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Transcript of Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of...
![Page 1: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/1.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
The Problem PouchThe Problem Pouch
Bruce GeorgeBruce George
Department of Colorectal Surgery Department of Colorectal Surgery John Radcliffe Hospital, OxfordJohn Radcliffe Hospital, Oxford
M25 Course 2011
![Page 2: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/2.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Pouch surgery – the agony
![Page 3: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/3.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Long Term Failure Rates from St Mark’s
Karoui Cohen and Nicholls DCR 2004
![Page 4: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/4.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Indications for Pouch Excision at St Mark’s
St Mark’s n=996
Referred n=245 Total
No patients 58(5.6%) 10(4%) 68Pelvic sepsis 28 5 33(48.5%)
Pouch fistula 24 4
Crohns 3 2Poor function 21 3 24(35.2%)
Pouchitis 4 1
other 5 1Karoui, Cohen, and Nicholls DCR 2004
![Page 5: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/5.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Causes of Pouch FailureCauses of Pouch Failure
49 (8.8%) of 551 pouches failed
9 (1.6%) defunctioned
- 21 (39%) anastomotic leak
- 13 (23%) poor function
- 7 (12%) pouchitis
- 7 (12%) pouch leakage
- 7 (12%) perianal disease
- 3 (5%) variousMacRae et al Dis Col Rect 1997
![Page 6: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/6.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Timing of pouch excision
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10 <20 years after pouch construction
number
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Oxford
Colorectal
Restorative Proctocolectomy
Initial Assessment of Poor Pouch Function
• History of poor function–Always bad
–Recent deterioration
• Review histology
• Review peri-operative course
• Clinical examination
• PR
• Pouchoscopy + biopsy
![Page 8: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/8.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Common problems
• Pouchitis–Metronidazole
– ciprofloxacin
• Pouch-anal anastomotic stricture–EUA + gentle dilatation
• Cuffitistopical steroids or mesalazine
![Page 9: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/9.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Persisting poor function
• Look:– In the pouch
–Outside the pouch
–Below the pouch
–Above the pouch
![Page 10: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/10.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Problems Arising in the PouchProblems Arising in the Pouch
Pouchitis
Inadequate pouch volume (n = 200 - 450 ml)
Abnormal motility
![Page 11: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/11.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
• Problems outside the pouch:
–Pelvic abscess
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Oxford
Colorectal
Restorative Proctocolectomy
Problems below the pouchProblems below the pouch
Pouch anal anastomotic stenosis (9-19%)
Pouch vaginal fistulas (4-10%)
Poor sphincter function
Cuffitis
Paradoxical puborectalis contraction
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Oxford
Colorectal
Restorative Proctocolectomy
Small Bowel Problems above the pouchSmall Bowel Problems above the pouch
Adhesions 15-30% symptomatic
5-10% need re-operation
Functional obstruction - ileal brake
Small bowel bacterial overgrowth
Crohn’s disease (5-7%)
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Oxford
Colorectal
Restorative Proctocolectomy
Assessment of persistent 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
![Page 15: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/15.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
Cuffitis - TreatmentCuffitis - Treatment
• medical - largely empirical
- steroids, per anal or oral
- 5ASA compounds, per anal or oral
- lignocaine jelly, per anal
• surgery - mucosectomy Curran & Hill 1992
- mucosectomy & pouch advancement
Fazio & Tjandra 1994
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Oxford
Colorectal
Restorative Proctocolectomy
Treating the early abscess or anastomotic dehiscence
• EUA assessment
• Abscess – drain mushroom catheter, CT drain
• Dehiscence – drain, early resuture or advancement
• Wait, pouchogram, consider re operation
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Oxford
Colorectal
Restorative Proctocolectomy
0.5
0.4
0.3
0.2
0.1
0.00 20 40 60 80 100 120 140
overall
chronic
Follow up (m)
Pro
po
rtio
n o
f ri
sk
Keranen et al Dis Col Rect 1997
Cumulative Risk of Pouchitis
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Oxford
Colorectal
Restorative Proctocolectomy
Fistula at AnastomosisFistula at Anastomosis
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Oxford
Colorectal
Restorative Proctocolectomy
Pouch related fistulaPouch related fistula
59 of 1040 IPAA
• 24 pouch vaginal
• 11 pouch cutaneous
• 16 pouch perineal
• 8 pouch presacral
32% eventually excised
Ozuner et al Dis Col Rect 1997
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Oxford
Colorectal
Restorative Proctocolectomy
Try Local Repair First if:Try Local Repair First if:
• gross sepsis absent
• granulation tissue minimal
• fistulas close to anal verge
• strictures are short
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Oxford
Colorectal
Restorative Proctocolectomy
Repeat IPAA - indicationsRepeat IPAA - indications
• mechanical outlet obstruction
• lack of reservoir capacity
• sepsis
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Oxford
Colorectal
Restorative Proctocolectomy
Pouch Revision for septic complications35 patients repeat IPAA
Outcome 86% functioning pouches, 4 excised
Function 57% good, 43% fair or poor,
Pad usage and seepage 60-70%
Fazio et al Ann Surg 1998
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Oxford
Colorectal
Restorative Proctocolectomy
SummaryInitial Assessment of Poor Pouch Function
• History of poor function–Always bad
–Recent deterioration
• Review histology
• Review peri-operative course
• Clinical examination
• PR
• Pouchoscopy + biopsy
![Page 24: Oxford Colorectal Restorative Proctocolectomy The Problem Pouch Bruce George Department of Colorectal Surgery John Radcliffe Hospital, Oxford M25 Course.](https://reader034.fdocuments.in/reader034/viewer/2022051001/56649e465503460f94b3ad8e/html5/thumbnails/24.jpg)
Oxford
Colorectal
Restorative Proctocolectomy
SummaryAssessment of persistent 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