LONG RECTAL CUFF SYNDROME AFTER ILEOANAL POUCH FOR INFLAMMATORY BOWEL DISEASE
Marianna Maspero*, David Liska, Hermann Kessler, Jeremy M. Lipman, Scott Steele, Tracy L. Hull, Taha Qazi, Florian Rieder, Benjamin L. Cohen, Stefan D. Holubar
Cleveland Clinic, Cleveland, OH
Background: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) removes the entire rectum to the anal canal, but is technically challenging, especially with minimally invasive (MIS) approaches. Pouches are most commonly double-stapled, leaving a 1-2 cm "rectal cuff". If the cuff is longer, patients may develop recurrent ulcerative proctitis (UP) or rectal stricture (RS) of the retained rectum. The aim of this study is to describe long rectal cuff syndrome (LRCS) and its outcomes after redo IPAA performed for long rectal cuffs.
Methods: We defined LRCS as a constellation of UP or RS symptoms related to a long (≥ 4 cm) rectal cuff. We retrospectively reviewed our prospectively maintained Pouch Registry to identify patients whose indication for redo pouch was LRCS. We report their presentation and outcomes after redo IPAA for LRCS. Figures are frequency (percentange) and median (interquartile range).
Results: LRCS was the primary indication for redo IPAA in 40 patients (7% of the redo IPAA cases at our Center); median age at redo surgery, 42.5 (29 – 49 years; 18 (42%) were females; 36 (90%) patients were referral cases. Diagnosis at index IPAA was ulcerative colitis in 39 (97.5%), and Crohn's in 1 (2.5%) case. The index pouch was performed MIS in 14 (35%). The median rectal cuff length was 6 (5 – 8) cm, with 13 (32.5%) patients having a cuff ≥ 8 cm.
After a median of 21 (16 – 68) months, patients most commonly presented (31, 77.5%) with UP-symptoms (urge-incontinence, frequency, abdominopelvic or rectal pain) or with obstructive (9, 22.5%) symptoms (crampy abdominopelvic pain, outlet obstruction). Preoperative pouchoscopy was available in 32 (80%) cases: pouchoscopy findings included proctitis (18, 56%), rectal stricture (16, 50%), and/or dilated pouch (7, 22%). The median interval between the index pouch and redo pouch was 31 months (16 – 67.5). The pouch was disconnected and re-anastomosed to anus in 16 (40%), while excised with neo-pouch construction in 24 (60%) of cases. The anastomosis was stapled vs. handsewn 25 (62.5%) vs. 15 (27.5%). Pathologic exam revealed chronic active proctitis in 38 (90%) cases; the remained showed other pathologic changes.
In terms of long-term outcomes, two (5%) patients never had their stoma closed after redo due to Crohn's-related pouch complication, and fistulae development, respectively. After a median follow up of 34.5 (12 – 109) months, pouch failure occurred in 9 (22.5%) cases (Figure 1). The median interval between redo IPAA and pouch failure was 10 (4 – 34) months. Pouch survival at 3-, 5- and 10-years was 78%, 72%, and 63%.
Conclusion: Long rectal cuff syndrome is a potentially avoidable complication which presents with symptoms from either ulcerative proctitis or stricture. Redo IPAA can be offered as treatment to maintain intestinal continuity and may allow long-term pouch salvage.
Figure 1. Preoperative work up of a patient with long rectal cuff syndrome
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