Outcomes of Salvage Surgery for Ileal Pouch Complications and Dysfunctions. The Experience of a Referral Centre and Review of Literature

Abstract

Background and Aims: Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction. Methods: We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre-and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3). Results: Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003). Conclusions: Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction.

Redo ileal pouch‐anal anastomosis: outcomes from a case–controlled study

“…McLean et al . chose to perform an abdominal approach directly in order to avoid iterative transanal procedures , whereas Faucheron et al . preferred local procedures at first attempt (48).…”

“…For all of these reasons, some surgeons perform a permanent ileostomy rather than a redo-IPAA. Nevertheless, encouraging results regarding function and QoL after redo-IPAA have been reported [23,[25][26][27][28][29][30][31][32][33]; however, the level of evidence is low with mostly descriptive studies and wide variation in population size, type of salvage procedures and assessment scores for QoL and pouch function. Finally, we did not find any study assessing sexual function after salvage pouch surgery.…”

“…In the review by Tulchinsky et al, there were no structured indication guidelines for the transanal approach [23]. McLean et al chose to perform an abdominal approach directly in order to avoid iterative transanal procedures [30], whereas Faucheron et al preferred local procedures at first attempt (48). For Shawki et al, the type of surgical approach depended on the anatomy, histological diagnosis and surgeon's preference [33].…”

“…Redo-IPAA is only acceptable if postoperative morbidity is low, and both QoL and function are similar to those observed in patients with successful primary IPAA. Nevertheless, few studies have compared the postoperative and long-term results of redo-IPAA with primary IPAA and none, to the best of our knowledge, included sexual function [23,[25][26][27][28][29][30][31][32][33].…”

Hormonal contraceptives and venous thromboembolism: Are inflammatory bowel disease patients at increased risk? A retrospective study on a prospective database

“…However, we used a prospective database and excluded patients operated on and those with active disease (confounders for VTE [54] ), significantly reducing the number of patients suitable for inclusion observed at an ambulatory of Colorectal Surgery. Surgery plays a relevant role in IBD patients, and complex or repeated procedures can be needed [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [55] , [56] , [57] , [58] , [59] , [60] , [61] , [62] . This could have weakened the results, but at the same time is offering a snapshot on outpatient IBD subjects, and is providing IBD physicians with a practical, clinical insight on how to manage IBD patients willing to use oral contraceptives.…”