27 (6.6%) in house 3 elsewhere

  9. Oxford Pouch Excision Reasons for excision 8 pouchitis 6 ischaemia 6 sepsis 5 Crohns 3 incontinence 1 bleeding 1 desmoid

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

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

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

  13. Please don’t let it leak

  14. 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

  15. Restorative Proctocolectomy - Anastomotic Leakage n % leaks single stage 22 32 previous colectomy 49 12* steroids > 15mg 15 33 no steroids 56 14* under 40 yrs 54 13 over 40 yrs 17 35* Pemberton et al 1994

  16. Patient Selection : Steroids • 671 patients • 20 mg Prednisolone threshold • no differences in septic complications • IPAA without diversion, 50% complication on high dose steriods Ziv et al Dis Col Rect 1996

  17. Incidence and Impact Pelvic Abscess after IPAA • 73 of 1508 pelvic abscess • pouch failure 26% • 55% need transabdominal salvage • 8% local surgery • 37% non surgical • functional outcome poorer Farouk et al Dis Col Rect 1998

  18. Patient Selection - indeterminate colitis • 71 indeterminate v. 1232 UC • no difference in frequency, continence or pouchitis • failure rate 19% v. 8% McIntyre et al Dis Col Rect 1995

  19. Long Term Results of IPAA in Patients with Crohn’s Disease 37 patients Original diagnosis UC (22), indeterminate (9), Crohn’s (6), Complex fistulas in 11 Site of Crohn’s pouch (20), anal (4), both (10) Failure in 17 Sagar et al Dis Col Rect 1996

  20. Pouch Failure & Crohn’s - Cleveland Clinic Overall failure 3.4%, 1.1% non function Of 34 failures - 17 had Crohn’s 25% Crohn’s fail Fazio et al Ann Surg 1995

  21. 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

  22. Fistula at Anastomosis

  23. 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

  24. Pouch Related Fistula after Restorative Proctocolectomy 21 patients, in 6 > 5 m after ileostomy closure Site : anastomosis 14 vertical staple line 2 efferent limb end 5 Adverse factors : late fisutula enterocutaneous pouch vaginal suspect Crohn’s Paye et al 1996 BJS

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

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

  27. 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

  28. Pouch Revision by Disconnection - Reconnection • 23 patients 9 long efferent • 4 sepsis fistula • 3 redundant blind limb • 3 twisted pouch • 3 anastomotic problem • Pouch Salvaged in 16 • Good function 11 • Pouch excision 6 Sagar et al 1996 BJS

  29. 112 underwent 117 pouch salvage procedures Common indications - sepsis 45, stricture 13, retained stump 35 21% pouch failure Associated with Crohn’s, sepsis Long Term Results of Abdominal Salvage Tekkis et al BJS 2006

  30. Cumulative Pouch Survival Tekkis et al BJS 2006

  31. Restorative Proctocolectomy - Technique Get it right first time

  32. The risks of maintaining Columnar Cuff - Some 6-10% of the total anorectal mucosa is retained - risk of malignancy - risk of inflammation

  33. Cuffitis - symptoms • urgency • frequency • leakage • bleeding • anal irritation or burning discomfort

  34. Cuffitis and Inflammatory Changes • 113 patients, 715 biopsies • acute inflammation in columnar cuff in 13% • in 9% symptomatic with endoscopic inflammation • no relationship with pouchitis, pouch frequency or anastomotic height Thompson-Fawcett, Warren, Mortensen Dis Col Rect 1999

  35. 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

  36. Pouch Vaginal Fistula • avoid catching vagina with stapler • repair by endo vaginal advancement flap • defunction ?

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

  38. Pouches Misbehaving Badly - the 3 problem areas Upstream Small bowel Within the pouch Pouch outlet

  39. 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

  40. Refractory Pouchitis • Review the previous histology • Is there a pelvic abscess? • Is there partial obstruction to ileum? • Is there a small bowel motility disturbance • Is there dietary intolerance?

  41. Summary 10% lose pouch 10% have poor function but prefer to keep their pouch 80% report an excellent quality of life

  42. But….. Some worries Increasing numbers of patients needing chronic ciproxin dosing Perianal disease being treated with infliximab

More Related