1. Oxford Colorectal People, Pouches and Places:The Generation Game - Pouch Salvage and Reconstruction Prof Neil Mortensen MA, MB ChB, MD, FRCS Eng hon FRCS Glas, hon FRCS Edin Kangaroo Club October 2016

2. Oxford Colorectal

4. Parks and Nicholls Proctocolectomy without ileostomy for ulcerative colitis BMJ 1978;2:65-8

5. Oxford Colorectal Pouches around the World 2014 USA 20600 UK 5500 Sweden 2000 Canada 4500 Germany 3000 France 1750 Australia 750 Estimated Total 40,000

6. Oxford Colorectal Pouch surgery – the ecstasy

7. Oxford Colorectal

8. Disparity in experience ACPGBI Pouch Registry 2012

9. Oxford Colorectal W and J inversion

10. Oxford Colorectal The Rise of the use of Biologics

11. Oxford Colorectal 2383 IPAA in ACPGBI Pouch Registry

12. Oxford Colorectal Redo are 7% total ACPGBI Pouch Registry 2012

13. Oxford Colorectal Oxford IPAA 1986-2014 Redo increased from 0% to 20%

14. Oxford Colorectal Bleeding Infarction Peritonitis Leak Pouch anal fistula Pouch vaginal fistula Stricture Small bowel stricture Pouch complications

15. Oxford Colorectal Septic complications 20% ACPGBI Pouch Registry 2012

16. Oxford Colorectal Please don’t let it leak

17. Oxford Colorectal n% leaks single stage22 32 previous colectomy49 12* steroids > 15mg15 33 no steroids56 14* under 40 yrs54 13 over 40 yrs17 35* Pemberton et al 1994 Restorative protocolectomy – anastomotic leakage

18. Oxford Colorectal Site of pouch sepsis After Fazio

19. Oxford Colorectal Pelvic Sepsis after Pouch Surgery 200 of 3234 pouch patients had septic complications within 3 months Higher rate of pouch failure 19.5% v 4% Incontinence worse Lower CGQoL score Kiely et al DCR 2012

20. Oxford Colorectal Pouch Failure Pouch excision or defunction for more than 6 months

21. Oxford Colorectal Two Peaks ACPGBI Pouch Registry 2012

22. Oxford Colorectal Indications for Pouch Excision at St Mark’s St Mark’s n=996 Referred n=245 Total No patients 58(5.6%)10(4%)68 Pelvic sepsis 28533(48.5%) Pouch fistula 244 Crohns32 Poor function 21324(35.2%) Pouchitis41 other51 Karoui, Cohen, and Nicholls DCR 2004

23. Oxford Colorectal Long Term Failure Rates from St Mark’s Karoui Cohen and Nicholls DCR 2004

24. Oxford Colorectal Salvage early and late

25. Oxford Colorectal Make an early diagnosis High index of suspicion Contrast enema or CT with rectal contrast EUA or digital rectal exam Leakage comes like a thief in the night

26. Oxford Colorectal Endo sponge – vacuum assisted healing

27. Oxford Colorectal The Healing Cavity

28. Oxford Colorectal Indications for Pouch Reconstruction - Mechanical Long efferent limb Small pouch Long blind limb Twisted pouch Intra pouch prolapse or hour glassing Anastomotic stricture

29. Oxford Colorectal Indications for Pouch Reconstruction - sepsis Partial anastomotic separation Anastomotic sinus Anastomotic stenosis

30. Oxford Colorectal local abdominal salvage

31. Oxford Colorectal Local repairs Endoanal pouch advancement Endovaginal repair of pouch vaginal fistula Repeated repairs often necessary Overall 50% success Heriot et al DCR 2005

32. Oxford Colorectal Pouch reconstruction Cleveland Clinic 241 abdominal reconstructions Indications: Fistula 67, leak 65, stricture 42, pouch dysfunction 40, pelvic abscess 25 71 new pouch, 170 original pouch refurbished 29 failures Functionally more minor incontinence Remzi et al DCR 2009

33. Oxford Colorectal Pouch Revision Mayo 51 pouch revisions 65% for septic causes, 35% mechanical Function median 5 pouch emptyings per day Pouch survival 93% 1yr, 89% 5yr Mathis et al Ann Surg 2009

34. Oxford Colorectal Long Term Results of Abdominal Salvage St Marks 112 underwent 117 pouch salvage procedures Common indications - sepsis 45, stricture 13, retained stump 35 21% pouch failure Associated with Crohn’s, sepsis Tekkis et al BJS 2006

35. Oxford Colorectal Cumulative Pouch Survival Tekkis et al BJS 2006 overallsepsis

36. Oxford Colorectal Leaks after IPAA – improved outcomes – 1981/4 v 2001/3 141 of 1424 IPAA 10% leaks 118 from anast and 23 from pouch Non op treatment initially in 100 with 80% success 59 had an operative intervention 34 transanal - 66% success Lap and suture repair in 7 - 57% success Combined AP repair in 18 - 72% success Overall 84% functioning pouch Pouch salvage after leak up from 67% to 88% Raval et al Ann Surg 2007

37. Oxford Colorectal Most promising candidates - mechanical outflow obstruction Distal segment of an S pouch Ileoanal anastomotic stricture Long retained rectal remnant

38. Oxford Colorectal Oxford Salvage 2009-2015 29 abdominal redo – one later failure all others closure stoma 1 attempted but thick mesentery and no reach 6 excision 1 excision and conversion to K pouch 11 indefinite diversion

39. Oxford Colorectal 70% OVERALL SALVAGE INCONTINENCE UNCOMMON The take home message

40. Oxford Colorectal Complications after redo surgery ACPGBI Pouch Registry 2012

41. Oxford Colorectal Failure is 3 x worse after redo ACPGBI Pouch Registry 2012

42. Oxford Colorectal Summary of Treatment Options After Sagar and Pemberton BJS 2012

43. Oxford Colorectal What if it is not possible to reconstruct ? Excise pouch Convert to a Koch Pouch

44. Oxford Colorectal Pouch Excision Not for the feint hearted Usually follows sepsis and local destructive effects Must take anus, but healing may be delayed Consider do you really need to take it out? Why not indefinite diversion? Kiran et al DCR 2012

45. Oxford Colorectal Leaving the Pouch as is –Indefinite Diversion No evidence for mucosal deterioration a median 12 years after IPAA and 3.6yrs after defunction in 20 patients, 5 developed type C villous atrophy, no cancer or dysplasia even in anastomosis biopsies 22 indefinite diversion median 10yrs no cancer or dysplasia and clinically fine Das et al Colorectal Dis 2008 Bengtsson et al Colorectal Dis 2007

46. Oxford Colorectal Conversion of failed pouch to continent ileostomy 64 patients at Cleveland Clinic 5 yr FU Main indication septic complications in 56% Previous pouch used in 25% Complications in 30% Long term dysfunction 50%, complications 61%, revision 45% Durability 95%, median revision free interval 2.8yrs Lian et al DCR 2009

47. Oxford Colorectal Pouch Failure Options Local repairAbdominal repair Leave in place Indefinite defunction Repair old pouch Make new pouch Convert to Kock pouch 70% success

48. Oxford Colorectal Restorative Proctocolectomy - Technique Get it right first time Spend quality time with your anastomosis !

49. Oxford Colorectal Within a generation we have seen The creation of pouch surgery Technical refinement Advances in medical therapy Now the age of redo surgery

50. Oxford Colorectal A big thank you for your support