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

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 2004

St Mark’s Referred n=996 n=245 Total Pouch Dysfunction 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 other 5 1 Karoui et al. DCR 2004

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

Oxford experience (2009) Pouch Dysfunction Reasons for excision 8 8 pouchitis 7 6 ischaemia 6 6 sepsis 5 4 5 Crohns 3 3 incontinence 2 1 1 bleeding 0 1 desmoid 1 2 3 4 5 6 7 8 9 10 <20 years after pouch construction

Pouch dysfunction Dysfunction of the ileal pouch

Pouch dysfunction Dysfunction of the ileal pouch (in the pouch) (Above the pouch) (Below the pouch) (the pouch)

Pouch dysfunction Dysfunction of the ileal pouch Pouchitis Problems with the small bowel (in the pouch) (Above the pouch) Problems with ileal Structural pouch pouch outlet problems (the pouch) (Below the pouch)

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

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

Pouchitis 2/52 metronidazole or ciprofloxacin Pouchitis Poor response to AB Combination Topical Rx with 5- Self intubation with or cyclic AB ASA / Steroids irrigation Good response No improvement Defunctioning ileostomy Good response Poor response Consider ileostomy revearsal Consider Pouch excision

Structural problems with the pouch Structural dysfunction

Structural problems with the pouch Structural dysfunction Ileal pouch Long Small Pouch Twisted Crohns rectostomy efferent Volume Pouch Disease limb / within Pouch afferent loop syndrome Revisional Revisional Excise and surgery: surgery Aggressive re-do pouch excision of Medical MX pouch & new Revisional surgery IPAA Good Poor response response Transabdomi Transanal: nal : new mobile pouch Consider IPAA on DRE ileostomy or pouch excision Sagar et al. BJS 2012

Pouch Dysfunction

Structural problems with the pouch Structural dysfunction Ileal pouch Long Small Pouch Twisted Crohns rectostomy efferent Volume Pouch Disease limb / within Pouch afferent loop syndrome Revisional Revisional Excise and surgery: surgery Aggressive re-do pouch excision of Medical MX pouch & new Revisional surgery IPAA Good Poor response response Transabdomi Transanal: nal : new mobile pouch Consider IPAA on DRE ileostomy or pouch excision Sagar et al. BJS 2012

Problems with the outlet of the pouch Outlet dysfunction

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

Problems with the small bowel Small bowel dysfunction

Problems with the small bowel Pre-pouch Celiac Stenosis at the Irratible Inflammation Bacterial overgrowth site of ileostomy or Pouch / Small bowel dysfunction adhesional Bowel obstruction Exclude Crohns disease Refer to physician with Revesional surgery interest in Conservative Mx Oral 5-ASA / Steroids functional bowel Consider anit-TNF disorders Sagar et al. BJS 2012

• History of poor function Assesment of Poor pouch – Always bad – Recent deterioration • Review histology function • Review peri-operative course • Clinical examination • PR • Pouchoscopy + biopsy

Assesment of Poor pouch • Inside – Flexible pouchoscopy + biopsy • Outside – CT or MR pelvis function • Below – Sphincter physiology and ultrasound – Pouchogram – Defaecating pouchogram – EUA, pouch and cuff biopsies • Above – Small bowel enema

• “Normal/tolerable” function varies considerably Pouch Dysfunction • 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!

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 ¡

Kock Pouch

Pouch Dysfunction

Oxford Colorectal