39 conclusion that stapled anastomoses are safer than hand-
-
PELVIC POUCH
ANASTOMOTIC
COMPLICATIONS
AND MANAGEMENT
Kutt Sing Wong, MD, MBBS, FRCS (Ed),
FRCS (Glas), FAMS
Feza H. Remzi, MD, FACS, FASCRS
-
S ince its introduction by Parks in 1978, restorative proc-
tocolectomy (RP) with ileal pouch–anal anastomosis
(IPAA) has become the preferred surgical option for treat-
ment of mucosal ulcerative colitis (MUC) and familial
adenomatous polyposis (FAP). It restores gastrointestinal
continuity, re-establishes transanal defecation, and avoids
a permanent stoma. While there is a high degree of patient
satisfaction with this procedure, it has a significant inci-
dence of anastomotic complications, ranging between 24
and 32%. Poor bowel function and sometimes pouch loss
are potential outcomes of such complications, which
undermine the merits of this operation.
Anastomotic complications after RP are classified as
follows:
1. Anastomotic leaks
2. Pouch fistulas
3. Anastomotic strictures
4. Leaks from the tip of the J-pouch
■ ANASTOMOTIC LEAKS
Pouch-anal anastomotic leaks may be clinically overt or
detectable radiologically only by a Gastrografin enema per-
formed before ileostomy closure. Depending on the diag-
nostic criteria, the incidence varies between 4.5% and 10%.
Risk Factors
Risk factors for anastomotic leakage are prolonged steroid
usage, hypoalbuminemia, anemia, hypoxemia from car-
diac or respiratory insufficiency, ischemia of bowel ends,
and tension on the anastomosis. Whether the anastomotic
technique (hand-sewn with mucosectomy versus stapled
without mucosectomy) contributes to any differences in
anastomotic complications is debatable. Two prospective
randomized studies found no differences in anastomotic
complications. However, a large nonrandomized series
from the Cleveland Clinic, comparing 238 hand-sewn
with 454 stapled IPAAs, found significantly fewer anasto-
motic complications in the stapled group, leading to the
sewn. Conceivably, a higher level of the anastomosis in
stapled IPAA exerts less tension on the anastomosis than
the hand-sewn technique.
A temporary defunctioning loop ileostomy has tradi-
tionally been used because of the risks of anastomotic leak
and the fact that many patients with MUC frequently are
on steroids and malnourished. In contrast to a defunc-
tioning loop ileostomy after a low anterior resection and a
colonic J-pouch, RP involves a more proximal loop
ileostomy with high stoma output, predisposing to dehy-
dration and electrolyte abnormalities. Furthermore, there
is the issue of a second operation to close the stoma, which
incurs additional cost and significant operative morbidity
in some series. For these reasons, some surgeons have
advocated a single-stage procedure in good-risk patients.
Although a diverting loop ileostomy does not prevent
anastomotic leaks, the sepsis associated with a leak is consid-
erably reduced. Moreover, in the presence of an anastomotic
leak, there is a lower relaparotomy rate and a lower likeli-
hood of pouch failure in diverted patients. In a recent large
series of 1504 cases of ileostomy closure after RP, operative
morbidity is acceptable when compared to the risk of an
anastomotic leak. The most common complication of
ileostomy closure after RP is small bowel obstruction, which
responds to conservative therapy in the majority of cases.
Therefore, the decision to perform RP without temporary
diversion should be carefully considered.
A one-stage procedure may be considered only in the
absence of risk factors endangering anastomotic healing
such as anemia, malnutrition, and steroid usage. Equally
important in making that decision is the conduct of the
operation with good hemostasis, minimal contamination,
lack of tension on the anastomosis, and complete tis-
sue donuts. Our recent experience with omission of
temporary diversion in RP showed that, in the presence
of stringent selection criteria, quality of life at intervals of
3 months, 1 year, 3 years, 5 years, and 10 years is similar
between diverted and nondiverted patients. In addition,
the incidence of septic complications such as pelvic
abscesses, anastomotic leaks, and fistulas is similar
between both groups. However, it must be cautioned that
failure to meet these criteria made diversion necessary to
minimize postoperative septic sequelae and the prospect
of pouch loss.
Diagnosis
Clinical presentation of a pouch-anal anastomotic leak
ranges from persistent lower abdominal pain and ten-
derness to generalized peritonitis and pouch-cutaneous
fistulas. Occasionally, ileus with associated abdominal dis-
tention and absent bowel sounds may be the main pre-
senting feature. Other “telltale” signs include persistent
postoperative fever, profuse vomiting, anorexia, and fre-
quent loose stools. Varying degrees of systemic sepsis may
be found. Subtlety of clinical manifestations often requires
the clinician to have a high index of suspicion in order to
rule out the likelihood of an anastomotic leak.
