What Are the Outcomes of Reoperative Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis Surgery?

• Published in: Diseases of the colon & rectum Vol. 52; no. 5; pp. 884 - 890
• Main Authors: SHAWKI, Sherief, BELIZON, Avraham, PERSON, Benjamin, WEISS, Eric G, SANDS, Dana R, WEXNER, Steven D
• Format: Journal Article
• Language: English
• Published: Hagerstown, MDc Lippincott Williams & Wilkins 01-05-2009
• Subjects: Abscess - etiology; Abscess - surgery; Adenomatous Polyposis Coli - surgery; Adolescent; Adult; Aged; Biological and medical sciences; Colitis - diagnosis; Colitis - surgery; Colonic Pouches - adverse effects; Crohn Disease; Fecal Incontinence - etiology; Fecal Incontinence - surgery; Female; Fistula - etiology; Fistula - surgery; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Male; Medical sciences; Middle Aged; Outcome Assessment (Health Care); Proctocolectomy, Restorative - adverse effects; Proctocolectomy, Restorative - methods; Reoperation; Retrospective Studies; Salvage Therapy; Sepsis - etiology; Sepsis - surgery; Stomach, duodenum, intestine, rectum, anus; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Young Adult; Pouch salvage; Ileal J-pouch; Prognosis; Treatment; Surgery; Reoperative pouch surgery; Gastroenterology; Ileal pouch; Ileal pouch-anal anastomosis
• ISSN: 0012-3706; 1530-0358
• DOI: 10.1007/dcr.0b013e31819eef8f

Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery.
The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence.
Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohn's disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohn's disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohn's disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent.
Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeon's preference and patient-related factors such as diagnosis.