People Pouches and PlacesThe Generation Game Pouch Salvage and Reconstruction Prof Neil Mortensen MA MB ChB MD FRCS Eng hon FRCS Glas hon FRCS Edin Kangaroo Club October 2016 ID: 769337
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People, Pouches and Places:The Generation Game - Pouch Salvage and Reconstruction Prof Neil Mortensen MA, MB ChB, MD, FRCS Eng hon FRCS Glas, hon FRCS Edin Kangaroo Club October 2016
Parks and NichollsProctocolectomy without ileostomy for ulcerative colitis BMJ 1978;2:65-8
Pouches around the World 2014 USA 20600 UK 5500Sweden 2000 Canada 4500 Germany 3000 France 1750 Australia 750 Estimated Total 40,000
Pouch surgery – the ecstasy
Disparity in experienceACPGBI Pouch Registry 2012
W and J inversion
The Rise of the use of Biologics
2383 IPAA in ACPGBI Pouch Registry
Redo are 7% totalACPGBI Pouch Registry 2012
Oxford IPAA 1986-2014Redo increased from 0% to 20%
BleedingInfarctionPeritonitis Leak Pouch anal fistula Pouch vaginal fistula Stricture Small bowel stricture Pouch complications
Septic complications 20%ACPGBI Pouch Registry 2012
Please don’t let it leak
n % leakssingle stage 22 32previous 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 Restorative protocolectomy – anastomotic leakage
Site of pouch sepsisAfter Fazio
Pelvic Sepsis after Pouch Surgery 200 of 3234 pouch patients had septic complications within 3 monthsHigher rate of pouch failure 19.5% v 4%Incontinence worseLower CGQoL score Kiely et al DCR 2012
Pouch Failure Pouch excision or defunction for more than 6 months
Two PeaksACPGBI Pouch Registry 2012
Indications for Pouch Excision at St Mark’s St Mark’s n=996 Referred n=245 Total No patients 58(5.6%) 10(4%) 68 Pelvic sepsis 28 5 33(48.5%) Pouch fistula 24 4 Crohns 3 2 Poor function 21 3 24(35.2%) Pouchitis 4 1 other 5 1 Karoui, Cohen, and Nicholls DCR 2004
Long Term Failure Rates from St Mark’sKaroui Cohen and Nicholls DCR 2004
Salvage early and late
Make an early diagnosisHigh index of suspicionContrast enema or CT with rectal contrastEUA or digital rectal exam Leakage comes like a thief in the night
Endo sponge – vacuum assisted healing
The Healing Cavity
Indications for Pouch Reconstruction - MechanicalLong efferent limbSmall pouchLong blind limbTwisted pouchIntra pouch prolapse or hour glassingAnastomotic stricture
Indications for Pouch Reconstruction - sepsisPartial anastomotic separationAnastomotic sinusAnastomotic stenosis
local abdominal salvage
Local repairsEndoanal pouch advancementEndovaginal repair of pouch vaginal fistula Repeated repairs often necessaryOverall 50% success Heriot et al DCR 2005
Pouch reconstruction Cleveland Clinic241 abdominal reconstructionsIndications: Fistula 67, leak 65, stricture 42, pouch dysfunction 40, pelvic abscess 2571 new pouch, 170 original pouch refurbished29 failures Functionally more minor incontinence Remzi et al DCR 2009
Pouch Revision Mayo51 pouch revisions65% for septic causes, 35% mechanicalFunction median 5 pouch emptyings per dayPouch survival 93% 1yr, 89% 5yrMathis et al Ann Surg 2009
Long Term Results of Abdominal Salvage St Marks112 underwent 117 pouch salvage proceduresCommon indications - sepsis 45, stricture 13, retained stump 3521% pouch failure Associated with Crohn’s, sepsis Tekkis et al BJS 2006
Cumulative Pouch Survival Tekkis et al BJS 2006 overall sepsis
Leaks after IPAA – improved outcomes – 1981/4 v 2001/3141 of 1424 IPAA 10% leaks118 from anast and 23 from pouchNon op treatment initially in 100 with 80% success59 had an operative intervention34 transanal - 66% success Lap and suture repair in 7 - 57% success Combined AP repair in 18 - 72% successOverall 84% functioning pouch Pouch salvage after leak up from 67% to 88% Raval et al Ann Surg 2007
Most promising candidates -mechanical outflow obstructionDistal segment of an S pouchIleoanal anastomotic strictureLong retained rectal remnant
Oxford Salvage 2009-201529 abdominal redo – one later failure all others closure stoma1 attempted but thick mesentery and no reach6 excision1 excision and conversion to K pouch11 indefinite diversion
70% OVERALL SALVAGE INCONTINENCE UNCOMMONThe take home message
Complications after redo surgeryACPGBI Pouch Registry 2012
Failure is 3 x worse after redoACPGBI Pouch Registry 2012
Summary of Treatment OptionsAfter Sagar and Pemberton BJS 2012
What if it is not possible to reconstruct ?Excise pouchConvert to a Koch Pouch
Pouch ExcisionNot for the feint heartedUsually follows sepsis and local destructive effectsMust take anus, but healing may be delayedConsider do you really need to take it out? Why not indefinite diversion?Kiran et al DCR 2012
Leaving the Pouch as is –Indefinite DiversionNo evidence for mucosal deterioration a median 12 years after IPAA and 3.6yrs after defunction in 20 patients, 5 developed type C villous atrophy, no cancer or dysplasia even in anastomosis biopsies22 indefinite diversion median 10yrs no cancer or dysplasia and clinically fineDas et al Colorectal Dis 2008 Bengtsson et al Colorectal Dis 2007
Conversion of failed pouch to continent ileostomy64 patients at Cleveland Clinic 5 yr FUMain indication septic complications in 56%Previous pouch used in 25% Complications in 30%Long term dysfunction 50%, complications 61%, revision 45%Durability 95%, median revision free interval 2.8yrs Lian et al DCR 2009
Pouch Failure OptionsLocal repair Abdominal repair Leave in placeIndefinite defunction Repair old pouch Make new pouch Convert to Kock pouch 70% success
Restorative Proctocolectomy - Technique Get it right first time Spend quality time with your anastomosis !
Within a generation we have seenThe creation of pouch surgeryTechnical refinementAdvances in medical therapyNow the age of redo surgery
A big thank you for your support