Comparing continent ileostomy (CI) conversion to repair/redo IPAA: favorable outcomes.

PURPOSE: This study aims to compare the outcomes of repair/redo ileal pouch-anal anastomosis (repair/redo-IPAA) with the conversion of IPAA to continent ileostomy (CI) in an effort to prevent the need for a permanent ileostomy (IS) following IPAA failure. METHODS: This research involved a retrospective analysis of surgical records, employing descriptive statistics and Kaplan-Meier survival analysis. RESULTS: Among 57 patients with an IPAA, up to three revisions were necessary due to complications or complete failure. Ultimately, repair/redo-IPAA preserved the IPAA in 14 patients (24.6%), conversion to CI salvaged the pouch in 21 patients (36.8%), and IS was unavoidable in 22 patients (38.6%). The cumulative probability of requiring conversion surgery was calculated to be 54.0% at 20 years, thereby reducing the cumulative risk of IS to 32.3%. The 20-year cumulative probability of pouch salvage by repair/redo IPAA was only 21.9%. However, this rate increased to 67.7% when conversion procedures were considered. Following repair/redo-IPAA, only 8.3% of patients reported evacuation frequencies of ≤ 4 during the day, and 16.7% were evacuation-free at night. In contrast, after conversion to CI, 98.0% of patients reported a maximum of four evacuations in a 24-h period. After undergoing repair/redo IPAA, between half and two-thirds of patients reported experiencing incontinence or soiling, while complete continence was achieved in all patients following conversion to CI. Notably, the majority of patients expressed overall satisfaction with their respective procedures. A positive correlation was identified between very high subjective satisfaction and positive objective surgical outcomes exclusively in patients who underwent conversion to CI. CONCLUSION: When complications or failure of IPAA occur, conversion to CI emerges as a highly viable alternative to repair/redo IPAA. This conclusion is supported by the observation that patient satisfaction appears to be closely tied to stable surgical outcomes. To reinforce these findings, further prospective studies are warranted.

Predictors of pouch failure: A tertiary care inflammatory bowel disease centre experience.

AIM: Rates of pouch failure after total proctocolectomy with ileal pouch-anal anastomosis (IPAA) range from 5% to 18%. There is little consistency across studies regarding the factors associated with failure, and most include patients who underwent IPAA in the pre-biologic era. Our aim was to analyse a cohort of patients who underwent IPAA in the biologic era at a large-volume inflammatory bowel disease institution to better determine preoperative, perioperative and postoperative factors associated with pouch failure. METHODS: A retrospective cohort analysis was performed with data from an institutional review board approved prospective database with ulcerative colitis or unclassified inflammatory bowel disease patients who underwent total proctocolectomy with IPAA at Mount Sinai Hospital between 2008 and 2017. Preoperative, perioperative and postoperative data were collected and univariate and multivariate analyses were performed to identify factors associated with increased risk of pouch failure. RESULTS: Out of 664 patients included in the study, pouch failure occurred in 41 (6.2%) patients, a median of 23.3 months after final surgical stage. Of these, 17 (41.4%) underwent pouch excision and 24 (58.5%) had diverting ileostomies. The most common indications for pouch failure were Crohn's disease like pouch inflammation (CDLPI) (n = 17, 41.5%), chronic pouchitis (n = 6, 14.6%), chronic cuffitis (n = 5, 12.2%) and anastomotic stricture (n = 4, 9.8%). On multivariate analysis, pre-colectomy biologic use (hazard ratio [HR] 2.25, 95% CI 1.09-4.67), CDLPI (HR 3.18, 95% CI 1.49-6.76) and pouch revision (HR 2.59, 95% CI 1.26-5.32) were significantly associated with pouch failure. CONCLUSIONS: Pouch failure was significantly associated with CDLPI, preoperative biologic use and pouch revision; however, reassuringly it was not associated with postoperative complications.

Prevalence of 'pouch failure' of the ileoanal pouch in ulcerative colitis: a systematic review and meta-analysis.

