The Failed J Pouch

Abstract

Restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was first described by Parks and Nicholls in 1978. 1 In their first description, IPAA was performed along with a mucosal proctectomy and a hand-sewn anastomosis, with the ileal reservoir created in a triple-loop (S) pouch configuration. Since that time, the technique has been further developed and refined. In the current era, mucosectomy has been largely abandoned and the most commonly performed IPAA procedure is the creation of a double loop stapled "J-shaped" pouch, with the creation of a stapled anastomosis between the reservoir and the rectum. 2,3 IPAA nowadays remains the optimal surgical procedure for patients with chronic ulcerative colitis (UC) and patients with familial adenomatous polyposis. This operation offers excellent quality of life for the majority of patients with a durable surgical and functional result, avoiding the need for a permanent ileostomy with its attendant potential effects on social, physical, psychological, and sexual areas. Nevertheless, IPAA is associated with several pouch-related complications that challenge both surgeon and patient. Reasons for pouch failure include infection, mechanical or functional difficulties, and complications of Crohn disease (CD) when this develops. Therefore, it is critical that thoughtful consideration and judgment be utilized in preparing, planning, and performing IPAA surgery to achieve optimal results.The aim of this review is to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative, and reoperative problems associated with IPAA surgery so as to minimize the occurrence of pouch failure and also to discuss the management of the poorly functioning or failed pouch. Intraoperative ChallengesThe first hurdle to overcome in IPAA surgery revolves around the need to surmount certain intraoperative difficulties such as the failure of the pouch to reach and the technical aspects of performing the IPAA.

Intestinal Ostomy: Classification, Indications, Ostomy Care and Complication Management

“…Literature reports show that patients with a Kock pouch are much more satisfied and have a greatly improved quality of life (4). However, it has to be mentioned that creation of a Kock pouch is associated with an elevated revision rate; in some cases the pouch even has to be removed (5).…”

Ileal pouch–anal anastomosis—a personal experience reevaluating complications, pouch survival, and quality of life

“…The occasional generous referral to IPAA as the gold standard for proctocolectomy [26] suggests that strategic and technical questions pertaining to the surgical procedure have been conclusively answered and that the results, including QOL, leave no room for doubting this assessment. In fact, while the literature consistently reports very satisfactory surgical outcomes, it also recognizes not inconsiderable rates of complications and pouch failure [9,15,24]. This apparentcontradictionruns like a thread through the literature and needs to be resolved.…”

“…Sur-prisingly, this is not diminished by the fact that perioperative morbidity associated with this demanding operation is not negligible, and that numerous complications, including those with drastic surgical consequences, occur in the longterm course [15]. As a consequence of one or even multiple complications, definitive pouch failure may result in the long term [24].…”

Combination of Sulindac and Eflornithine Delays the Need for Lower Gastrointestinal Surgery in Patients With Familial Adenomatous Polyposis: Post Hoc Analysis of a Randomized Clinical Trial

“…7,8,26 Such a strategy will provide opportunities to delay or avoid life-altering surgery and associated reduced QoL. 27 Prevention of advanced adenomas has been recognized as an appropriate end point in pharmacotherapy trials. 22,28,29 Our analysis of the data for patients with at least a partially intact LGI tract in the CPP FAP-310 trial demonstrated that they responded very well to combination treatment with sulindac and eflornithine, exhibiting ≥80% reduction in risk for disease progression compared with either drug alone.…”