Pelvic Pouch: Complications and Their Management

Introduction

When a total proctocolectomy is required, the ileal pouch–anal anastomosis (IPAA) procedure is favored over an end ileostomy because the IPAA allows continence with defecation by the normal route. The procedure can be performed with favorable results for patients with ulcerative colitis and familial adenomatous polyposis, as well as in some patients with indeterminate colitis and highly selectively in patients with Crohn disease that is confined to the large intestine. Good early and long-term function and quality of life can be expected; however, because complications influence long-term results and hence pouch retention, sound surgical decision making and use of sound technique are critical.

Use of strategies that can target modifiable risk factors for complications and reduce risk in persons most likely to have complications optimizes good long-term outcomes. A staged procedure with an initial subtotal colectomy reduces risk of complications in high-risk patients with poor general health or malnutrition, in patients receiving high doses of immunosuppressive drugs or who are being treated with steroids, and in patients who have severe acute colitis. Similarly, an awareness of the perioperative complications that can occur facilitates their identification and prompt management, which affects both short-term results and long-term pouch function and retention.

For certain pouch-related problems, correction by both perineal and abdominal approaches is feasible, allowing the pouch to be salvaged. Pouch failure is generally defined as the need for the creation of a permanent ostomy with or without excision of the pouch. Factors shown to be associated with pouch failure include certain diseases (e.g., Crohn disease), prior anal disease, abnormal anal manometry findings, comorbid conditions, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, and anastomotic stricture and separation. The following preoperative factors have the strongest influence on pouch survival: extent of resection (total proctocolectomy vs. completion proctectomy), type of anastomosis (stapled vs. hand sewn), patient diagnosis (mucosal ulcerative colitis and others vs. Crohn disease), and comorbidity. In this chapter, various complications related to the ileoanal pouch—several of which may lead to pouch failure—and their management are discussed.

Pouch Dysfunction

Patients with a well-constructed, uncomplicated ileoanal pouch typically have six to eight bowel movements over a 24-hour period. Most patients do not need to wear pads, although some patients do so for peace of mind. Patients can defer defecation for at least an hour, and incontinence is rare. Quality of life is high, and most patients deny having physical, social, work-related, or sexual restrictions.

When patients experience pouch dysfunction, a detailed history of symptoms, function of the pouch, and the timing of the onset of symptoms need to be obtained. The state of the anoperineum and the integrity of the sphincter mechanism are assessed by examination, followed by pouchoscopy with biopsies of the pouch, residual anal canal, and afferent limb. Biopsies help evaluate the presence of inflammation, suggesting pouchitis or cuffitis, Crohn disease, or other inflammatory and infectious complications. Stool and blood tests help exclude an infection as the cause of the changes in pouch function. The potential diagnosis of Crohn disease needs to be considered in any patient who experiences fistulous and septic complications after creation of an ileoanal pouch. However, septic complications after ileoanal pouch creation may mimic Crohn disease, and the distinction may be challenging. In general, septic complications that occur within 1 year of pouch creation or closure of a defunctioning ostomy above a pouch are likely to be due to perioperative anastomotic or pelvic infections. If complications occur more than 1 year after creation of the pouch, the degree of suspicion for Crohn disease should increase.

A Gastrografin enema helps evaluate pouch structure and capacity and identify pouch-perineal or pouch-vaginal fistulae, narrowing of the afferent limb, inlet, or outlet, and any posterior sinus tract leading from the anastomosis. Magnetic resonance imaging (MRI) of the pelvis helps detect any persistent presacral collections, abscesses, or fistulae that could be contributing to the patient’s symptoms. Computed tomography (CT) enterography is useful in the evaluation of the small intestine proximal to the pouch; inflammation indicates the possibility of Crohn disease. Anorectal manometry and endoanal ultrasound are used to assess the sphincter tone, anatomic integrity, and presence of paradoxical pressures, which, when correlated with difficulties with evacuation, suggest outlet obstruction. A defecating pouchogram or magnetic resonance defecography identifies problems with evacuation.

Intraoperative Complications

Intraoperative complications specifically related to pouch creation include bleeding, difficulty with reach of the pouch, and pouch ischemia resulting either from tension or extrazealous attempts at vascular division to allow an ileoanal pouch to reach to the residual anal canal.

Postoperative Complications

Postoperative complications include pelvic sepsis, anastomotic dehiscence, pouch bleeding, pouch-perineal and pouch-vaginal fistulae, pouch sinus, leak from the tip of the J limb, pouch prolapse, pouchitis and cuffitis, Crohn disease of the pouch, outlet dysfunction, pouch cancer, and pouch failure. Late complications typically occur 3 months after creation of the pouch or after takedown of the ileostomy when the pouch has been defunctioned.