BACKGROUND AND AIMS: The ileoanal pouch (IPAA) provides patients with ulcerative colitis (UC) that have not responded to medical therapy an option to retain bowel continuity and defecate without the need for a long-term stoma. Despite good functional outcomes, some pouches fail, requiring permanent diversion, pouchectomy, or a redo pouch. The incidence of pouch failure ranges between 2 and 15% in the literature. We conducted a systematic review and meta-analysis aiming to define the prevalence of pouch failure in patients with UC who have undergone IPAA using population-based studies. METHODS: We searched Embase, Embase classic and PubMed from 1978 to 31st of May 2021 to identify cross-sectional studies that reported the prevalence of pouch failure in adults (≥ 18 years of age) who underwent IPAA for UC. RESULTS: Twenty-six studies comprising 23,389 patients were analysed. With < 5 years of follow-up, the prevalence of pouch failure was 5% (95%CI 3-10%). With ≥ 5 but < 10 years of follow-up, the prevalence was 5% (95%CI 4-7%). This increased to 9% (95%CI 7-16%) with ≥ 10 years of follow-up. The overall prevalence of pouch failure was 6% (95%CI 5-8%). CONCLUSIONS: The overall prevalence of pouch failure in patients over the age of 18 who have undergone restorative proctocolectomy in UC is 6%. These data are important for counselling patients considering this operation. Importantly, for those patients with UC being considered for a pouch, their disease course has often resulted in both physical and psychological morbidity and hence providing accurate expectations for these patients is vital.

Inflammation of the rectal remnant endangers the outcome of ileal pouch-anal anastomosis: a case-control study.

BACKGROUND: Inflammation of the rectal remnant may affect the postoperative outcome of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We aimed to determine the extent of inflammation in the anastomotic area during IPAA and to investigate the impact of proctitis on postoperative complications and long-term outcomes. METHODS: Three hundred thirty-four UC patients with primary IPAA were included in this retrospective case-control study. The histopathologic degree of inflammation in the anastomotic area was graded into three stages of no proctitis ("NOP"), mild to medium proctitis ("MIP"), and severe proctitis ("SEP"). Preoperative risk factors, 30-day morbidity, and follow-up data were assessed. Kaplan-Meier analysis was performed in the event of pouch failure. RESULTS: The prevalence of proctitis was high (MIP 40.4%, and SEP 42.8%). During follow-up, the incidence of complications was highest among SEP: resulting in re-intervention (n = 40; 28.2%, p = 0.017), pouchitis (n = 36; 25.2%, p < 0.01), and pouch failure (n = 32; 22.4%, p = 0.032). The time interval to pouch failure was 5.0 (4.0-6.9) years among NOP, and 1.2 (0.5-2.3) years in SEP (p = 0.036). ASA 3, pouchitis, and pouch fistula were independent risk factors for pouch failure. CONCLUSION: Proctitis at the time of IPAA is common. A high degree of inflammation is associated with poor long-term outcomes, an effect that declines over time. In addition, a higher degree of proctitis leads to earlier pouch failure.

Pelvic Pouch Failure: Treatment Options.

Up to 30% of patients with ulcerative colitis (UC) will require surgical management of their disease during their lifetime. An ileal pouch-anal anastomosis (IPAA) is the gold standard of care, giving patients the ability to be free from UC's bowel disease and avoid a permanent ostomy. Despite surgical advancements, a minority of patients will still experience pouch failure which can be debilitating and often require further surgical interventions. Signs and symptoms of pouch failure should be addressed with the appropriate workup and treatment plans formulated according with the patient's wishes. This article will discuss the identification, workup, and treatment options for pouch failure after IPAA.

Pouch failures following restorative proctocolectomy in ulcerative colitis.

PURPOSE: Restorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision. METHODS: The number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016. RESULTS: Out of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn's disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn's disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I-II). CONCLUSIONS: Eleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn's disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.

Greater Peripouch Fat Area on CT Image Is Associated with Chronic Pouchitis and Pouch Failure in Inflammatory Bowel Diseases Patients.

BACKGROUND: The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis. AIMS: To explore the relationship between peripouch fat area on CT imaging and pouch outcomes. METHODS: This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level. RESULTS: A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016-1.047, P < 0.001) or mesenteric peripouch fat area were independent risk factors for CARP. Of the 435 patients, 139 (32.0%) had two or more CT scans. Multivariable Cox proportional hazard analyses showed that "peripouch fat area increase ≥ 15%" (OR 3.808, 95%CI 1.703-8.517, P = 0.001) was an independent predictor of pouch failure. CONCLUSIONS: A great peripouch fat area measured on CT image is associated with a higher prevalence of CARP, and the accumulation of peripouch fat is a risk factor for pouch failure. The assessment of peripouch fat may be used to monitor the disease course of the ileal pouch.

Ileo-anal pouch excision and permanent ileostomy - Indications and outcomes from a tertiary centre.

