Tip of the J-pouch Leaks: Diagnosis, Management, and Long-term Pouch Survival

Abstract

BACKGROUND: The standard of care for surgical treatment of ulcerative colitis is restorative proctocolectomy with ileal J-pouch. Leaks from the tip of the J-pouch are a known complication, but there is a paucity of literature regarding this type of leak. OBJECTIVE: We aimed to describe the diagnosis, management, and long-term clinical outcomes of leaks from the tip of the J-pouch at our institution. DESIGN: This was a retrospective study of a prospectively maintained pouch registry. SETTING: This study was conducted at a quaternary IBD referral center. PATIENTS: Patients included those with ileal J-pouches diagnosed with leaks from the tip of the J-pouch. MAIN OUTCOME MEASURES: The main measures of outcomes were pouch salvage rate, type of salvage procedures, and long-term Kaplan-Meier pouch survival. RESULTS: We identified 74 patients with leaks from the tip of the J-pouch. Pain (68.9%) and pelvic abscess (40.9%) were the most common presentations, whereas 10.8% of patients presented with an acute abdomen. The leak was diagnosed by imaging and/or endoscopy in 74.3% of patients but only discovered during surgical exploration in 25.6% of patients. Some 63.5% of patients were diagnosed only after loop ileostomy closure, whereas 32.4% of patients were diagnosed before ileostomy closure. The most common methods used for diagnosis were pouchoscopy (31.1%) and gastrograffin enema (28.4%). A definitive nonoperative approach was attempted in 48.6% of patients but was successful in only 10.8% of patients overall. Surgical repair was attempted in 89.2% of patients, whereas 4.5% of patients had pouch excision. Salvage operations (n = 63) included sutured or stapled repair of the tip of the J (65%), pouch excision with neo-pouch (25.4%), and pouch disconnection, repair, and reanastomosis (9.5%). Ultimately‚ 10 patients (13.5%) required pouch excision, yielding an overall 5-year pouch survival rate of 86.3%. LIMITATIONS: This was a retrospective review; referral bias may limit the generalizability. CONCLUSIONS: Leaks from the tip of the J-pouch have variable clinical presentations and require a high index of suspicion. Pouch salvage surgery is required in the majority of patients and is associated with a high pouch salvage rate. See Video Abstract at http://links.lww.com/DCR/C50. FUGAS DEL EXTREMO DE LA BOLSA EN J: DIAGNÓSTICO, MANEJO Y SUPERVIVENCIA A LARGO PLAZO DE LA BOLSA ANTECEDENTES: El estándar de atención para el tratamiento quirúrgico de la colitis ulcerosa es la proctocolectomía restauradora con bolsa ileal en J. Las fugas del extremo de la bolsa en J son una complicación conocida, pero hay escasez de literatura sobre este tipo de fuga. OBJETIVO: Describir el diagnóstico, manejo y resultados clínicos a largo plazo de las fugas del extremo de la bolsa en J en nuestra institución. DISEÑO: Estudio retrospectivo de registro de bolsa mantenido prospectivamente. ENTORNO CLINICO: Centro de referencia de enfermedad inflamatoria intestinal cuaternaria. PACIENTES: Pacientes con bolsas ileales en J diagnosti...

Segmental Colectomy in Ulcerative Colitis

“…5 Morbidities include pelvic sepsis, acute and chronic leaks, pouchitis, anastomotic stricture, and pouch-related perineal fistulas. 5,[15][16][17] Despite the high risk of complications, the majority (more than 90%) of patients report a good-to-excellent quality of life and that they would undergo the procedure again or recommend it to a friend or family. 5 However, this group typically consists of young and otherwise healthy patients who are fit for major surgery.…”

Diagnosis and management of tip of J‐pouch leaks – A video vignette

“…Dear Editor, While anastomotic leaks are estimated at 5%-10% following creation of a J-pouch, the incidence of leak from the tip of the J-pouch is poorly characterized and can pose significant diagnostic challenges given its sometimes indolent presentation [1]. Appropriate surgical management has been associated with good long-term results, including pouch function and retention [2,3].…”

“…Unfortunately, he presented again 5 months later with abdominal pain and pneumoperitoneum and underwent a diverting loop ileostomy. Tip of the J-pouch leaks can be subtle in presentation [2].…”

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Iatrogenic splenic injury, although uncommon [1,2], poses a serious complication in colorectal surgery, often necessitating splenectomy [3, 4]. This procedure is associated with a significant increase in postoperative morbidity and mortality [5], along with long-term risks of systemic infections [6].

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