HEGAZY SURGERY

1. Complications of ileal pouch
after total proctocolectomy
Dr/ Mohamed A Nada
Ass Professor General Surgery
Ain Shams University
2014

2. • 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

4. 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

7. 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?

8. 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

12. 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)

13. • 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

16. 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

17. Difficult evacuation
• Mechanical, non mechanical
• Long efferent ileal limb (S pouch), long anorectal stump
Portal vein thrombosis
• Abdominal pain, fever, leukocytosis, delayed bowel
function

20. 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)

21. criteria score
clinical
Stool frequency
Usual postoperative stool frequency
1 to 2 stool/day greater than PO usual
3 or more stools/day greater than PO usual
0
1
2
Rectal bleeding
None or rare
Present daily
0
1
Fecal urgency or abdominal cramps
None
Occasional
Usual
0
1
2
fever more than 37.8
Absent
present
0
1
Pouchitis disease activity index Sandborn et al

22. criteria score
Endoscopic inflammation
Edema
Granularity
Friability
Loss of vascular pattern
Mucous exudates
Ulcerations
1
1
1
1
1
1
Acute histologic inflammation
Polymorphonuclear leukocyte infiltration
Mild
Moderate with crypt abscess
Severe with crypt abscess
1
2
3
1
2
3
Ulceration per low power field (mean)
Less than 25%
25% to 50%
More than 50%
Pouchitis disease activity index Sandborn et al

23. • 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

24. • 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

25. Symptoms of pouchitis followed by endoscopy and biopsy
Pouchitis treated with
metronidazole or ciprofloxacin
Response
Recurrence
Repeat antibiotic
Recurrence
Repeat antibiotic or add
probiotics
No response
Other
antibiotic
Antiinflammatory drugs
Immunosuppressive
drugs surgical
No
pouchitis
Irritable pouch
syndrome
Imodium, lomotil
Pelvic floor assessmentca
surgical

26. 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

27. 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

28. 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

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

30. 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.