PURPOSE: Pouch excision is a major complication of ileoanal pouch surgery. Current practice is for this type of surgery to be performed in a specialist centre. We present a series of patients undergoing pouch excision surgery in a high volume centre in the UK and assess the outcomes in these patients. METHODS: All patients undergoing pouch excision at the Royal Liverpool Hospital between 1995 and 2015 under the care of a single surgeon were included. Demographics and outcomes were taken from patients' notes and a dedicated retrospectively compiled database. RESULTS: 35 patients underwent pouch excision surgery during this period. Around half the patients had their original pouch surgery elsewhere and were referred for management of complications. Median time to pouch excision was 13 years from the original operation. Overall complication rate was 31% with 11% requiring re-intervention post-operatively. There was no mortality in this series. CONCLUSION: Pouch excision is a complex, high-risk procedure that should be carried out in specialist centres. Our series shows that in such settings, good outcomes can be achieved for these patients.

Characterization of megapouch in patients with restorative proctocolectomy.

BACKGROUND: Megapouch is a rare functional complication of restorative proctocolectomy with ileal pouch-anal anastomosis characterized by pouch ± small bowel dilatation with no evidence of obstruction on endoscopy and imaging. Little is known about clinical characteristics and outcomes of this entity. METHODS: We included all patients diagnosed with megapouch at our institution, identified from a pouch database. Data on baseline characteristics, management, and outcomes were documented and analyzed from electronic medical records. Appropriate statistical measures were used. p < 0.05 was considered significant. RESULTS: Twenty-three patients with megapouch were identified. The mean age was 40.7 years; 95.6% had underlying ulcerative colitis; most common indication for colectomy was medically refractory disease (56.5%). Abdominal pain (82.6%) and bloating (52.2%) were most common presenting symptoms. Most common finding on pouchoscopy was pouch dilatation (81.8%), while barium or gastrografin enemas and MRI/CT mostly revealed dilatation of pouch and/or small bowel. Fourteen (66.7%) patients required some forms of surgery-six patients required pouch excision and three required either pouch redo or revision. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically versus those managed medically (p = 0.007 and 0.024, respectively), while need for escalation of IBD-therapy was comparable between the groups (p = 0.133). No deaths were reported and no patient had recurrence of megapouch. IPAA revision or redo did not lead to more IBD-related morbidity. CONCLUSIONS: Majority of our patients with megapouch required surgery. In selected patients, redo pouch offered cure. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically.

Transabdominal re-do pouch surgery in pediatric patients for failed ileal pouch anal anastomosis: a case matched study.

PURPOSE: Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. METHODS: Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. RESULTS: 60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. CONCLUSION: Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

Pouch failures following ileal pouch-anal anastomosis for ulcerative colitis.

AIM: Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure. METHOD: The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis. RESULTS: Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy. CONCLUSION: In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.

Survival of ileal pouch anal anastomosis constructed after colectomy or secondary to a previous ileorectal anastomosis in ulcerative colitis patients: a population-based cohort study.

OBJECTIVES: Ileorectal anastomosis (IRA) affects bowel function, sexual function and reproduction less negatively than ileal pouch anal anastomosis (IPAA), the standard reconstruction after colectomy for ulcerative colitis (UC). In younger UC patients, IRA may have a role postponing pelvic surgery and IPAA. The aim of the present study was to investigate the survival of IPAA secondary to IRA compared to IPAA as primary reconstruction, as this has not previously been studied in UC. PATIENTS AND METHODS: All patients with UC diagnosis between 1960 and 2010 in Sweden were identified from the National Patient Registry. From this cohort, colectomized patients reconstructed with primary IPAA and patients reconstructed with IPAA secondary to IRA were identified. The survival of the IPAA was followed up until pouch failure, defined as pouchectomy and ileostomy or a diverting ileostomy alone. RESULTS: Out of 63,796 patients, 1796 were reconstructed with IPAA, either primarily (n = 1720) or secondary to a previous IRA (n = 76). There were no demographic differences between the groups, including length of follow-up (median 12.6 (IQR 6.7-16.6) years and 10.0 (IQR 3.5-15.9) years, respectively). Failure of the IPAA occurred in 103 (6.0%) patients with primary and in 6 (8%) patients after secondary IPAA (P = 0.38 log-rank). The 10-year pouch survival was 94% (95% CI 93-96) for primary IPAA and 92% (81-97) for secondary. CONCLUSIONS: Patients choosing IRA as primary reconstruction do not have an increased risk of failure of a later secondary IPAA in comparison with patients with primary IPAA.

External validation of a prognostic model of preoperative risk factors for failure of restorative proctocolectomy.

