Ileal-anal pouches: A review of its history, indications, and complications

Abstract

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but "early" and "late" complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Keywords: Crohn’s disease; Familial adenomatous polyposis; Ileal pouch; Restorative proctocolectomy; Ulcerative colitis.

Figure 1

History of the ileal pouch. A: The Kock continent ileostomy; B: Common pouch configurations used in ileal pouches.

Figure 2

Endo-cavitational vacuum therapy (Endo-SPONGE^®). A: Endoscopic view of a pouch with a cavity (arrow) at the anastomosis secondary to anastomotic leak. The true lumen is at the inferior aspect; B: Contents of the Endo-SPONGE^® kit (B Braun Medical Ltd); C: The foam of the Endo-SPONGE^® is passed into the cavity and negative pressure applied to collapse the cavity.

Figure 3

Examination under anaesthesia performed for a female patient who presented with perineal sepsis and abnormal per vaginal discharge following ileal pouch anal anastomosis. A pouch-vaginal fistula was identified and confirmed with a probe.

Figure 4

A coronal computed tomography image of a patient who presented with early small bowel obstruction following closure of ileostomy (6 mo post pouch creation). Computed tomography and operative findings confirmed small bowel obstruction secondary to a 360° twist at the level of the anastomosis.

Figure 5

Obstruction to pouch outflow usually occurs at the level of the anastomosis. A: A coronal computed tomography image demonstrating a pouch outlet stricture. A stricture at the level of the anastomosis (arrow) caused a dilated pouch that could not empty without intubation; B: A pouchogram of the same patient confirmed an anastomotic stricture that eventually yielded to serial Hegar dilations.

Figure 6

Endoscopic view of pouchitis (Pouch Disease Activity Index endoscopic sub-score 4).

Figure 7

Pouch adenoma. A: Magnetic resonance image and endoscopic view of a pedunculated pouch polyp (arrow) arising in the mid pouch that was completely excised endoscopically; B: A serrated, near circumferential, lesion (arrow) that required formal pouch excision. Both pouch lesions were confirmed histologically to be pouch adenomas.

Figure 8

A magnetic resonance image of a pouch with a large exophytic lesion (arrow) arising from its posterior aspect. Biopsies and formal histopathology confirmed this to be a pouch carcinoma.