- 1. Complications of ileal pouchafter total proctocolectomyDr/ Mohamed A NadaAss Professor General SurgeryAin Shams University2014
2. Park & Nicholls 1978 Low mortality rate ( young age, highly specializedcenters) Mayo Clinic (1407 IPAA) 0.2% early mortality, and 1.8%late mortality The late mortality was due to rectal carcinoma,haematological carcinoma, cholangiocarcinoma, others 3. Small bowel obstruction 15% to 44%, and 5% to 20% require reoperation Cleveland Clinic: 254 patients (25.3%) with small bowelobstruction( 7.5% early, 17.8% late)70 (27.6%) requiredoperation Stomal stenosis, volvulus, internal hernia and adhesions Temporary loop ileostomy as a cause of IO? Cumulative results 14% at 5 years and 22% at 10 years 4. Pelvic abscess 4% to 6% Contamination of the presacral space (intraoperative orpostoperative) Postoperative due to disruption of the PA anastomosis, latediagnosis after closure of the ileostomy Don't panic, CT scan and Pouchogram Ct guided drainage, local drainage +Abs Reexploration, drainage and reestablishment of the ileostomy Pouch resection? 5. Leaking pouch or PAA 2% to 10% Asymptomatic leak (X ray) delay the closure of ileostomy Symptomatic leak (fever, perianal pain and discharge)..Sinus tract from anastomosis EUA ( drainage & curette) Site and size of the leak Type of radiology management 6. Vaginal fistula 6% (1/3 before closure of ileostomy) Hand sewn and stapled PA anastomosis and low vaginal wall 75% acute fulminante UC, other group ( one stage withoutileostomy) Risk factors (Tekkis et al) female, perianal abscess,perianal fistula, Crohns, abnormal anal manometry andpelvic abscess) 7. 92% diagnosed clinically Basic principle of management ( keep ileostomy, drainageof any abscess, Abs) If ileostomy was closed, reestablish it (poor outcome) Intraanal approach , trans vaginal or perineal approach Combined abdominoperineal repair Pouch excision 8. Anal stricture 5% to 16% (ST. Marks Hospital 14.2% handsewn, 39.6% stapled) Pelvic sepsis, tension on IPAA, poor blood supply, poor technique,leakage) Lewis et al (small stapling gun, W pouch, defunctioning ileostomy,anastomotic dehiscence and pelvic abscess) Nonfibrotic and fibrotic (Mayo Clinic 84% nonfibrotic) Dilatation success 95% in nonfibrotic, 45% in fibrotic Stricturotomy or stricturectomy with mucosal advancement flap, redopouch, or excision with end ileostomy Fazio & Tjandra ( pouch advancement and neo-ileoanal anastomosis 9. Difficult evacuation Mechanical, non mechanical Long efferent ileal limb (S pouch), long anorectal stumpPortal vein thrombosis Abdominal pain, fever, leukocytosis, delayed bowelfunction 10. Pouchitis Acute and/or chronic inflammation of ileal reservoir Not related to the type of reservoir, 7% to 59% Highest during early 6 months, cumulative risk off after 2years, 10% severe and 1% to 3% need pouch removal Increase stool frequency and urgency, bright red bleeding,fecal incontinence and extraintestinal manifestation of IBD Accurate diagnosis of pouchitis (endoscopic & microscopic) 11. criteria scoreclinicalStool frequencyUsual postoperative stool frequency01 to 2 stool/day greater than PO usual13 or more stools/day greater than PO usual2Rectal bleedingNone or rarePresent daily01Fecal urgency or abdominal crampsNoneOccasionalUsual012fever more than 37.8Absentpresent01Pouchitis disease activity index Sandborn et al 12. criteria scoreEndoscopic inflammationEdema1Granularity1Friability1Loss of vascular pattern1Mucous exudates1Ulcerations1Acute histologic inflammationPolymorphonuclear leukocyte infiltrationMildModerate with crypt abscessSevere with crypt abscess123123Ulceration per low power field (mean)Less than 25%25% to 50%More than 50%Pouchitis disease activity index Sandborn et al 13. Colitis patients have a much greater incidence than FAP Colitis with extraintestinal manifestations have a muchgreater incidence than without In contrast, patients with backwash ileitis are notpredisposed to the condition Anastomotic stricture and very large pouch Pouchitis seems to be related to stasis in the pouch, withsubsequent proliferation of bacteria in the pouch,especially anaerobic and the bacteria and their exotoxinsare responsible for damaging the pouch mucosa 14. Change in the histology of the pouch mucosa Deficiency of short chain fatty acids Ischemia and production of oxygen free radicals Pathogenic bacteria theory Metronidazole 500 mg/8 hours for 7 to 10 days Ciprofloxacin 1000mg/ day Probiotic therapy in chronic pouchitis 15. Symptoms of pouchitis followed by endoscopy and biopsyPouchitis treated withmetronidazole or ciprofloxacinResponseRecurrenceRepeat antibioticRecurrenceRepeat antibiotic or addprobioticsNo responseOtherantibioticAntiinflammatory drugsImmunosuppressivedrugs surgicalNopouchitisIrritable pouchsyndromeImodium, lomotilPelvic floor assessmentcasurgical 16. Other reported complications Perianal fistula and abscess Intraabdominal fistula and abscess Residual septum in J pouch Long efferent limb in S pouch Unsatisfactory bowel function 17. Indication for reoperation and outcome in 23 patients, Mayo Clinicproblem Patients No treatment outcomeLong efferent limb 9 New pouch (5)Revised pouch (4)Success (7)Sepsis and/orfistula4 Revised pouch Success (2)Blind limb 3 Revised pouch Success (1)Twisted pouch 3 New pouch (1)Old pouch retained (2)Success (3)No pouch ( folded J) 1 New pouch Success (1)Ileal pouch- anal3 Old pouch retained Success (3)anastomosis 18. Salvage surgery for majorcomplications following IPAA isworthwhile. And the need forreconstruction of the pouch oreven new pouch formationcarries a respectable rate ofsuccess between expert hands 19. Sexual dysfunction Impotence 1% to 2% Retrograde ejaculation 2% to 3% Dysparonia 7% Fecal leaks during intercourse 2% 20. Functional results Complex interaction of many factors including (analsphincter and PR muscle activity, reservoir capacity,compliance, motility and emptying, anorectal pelvic floorsensation and innervation, upper intestinal activity, stoolconsistency, content, volume, and transit. The functional results most determining the patientsatisfaction are frequency of bowel movements per dayand fecal continence.