Complications of Ileoanal Pouches

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical therapy of choice for patients with chronic ulcerative colitis and the majority of patients with familial adenomatous polyposis. It restores gastrointestinal continuity, re-establishes transanal defecation, and avoids a permanent stoma. Although this technically demanding procedure is associated with low mortality rates, it is frequently accompanied by early and late complications. This article will review these complications and discuss the interventions that are needed to provide appropriate treatment.

KEYWORDS

Restorative proctocolectomy - ileal pouch-anal anastomosis - complications, morbidity

REFERENCES

• 1 Parks A G, Nicholls R J. Proctocolectomy without ileostomy for ulcerative colitis.  BMJ. 1978;  2 85-88
• 2 Bentrem D J, Wang K L, Stryker S J. Adenocarcinoma in an ileal pouch occurring 14 years after restorative proctocolectomy: report of a case.  Dis Colon Rectum. 2003;  46 544-546
• 3 Blumberg D, Opelka F G, Hicks T C, Timmcke A E, Beck D E. Restorative proctocolectomy: Ochsner Clinic experience.  South Med J. 2001;  94 467-471
• 4 Fazio V W, Ziv Y, Church J M et al.. Ileal pouch-anal anastomoses complications and function in 1005 patients.  Ann Surg. 1995;  222 120-127
• 5 Fleshman J W, Cohen Z, McLeod R S, Stern H, Blair J. The ileal reservoir and ileoanal anastomosis procedure. Factors affecting technical and functional outcome.  Dis Colon Rectum. 1988;  31 10-16
• 6 Kelly K A. Anal sphincter-saving operations for chronic ulcerative colitis.  Am J Surg. 1992;  163 5-11
• 7 Marcello P W, Roberts P L, Schoetz Jr D J, Coller J A, Murray J J, Veidenheimer M C. Long-term results of the ileoanal pouch procedure.  Arch Surg. 1993;  128 500-504
• 8 Meagher A P, Farouk R, Dozois R R, Kelly K A, Pemberton J H. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients.  Br J Surg. 1998;  85 800-803
• 9 Hyman N H, Fazio V W, Tuckson W B, Lavery I C. Consequences of ileal pouch-anal anastomosis for Crohn's colitis.  Dis Colon Rectum. 1991;  34 653-657
• 10 Nicholls R J. Restorative proctocolectomy with ileal reservoir: indications and results.  Schweiz Med Wochenschr. 1990;  120 485-488
• 11 McMullen K, Hicks T C, Ray J E, Gathright J B, Timmcke A E. Complications associated with ileal pouch-anal anastomosis.  World J Surg. 1991;  15 763-767
• 11a Seidel S A, Peach S E, Newman M , Sharp K W. Ileoanal pouch procedures: clinical outcomes and quality-of-life assessment.  Am Surg. 1999;  65 40-46
• 11b Johnson E, Carlsen E, Nazir M, Nygaard K. Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis.  Eur J Surg. 2001;  167 40-45
• 12 Ziv Y, Fazio V W, Church J M, Lavery I C, King T M, Ambrosetti P. Stapled ileal pouch-anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis.  Am J Surg. 1996;  171 320-323
• 13 Gecim I E, Wolff B G, Pemberton J H, Divine R M, Dozois R R. Does technique of anastomosis play any role in developing late perianal abscess or fistula?.  Dis Colon Rectum. 2000;  43 1241-1245
• 14 Sugerman H J, Sugerman E L, Meador J G, Newsome Jr H H, Kellum Jr J M, DeMaria E J. Ileal pouch-anal anastomosis without ileal diversion.  Ann Surg. 2000;  232 530-541
• 15 Fukushima T, Sugita A, Koganei K, Shinozaki M. The incidence and outcome of pelvic sepsis following handsewn and stapled ileal pouch anal anastomoses.  Surg Today. 2000;  30 223-227
• 16 Tjandra J J, Fazio V W, Milsom J W, Lavery I C, Oakley J R, Fabre J M. Omission of temporary diversion in restorative proctocolectomy-is it safe?.  Dis Colon Rectum. 1993;  36 1007-1014