AIM: The Cleveland Clinic has proposed a prognostic model of preoperative risk factors for failure of restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis. The model incorporates four predictive variables: completion proctectomy, handsewn anastomosis, diabetes mellitus and Crohn's disease. The aim of the present study was to perform an external validation of this model in a new cohort of patients who had RPC. METHOD: Validation was performed in a multicentre cohort of 747 consecutive patients who had an RPC between 1990 and 2015 in three tertiary-care facilities, using a Kaplan-Meier survival analysis and Cox regression analysis. The performance of the model was expressed using the Harrell concordance error rate. The primary outcome measure was pouch survival with maintenance of anal function. RESULTS: During the study period, 45 (6.0%) patients experienced failure at a median interval of 31 months (interquartile range 9-82 months) from the original RPC. Multivariable analysis showed handsewn anastomosis to be the only significant independent predictor. The Harrell concordance error rate was 0.42, indicating poor performance. Anastomotic leakage and Crohn's disease of the pouch were strong postoperative predictors for pouch failure and showed a significant difference in pouch survival after 10 years (P < 0.001). CONCLUSION: The poor performance of the Cleveland Clinic prognostic model makes it unsuitable for daily clinical practice. Handsewn anastomosis was associated with pouch failure in our cohort with relatively few events. A prediction model for anastomotic leakage or Crohn's disease of the pouch may be a better solution since these variables are strongly associated with pouch failure.

Outcome and functional prognosis of pelvic sepsis after ileal pouch-anal anastomosis in patients with ulcerative colitis.

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure for ulcerative colitis, but pouch failure or pelvic sepsis still occurs in some patients. We conducted this study to investigate the cause of pouch failure and evaluate defecatory function after pelvic sepsis. METHODS: A total of 234 patients who underwent restorative proctocolectomy were enrolled. We analyzed the cause of pouch failure, as well as defecatory function and manometric outcomes, with and without the complication of pelvic sepsis. RESULTS: Pelvic sepsis developed in 29 (12.3%) of the 234 patients who underwent restorative proctocolectomy (pelvic sepsis group). The pelvic sepsis led to pouch failure in two of these patients (as a vaginal fistula in one and ileo-anal anastomotic leakage in one). Of the remaining majority of patients who did not suffer pelvic sepsis (control group), nine suffered pouch failure (as vaginal fistula in four, perianal abscess in two, pouch-spinal marrow fistula in one, and chronic pouchitis in two). There were no significant differences in defecatory function or manometric outcomes between the two groups. In the pelvic sepsis group, stool frequency was significantly correlated with white blood cell count (P = 0.01) and the duration until onset of pelvic sepsis (P < 0.01). CONCLUSIONS: Pelvic sepsis after restorative proctocolectomy for ulcerative colitis does not affect defecatory and manometric function, but control of the inflammation caused by pelvic sepsis is integral for defecatory function.

Diagnosis and treatment of primary ileal pouch leaks: a 27-year experience at a referral center.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures. METHODS: Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients. RESULTS: Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4 kg/m2, and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the "J" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever. CONCLUSION: Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.

2-Stage and 3-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis show comparable short- and long-term outcomes.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) represents the standard treatment for therapy-refractory, malignant or complicated ulcerative colitis (UC) and can be performed as a 2-stage or 3-stage procedure. This study aimed to compare the short- and long-term outcomes after 2- and 3-stage IPAA in patients with UC in our department. A retrospective analysis of 176 patients with UC who received 2- or 3-stage restorative proctocolectomy with IPAA at our institution from 2001 to 2021 was performed. Outcomes for short-term (morbidity, longer hospital stay, readmission) and long-term (pouch failure and quality of life) parameters were compared between the 2- and 3-stage procedure. Regarding short-term outcomes for all patients, in-hospital morbidity and readmission rates after any surgical stage were observed in 69% and 24%, respectively. Morbidity and readmission did not differ significantly between the 2- and 3-stage procedure in uni- and multivariate analysis. Median length of hospital stay for all stages was 17 days. The 3-stage procedure was identified as an independent factor for longer hospital stay (OR 3.8 (CI 1.3-10.8), p = 0.014). Pouch failure and failure of improved quality of life during long-term follow-up occurred both in 10% of patients, with no significant differences between the 2- and 3-stage procedure in uni- and multivariate analysis. Our data suggest that both the 2- and 3-stage proctocolectomy with IPAA demonstrate favourable and comparable postoperative short- and long-term outcomes, with a high rate of improved quality of life in patients with UC.

Ileoanal Pouch-Related Fistulas: A Narrative Review.

