1. Q & A

2. Greetings from New Orleans
&
The Ochsner Clinic

3. Restorative Proctocolectomy “The Pelvic Pouch Procedure in 2004” The Royal Infirmary Manchester U.K. April 1, 2004
Terry C. Hicks, M.D.

4. GOALS:
Indications
Technique
Complications
Controversies

5. Know the Enemy!

6. Restorative Proctocolectomy The Disease of Concern
Ulcerative Colitis
Familial adenomatous polyposis
Crohn’s disease
Indeterminate Colitis

7. Ulcerative Colitis
Ulcerative Colitis is an inflammatory disorder. It affects the rectum and extends proximally to affect a variable extent of the colon.
The cause of the disease, and the factors determining its chronic course are unknown.

10. Etiology of Ulcerative Colitis
150 years after the discovery of this disease by Samuel Wilkes, the etiology of ulcerative colitis remains unknown.
The major hypotheses in 2003 include: infection, allergy to dietary components, immune responses to bacterial or self-antigens, and the psychosomatic theory.

11. Incidence of Ulcerative Colitis
Period of INCIDENCE
Study (Per 100,000)
USA
Minnesota
Baltimore UK
Oxford
Wales
Aberdeen
Denmark
Copenhagen
Holland
Leiden
Sweden
Stockholm County
Israel
Tel-Aviv

12. Medical Management of Ulcerative Colitis
Active disease
Mild-moderate disease Distal colitis Sulfasalazine or 5-ASA preparation
(oral or rectal) Topical corticosteroid Extensive colitis Sulfasalazine or oral 5-ASA preparation
Moderate-severe disease Distal colitis Topical corticosteroid Prednisone Extensive colitis Prednisone
Severe-fulminant disease Extensive colitis Parenteral corticosteroid Intravenous cyclosporine
Infliximab (Remicade) reports of small bowl tumors
Inactive disease
Distal colitis Sulfasalazine or 5-ASA
preparation (oral or rectal) Azathioprine or 6-MP
Extensive colitis Sulfasalazine or oral 5-ASA
preparation Azathioprine or 6-MP

13. “Familial Adenomatous Polyposis Syndrome”

14. “Familial Adenomatous Polyposis Syndrome”
Gastrointestinal polyposis refers to the presence of numerous polyps throughout the GI tract. Most of these syndromes are inherited, and most are associated with an increased colon cancer risk.
FAP is the most common adenomatous polyposis syndrome. Patients develop hundreds to thousands of adenomas, and if the colon is not removed, colon cancer is inevitable.
This disease is autosomal dominant with 80% to 100% penetrance and a prevalence of 1:7500.

15. “Familial Adenomatous Polyposis Syndrome”
In 1987, a gene for FAP was isolated, and genetic testing is now available to identify family members that are carriers.
The average age of detectable polyps is 15 years.
Average age of cancer is years after the onset of the polyps.
Associated findings:
Gastric polyps – 30 to 100%
Duodenal polyps – 60 to 90%
Papilla Vater Adenomatous Changes – 50 to 85%
Duodenal Cancer Lifetime Risks – 4 to 12%
Desmoid Tumors – 4 to 32%

16. Familial Adenomatous Polyposis

17. Crohn’s

21. The “Crohn’s Disease” Trio in 1932

22. Crohn’s Morphology

23. Endoscopic Features of Ulcerative Colitis and Crohn's Disease
Characteristics Ulcerative Crohn's
Colitis Disease
Distribution Symmetric Asymmetric Rectal involvement Always Variable Skip lesions No Yes Vascular pattern Blunted Frequently normal Friability Frequent Infrequent Erythema Frequent Less frequent Aphthous ulcers No Yes Linear ulcers Rare Frequent Serpiginous ulcers Rare Frequent Cobblestoning No Yes Pseudo-polyps Frequent Frequent

24. The Case Against R.P. for Crohn’s Disease
High complication rate (vs UC)
High pouch failure rate (vs UC)
Pouch excision risky, complicated
Small bowel loss is failure
Salvage surgery…High failure rate
Literature reports…Where
presumptive diagnosis was UC or indeterminate

25. Final Thoughts on Crohn’s
Rarely should restorative proctocolectomy be advised if a diagnosis of Crohn’s is known prior to surgery.
One stage restorative proctocolectomy should be resisted in nearly all emergency situations.
At all times, it is the duty of the surgeon to inspect the resected specimen before pouch construction. If there are questions as to the diagnosis (even after frozen sections) forego pouch formation.
If patients with a pouch later develop clear evidence of Crohn’s, judge each case on its merits (i.e. Function: Are complications amenable to further surgical treatment?)

