Complications of the Pelvic Pouch
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Complications of the Pelvic Pouch- Key Concepts
- Introduction
- Risk Factors for Pouch Dysfunction
- Approach to the Patient with a Dysfunctional Pouch
- Etiology and Management of Pouch Complications
- Structural Complications of the Pouch
- Afferent Limb (AF) Complications
- Issues of the Pouch Body
- Pouch-Anal Anastomotic (PAA) Defect
- “Tip of J” Pouch Leak
- Failure of Pouch “Scaffolding”
- 180°/360° Mesenteric Rotation
- Efferent Limb (EL) Problems
- Inflammatory Complications of the Pouch
- Diagnosis with Exam Under Anesthesia
- Control of Sepsis
- Fecal Diversion
- Pouch Excision
- Functional Complications of the Pouch
- Neoplasia of the Pouch
- Outcomes of Surgical Management of Pouch Complications
- Conclusion
- References
Management of the Failing Pelvic Pouch
Benign Disease- A 39-year-old woman with a history of long-standing ulcerative colitis (UC) undergoes an elective total proctocolectomy and ileoanal pouch anal anastomosis (IPAA). Two months postoperatively, she reports a persistent low-grade fever, dyspareunia, vaginal air, and mucopurulent rectal drainage. A gastrografin pouch study demonstrates a pouch vaginal fistula. What is the most likely etiology?
- A 54-year-old man with a history of inflammatory bowel disease (IBD) has a 3-stage total proctocolectomy with ileal pouch-anal anastomosis (IPAA) 9 years prior. He notes that there was a long delay between his second and third stage surgery. He has had significant diarrhea, fecal incontinence, and pelvic pain for years despite multiple medical therapies, including ciprofloxacin, steroid enemas, and rifaximin. He says he has never had good pouch function. What is the most likely cause of his current clinical condition?
- A 34-year-old otherwise healthy woman, who underwent total abdominal colectomy with end ileostomy 1 year ago for fulminant Crohn’s disease colitis, presents to the office with ongoing bloody mucoid discharge per rectum and tenesmus. On examination, her abdomen is unremarkable with end ileostomy. Ileostomy is healthy and pouches well. Rectal examination is remarkable for normal perineal skin, normal tone, and absence of fistula and fissure. She has been through four different biologics. Endoscopy shows deep ulcers in the rectum with mucosal friability. She has bothersome mucoid anal discharge multiple times per day and wishes to know whether this can be resolved. Her small bowel disease was previously active and is now quiescent on entyvio. What is the best next option in her management?
- Eight days after ileal-pouch anal anastomosis (IPAA) and diverting loop ileostomy, your patient presents to the emergency department with pelvic pain, low-grade fever, and purulent drainage per anus. The patient is hemodynamically stable with a white blood cell (WBC) count of 14. Intravenous (IV) antibiotics and fluids are initiated. Computed tomography (CT) with rectal contrast reveals a deep pelvic abscess with contrast extravastion into the cavity. What is the best next step in the management of this patient?
- A 48-year-old man with a history of ulcerative colitis (UC) underwent the closure of a diverting ileostomy following an open restorative proctocolectomy with the creation of a J-pouch. Three weeks following stoma closure, he develops enteric drainage from his midline surgical-site, and computed tomography (CT) demonstrates a fistula tract from the tip of the J pouch. This drainage persists after an additional 4 weeks of observation. What is the most appropriate next step in management for this patient?
- A 24-year-old man with history of ulcerative colitis (UC) is 3 days status postemergent subtotal colectomy with end ileostomy for toxic megacolon. He has a low-grade fever of 38.0 °C, rising heart rate to the 110s, rising leukocytosis to 15 x 109, and lower pelvic pain and pressure. Computed tomography (CT) of the abdomen and pelvis demonstrates abscess with fluid and gas adjacent and superior to the rectal stump staple line. How could the chance of complication have been reduced?
Benign Disease- A 28-year-old man with a history of ulcerative colitis undergoes a total proctocolectomy with stapled ileal pouch–anal anastomosis. Six months after surgery, he presents with urgency, increased stool frequency, and bloody bowel movements. Endoscopic examination findings are shown (Figure A and B). What is the best next step in management?
- A 37-year-old woman with a history of ulcerative colitis underwent restorative proctocolectomy with the construction of a J-pouch ileoanal anastomosis 2 years ago. The patient presents to your clinic with tenesmus of 3 months’ duration, pelvic discomfort, and fecal urgency. Pouchoscopy reveals inflamed pouch mucosa, with normal prepouch ileum. Which medical therapy is the treatment of choice?
- A 58-year-old man with chronic ulcerative colitis is found to have a 3-cm mass approximately 5 cm from the anal verge on surveillance colonoscopy. Biopsies reveal moderately differentiated adenocarcinoma. On rectal examination, the mass is fixed and tethered. Staging reveals a T3N0 lesion, with no evidence of distant metastasis. The best next step in management is:
- A 35-year-old man with ulcerative colitis underwent an ileal pouch–anal anastomosis. Eight weeks after surgery, contrast enema and pouchoscopy demonstrate a normal pouch and a patent anastomosis. No leakage from the pouch was noted on radiography. He underwent an uneventful ileostomy takedown. He initially did well but 6 weeks postoperatively he presents with pelvic pain, fevers, and increased pouch output. Computed tomography of the abdomen and pelvis reveals a pelvic abscess high in the pelvis with a normal pouch–anal anastomosis. An image-guided percutaneous drain is placed and the patient is treated with antibiotics. A sinogram 6 weeks later demonstrates a persistent fistula to the pouch. What is the appropriate management for this patient?
- A 51-year-old man with a 10-year history of ulcerative colitis presents with more than 10 bloody stools per day, temperature of 100.4°F (38°C), pulse of 110 beats/min, and colonic distention on radiography with a transverse colon diameter of 6 cm. Laboratory findings include hemoglobin of 9.5 g/dL (95 g/L), erythrocyte sedimentation rate of 55 mm/h, and albumin of 2.3 g/dL (23 g/L). The patient’s abdomen is distended and diffusely tender. After 48 hours of medical treatment with steroids and broad-spectrum antibiotics, the patient’s condition remains unchanged. What is the most appropriate next step?
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