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POUCHITIS AS AN INDICATION FOR ILEAL POUCH SURGICAL REVISION
Matteo Novello*2, Luca Stocchi2, Bo Shen1
1 Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; 2Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Background: Surgical revision of a failed ileal pouch is a recognized option after failure of the primary ileal pouch-anal anastomosis. Chronic pouchitis alone is an unusual indication for redo ileal pouch-anal anastomosis (IPAA) but is a common condition which can lead to primary pouch failure. It is uncertain if redo IPAA is effective in the management of chronic pouchitis. The aim of this study was to describe our experience with the surgical management of this rare condition.
Methods: We evaluated all patients undergoing transabdominal pouch revisionary surgery for failed IPAA between 2001 and 2016 and included in an IRB-approved prospectively maintained database, corroborated by chart review. We assessed patient demographics, disease-related factors, surgical procedure details, perioperative outcomes and redo pouch survival. By following up the patients after their stoma closure up to the present date, we were able to describe long-term outcomes of the surgical procedure.
Results: Three female patients were identified (mean age: 42.8, mean BMI: 22.6), all diagnosed with ulcerative colitis as an indication for their primary J-IPAA. All the patients failed medical management of chronic pouchitis, which was reported as the redo IPAA indication by the attending surgeon. One patient was receiving steroids, and another one was receiving biologics at the time of the redo pouch. The average ASA score was 3.6 and the average length of stay was 11 days. In one case the pouch was excised and a new j pouch was constructed while in the remaining two cases the old pouch was repaired. One patient required reoperation due to ileostomy stricture, another one suffered superficial wound infection and the third postoperative ileus. None of the three patients experienced pelvic sepsis. All cases underwent proximal stoma diversion and ultimate ostomy closure after a mean interval of 148 days. The long-term management of our patients was complicated by two readmissions for acute abdominal pain, one case of recurrent pouchitis and several cases of poor oral tolerance. All the patients retained the pouch after the redo IPAA. After a follow-up of 15 months, one developed recurrent pouchitis which resolved after a prolonged administration of antibiotics followed by biologic therapy. Another patient developed clinical Crohn's disease of the J pouch after a follow-up of 24 months.
Conclusions: The management of patients undergoing redo pouch for chronic pouchitis is highly variable and challenging. It is critical to understand what the cause of the pouchitis symptoms is and rule out any other more frequent complications such as leak and pelvic sepsis. Redo IPAA should be offered very cautiously after medical management failure as a treatment for chronic pouchitis.
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