26. Forrest says, “Inflammatory Bowel Disease is like a box of choc-lits”

27. “Indeterminate Colitis”
Those five to ten percent of inflammatory bowel disease patients that can not be clearly diagnosed as either Crohn’s or ulcerative colitis.

28. IPAA for Indeterminate Colitis at CCF
Indeterminate Ulcerative p
Stool frequency
Night frequency
Q. Of life
Q. Of health
L. Of energy
L. Of happiness
IPAA again? (%)
IPAA for others? (%)

29. Surveillance for Colorectal Cancer
in Ulcerative Colitis

30. Surveillance for Colorectal Cancer in Ulcerative Colitis
Colorectal cancer occurs in approximately six percent of patients with extensive disease and will be the cause of death in about three percent.
The risk of developing colorectal cancer increases over time, is greater in patients with extensive disease, older age at the onset of symptoms, and in those with cholestatic liver disease and sclerosing cholangitis .
The frequency of surveillance colonoscopies is contentious.
Goal of surveillance is to detect dysplasia.

31. Surveillance for Colorectal Cancer in Ulcerative Colitis (cont’)
Low-grade dysplasia progresses or is synchronous with cancer 18% to 30% of patients.
High-grade dysplasia is concurrent with cancer or progresses to cancer in 40% of patients.
It is suggested that four biopsies be taken at ten centimeter intervals throughout the colon.

32. Colonoscopic View
Normal UC

33. Normal UC UC

34. SURGICAL INDICATIONS FOR ULCERATIVE COLITIS
Urgent Non-urgent
Severe/fulminant colitis Medically refractory disease
Toxic megacolon Unacceptable medication-related toxicity
Perforation Dysplasia, DALM, or suspected cancer
Massive hemorrhage Selected extraintestinal manifestations
Acute colonic obstruction Growth failure in children
Colon cancer
DALM = dysplasia-associated lesion or mass
Immediate surgery warranted
Prompt but not immediate surgery warranted
Refractory to medical therapy
Refractory to 5-aminosalicylic acid, corticosteroids, and immunomodulators

35. Contraindications to Restorative Proctocolectomy Ulcerative Colitis
Absolute
Acute, fulminant colitis, especially with clinical toxicity, peritonitis, or perforation of the colon
Known Crohn’s disease at time of operation
Severe anal sphincter dysfunction
Carcinoma of the distal rectum
Relative contraindications
Morbid obesity
Severe malnutrition or debility
Age > 65 years
Psychologically impaired or patients at high risk for non-compliance.

36. Age and IPAA Early restrictions Safety as experience increases
Expansion of age limits
Patient assessment of quality of life vs.
function
Function Quality of Life
Under 60 years
61–70 years
70 years plus

37. The Presence of Cancer…..Does it Rule Out IPAA?
The presence of colon cancer does not preclude IPAA (adherence to traditional standards of oncologic resection need to be maintained).
If advanced mid or low rectal cancer is diagnosed, this may preclude IPAA.

38. Ulcerative Colitis Surgical Options
Proctocolectomy and Ileostomy
Colectomy and Ileostomy
Colectomy and Ileorectostomy
Proctocolectomy and Continent Ileostomy
Restorative Proctocolectomy

39. Continent Ileostomies
- Kock pouch ( )

40. Continent Ileostomies
Stoma
Smaller & Flush
Lower in Abdomen

44. Late Complications Valve Slippage: 3 - 25% Fistula : 3%
Skin Level Stenosis : 8%
Prolapse : 3%
Pouchitis : %

45. Restorative Proctocolectomy
Major Operation
Cures Disease
Evacuation vs Normal Route
Bowel Function
Technical Variations or Controversy

