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نوفمبر2014 محاضرات عين شمس
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Complications of ileal pouch after total proctocolectomy
Dr/ Mohamed A NadaAss Professor General Surgery
Ain Shams University2014
• Park & Nicholls 1978• Low mortality rate ( young age,
highly specialized centers)• Mayo Clinic (1407 IPAA) 0.2% early
mortality, and 1.8% late mortality• The late mortality was due to rectal
carcinoma, haematological carcinoma, cholangiocarcinoma, others
Small bowel obstruction• 15% to 44%, and 5% to 20% require
reoperation• Cleveland Clinic: 254 patients (25.3%) with
small bowel obstruction( 7.5% early, 17.8% late) \ 70 (27.6%) required operation
• Stomal stenosis, volvulus, internal hernia and adhesions
• Temporary loop ileostomy as a cause of IO?• Cumulative results 14% at 5 years and
22% at 10 years
Pelvic abscess
• 4% to 6%• Contamination of the presacral space
(intraoperative or postoperative)• Postoperative due to disruption of the PA
anastomosis, late diagnosis after closure of the ileostomy
• Don't panic, CT scan and Pouchogram• Ct guided drainage, local drainage +Abs• Reexploration, drainage and reestablishment of the
ileostomy • Pouch resection?
Leaking pouch or PAA
• 2% to 10%• Asymptomatic leak (X ray) delay the closure
of ileostomy• Symptomatic leak (fever, perianal pain and
discharge).. Sinus tract from anastomosis… EUA ( drainage & curette)
• Site and size of the leak• Type of radiology• management
Vaginal fistula
• 6% (1/3 before closure of ileostomy)• Hand sewn and stapled• PA anastomosis and low vaginal wall• 75% acute fulminante UC, other group
( one stage without ileostomy)• Risk factors (Tekkis et al) female,
perianal abscess, perianal fistula, Crohns, abnormal anal manometry and pelvic abscess)
• 92% diagnosed clinically• Basic principle of management
( keep ileostomy, drainage of any abscess, Abs)
• If ileostomy was closed, reestablish it (poor outcome)
• Intraanal approach , trans vaginal or perineal approach
• Combined abdominoperineal repair• Pouch excision
Anal stricture
• 5% to 16% (ST. Mark’s Hospital 14.2% handsewn, 39.6% stapled)
• Pelvic sepsis, tension on IPAA, poor blood supply, poor technique, leakage)
• Lewis et al (small stapling gun, W pouch, defunctioning ileostomy, anastomotic dehiscence and pelvic abscess)
• Nonfibrotic and fibrotic (Mayo Clinic 84% nonfibrotic)• Dilatation success 95% in nonfibrotic, 45% in fibrotic• Stricturotomy or stricturectomy with mucosal
advancement flap, redo pouch, or excision with end ileostomy
• Fazio & Tjandra ( pouch advancement and neo-ileoanal anastomosis
Difficult evacuation• Mechanical, non mechanical• Long efferent ileal limb (S pouch),
long anorectal stump
Portal vein thrombosis• Abdominal pain, fever, leukocytosis,
delayed bowel function
Pouchitis• Acute and/or chronic inflammation of ileal reservoir• Not related to the type of reservoir, 7% to 59%• Highest during early 6 months, cumulative risk off
after 2 years, 10% severe and 1% to 3% need pouch removal
• Increase stool frequency and urgency, bright red bleeding, fecal incontinence and extraintestinal manifestation of IBD
• Accurate diagnosis of pouchitis (endoscopic & microscopic)
criteria score
clinicalStool frequencyUsual postoperative stool frequency1 to 2 stool/day greater than PO usual3 or more stools/day greater than PO usual
012
Rectal bleedingNone or rarePresent daily
01
Fecal urgency or abdominal crampsNoneOccasionalUsual
012
fever more than 37.8Absentpresent
01
Pouchitis disease activity index Sandborn et al
criteria score
Endoscopic inflammationEdemaGranularityFriabilityLoss of vascular patternMucous exudatesUlcerations
111111
Acute histologic inflammation
Polymorphonuclear leukocyte infiltrationMildModerate with crypt abscessSevere with crypt abscess
123
123
Ulceration per low power field (mean)Less than 25%25% to 50%More than 50%
Pouchitis disease activity index Sandborn et al
• Colitis patients have a much greater incidence than FAP
• Colitis with extraintestinal manifestations have a much greater incidence than without
• In contrast, patients with backwash ileitis are not predisposed to the condition
• Anastomotic stricture and very large pouch • Pouchitis seems to be related to stasis in the
pouch, with subsequent proliferation of bacteria in the pouch, especially anaerobic and the bacteria and their exotoxins are responsible for damaging the pouch mucosa
• Change in the histology of the pouch mucosa
• Deficiency of short chain fatty acids• Ischemia and production of oxygen free
radicals• Pathogenic bacteria theory• Metronidazole 500 mg/8 hours for 7 to 10
days• Ciprofloxacin 1000mg/ day• Probiotic therapy in chronic pouchitis
Symptoms of pouchitis followed by endoscopy and biopsy
Pouchitis treated with metronidazole or ciprofloxacin
Response
Recurrence
Repeat antibiot
ic
RecurrenceRepeat antibiot
ic or
add probiotics
No response
Other antibiotic
Antiinflammat
ory drugsImmunosuppressive
drugs
surgical
No pouchitis
Irritable pouch syndrome
Imodium, lomotil
Pelvic floor assessmentca
surgical
Other reported complications• Perianal fistula and abscess• Intraabdominal fistula and abscess• Residual septum in J pouch• Long efferent limb in S pouch• Unsatisfactory bowel function
problem Patients No treatment outcome
Long efferent limb 9 New pouch (5)Revised pouch (4)
Success (7)
Sepsis and/or fistula 4 Revised pouch Success (2)
Blind limb 3 Revised pouch Success (1)
Twisted pouch 3 New pouch (1)Old pouch retained (2)
Success (3)
No pouch ( folded J) 1 New pouch Success (1)
Ileal pouch- anal anastomosis
3 Old pouch retained Success (3)
Indication for reoperation and outcome in 23 patients, Mayo Clinic
Salvage surgery for major complications following
IPAA is worthwhile. And the need for reconstruction of
the pouch or even new pouch formation carries a
respectable rate of success between expert hands
Sexual dysfunction• Impotence 1% to 2%• Retrograde ejaculation 2% to 3%• Dysparonia 7%• Fecal leaks during intercourse 2%
Functional results
• Complex interaction of many factors including (anal sphincter and PR muscle activity, reservoir capacity, compliance, motility and emptying, anorectal pelvic floor sensation and innervation, upper intestinal activity, stool consistency, content, volume, and transit.
• The functional results most determining the patient satisfaction are frequency of bowel movements per day and fecal continence.
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