Typically, there is leukocytosis with a preponderance
of neutrophils. However, in patients who had been on
226 The Colon
prolonged steroid therapy, white blood cell count may be
normal. Dilated bowel loops or free intraperitoneal air
may be evident on a plain abdominal radiograph. A com-
puted tomographic (CT) scan of the abdomen and pelvis
with triple contrast (oral, intravenous, and perianal) is the
preferred radiologic imaging study. Besides providing
radiologic evidence of a leak, a CT scan allows percuta-
neous drainage of a localized pelvic collection, which may
prevent a relaparotomy.
In some asymptomatic patients, a leak is detected only
by a Gastrografin enema prior to ileostomy closure.
Management
Fortunately, most IPAA leaks are not life threatening.
When a leak is detected in an asymptomatic patient by a
preileostomy closure Gastrografin enema, no further
treatment is required, except to defer ileostomy closure.
A repeat Gastrografin enema should be performed 3 months
later. If no abscess cavities are present and the sinus track
leading from the anastomosis is narrowed or obliterated,
then ileostomy closure can be performed, provided the
patient remains stable and asymptomatic.
In a symptomatic patient who is stable, is not sep-
tic, and has no peritonitis, initial treatment should
include intravenous antibiotics, drainage, and bowel
rest. Antibiotic coverage should include both aerobic
gram-negative and anaerobic organisms. In the presence
of a sizable pelvic abscess with no definite leak, percuta-
neous drainage under CT guidance may avert a relap-
arotomy. When drain output decreases to less than
100 mL over 24 hours, a tube sinogram provides use-
ful information in terms of the decision to remove the
drainage tube.
In some instances, a leak results in a presacral collec-
tion. Examination under anesthesia (EUA) allows evalua-
tion of the abscess collection and passage of a transanal
catheter through the anastomotic defect into the cavity.
The catheter is changed for a smaller one when sinogram
demonstrates shrinkage and resolution of the abscess cav-
ity. Removal of the catheter can be carried out safely when
there is clinical and radiologic evidence of resolution of
the abscess cavity/presacral sinus tract.
Bowel rest is instituted initially in all symptomatic
cases. When there are signs of clinical improvement, the
patient may be advanced to oral liquids and eventually
resumption of diet.
Worsening signs and symptoms after EUA and
transanal drainage through the defect or generalized peri-
tonitis are indications for emergent laparotomy. This pro-
cedure should be preceded by immediate fluid resuscitation
and administration of intravenous broad-spectrum
antibiotics.
In patients with a diverting ileostomy, thorough peri-
toneal lavage with copious amounts of warm saline fol-
lowed by placement of wide-bore drains would be the
cornerstone of surgical therapy. In nondiverted patients,
adding a diverting loop ileostomy after peritoneal lavage
and drainage is appropriate. Except when the pouch is
nonviable, rarely will pouch disconnection or excision be
necessary.
■ POUCH FISTULAS
Pouch fistulas are defined as connections from the pouch
to the vagina, bladder, or perineal skin. They were first
reported in 1985 and rates have ranged from 4 to 16%.
The development of pouch fistulas occurs more com-
monly in patients with inflammatory bowel disease than
patients with FAP. Underlying factors for development of
pouch fistulas include presence of sepsis, anastomotic
leaks, type of pouch constructed, and a postoperative
diagnosis of Crohn’s disease. Technical risk factors include
local pouch ischemia and, in the case of a pouch-vaginal
fistula (PVF), entrapment of the posterior vaginal wall in
a stapled anastomosis. The higher incidence of PVF after
an ileal J-pouch compared with an S-pouch could well be
a reflection of the use of staplers in the anastomosis. From
a technical perspective, a key point to note is that when the
circular stapler is introduced transanally, the trocar should
emerge posterior to the stapler line before “marrying”
with the anvil so that the risk of vaginal wall entrapment
is minimized.
Signs and symptoms of pouch fistulas are dependent
on the location and size of the fistula. They include per-
ineal discharge and sepsis, poor bowel function, pneuma-
turia, and fecal discharge per vagina. Diagnosis of a fistula
can generally be made clinically. Imaging studies such as a
Gastrografin enema and CT scanning may be necessary to
define its exact anatomy. In order to delineate its origin
from the ileoanal anastomotic site, careful inspection of
the anastomosis and use of a small catheter placed distally
so as not to exclude the anastomosis are essential.
Pouch-Vaginal Fisulas
Development of a PVF can lead to a poor functional result
and is one of the main causes of pouch failure. The major-
ity of patients with PVF can be managed initially by local
procedures. More commonly, the transanal ileal advance-
ment flap is employed. The technique of this advancement
flap is similar to that for a transanal advancement flap for
anal fistulas. The tenets of a successful transanal ileal
advancement flap repair are control of sepsis, careful
hemostasis, excision of concurrent strictures, and a ten-
sion-free closure. This approach may involve the use of
draining setons and drainage of any associated abscess
before repair.