46. Restorative Proctocolectomy
Variations or Controversy
Pouch Design
J , S , W , H
Anastomosis
Double-Stapled
Mucosectomy
Diversion

51. Pouch Design
Original IPAA was hand sewn “S” configuration by Parks [BMJ 1978; 2:85-88].
Ingenious thinking and the use of stapling techniques now provide multiple options for constructing pouches J, W, K, H, B, & U.
Initially the “S” pouch required pouch intubation in up to 50% of patients.
Subsequent shortening of the efferent limbs to 2-3 cm, reduced this condition.
Manovolumetic studies demonstrate that “S” pouches have a greater median volume than “J” pouches 420 ml vs. 305 ml but without functional differences. (Hallgren, INT J Col. Dis. 1989, 4:156;160)
Major advantage of the “S” pouch is on extra couple of centimeters in length than other pouches, helping form a tension free IPAA.
The “W” pouch proposed by Nicholls in 1985 has the major problem of being
bulky and difficult to advance in the narrow pelvis.

52. “J” pouch vs. “W” pouch Johnston [Gut 1996] 60 pts.  no difference
Keighley [BR J Surg 1988] 33 pts.  no difference
Salvaggi [DC&R 2000] 24 pts.  daily defecation frequency of three in “W” pouches and five in “J” pouches (at 12 months). The “W” also had less night time defecation and less anti-diarrheal usage.
Farock [Ann Surg 2000]  “J” pouch stool frequency per day :
six in males
seven in females

53. Comparing Pouch Design & Function
What is missing in the analysis?
Sphincter function
Stool consistency
Patterns of motility
Capacity of the pelvis to accommodate the pouch

54. Pouches – My Choice All use 30-40 cm of terminal ileum
Small differences in function and design
The “J” is easy to construct and conserves operative time and provides equivalent function

55. Restorative Proctocolectomy
J - Pouch

56. Preoperative Preparation
Confer with patient and family so they understand the nature of the operation, the necessity for surgery, alternative therapies, operative hazards, possible complications, and potential benefits.
Understanding of the nature of an ileostomy.
Possibility of awareness of possible function impairment.
Offer male patients cryopreservation of sperm prior to operation.
Selection of ileostomy site.

57. Preoperative Preparation (cont’)
Correct specific medical problems (anemia, hyperglycemia, electrolyte abnormalities)
Bowel preparation
Stress steroid therapy
Antibiotic prophylaxis

58. Pitfalls and Danger Points
Injury to pelvic autonomic nerves with resultant sexual and urinary dysfunction.
Ureteral injuries.
Fecal contamination with risk of intra-abdominal sepsis and wound infections.
Presacral venous bleeding.
Improper ileostomy placement and construction.
Splenic injury.

59. Operative Strategies
Wide surgical dissection with radical mesentery resection is unnecessary and meddlesome (unless invasive carcinoma is suspected).
Close adherence to rectal wall during lateral and posterior dissection to avoid injury to pelvic nerves.

62. Exploration
Look for manifestations of possible Crohn’s disease.
If diagnosis is unclear, need for total proctocolectomy needs reassessment.

65. Proctectomy a. Avoid injury to the pelvic autonomic nerves.
b. We use mesorectal dissection; bloodless plane . Impotence: injury during antero-lateral dissection of the rectum (necessary with both close or mesorectal resection) Injury at upper rectum: hurts the hypogastric nerves = retrograde ejaculation
c. At S3; the anterior ® angle turn of the rectum occurs, so don’t dig deep into the presacral fascia.
d. Continue posterior dissection to a palpable coccyx.
e. Circumferential mobilization of levators.
f. Pressing in on perineum may give better exposure.

