Ileal Pouch-anal Anastomosis Complications and Pouch Failure

Abstract

Objective: This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure. Background: Previous studies demonstrated wide variation in postoperative complication rates following IPAA. Methods: A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman’s correlations. Results: Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56–10.59) and 10.3% (95% confidence intervals: 7.24–14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1–17%), pelvic sepsis (2–18%), fistula (1–30%), stricture (1–34%), pouchitis (11–61%), and Crohn’s disease of the pouch (0–18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01). Conclusions: The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak. Mini abstract: This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure.

Can preoperative CT/MR enterography preclude the development of Crohn's disease‐like pouch complications in ulcerative colitis patients undergoing J pouch surgery?

“…Heimann et al [28] reported that 9% of UC patients undergoing IPAA developed a perianal fistula, which is slightly lower than the cumulative rate of 12% reported in our study. However, unlike our study in which a 6‐month window from ileostomy closure was used, Heuthorst et al [27] arbitrary defined early perianal fistula as the diagnosis of a perianal fistula within 5 years from the IPAA index surgery. Therefore, they were unable to discern which patients developed fistulas as part of an early postoperative complication, such as anastomotic dehiscence, from fistulas arising as part of CDLPC.…”

“…The overall pouch failure rate described in our study (6.1%) is close to that described in a more recent meta‐analysis that reviewed IPAA complications and pouch failure. This meta‐analysis reported a pooled pouch failure rate of 7.7% for studies with a median follow‐up of five or more years and 10.3% for studies with a median follow‐up of 10 or more years [27]. However, this meta‐analysis did not exclude pouch failures not attributed to CDLPC.…”

“…Crohn's disease-like pouch complications are responsible for considerable morbidity among UC and IBDU patients undergoing TPC with IPAA [27]. These patients should be counselled prior to surgery concerning the possibility of developing CDLPC, and those of them presenting with backwash ileitis and a history of previous perianal disease should be made aware that they may be at an increased risk for developing such complications.…”

Editorial: Regionalisation of ileoanal pouch surgery

“…Most patients undergoing pouch surgery have a good outcome post-operatively, but a significant minority have complications following surgery that may lead to pouch failure. A recent meta-analysis demonstrated that the long-term pouch failure rate is 10% after 10 years of follow-up [5]. Pouch surgery is a quality-of-life operation.…”

Pelvic Pouch Failure: Treatment Options

“…3 4 Two recent meta-analyses with more than 20,000 UC patients each, showed a prevalence of PF of 5% at 5 years and 9 to 10% at 10 years from the operation. 5 6 In this review article we describe the presentation, workup, diagnosis treatment, and outcomes of PF.…”