Ileoanal pouch-related fistula (IAPRF) is a possible complication after ileal pouch-anal anastomosis that significantly impacts pouch prognosis and the patient's quality of life. This study aimed to perform a comprehensive narrative review to better classify the epidemiology, risk factors, etiology, management, and outcomes of IAPRF, and to propose an algorithm for its systematic classification. Ten studies comprising 664 patients with IAPRF were identified, with a prevalence ranging from 4% to 45%. The reported fistula types were as follows: pouch-vaginal (n = 236, 35.5%), perineal (n = 139, 21%), enterocutaneous (n = 54, 8%), pouch-anal (n = 53, 8%), presacral (n = 18, 2%), and anastomotic (n = 15, 2%). Postsurgical pelvic sepsis occurred in 21%-37.2% of patients. Twenty additional studies regarding fistula classification divided them according to onset time and etiology, defining 5 categories: anastomotic-related, technical aspects of the surgery, Crohn's disease-like pouch inflammation, cryptoglandular, and malignancy. Pouch excision was reported in up to 70% of patients. Fistulas associated with anastomotic complications, technical surgical issues, and cryptoglandular fistulas warrant surgical management. On the other hand, fistulas associated with inflammation are preferentially managed with biologics or small molecules.

Ileoanal pouch­related fistula is a complication after ileal pouch­anal anastomosis. This study aimed to perform a comprehensive review to better classify the epidemiology, risk factors, etiology, management, and outcomes, and to propose an algorithm for its systematic classification.

Quality of life following ileoanal pouch failure.

This article describes a novel qualitative study exploring the lived experience of participants having undergone ileoanal pouch failure, on a background of ulcerative colitis (UC). It focuses on the impact of living with indefinite diversion of the pouch and a permanent end ileostomy. Six participants were interviewed with an aim to establish their experience of pouch failure and the support they required. Five pertinent themes emerged that suggested participants did not expect pouch failure and were unprepared for the regression towards UC. Some participants recommenced drug therapy, wore pads to manage leakage from the diverted pouch, avoided certain social settings or manipulated diet and lifestyle in order to gain an acceptable quality of life with a permanent ileostomy. Pouch failure potentially presents adverse effects on patients' quality of life, but currently there is a deficit in support and resources available in order to provide acceptable outcomes for patients experiencing pouch failure.

Review of long-term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease.

BACKGROUND: In medically refractory Ulcerative Colitis (UC), proctocolectomy with ileoanal pouch procedure (IAPP) is the preferred continence-preserving surgical option. Functional outcomes post-surgery and long-term complication rates in the biologic era remain ambiguous. This review primarily aims to provide an update on these outcomes. Secondarily, risk factors associated with chronic pouchitis and pouch failure are explored. METHODS: Two online databases (MEDLINE and EMBASE) were searched on 4 October 2022 for English studies from 2011-present relating to long-term outcomes of IAPP in inflammatory bowel disease (IBD) patients. Adult patients with 12 month follow-up were included. Studies focused on 30-day post-operative outcomes, non-IBD patients or studies including less than 30 patients were excluded. RESULTS: Following screening and full-text review of 1094 studies, 49 were included. Median sample size was n = 282 (IQR: 116-519). Median incidences for chronic pouchitis and pouch failure were 17.1% (IQR: 12-23.6%) and 6.9% (IQR: 4.8-10.8%), respectively. Upon multivariate analysis, chronic pouchitis development was most significantly associated with pre-operative steroid use, pancolitis and extra-intestinal IBD manifestations, whilst pouch failure was most significantly associated with pre-operative diagnosis of Crohn's disease (compared to UC), peri-operative pelvic sepsis and anastomotic leak. Overall patient satisfaction was very high with four included studies reporting greater than 90% satisfaction rates. CONCLUSION: Long-term complications for IAPP were common. However, despite this, patient satisfaction post-IAPP was high. Up-to-date knowledge of complication rates and their risk factors improves pre-operative counselling, management planning and patient outcomes.

[Complications and corrective surgery after ileal pouch-anal reconstruction?] / Komplikationen und Revisionsoperationen nach ileopouchanaler Rekonstruktion?

Proctocolectomy with ileal J­pouch-anal and rectal reconstruction is the standard surgical treatment for ulcerative colitis, selected cases of Crohn's disease, FAP and multilocular colon carcinoma. Although this treatment has been continuously developed over the last 40 years, the long-term success rate is 80-90% of the treated patients. The reasons for this are manifold: chronic pouchitis, incontinence, secondary diagnosis of Crohn's disease, fistulas, severe surgical complications, rectal stump left for too long, chronic abscess and surgical technical errors. This article deals with the control of acute complications and with the management of long-term complications. Some of the triggering complications for pouch failure do not generally imply failure of the method. A correction, closure of the fistula and in individual cases also a completely new pouch creation can restore a good pouch function in about 75% of cases. Various indications, techniques and results are presented.