• 17 Remzi F H, Fazio V M, Preen M et al.. Omission of temporary diversion after restorative proctocolectomy and ileal pouch anal anastomosis: surgical complications, functional outcome and quality of life analysis. Paper presented at: 103rd Meeting of the American Society of Colon and Rectal Surgeons June 2003 Chicago, IL;
• 18 Tjandra J J, Fazio V W, Church J M, Oakley J R, Milsom J W, Lavery I C. Similar functional results after restorative proctocolectomy in patients with familial adenomatous polyposis and mucosal ulcerative colitis.  Am J Surg. 1993;  165 322-325
• 19 Pemberton J. Complications, Management, Failure and Revisions. Restorative Proctocolectomy. Oxford; Blackwell Scientific Publications 1993: 34-52
• 20 Mathey P, Ambrosetti P, Morel P et al.. The Swiss experience of ileo-anal anastomosis with reservoir (AIA). Complications and functional results [in French].  Ann Chir. 1993;  47 1020-1025
• 21 Cohen Z, McLeod R S, Stephen W et al.. Continuing evolution of the pelvic pouch procedure.  Ann Surg. 1992;  216 506-512
• 22 Oncel M, Remzi F H, Church J M et al.. Leak from the tip of J-pouch after restorative proctocolectomy: risk factors, presentation, management and outcome. Paper presented at: Annual Meeting of the American Society of Colon and Rectal Surgeons May 2003 New Orleans, LA;
• 23 Francois Y, Dozois R R, Kelly K A et al.. Small intestinal obstruction complicating ileal pouch-anal anastomosis.  Ann Surg. 1989;  209 46-50
• 24 MacLean A R, Cohen Z, MacRae H M et al.. Risk of small bowel obstruction after the ileal pouch-anal anastomosis.  Ann Surg. 2002;  235 200-206
• 25 Fazio V W, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula.  World J Surg. 1983;  7 481-488
• 26 Becker J M, Dayton M T, Fazio V W et al.. Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study.  J Am Coll Surg. 1996;  183 297-306
• 27 Chalikonda S, Remzi F, Cutait de Castro Cotti G et al.. Perioperative pouch bleeding (PPB) after ileal pouch-anal anastomosis (IPAA) can be managed non-operatively. Paper presented at: Annual Meeting of the American Society of Colon and Rectal Surgeons May 2003 New Orleans, LA;
• 28 Kartheuser A H, Dozois R R, Wiesner R H et al.. Complications and risk factors after ileal pouch-anal anastomosis for ulcerative colitis associated with primary sclerosing cholangitis.  Ann Surg. 1993;  217 314-320
• 29 Gray M, Colwell J C. Pouchitis: part 1: etiologies and risk factors.  J Wound Ostomy Continence Nurs. 2002;  29 68-73
• 30 Nicholls R J, Banerjee A K. Pouchitis: risk factors, etiology, and treatment.  World J Surg. 1998;  22 347-351
• 31 Subramani K, Harpaz N, Bilotta J et al.. Refractory pouchitis: does it reflect underlying Crohn's disease?.  Gut. 1993;  34 1539-1542
• 32 Salemans J M, Nagengast F M, Lubbers E J, Kuijpers J H. Postoperative and long-term results of ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis coli.  Dig Dis Sci. 1992;  37 1882-1889
• 33 Sandborn W J, Tremaine W J, Batts K P et al.. Pouchitis after ileal pouch-anal anastomosis: a pouchitis disease activity index.  Mayo Clin Proc. 1994;  69 409-415
• 34 Shen B, Achkar J P, Connor J T et al.. Modified Pouchitis Disease Activity Index: a simplified approach to the diagnosis of pouchitis.  Dis Colon Rectum. 2003;  46 748-753
• 35 Bertoni G, Sassatelli R, Bedogni G, Nigrisoli E. Sulindac-associated ulcerative pouchitis in familial adenomatous polyposis.  Am J Gastroenterol. 1996;  91 2431-2432
• 36 Shen B, Achkar J P, Lashner B A et al.. A randomized clinical trial of ciprofloxacin and metronidazole to treat acute pouchitis.  Inflamm Bowel Dis. 2001;  7 301-305
• 37 Sartor R B. Probiotics in chronic pouchitis: restoring luminal microbial balance.  Gastroenterology. 2000;  119 584-587