69. Achieving Length
Magnitude of the problem  of 74 pouches that could not be constructed in the Mayo series, 32 were due to length problems. [Browning A, J.AM.Col. Surg ) of the pouch should reach the inferior border of the pubic symphysis.
Maneuvers to obtain extra length
a. Division of terminal ileum should be done within tow to three cm. of the cecum.
b. Divide adhesions; mobilize the terminal ileal mesentery to the level of the duodenum
c. Mesenteric peritoneum division in stair step technique
d. Retest length before pouch formation
e. Division of the terminal divisions of the SMA or the ileal-colic artery (IC); confirming adequate vascularity of the ileum.
f. Clamp the vessels for at least 15 minutes prior to ligation
g. “S” pouch is always an alternative

72. Controversies in IPAA

73. Mucosectomy vs. Double Staple Technique
The aim of IPAA is to remove all of the diseased colonic and rectal mucosa.
The double stapled technique leaves a cuff of anal transitional zone (ATZ).
The ATZ contains residual columnar mucosa.
Anastomosis at this point gives better function than
anastomosis at the dentate line.
Inherent risks of leaving the ATZ are malignancy and
recurrent inflammation (cuffitis).
The theories for poorer function with mucosectomy include trauma to anal sphincter during dissection and removal of the anal transition zone.

74. Type of Anastomosis (handsewn vs. stapled)
and The Rate of Sepsis
ZIV et al report stapled IPAA are safer than handsewn (fewer septic complications).
ZIV found the rate of anastomosis disruption and parapouch abscess were higher in the handsewn group.
Gecim (Mayo Clinic) stated the rate of abscess or fistula may be influenced by the surgeons experience.
Gecim pointed to long term steroids and other immunomodulants as contributors to fistula formations.
Gecim found no difference in perianal abscess rate or fistula rate in stapled vs. handsewn pouches.
ZIV Y, AM J Surg 1996; 172(3): 320-3
Gecim IE, Dis Colon Rectum 2000; 43(9):

75. Function Following Mucosectomy and Double Staple Technique
DOUBLE STAPLED
Reilly [Ann Surg 1997] Notes occ. episodes of incontinence is 38% in stapled group and 64% in mucosectomy group.
Anal canal resting pressures stapled 78.3 mm Hg mucosectomy 49.4 mm Hg
Squeeze pressures
stapled 195 mm Hg mucosectomy 144 mm HG
Hallgren EUR, J Surg 1995, 161, 95 pg 21, found similar results
MUCOSECTOMY
Sew-Chen BR J. Surg 1991
Luukkeon Arch Surg 1993
Both randomized trials found no difference in function between the two techniques.

76. The Factors in Choosing Mucosectomy vs. Double Stapled
What is safest and best for patient.
In the presence of mucosal neoplastic change
perform mucosectomy.
If double-stapled technique is used, you must:
Do yearly follow-up of the anal transition zone with digital examination and endoscopy with biopsy.

77. What is The Role of a Defunctioning Ileostomy?
Pelvic sepsis occurs in 4.8% of patients undergoing IPAA [Farouk etal, Dis Colon Rectum 1998].
In patients with pelvic sepsis, the pouch failure rate (permanent diversion or excision) was 26% compared to 5.9% in patient without pelvic sepsis.
Patients with pelvic sepsis who retained their pouch had similar evacuation rates as non- pelvic sepsis patients but retained their protective pad use, incontinence rates, and medication rates were all increased.
Pelvic sepsis can be life threatening.

78. The Role of Ileostomy in IPAA
Sugerman reported an abscess or enteric leak rate of 12% in patients who underwent one stage procedures without ileostomy.
Tjandra et al reported a higher rate of septic complications in patients without an ileostomy.
ZIV at the same institution reported that as the number of IPAA without ileostomy cases have increased the two groups of patients are showing a nonstatistical difference in complication rate.
Remzi reported on 1,725 patients with ileostomy vs patients without ileostomy.
Remzi found no differences between the groups in respect to:
sepsis, leaks, or fistula occurrence.
1) Sugerman H J et al. Ann Surg 2000;232(4):
2) Tjandra et al. Dis Colon Rectum 1993; 36(11):
3) ZIV Y et al. AM J Surg 1996; 171(3):320-3.
4) Remzi FH, et al. Dis Colon Rectum 2003.

