Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis

Abstract

Objective: To assess the clinical presentation, management, and outcome of leaks after the ileal pouch-anal anastomosis (IPAA) procedure.

Methods: Of 1424 IPAA procedures performed at Mount Sinai Hospital from 1981 to 2003, 141 patients experienced leaks (9.9%). Data were reviewed retrospectively from the Inflammatory Bowel Disease database and clinic and hospital charts. Statistical comparisons were performed with the chi2 test.

Results: There were 81 men and 60 women with a median age of 36 years (12-69). Indication for surgery was ulcerative colitis in 93% of patients. Twenty-three leaks (16.3%) originated from the pouch whereas 118 (84.1%) arose from the ileoanal anastomosis. Of ileoanal anastomosis leaks, 24.6% were associated with and 38.1% without an abscess, 12.7% were associated with a pouch-cutaneous fistula, 15.3% were associated with a pouch-vaginal fistula, and 9.3% were diagnosed radiologically. Of the 130 patients who developed symptoms, 67% had fever, 38% had abdominoperineal pain, and 6% had perineal abscess. Twenty-nine percent of those who did not have an ileostomy had increased stool frequency. Nonoperative treatment was attempted initially in 100 patients with an 80% success rate. An operative procedure was performed in 59 patients (including those who failed nonoperative treatment), including transanal repair in 34 patients with a success rate of 66%; laparotomy with direct suture repair in 7 with a success rate of 57% and combined abdominoperineal pouch reconstruction in 18 with a success rate of 72%. Overall, 119 patients (84%) have a functioning pouch. Pouch salvage after a leak increased from 67% in 1981-1984 to 88% in 2001-2003 (P = 0.0004, chi2).

Conclusions: A high rate of ileal pouch salvage can be achieved after leaks associated with the IPAA procedure if management is individualized. Improved salvage rate over time is likely a reflection of increased experience with the management of complications as well as the strategy of individualized management.