Diagnosis and treatment of primary ileal pouch leaks: a 27-year experience at a referral center

Abstract

Background: Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures.

Methods: Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients.

Results: Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4 kg/m², and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the "J" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever.

Conclusion: Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.

Keywords: Anastomotic leak; Ileal pouch-anal anastomosis; Pouch failure; Salvage surgery; Ulcerative colitis.