M25 Course 2011 Restorative Proctocolectomy The Problem Pouch

M25 Course 2011 Restorative Proctocolectomy The Problem Pouch

M25 Course 2011 Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford Oxford Colorectal Restorative Proctocolectomy Pouch surgery the agony Oxford Colorectal

Restorative Proctocolectomy Long Term Failure Rates from St Marks Oxford Karoui Cohen and Nicholls DCR 2004 Colorectal Restorative Proctocolectomy Indications for Pouch Excision at St Marks No patients Pelvic sepsis Pouch fistula Crohns

Poor function Pouchitis other St Marks n=996 Referred n=245 58(5.6%) 28 24 3 10(4%) 5 4

2 68 33(48.5%) 21 4 5 3 1 1 24(35.2%) Oxford Total Karoui, Cohen, and Nicholls DCR 2004

Colorectal Restorative Proctocolectomy 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 Oxford MacRae et al Dis Col Rect 1997

Colorectal Restorative Proctocolectomy Timing of pouch excision number 8 7 6 5 4 3 2 1 Oxford 0

1 2 3 4 5 6 7 8 9 10 years after pouch construction <20 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 Cuffitis Oxford topical steroids or mesalazine 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 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 pouch

Pouch anal anastomotic stenosis (9-19%) Pouch vaginal fistulas (4-10%) Poor sphincter function Cuffitis Oxford Paradoxical puborectalis contraction Colorectal Restorative Proctocolectomy Small Bowel Problems above the pouch Adhesions 15-30% symptomatic 5-10% need re-operation Functional obstruction - ileal brake Small bowel bacterial overgrowth Crohns 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 Oxford Small bowel enema Colorectal Restorative Proctocolectomy 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 Oxford Fazio & Tjandra 1994 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 Cumulative Risk of Pouchitis 0.5 Proportion of risk

0.4 0.3 overall 0.2 0.1 chronic 0.0 0 20 40

60 80 100 120 Follow up (m) 140 Oxford Keranen et al Dis Col Rect 1997 Colorectal Restorative Proctocolectomy Fistula at Anastomosis

Oxford Colorectal Restorative Proctocolectomy 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 Oxford Dis Col Rect 1997

Colorectal Restorative Proctocolectomy 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 - indications mechanical outlet obstruction lack of reservoir capacity sepsis

Oxford Colorectal Restorative Proctocolectomy 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% Oxford Fazio et al Ann Surg 1998 Colorectal

Restorative Proctocolectomy Summary 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 Summary 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 Oxford Small bowel enema Colorectal

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