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P644 Factors and salvage surgery for treatment of pouch failure after restorative proctocolectomy for ulcerative colitis – a single-institution study

Kuroki H., Sugita A., Koganei K., Tatsumi K., Futatsuki R., Obara N.

Yokohama Municipal Citizen's Hospital, Inflammatory Bowel Disease Center, Yokohama City, Japan

Background

For many patients with ulcerative colitis (UC), total colectomy and pouch surgery (ileal pouch-anal canal anastomosis (IACA), ileal pouch-anal anastomosis (IAA)) are performed, improving the quality of life (QOL). However, pouch failure occurs in some patients, markedly reducing their QOL. In this study, we examined the course of patients with pouch failure.

Methods

Of 1,156 patients who underwent total colectomy and pouch surgery under a preoperative diagnosis of UC between 1992 and 2015, the subjects were 26 patients (2.2%) in whom pouch-associated complications led to pouch failure (ileostomy state for 2 years or more or pouch resection). Total colectomy was indicated for 14 patients with refractory UC, 12 with severe UC, and 1 with cancer/dysplasia. Concerning techniques, IACA was selected for 21 patients, and IAA for 5. The median age at the time of pouch surgery was 31 years. The median interval from surgery until the appearance of complication-related symptoms was 19.5 months. The median follow-up period from pouch failure was 60 months.

Results

Among complications causing pouch failure, fistulae from the anastomotic site accounted for 38% (10 patients), the highest percentage. In 4 of these, suture failure was noted as an early complication. In addition, anal canal-associated complications were observed in 34% (9 patients: 7 with anal fistulae, 1 with a vaginal fistula, and 1 with a pouch fistula (5%)). The final outcomes consisted of anal and pouch excision in 11 patients (after re-ileal pouch anal anastomosis in 2), pouch vacant in 14, and redo ileal pouch anal anastomosis in 1 (12%, 3/26). Of these, 1 required additional ileostomy. Finally, concerning the pouch function after stoma closure, the frequency of defecation was 10 to 15 times/day in both patients, facilitating rehabilitation.

Conclusion

In UC patients with pouch failure, the incidence of complications related to fistulae from the anastomotic site was high, suggesting the possibility of early suture failure. For 92% of the subjects, permanent ileostomy was selected. However, redo ileal pouch anal anastomosis was possible in some patients, and closure was possible after temporary ileostomy in others. Treatment methods must be examined in accordance with individual patients.