79. Ileostomy Avoidance in 277 Patients *No
ileostomy
n = 1725
n = 277
Pelvic sepsis
6.5%
5.4%
Leak
5.5%
4.3%
SBO
18.8%
10.1%
Need for ileostomy NA
4.0%
Pouch failure
4.5%
1.8%
Comparable functional results
Remzi et all 2002

80. Temporary Diversion vs. Single Stage Procedures
OUTCOMES
Temporary Diversion vs. Single Stage Procedures
Grobler [BR. J Surg 1992;79: ]
23 patients with IPA and loop ileostomy
22 patients with IPAA without loop ileostomy
No patients taking steroids
All operations without intra-op complications
All were double stapled “J” pouches
No statistically significant differences in postoperative complication rates or pouch function

81. Temporary Diversion vs. Single Stage Procedures
OUTCOMES
Temporary Diversion vs. Single Stage Procedures
Galandiuk [Dis Colon Rectum 1991;34: ]
37 pts with diversion pts without diversion
Complication rate NSD NSD
Reoperation NSD NSD
Functional outcomes NSD NSD

82. Potential Complications Associated with Defunctioning Ileostomy
Defunctioning ileostomy may help reduce the incidence of pelvic sepsis, but is not a risk free procedure.
Mechanical and functional complications may follow construction and closure of the stoma.
[Metcalf Dis Colon Rectum 1986]
157 temporary loop ileostomies
39 patients had mechanical complications
Retraction 15.9%
Prolapse 1.3%
Fistula .6%
Abscess .6%
Bowel obstruction (stoma related)

83. Potential Complications Associated with Defunctioning Ileostomy (con’t)
111 patients had functional complications
Peristomal irritation 53.5%
Leakage 7.6%
High output 3.8%
Incomplete diversion 5.7%
After closure: Bowel obstruction 14.7%
Peritonitis 7.4%
Wound infections 1.6%
Advantages of omitting a loop ileostomy
Required one hospital admission
Avoid potential complications of ileostomy closure
Financial advantage

84. Which Patients are Candidates for Single Stage Procedure?
Generalized good health
No chronic steroid therapy
Tension free anastomosis
No intraoperative complications

85. Laparoscopic IPAA vs. Open IPAA
Young – Faddock [Gastroenterology 2001 I A
Seven laparoscopic IPAA vs. seven open IPAA (matched controls)
Laparoscopic IPAA
OPEN IPAA
2 days 4
NSD
340 min.
7 days p=0.010 9
237 min.
I.V. narcotic use
Resumption of diet
Hospital stay
Complication rate
Operation Time

86. Other Considerations With Laparoscopic IPAA
Schmitt suggested no reduction in ileus or postoperative length of stay with laparoscopic vs. open [Int J Colorectal0 Dis 1994;9:
Dunker [DC&R 2001, 44, ] Reports functional outcomes and quality of life are no different in open vs. laparoscopic IPAA
Patient satisfaction with the cosmetic result is higher with laparoscopic IPAA
Laparoscopic IPAA may reduce adhesion formation

87. Complications

88. Mortality After IPAA The mortality rate after IPAA is less than 1%
Patients are typically young
Patients usually do not have co-morbid disease
Operations are generally performed in tertiary centers on selected patients
Blumberg , Opelka, Hicks
South Med J 2001;94(5):467-71

89. Meagher AP et al BR J Surg 1998; 85(6): 800-3
Morbidity After IPAA
In early studies major complications were reported to be as high as 54%
With increased experience the rated has dropped to approximately 19%
Complications after IPAA may be categorized as early [within 30 days after surgery and late (after ileostomy closure)]
For one stage procedures early (within 30 days after surgery) and late (after 30 days post surgery)
Marcello PW et al
Arch Surg 1993;128(5) 500-3;
Meagher AP et al BR J Surg 1998; 85(6): 800-3

90. Early Complications
The most common early complications are pelvic sepsis, anastomosis leaks, small bowel obstruction, and pouch bleeding

91. Sepsis
Pelvic sepsis is the most serious early IPAA complication, and it one of the main causes of pouch failure.
The rate of sepsis after IPAA ranges from 5% to 24%.
The etiology may be suture line leaks, or bacterial contamination of the surgical space during the operation.
Risks factors for pelvic sepsis: malnutrition, prolonged steroid use, hypoalbuminemia, anemia, and hypoxemia.
The most common presenting signs are: fever, perineal pain, purulent discharge, and leukocytosis.
Early sepsis after IPAA usually presents between the third and sixth postoperative day.
McMullen K, Hicks TC, World J Surg 1991; 15(6):763-6
Hyman et al, Dis Colon Rectum 1991;34(8):653-7

