Surgical Prophylaxis of Pouchitis in Ulcerative Colitis

Abstract

Ileal pouch-anal anastomosis (IPAA) is now the procedure of choice for most patients requiring proctocolectomy for ulcerative colitis. The J-shaped pouch, usually 15-20 cm in length, is easiest to construct and has functional outcomes identical to those of the more complex designs. IPAA is a complex procedure, and complications occur frequently. Despite the significant improvements this surgical advance has made on the quality of life in these patients, inflammation of the surgically created ileal pouch or pouchitis remains a major late postoperative complication that can often overshadow the benefits of this otherwise curative operation. Several inflammatory and noninflammatory complications can occur after IPAA. Pouchitis is the most common, occurring in ≈50% of patients. Whereas acute pouchitis can be treated rapidly and successfully in the majority of patients, refractory and chronic pouchitis remain therapeutic challenges to patients and physicians. The problem is believed to be caused by stasis of feces in the pouch with overgrowth of aerobic and anaerobic organisms. The size of the pouch has a significant influence on the incidence of pouchitis: a smaller pouch usually empties better than a larger pouch and so may be less susceptible to pouchitis.

Pouchitis

“…It has been suggested that the size of the pouch had a significant impact on the incidence of pouchitis: a right-sized pouch usually empties better than an excessively large pouch and thus be less susceptible to pouchitis [8]. In our experience, pouchitis rarely occurs in pouches constructed by experienced colorectal surgeons, suggesting a contribution of suboptimal surgical technique to the development of pouchitis.…”

Prophylactic surgery in familial adenomatous polyposis (FAP)—a single surgeon’s short- and long-term experience with hand-assisted proctocolectomy and smaller J-pouches

“…Since then, the determination of the optimal length of the ileal limb used for pouch formation has been an issue of controversy. However, increasingly it has been realized that other factors in addition to the initial pouch volume determine functional short-and long-term outcomes [44]. The final volumetric capacity depends mainly on the length of the afferent loop [44].…”

“…Last but not least, the size of the pouch may have an important influence on the incidence of pouchitis, which occurs more frequently in patients with ulcerative colitis than in FAP after IPAA [44]. Assuming a better evacuation of smaller pouches with consecutive reduced fecal stasis, smaller pouches may be less susceptible to inflammation [44].…”

“…Assuming a better evacuation of smaller pouches with consecutive reduced fecal stasis, smaller pouches may be less susceptible to inflammation [44].…”

Komplikationsmanagement in der Chirurgie

“…Diese sind in den Kästen "Primär idiopathische Pouchitis" und "Sekundäre chirurgische Pouchitis" nachfolgend aufgeführt (modifiziert nach Heuschen et al 1999 (Brisinda et al 2011). mit einer chronischen Pouchitis gerechnet werden.…”