Transvaginal repair is preferred by some surgeons,
however. Advantages cited are a cleaner surgical field,
avoidance of sphincter injury with consequent fecal
incontinence, and easier access compared with a transanal
approach, especially when there is some degree of stric-
turing in the anal canal.
It is our belief that success rates are higher with closure
of the fistula on the high-pressure side, using the transanal
approach. In a large series of 60 patients with PVF from
the Cleveland Clinic, success rates were better with
transanal repair.
Repeat IPAA (R-IPAA) for pouch salvage, either as pri-
mary treatment or for recurrent PVF, is another option.
This procedure was performed in 16 patients from the
same series, with eventual healing in 10. Promising results
 Pelvic Pouch Anastomotic Complications and Management
were reported from other series, too, thus lending cre-
dence to R-IPAA as a viable option for pouch salvage.
The overall success rate for PVF repair is 52%.
Recurrence and pouch failure rates are high, portending a
substantial risk of pouch excision and a permanent
ileostomy. Temporary fecal diversion at the time of local
repair procedures may augment healing rates.
The success of primary healing appears to be related
to the timing of occurrence of a PVF following RP. A bet-
ter outcome is obtained with fistulas occurring within
6 months of RP than with those occurring later. This dif-
ference may be related to a delayed diagnosis of Crohn’s
disease. The majority of patients (up to 40%) with a late
diagnosis of Crohn’s disease and PVF ultimately under-
went pouch excision. Therefore, patients with a known
diagnosis of Crohn’s disease should not undergo RP
because of the high failure rates.
Pouch-Vesical Fistulas
Patients with pouch-vesical fistulas present with pneuma-
turia and recurrent urinary tract infections. This compli-
cation is rare. Most frequently, the bladder dome is
involved. Surgical treatment consists of disconnection of
the fistula and closure of defects of the bladder and ileal
pouch, preferably with omental interposition. Temporary
fecal diversion should also be performed.
Pouch-Anal Fistulas
These fistulas should be treated in a manner similar to cryp-
toglandular anal fistulas. Thus, the options would include
simple fistulotomy for low inter- or trans-sphincteric anal
fistulas and setons for high fistulas involving a substan-
tial portion of the anal sphincter complex. A transanal
mucosal advancement flap can be considered for patients
with more complex fistulas after control of any associated
sepsis.
Fibrin Glue
The use of fibrin glue for pouch-anal fistulas is controver-
sial as the only reports in the literature describe its use in
complex cryptoglandular anal fistulas.
Infliximab
Experience with infliximab, the anti–tumor necrosis fac-
tor monoclonal antibody, has been limited. Ricart and
associates treated seven ileoanal pouch patients with
pouch fistulas and a subsequent diagnosis of Crohn’s dis-
ease with infliximab. Of the three patients who had PVF,
two had complete healing and one sustained a recurrence
after initial healing. It may be worthwhile to implement a
trial of infliximab in patients with a revised diagnosis of
Crohn’s and subsequent fistulas.
■ ANASTOMOTIC STRICTURES
The incidence of an ileoanal anastomotic stricture varies
between 5% and 38%. The variability in the incidence
can be explained by the inconsistent definition of an
ileoanal stricture. Strictly speaking, an anastomotic stric-
227
ture should be defined as a symptomatic narrowing of
the ileoanal anastomosis requiring either two or more
outpatient dilatations or at least one dilatation under
anesthesia.
Symptoms of an ileoanal anastomotic stricture include
frequent watery stools, urgency of defecation, abdominal
cramping, feeling of incomplete evacuation, and minor
fecal leakage. Digital examination not only confirms the
diagnosis but also allows assessment of the severity of
stenosis as well as digital dilatation. Many patients will
have a fibrous web at the anastomosis prior to ileostomy
closure which can be disrupted by digital or proctoscopic
dilatation. For this reason, at the time of ileostomy clo-
sure, it has been our practice to perform a routine digital
and proctoscopic assessment and dilatation when the
patient is under general anesthesia. We believe that this
practice will prevent progression of these fibrous webs to
subsequent stricture development.
Significant predisposing factors to stricture formation
are use of a temporary defunctioning ileostomy and pre-
vious anastomotic complications such as a pelvic abscess
or a leak.
In the presence of a defunctioning loop ileostomy,
the dilating effect of an uninterrupted fecal stream in the
anastomosis is lost, which may account for the higher
incidence of stricture formation in diverted patients.