92. Leaks After IPAA
Overall leak rate after IPAA ranges between 5 % and 18%.
Leaks may develop from pouch-anal anastomosis, pouch itself, or from the tip of the “J” pouch.
The two major factors associated with leaks are anastomotic tension and bowel ischemia.
Elderly patients, males, and those patients on corticosteroids are also at greater risk for leak development.
Matty P et al. Ann Chir 1993; 47 (10)
Fazio V et al. Ann Surg 1995; 222 (2):120-7

93. Small Bowel Obstruction After IPAA
The overall incidence of small bowel obstruction after IPAA
ranges from 15% to 44%.
The incidence of obstruction requiring operative intervention
ranges from 5% to 20%.
Remzi reported on 2002 IPAA patients:
1725 had a diverting ileostomy with an 18% SBO rate
277 had no diverting ileostomy with a 10% SB0 rate
Remzi also noted that the ileostomy group required more
laparotomies for SBO than the non-diverted group.
MacLean reported on 1,178 IPAA patients
The cumulative risk of small bowel obstruction was
9% at 30 days; 18% at one year; 27% at five years;
and 31% at ten years.
MacLean noted that 32%of the obstructions were due to the pelvic
adhesions and the ileostomy closure site.
The surgical window = 2nd to 6th week is the most dangerous time
Francois Y et al. Ann Surg 19889; 209(1):46-50

94. Pouch Bleeding
Postoperative bleeding from the pouch may arise from the suture line or because of pouch ischemia.
Fazio reported bleeding from the pouch in 38 (3.8%) of patients.
Thirty patients were treated with local irrigation of .9% saline and adrenaline 1:200,000
Eight patients were treated with trans-anal suturing
Significant bleeding occurring five to seven days post surgery may suggest a partial dehiscence.
Chalikonda S, Podium Presentation ASCRS 2003 New Orleans, La.
Fazio VW, Ann Surg 1995; 222(2):120-7

95. Pouchitis The most common complication following IPAA.
Symptoms: Increased frequency, urgency, cramping pain, bright
red bleeding, incontinence, diarrhea, and fever.
Extraintestinal manifestations: Arthritis, iritis, and Pyoderma Gangrenosum.
Histology: Acute granulocyte infiltration.
Prevalence: Varies from 15% to 50%.
Etiology: Unknown. Theories include genetic, immune, microbial, and toxic mediators.
Most popular theory: Fecal stasis with an increased anaerobe/aerobe bacterial ratio.
Rarely seen with FAP.
Male predominance Nicholls RJ, World J Surg 1998;22(4):347-51
Subraman:K Gut; 1993, 34(11):

96. Diagnosis of Pouchitis
Diagnosis should be made on the basis of clinical, endoscopic, and histologic features.
Pouch disease activity index (PDAI) is the most commonly used diagnostic instrument.
The PDAI has three separate scales: clinical symptoms, endoscopic findings, and histologic changes.
Total score of seven or higher is defined as Pouchitis.
Because the PDAI is costly, a modified scale was introduced in which the histology is omitted.
This modified scale offers similar sensitivity, decreases cost, and avoids delay in diagnosis awaiting histology report.
Shen B, Drs Colon Rectum 2003, 46(6):748-53
Sandborn, Mayo Clinic Proc 1994; 69(5):409-15

97. Pouchitis Disease Activity Index
Stool frequency
Rectal Bleeding
Fecal urgency or abdominal cramps
Fever (temperature>37.8° C)
Endoscopic inflammation
Acute histological inflammation
Ulceration per low-power field (mean)

98. Treatment for Pouchitis
Includes antibiotic therapy and symptomatic relief with
anti-diarrheal agents.
Most effective agents are metronidazole and ciprofloxacin.
80% of pouchitis patients are successfully treated with
metronidazole alone.
Steroids, 5 – aminosalicylates, azathioprine, and six-
mercaptopurine compromise the other major category of treatment.
Surgery?
Bertoni: G, Dis Colon Rectum 2003;46(6):748-53

