Pouch Function and Dysfunction Mr Roel Hompes MD Consultant - - PowerPoint PPT Presentation

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pouch function and dysfunction mr roel hompes md
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Pouch Function and Dysfunction Mr Roel Hompes MD Consultant - - PowerPoint PPT Presentation

Sep 29, 2023 137 likes •434 views

Pouch Function and Dysfunction Mr Roel Hompes MD Consultant Colorectal Surgeon OUH What is normal ? 20% of pouches behaves badly Pouch Dysfunction Upstream Within the Small bowel pouch Pouch outlet Pouch Dysfunction Karoui et al. DCR

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Mr Roel Hompes MD Consultant Colorectal Surgeon OUH Pouch Function and Dysfunction

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What is normal ?

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Pouch Dysfunction

20% of pouches behaves badly Pouch outlet Upstream Small bowel Within the pouch

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Pouch Dysfunction

Karoui et al. DCR 2004

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Pouch Dysfunction

Karoui et al. DCR 2004

St Mark’s n=996 Referred n=245 Total No patients 58(5.6%) 10(4%) 68 Pelvic sepsis 28 5 33(48.5%) Pouch fistula 24 4 Crohns 3 2 Poor function 21 3 24(35.2%) Pouchitis 4 1

  • ther

5 1

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Pouch Dysfunction

498 IPAA 30 Pouch excisions, 7 immediate 27 in house 3 elsewhere Oxford experience (2009)

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Pouch Dysfunction

Oxford experience (2009)

Reasons for excision 8 pouchitis 6 ischaemia 6 sepsis 5 Crohns 3 incontinence 1 bleeding 1 desmoid

1 2 3 4 5 6 7 8

1 2 3 4 5 6 7 8 9 10 <20 years after pouch construction

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Pouch dysfunction

Dysfunction of the ileal pouch

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Pouch dysfunction

Dysfunction of the ileal pouch

(Above the pouch) (Below the pouch) (in the pouch) (the pouch)

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Pouch dysfunction

Dysfunction of the ileal pouch Problems with ileal pouch outlet Pouchitis Structural pouch problems Problems with the small bowel

(Above the pouch) (Below the pouch) (in the pouch) (the pouch)

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Pouchitis

Pouchitis

2/52 metronidazole or ciprofloxacin Good response Recurrent episodes Repeat Tx with AB Commence probiotics such as VSL3

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Pouchitis

Pouchitis

2/52 metronidazole or ciprofloxacin Poor response Change AB Good response Poor response

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Pouchitis

Pouchitis

2/52 metronidazole or ciprofloxacin Poor response to AB Combination

  • r cyclic AB

Good response No improvement Topical Rx with 5- ASA / Steroids Self intubation with irrigation Defunctioning ileostomy Good response Poor response Consider ileostomy revearsal Consider Pouch excision

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Structural dysfunction

Structural problems with the pouch

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Structural dysfunction

Structural problems with the pouch

Ileal pouch rectostomy Crohns Disease within Pouch Twisted Pouch Small Pouch Volume Long efferent limb / afferent loop syndrome Revisional surgery Revisional surgery: excision of pouch & new IPAA Revisional surgery Transabdomi nal : new IPAA Transanal: mobile pouch

  • n DRE

Excise and re-do pouch Aggressive Medical MX Poor response Consider ileostomy or pouch excision Good response Sagar et al. BJS 2012

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Pouch Dysfunction

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Structural dysfunction

Structural problems with the pouch

Ileal pouch rectostomy Crohns Disease within Pouch Twisted Pouch Small Pouch Volume Long efferent limb / afferent loop syndrome Revisional surgery Revisional surgery: excision of pouch & new IPAA Revisional surgery Transabdomi nal : new IPAA Transanal: mobile pouch

  • n DRE

Excise and re-do pouch Aggressive Medical MX Poor response Consider ileostomy or pouch excision Good response Sagar et al. BJS 2012

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Outlet dysfunction

Problems with the outlet of the pouch

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Outlet dysfunction

Problems with the outlet of the pouch

Stenosis Perianal excoriation Paradoxal puborectalis contraction Prolapse Pouch vaginal fistula Anal fistula FI Cuffitis Dilatation with Hegar dilators Good response Recurrence Consider self dilatation Clean, avoid soap, dry with hairdryer, Zn based paste Topical 5- ASA / sterioids Mucosectomy +/- PA Loperamideb ulking agents diet Lay open Seton / Plug AF Button plug Formal repair BFB Botox injection Pouch Pexy Sagar et al. BJS 2012

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Small bowel dysfunction

Problems with the small bowel

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Small bowel dysfunction

Problems with the small bowel

Pre-pouch Inflammation Irratible Pouch / Bowel Stenosis at the site of ileostomy or adhesional

  • bstruction

Exclude Crohns disease Oral 5-ASA / Steroids Consider anit-TNF Revesional surgery Conservative Mx Refer to physician with interest in functional bowel disorders Celiac Bacterial overgrowth Sagar et al. BJS 2012

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Assesment of Poor pouch function

  • History of poor function

– Always bad – Recent deterioration

  • Review histology
  • Review peri-operative course
  • Clinical examination
  • PR
  • Pouchoscopy + biopsy
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Assesment of Poor pouch function

  • Inside

– Flexible pouchoscopy + biopsy

  • Outside

– CT or MR pelvis

  • Below

– Sphincter physiology and ultrasound – Pouchogram – Defaecating pouchogram – EUA, pouch and cuff biopsies

  • Above

– Small bowel enema

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Pouch Dysfunction

  • “Normal/tolerable” function varies considerably
  • Not all pouch dysfunction is pouchitis
  • Problems may not just be within the pouch
  • Sepsis is commonest factor leading to failure
  • Consider salvage before excision
  • Kock pouch may have a future!
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Kock Pouch

¡ Kock ¡NG. ¡Intra-­‑abdominal ¡"reservoir" ¡in ¡pa9ents ¡with ¡permanent ¡ ileostomy: ¡preliminary ¡observa9ons ¡on ¡a ¡procedure ¡resul9ng ¡in ¡ faecal ¡"con9nence" ¡in ¡five ¡ileostomy ¡pa9ents. ¡Arch ¡Surg ¡ 1969;99:223-­‑231 ¡

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Kock Pouch

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Pouch Dysfunction

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Oxford Colorectal