Complications of ipaa

Complications of ileal pouch after total proctocolectomy

Dr/ Mohamed A NadaAss Professor General Surgery

Ain Shams University2014

• Park & Nicholls 1978• Low mortality rate ( young age,

highly specialized centers)• 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

Small bowel obstruction• 15% to 44%, and 5% to 20% require

reoperation• Cleveland Clinic: 254 patients (25.3%) with

small bowel obstruction( 7.5% early, 17.8% late) \ 70 (27.6%) required operation

• 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

Pelvic abscess

• 4% to 6%• Contamination of the presacral space

(intraoperative or postoperative)• Postoperative due to disruption of the PA

anastomosis, late diagnosis 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?

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

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 without ileostomy)• Risk factors (Tekkis et al) female,

perianal abscess, perianal fistula, Crohns, abnormal anal manometry and pelvic abscess)

• 92% diagnosed clinically• Basic principle of management

( keep ileostomy, drainage of any abscess, Abs)

• If ileostomy was closed, reestablish it (poor outcome)

• Intraanal approach , trans vaginal or perineal approach

• Combined abdominoperineal repair• Pouch excision

Anal stricture

• 5% to 16% (ST. Mark’s 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, redo pouch, or excision with end ileostomy

• Fazio & Tjandra ( pouch advancement and neo-ileoanal anastomosis

Difficult evacuation• Mechanical, non mechanical• Long efferent ileal limb (S pouch),

long anorectal stump

Portal vein thrombosis• Abdominal pain, fever, leukocytosis,

delayed bowel function

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 2 years, 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)

criteria score

clinicalStool frequencyUsual postoperative stool frequency1 to 2 stool/day greater than PO usual3 or more stools/day greater than PO usual

012

Rectal bleedingNone or rarePresent daily

01

Fecal urgency or abdominal crampsNoneOccasionalUsual

012

fever more than 37.8Absentpresent

01

Pouchitis disease activity index Sandborn et al

criteria score

Endoscopic inflammationEdemaGranularityFriabilityLoss of vascular patternMucous exudatesUlcerations

111111

Acute histologic inflammation

Polymorphonuclear leukocyte infiltrationMildModerate with crypt abscessSevere with crypt abscess

123

123

Ulceration per low power field (mean)Less than 25%25% to 50%More than 50%

Pouchitis disease activity index Sandborn et al

• Colitis patients have a much greater incidence than FAP

• Colitis with extraintestinal manifestations have a much greater incidence than without

• In contrast, patients with backwash ileitis are not predisposed to the condition

• Anastomotic stricture and very large pouch • Pouchitis seems to be related to stasis in the

pouch, with subsequent proliferation of bacteria in the pouch, especially anaerobic and the bacteria and their exotoxins are responsible for damaging the pouch mucosa

• 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

Symptoms of pouchitis followed by endoscopy and biopsy

Pouchitis treated with metronidazole or ciprofloxacin

Response

Recurrence

Repeat antibiot

ic

RecurrenceRepeat antibiot

ic or

add probiotics

No response

Other antibiotic

Antiinflammat

ory drugsImmunosuppressive

drugs

surgical

No pouchitis

Irritable pouch syndrome

Imodium, lomotil

Pelvic floor assessmentca

surgical

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

problem Patients No treatment outcome

Long efferent limb 9 New pouch (5)Revised pouch (4)

Success (7)

Sepsis and/or fistula 4 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- anal anastomosis

3 Old pouch retained Success (3)

Indication for reoperation and outcome in 23 patients, Mayo Clinic

Salvage surgery for major complications following

IPAA is worthwhile. And the need for reconstruction of

the pouch or even new pouch formation carries a

respectable rate of success between expert hands

Sexual dysfunction• Impotence 1% to 2%• Retrograde ejaculation 2% to 3%• Dysparonia 7%• Fecal leaks during intercourse 2%

Functional results

• Complex interaction of many factors including (anal sphincter and PR muscle activity, reservoir capacity, compliance, motility and emptying, anorectal pelvic floor sensation and innervation, upper intestinal activity, stool consistency, content, volume, and transit.

• The functional results most determining the patient satisfaction are frequency of bowel movements per day and fecal continence.