99. Refractory or Prolapsing Pouchitis
5% to 10% of pouchitis patients will develop refractory or
relapsing symptoms.
Probiotics are effective in these clinical situations
A recent trial using VSL #3 (probiotic) was shown to be
therapeutic for patients with acute relapsing pouchitis.
These patients were induced into remission using ciprofloxacin and rifaximin.
In follow-up only 15% in the probiotic group relapsed within nine months, whereas 100% of the placebo group developed a relapse.
1) Shen B, Inflamm Bowel Dis 2001, 7 (4) 301-5
2) Sarton RB, Gastroenterology 200; 119(2):584-7

100. Mechanism of Action of Probiotics
Suppression of resident pathogenic bacteria.
Stimulation of mucin glycoprotein by intestinal epithelial cells.
Prevention of adhesion of pathogenic strains to epithelial cells.
Induction of host immune responses.
Sartor R.B. Gastroenterology 2000; 119(2):584-7

101. Irritable Pouch Syndrome (IPS)
Patients with IPAA who have Pouchitis symptoms but normal endoscopic and histologic findings.
They have a PDAI of < 7 and the absence of cuffitis.
The etiology of IPS is unclear, and there is no algorithm for its management.
50% of IPS patients respond to irritable bowel treatments.
This includes reassurance, diet modification, fiber supplements, anti-diarrheal, antispasmodics, and antidepressants.
Giochetti P, Gastroenterology 2000; 119(2):305-9
Shen B, AM J Gastroenterol 2002; 97(4):972-7

102. Cuffitis The 1 to 2 cm. of anal canal mucosa retained after IPAA
(without mucosectomy) can become inflamed.
Cuffitis has endoscopic and histologic inflammation of the pouch.
4% of patients with preserved anal mucosa after IPAA develop cuffitis.
Most patients respond to local therapy with hydrocortisone suppositories or enemas.
Lavery IC, Dis Colon Rectum 1995;38(8):803-6

103. FISTULA Usually a late complication
6% of IPAA patients develop a fistula
Most common sites: vaginal, perineal, cutaneous, and presacral
Options for therapy: fistulotomy, seton, advancement flap, prolonged ileal diversion, antibiotics, and fibrin glue.
Fistula may represent undiagnosed Crohn’s.
Postoperative pathologic diagnosis of Crohn’s leads to a pouch failure rate of 25%.
1) Fazio VW, Ann Surg 1995; 222(2):125-7
2) Ozuner G, Dis Colon Rectum 1997; 40(5) 543-7

104. Pouch – Vaginal Fistula (PVF)
Leads to poor functional results and is a major cause of pouch failure.
Etiology: Sepsis, leaks, and “technical error”.
Most patients can be managed by local procedures.
The trans-anal ileal advancement flap is often successful.
SHAH reported on 60 patients with PVF.
65% of the SHAH group had a diverting ileostomy.
44% had a primary healing.
4 patients had repeat flap advancement and closed the fistula.
Recurrence and pouch failure rates are high.
Patients with fistula formation diagnosed within six months of surgery have better outcomes.
Those with > six month PVF presentation may be related to Crohn’s.
When local therapy fails, pouch reconstruction is an option.
1) SHAH NS, Dis Colon Rectum 2003

105. Anastomotic Strictures
Anastomosis is considered strictured if it will not allow the admission of an index finger DIP joint or is less than 1 cm. in diameter.
If stricture is severe, it can lead to outlet obstruction, pouch dilatation, and bacterial overgrowth.
The rate of stricture ranges from 7.8% to 14%
St. Marks reported a 14% rate in handsewn and 40% with stapled anastomosis.
Mayo reported a 12% rate with handsewn group having the greatest problems.
Treatment options : Hegar dilators (office) #13 to #18 vs. surgical incision. (OR)
For complex stricture pouch advancement and neo-ileal anastomosis. (good for strictures < 5 cm in length)
Fazio BR J Surg 1992; 27(7):694-6
Senapati A. INT J Colorectal Dis 1996, (2):57-59

106. Impotence, Retrograde Ejaculation, and Dyspareunia
1.5% of men will develop impotence.
4% of men will develop retrograde
ejaculation.
7% of women develop dyspareunia.
49% of women note sexual
dysfunction preoperatively. Their
sexual activity increases dramatically
after surgery.

