Anastomotic Leak after Ileal Pouch-Anal Anastomosis

Abstract

There are special considerations when treating anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis. The epidemiology, risk factors, anatomic considerations, diagnosis and management, as well as the short- and long-term consequences to the patient are unique to this patent population. Additionally, there are specific concerns such as "tip of the J" leaks, transanal management of anastomotic leak/presacral sinus, functional outcomes after leak, and considerations of redo pouch procedures.

Keywords: AL; Crohn's colitis; complications; familial adenomatous polyposis; ileoanal pouch; surgery; ulcerative colitis.

Fig. 1

AL anatomy. 1. Presacral sinus, 2. tip of the J-pouch leak, 3. staple line leak along the J-pouch body, 4. leak from the IPAA, and 5. pouch vaginal fistula. AL, anastomotic leak; IPAA, ileal pouch–anal anastomosis.

Fig. 2

Presacral abscess. MRI image of a 10-cm presacral abscess with connection to the pouch body as demonstrated by extravasation of contrast. MRI, magnetic resonance imaging.

Fig. 3

Presacral sinus. Presacral sinus demonstrated on ( A ) CT pelvis with rectal contrast extravasation from the IPAA and ( B ) water-soluble contrast enema after serial mushroom catheter downsizing and resolution of the abscess; note the persistent presacral soft-tissue thickening. CT, computed tomography; IPAA, ileal pouch–anal anastomosis.

Fig. 4

Mushroom catheter drainage. A presacral abscess ( A ) can be drained transanally with a mushroom catheter ( B ), healing is achieved with gradual shortening of the catheter, but residual fibrotic presacral soft-tissue thickening is common (panel C in Fig 5 ).

Fig. 5

Stapled sinusotomy. In selected cases with a short-anal canal, an endoscopic linear stapler can be insinuated into the presacral sinus ( A ) and used to perform a stapled sinusotomy ( B ); residual fibrotic presacral soft-tissue thickening is common ( C ).

Fig. 6

Tip of J fluoroscopic drain tube injection study demonstrating fistulous communication to the tip of the J; ( A ) anterior–posterior, ( B ) lateral.

Fig. 7

Revision the tip of the J by oversewing ( A ) or restapling ( B ) at 45 degrees to prevent relative ischemia to the tip of the J which is the farthest point from the mesentery.