Oxford

Colorectal

Management of the Problem Pouch

Bruce George

Oxford University Hospitals

Oxford

Colorectal

Pouch surgery – the agony

Oxford

Colorectal

Long Term Failure Rates from St Mark’s

Karoui Cohen and Nicholls DCR 2004

Oxford

Colorectal

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

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

• For every failed pouch, there are a few injured

Oxford

Colorectal

Phase 1assessment of poor pouch function

• History of poor function– Always bad

– Recent deterioration

• Review histology

• Review peri-operative course

• Clinical examination

• PR

• Pouchoscopy + biopsy

• Stool culture

Oxford

Colorectal

Common problems

• Acute pouchitis– ciprofloxacin

• Pouch-anal anastomotic stricture– EUA + gentle dilatation

• Cuffitistopical steroids or mesalazine

Oxford

Colorectal

Phase 2 Assessment of persistent poor pouch function

• Inside

– Flexible pouchoscopy + biopsy

– pouchogram

• Outside

– CT or MR pelvis

• Below

– Sphincter physiology and ultrasound

– Pouchogram

– EUA, pouch and cuff biopsies

• Above

– MRE

– endoscopy

• Emptying the pouch

– Dynamic evacuating “proctography”

Oxford

Colorectal

INSIDE THE POUCH

• Chronic pouchitis

• Irritable pouch

• Small volume/non compliant pouch

• Ischaemia

• Cmv/c diff

• Collagenous pouchitis

Oxford

Colorectal

OUTSIDE THE POUCH

• Pelvic abscess/induration

• Fistula

• Unrelated pathology– Fibroid, desmoid

Oxford

Colorectal

Below the pouch

• Stenosis/induration at anastomosis

• Pouch-vaginal fistula

• Sphincter weakness

• Cuffitis

• Long rectal cuff

Oxford

Colorectal

ABOVE THE POUCH

• Adhesions

• Bacterial overgrowth

• Crohn’s disease

• Pre-pouch ileitis

• NSAIDs

• coeliac

Oxford

Colorectal

EMPTYING THE POUCH

• Intussusception/prolapse

• Anismus

Oxford

Colorectal

Treatment

• Dependant on identification of cause of poor pouch function

Oxford

Colorectal

Phase 3the really failing pouch

• Septic

– Peri-pouch fistulae

– Strictured, indurated pouch-anal anastomosis

– Long retained rectal cuff

– Severe pouchitis

• Mechanical

– Small pouch

– Long blind end

– Long efferent spout

– intussusception

• Suspicion of Crohn’s disease

• Chronic resistant pouchitis

Oxford

Colorectal

Surgical options for the failing pouch

• Indefinite diversion– with pouch excision

– with pouch left in-situ

• Re-do pouch reconstruction

• Kock pouch

Follow-up (years)

543210

Cum

ulat

ive

ileal

pou

ch s

urvi

val

1.0

.8

.6

.4

.2

0.0

Sepsis

Other

Non-septic

Oxford

Colorectal

operative procedure

Oxford

Colorectal

operative procedure

Oxford

Colorectal

operative procedure

Oxford

Colorectal

operative procedure

Oxford

Colorectal

operative procedure

Oxford

Colorectal

operative procedure

Oxford

Colorectal

operative procedure

Oxford

Colorectal

Summary

• Structured approach to poor pouch function– Joint with gastroenterologists

– Probably main argument for large volume units

• Avoid salvage surgery if possible