107. IPAA for Ulcerative Colitis Does it Affect Female Fertility?
Olsen reported  fertility [B. J Surg 1999;PL:
Theory of Etiology: Pelvic Adhesions

108. Dysplasia and Malignancy
The ileal pouch undergoes a series of histologic changes.
The changes include slight villous atrophy to colonic metaplasia.
Colonic metaplasia may be a premalignant condition.
In 1997 Cox et al. reports an invasive adenocarcinoma in a longstanding
Koch pouch.
Heuschen et al. reported an IPAA pouch developed cancer.
Baratris reported an adenocarcinoma in the anus after IPAA for U.C.
Mucosectomy does not provide 100% removal of rectal mucosa.
The anal transitional zone (ATZ) in the double stapled technique is at risk
for dysplasia or cancer.
The risk of dysplasia was studied in 178 patients (double stapled IPAA)
over ten years.
The risk of dysplasia was 4.5% without cancer being reported.
Baretsis et al. Dis Colon Rectum (5):687-91
Remzi FH et al. Dis Colon Rectum 2503 :46(1):6-13

109. Dysplasia and Cancer Following IPAA
O’Connell published data showing residual rectal mucosa in 7% of their IPAA patients with mucosectomy.
Remzi reports ten year follow-up of the double staple technique with dysplasia in the residual anal transition zone to be 4.5% DC&R 2003, 46:6-13
Cancer has been reported after both techniques.

110. Pouch Failure
6% of IPAA patients require either pouch excision or permanent
ileostomy.
Most frequent causes of failure are pelvic sepsis, high stool volume,
Crohn’s disease, uncontrolled fecal incontinence.
A scoring system for calculating the risk of pouch failure identified
eight risk factors: 1) Crohn’s 2) Patient co-morbidity
3) Prior anal pathology 4) Diminished sphincter manometry
measurements 5) Anastomotic separation 6) Anastomotic
stricture 7) Pelvic sepsis and 8) Perineal fistula formation.
Overall salvage rates from pouches is 86%.
97% of patients who underwent pouch revision said they would
undergo it again if necessary.
Fazio BR J Surg 1992; 27(7):694-6
Senapati A. INT J Colorectal Dis 1996, (2):57-59

111. Incidence of Pouch Failure
CENTER
YEAR
# PATIENTS
% FAILURE
Mayo
1998
1310
10.2
Cleveland
1995
1005
4.5
Toronto
1997
551
10.5
Lahey
1993
460
3.5
Oxford
200
8.0
Buenos Aires
178
6.1
Ochsner
145
3.0
U of Minn
505
8.8

112. Repeat (IPAA) to Salvage Complication of Pelvic Pouches
Zmora 61
Dayton 52
Heuschen 48
Mc Lean 51
Fazio 50
Sagar 62
Baixauli 53
Institution
Florida
Salt Lake
Heidelberg
Toronto
Cleveland
Mayo
No. patients
411
650
706
1200
1680
1700
---
Reoperation 32 29
107 57 35 23
112
Repeat IPAA 5 6 4 17 31
101
Septic complications 16 14 64
Fistula 3 87 25 47
Stricture 1
Abscess 8 46
Salvage
21(84%)
29 (100%)
99 (92%)
42 (77%)
80 (86%)
17 (74%)
70 (82%)
Pouch failure 15
Complications after reop. 9 34

113. Rocket
Science?

114. CONCLUSION
Ileal pouch anal anastomosis has evolved over the last 25 years
Now it is the procedure of choice for patients requiring proctocolectomy for ulcerative colitis and selected FAP patients
As technical developments have emerged controversies have arisen
With continued commitment to research for pouch surgery hopefully these dilemmas will be resolved

115. “All at present known in medicine is almost nothing in comparison with what remains to be discovered”
R. Descartes ( )