• 38 Gionchetti P, Rizzello F, Venturi A et al.. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial.  Gastroenterology. 2000;  119 305-309
• 39 Shen B, Achkar J P, Lashner B A et al.. Irritable pouch syndrome: a new category of diagnosis for symptomatic patients with ileal pouch-anal anastomosis.  Am J Gastroenterol. 2002;  97 972-977
• 40 Lavery I C, Sirimarco M T, Ziv Y, Fazio V W. Anal canal inflammation after ileal pouch-anal anastomosis. The need for treatment.  Dis Colon Rectum. 1995;  38 803-806
• 41 Ozuner G, Hull T, Lee P, Fazio V W. What happens to a pelvic pouch when a fistula develops?.  Dis Colon Rectum. 1997;  40 543-547
• 42 Burke D, van Laarhoven C J, Herbst F, Nicholls R J. Transvaginal repair of pouch-vaginal fistula.  Br J Surg. 2001;  88 241-245
• 43 Shah N S, Remzi F H, Massmann A et al.. Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy.  Dis Colon Rectum. 2003;  46 911-917
• 44 Senapati A, Tibbs C J, Ritchie J K et al.. Stenosis of the pouch-anal anastomosis following restorative proctocolectomy.  Int J Colorectal Dis. 1996;  11 57-59
• 45 Prudhomme M, Dozois R R, Godlewski G et al.. Anal canal strictures after ileal pouch-anal anastomosis.  Dis Colon Rectum. 2003;  46 20-23
• 46 Fazio V W, Tjandra J J. Pouch advancement and neoileoanal anastomosis for anastomotic stricture and anovaginal fistula complicating restorative proctocolectomy.  Br J Surg. 1992;  79 694-696
• 46a Zmora O, Efron J E, Nogueras J J et al.. Reoperative abdominal and perineal surgery in ileoanal pouch patients.  Dis Colon Rectum. 2001;  44 1310-1314
• 46b Sagar P M, Dozois R R, Wolff B G. Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease.  Dis Colon Rectum. 1996;  39 893-898
• 47 Delaney C P, Remzi F H, Gramlich T et al.. Equivalent function, quality of life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcerative colitis.  Ann Surg. 2002;  236 43-48
• 48 Heuschen U A, Allemeyer E H, Hinz U et al.. Outcome after septic complications in J pouch procedures.  Br J Surg. 2002;  89 194-200
• 49 Fazio V W, Tekkis P P, Remzi F et al.. Quantification of risk for pouch failure following ileal pouch anal anastomosis surgery.  Ann Surg. 2003;  238 605-614
• 50 Fazio V W, Wu J S, Lavery I C. Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment.  Ann Surg. 1998;  228 588-597
• 51 MacLean A R, O'Connor B, Parkes R et al.. Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results.  Dis Colon Rectum. 2002;  45 880-886
• 52 Dayton M T. Redo ileal pouch-anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy?.  Am J Surg. 2000;  180 561-565
• 53 Baixauli J, Delaney C P, Wu J S et al.. Functional outcome and quality of life after repeat ileal pouch-anal anastomosis (R-IPAA) for septic and functional complications of ileo-anal surgery.  Dis Colon Rectum. 2004;  47 2-11
• 54 Gullberg K, Lindforss U, Zetterquist H et al.. Cancer risk assessment in long-standing pouchitis. DNA aberrations are rare in transformed neoplastic pelvic pouch mucosa.  Int J Colorectal Dis. 2002;  17 92-97
• 55 Cox C L, Butts D R, Roberts M P et al.. Development of invasive adenocarcinoma in a long-standing Kock continent ileostomy: report of a case.  Dis Colon Rectum. 1997;  40 500-503
• 56 Heuschen U A, Heuschen G, Autschbach F et al.. Adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy.  Int J Colorectal Dis. 2001;  16 126-130
• 57 Baratsis S, Hadjidimitriou F, Christodoulou M, Lariou K. Adenocarcinoma in the anal canal after ileal pouch-anal anastomosis for ulcerative colitis using a double-stapling technique: report of a case.  Dis Colon Rectum. 2002;  45 687-692
• 58 Remzi F H, Fazio V W, Delaney C P et al.. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years.  Dis Colon Rectum. 2003;  46 6-13