Evidence for the type of anastomosis (hand-sewn ver-
sus stapled) that might predispose to stricture develop-
ment is variable. However, because stapled anastomoses
result in fewer septic complications than hand-sewn ones,
it may well be that uncomplicated stapled anastomoses
result in a lower number of strictures.
Postoperative septic complications are the main con-
tributing factor in the development of a stricture.
Strictures resulting from postoperative sepsis are the most
difficult to treat, requiring repeated dilatation or other
revisional procedures.
The majority of patients with anastomotic strictures
are successfully treated with dilatation. Recurring stric-
tures may need excision of the fibrotic ring and ileal
mucosa advancement to bridge the mucosal gap. In a
small percentage of patients in whom all these measures
have failed, especially when the strictures are the result of
septic complications, R-IPAA may be necessary. In a series
of 141 strictures in 1005 IPAAs, only 3 patients underwent
relaparotomy.
The failure rate of IPAA as a result of a stricture alone
with no sepsis is low (0.5%). Key technical maneuvers to
avoid stricture formation are avoidance of tension on the
anastomosis and meticulous surgical technique so as to
avoid postoperative septic complications.
■ LEAK FROM THE TIP
OF THE J-POUCH
A leak from the tip of the J-pouch is a rare complication
following RP and is defined as a leak from the blind limb
of the ileal J-pouch. In a study describing 14 patients with
a documented leak from the tip of the J-pouch, steroid
228 The Colon
dependency and a high body surface area were found to be
significant predisposing factors for this complication.
The majority of these patients usually present in the
late postoperative period (>30 days after RP). Symptoms
include fever, purulent wound discharge, and abdominal
pain. The diagnosis can often be confirmed radiologically
by a CT scan with triple contrast or a contrast enema.
Choice of treatment depends on whether a divert-
ing loop ileostomy is present. In a stable patient who pre-
sents before ileostomy closure and with no peritonitis,
CT-guided drainage is all that is required as the ini-
tial treatment. Surgical repair of the leak is performed
at a later date and involves suturing or restapling of the
J-pouch tip. The ileostomy may be closed at the time of
the repair, or closure may be deferred.
In a nondiverted patient or in patients presenting after
ileostomy closure, laparotomy, drainage, and a diverting
ileostomy should be performed in the first instance.
Surgical repair of the leak should be attempted at least 3
months later and ileostomy closure performed either con-
currently or at a subsequent setting.
■ REPEAT ILEAL POUCH–ANAL
ANASTOMOSIS (R-IPAA)
When local procedures fail in patients with pouch-related
anastomotic complications, R-IPAA may be needed to sal-
vage the pouch. Surgery for R-IPAA is performed with the
patient in the modified Trendelenberg position with
Lloyd-Davis stirrups. Ureteric stents are inserted to mini-
mize the risk of inadvertent ureteric injury. Local
(transanal) repair of pouch anastomotic complications
should always be attempted if the following conditions are
present:
1. Absence of gross sepsis and tissue edema.
2. Granulation tissue associated with abscess cavities is
minimal and easily curetted.
3. Fistulas are close to the anal verge and easily accessible
locally.
4. Short stricture.
If local repair is not feasible, a laparotomy and complete
pouch mobilization should then be carried out.
Pelvic dissection begins laterally where tissue planes are
least distorted and continues caudally. Posterior dissection
proceeds cranially and caudally after entering the pre-
sacral space behind the superior mesenteric vessels. Pouch
mobilization is completed by anterior mobilization and
when all-around dissection is carried out caudally to the
level of the levators. Injury to the nervi erigentes must
be carefully avoided in the course of dissection so as to
reduce the incidence of postoperative sexual dysfunction.
After disconnection of the ileoanal anastomosis, the small
bowel is carefully lifted out of the pelvis and adhesions are
divided sharply. Enterotomies and serosal tears are identi-
fied and repaired. At this stage, all granulation tissue
should be thoroughly curetted, fibrotic scars excised, and
pouch defects repaired under direct vision. Anal mucosec-
tomy is then performed.
The pelvic pouch is then resewn to the anal canal at the
level of the dentate line using interrupted 2-0 polyglycolic
acid sutures. If the original pouch cannot be salvaged,
then a new J-pouch is created. However, the decision to
excise the original pouch and create a new one must be
weighed carefully because loss of small intestinal length
may result in a permanent ileostomy if the new pouch
were to fail. A defunctioning loop ileostomy is constructed
at the end of the operation.
In a series of 35 patients from the Cleveland Clinic who
underwent R-IPAA for septic complications, 86% had a
functioning pouch. Although functional problems such as
seepage and pad use are reported after R-IPAA, patients
with successful R-IPAA would still choose to undergo the
operation again. Thus, for prevention of pouch failure,
aggressive surgical therapy such as R-IPAA is justified
because of the high incidence of pouch salvage with this
operation.
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