Oxford

Colorectal

Restorative Proctocolectomy

The Problem PouchThe Problem Pouch

Bruce GeorgeBruce George

Department of Colorectal Surgery Department of Colorectal Surgery John Radcliffe Hospital, OxfordJohn Radcliffe Hospital, Oxford

M25 Course 2011

Oxford

Colorectal

Restorative Proctocolectomy

Pouch surgery – the agony

Oxford

Colorectal

Restorative Proctocolectomy

Long Term Failure Rates from St Mark’s

Karoui Cohen and Nicholls DCR 2004

Oxford

Colorectal

Restorative Proctocolectomy

Indications for Pouch Excision at St Mark’s

St Mark’s n=996

Referred n=245 Total

No patients 58(5.6%) 10(4%) 68Pelvic sepsis 28 5 33(48.5%)

Pouch fistula 24 4

Crohns 3 2Poor function 21 3 24(35.2%)

Pouchitis 4 1

other 5 1Karoui, Cohen, and Nicholls DCR 2004

Oxford

Colorectal

Restorative Proctocolectomy

Causes of Pouch FailureCauses 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%) variousMacRae et al Dis Col Rect 1997

Oxford

Colorectal

Restorative Proctocolectomy

Timing of pouch excision

0

1

2

3

4

5

6

7

8

1 2 3 4 5 6 7 8 9 10 <20 years after pouch construction

number

Oxford

Colorectal

Restorative Proctocolectomy

Initial Assessment of Poor Pouch Function

• History of poor function–Always bad

–Recent deterioration

• Review histology

• Review peri-operative course

• Clinical examination

• PR

• Pouchoscopy + biopsy

Oxford

Colorectal

Restorative Proctocolectomy

Common problems

• Pouchitis–Metronidazole

– ciprofloxacin

• Pouch-anal anastomotic stricture–EUA + gentle dilatation

• Cuffitistopical steroids or mesalazine

Oxford

Colorectal

Restorative Proctocolectomy

Persisting poor function

• Look:– In the pouch

–Outside the pouch

–Below the pouch

–Above the pouch

Oxford

Colorectal

Restorative Proctocolectomy

Problems Arising in the PouchProblems Arising in the Pouch

Pouchitis

Inadequate pouch volume (n = 200 - 450 ml)

Abnormal motility

Oxford

Colorectal

Restorative Proctocolectomy

• Problems outside the pouch:

–Pelvic abscess

Oxford

Colorectal

Restorative Proctocolectomy

Problems below the pouchProblems below the pouch

Pouch anal anastomotic stenosis (9-19%)

Pouch vaginal fistulas (4-10%)

Poor sphincter function

Cuffitis

Paradoxical puborectalis contraction

Oxford

Colorectal

Restorative Proctocolectomy

Small Bowel Problems above the pouchSmall Bowel Problems above the pouch

Adhesions 15-30% symptomatic

5-10% need re-operation

Functional obstruction - ileal brake

Small bowel bacterial overgrowth

Crohn’s disease (5-7%)

Oxford

Colorectal

Restorative Proctocolectomy

Assessment of persistent poor pouch function

• Inside– Flexible pouchoscopy + biopsy

• Outside– CT or MR pelvis

• Below– Sphincter physiology and ultrasound

– Pouchogram

– Defaecating pouchogram

– EUA, pouch and cuff biopsies

• Above– Small bowel enema

Oxford

Colorectal

Restorative Proctocolectomy

Cuffitis - TreatmentCuffitis - 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

Oxford

Colorectal

Restorative Proctocolectomy

Treating the early abscess or anastomotic dehiscence

• EUA assessment

• Abscess – drain mushroom catheter, CT drain

• Dehiscence – drain, early resuture or advancement

• Wait, pouchogram, consider re operation

Oxford

Colorectal

Restorative Proctocolectomy

0.5

0.4

0.3

0.2

0.1

0.00 20 40 60 80 100 120 140

overall

chronic

Follow up (m)

Pro

po

rtio

n o

f ri

sk

Keranen et al Dis Col Rect 1997

Cumulative Risk of Pouchitis

Oxford

Colorectal

Restorative Proctocolectomy

Fistula at AnastomosisFistula at Anastomosis

Oxford

Colorectal

Restorative Proctocolectomy

Pouch related fistulaPouch 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

Oxford

Colorectal

Restorative Proctocolectomy

Try Local Repair First if:Try Local Repair First if:

• gross sepsis absent

• granulation tissue minimal

• fistulas close to anal verge

• strictures are short

Oxford

Colorectal

Restorative Proctocolectomy

Repeat IPAA - indicationsRepeat IPAA - indications

• mechanical outlet obstruction

• lack of reservoir capacity

• sepsis

Oxford

Colorectal

Restorative Proctocolectomy

Pouch Revision for septic complications35 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

Oxford

Colorectal

Restorative Proctocolectomy

SummaryInitial Assessment of Poor Pouch Function

• History of poor function–Always bad

–Recent deterioration

• Review histology

• Review peri-operative course

• Clinical examination

• PR

• Pouchoscopy + biopsy

Oxford

Colorectal

Restorative Proctocolectomy

SummaryAssessment of persistent poor pouch function• Inside

– Flexible pouchoscopy + biopsy

• Outside– CT or MR pelvis

• Below– Sphincter physiology and ultrasound

– Pouchogram

– Defaecating pouchogram

– EUA, pouch and cuff biopsies

• Above– Small bowel enema