Abstract
BACKGROUND: Following proctocolectomy and ileal pouch-anal anastomosis, a small percentage of patients will have poor functional results attributable to pouchitis or anastomotic or septic complications. Additionally, functional failures can occur secondary to limited pouch capacity and compliance. We present five such patients managed with operative conversion to W-ileal pouch-anal anastomosis and examined physiologic parameters important for improving functional results. METHODS: Five female patients (mean age, 30 (range, 24–39) years) with poorly functioning J-ileal pouch-anal anastomoses were referred for evaluation with symptoms of high stool frequency and incontinence problems. Three had severe nocturnal incontinence, and the remaining two patients experienced minor nocturnal incontinence. Preoperative and postoperative evaluation included barium pouch studies, flexible sigmoidoscopy, anal manometry, evacuation volume, and pouch compliance. Pouch-to-anal pressure gradients were calculated. To improve reservoir capacity and compliance, all five patients underwent conversion to W-ileal pouch-anal anastomoses. RESULTS: Twenty-four hour and nocturnal stool frequencies decreased from 13.8±1.7 and 3±1.3 to 5.8±0.3 and 0.3±0.2 postconversion (P<0.05). Mean pouch evacuation volume increased from 83±27 to 290±29 ml postoperatively (P<0.05). Pouch compliance increased from 2.7±0.5 mmHg/ml to 7.7±0.6 mmHg/ml postconversion (P<0.05). Improvement in postconversion stool frequency correlated with an increase in pouch evacuation volume (r=−0.87). All patients reported improved day and nocturnal continence, despite no significant change between preoperative and postoperative anal manometric pressures. Improved continence correlated with a significant widening of the pouch-to-anal pressure gradients, which increased from 5 to 25 mmHg at 150 ml following pouch conversion. CONCLUSIONS: Poorly functioning ileal reservoirs secondary to limited capacity and compliance can be successfully managed with conversion to W-ileal pouch-anal anastomosis. The increased pouch capacity is associated with improvement in compliance and widening of the pouch-to-anal pressure gradients, providing excellent functional results.
Similar content being viewed by others
References
Kohler LW, Pemberton JH, Zinsmeister AR, Kelly KA. Quality of life after proctocolectomy: a comparison of Brooke ileostomy, Kock pouch, and ileal pouch-anal anastomosis. Gastroenterology 1991;101:679–84.
Harms BA, Andersen AB, Starling JR. The W ileal reservoir: long-term assessment after proctocolectomy for ulcerative colitis and familial polyposis. Surgery 1992;112:638–48.
Sagar PM, Dozois RR, Wolff BG, Kelly KA. Disconnection, pouch revision and reconstruction of the ileal pouch-anal anastomosis. Br J Surg 1996;83:1401–5.
Galandiuk S, Scott NA, Dozois RR,et al. Ileal pouch anal-anastomosis: reoperation for pouch-related complications. Ann Surg 1990;212:446–54.
Poggioli G, Marchetti F, Selleri S, Laureti S, Stocchi L, Gozzetti G. Redo pouches: salvaging of failed ileal pouchanal anastomosis. Dis Colon Rectum 1993;36:492–6.
Stryker SJ, Phillips SF, Dozois RR, Kelly KA, Beart RW Jr. Anal and neorectal function after ileal pouch-anal anastomosis. Ann Surg 1986;203:55–61.
Oresland R, Fasth S, Nordgren S, Hulten L. Pouch size: the important functional determinant after restorative proctocolectomy. Br J Surg 1990;77:265–9.
Tuckson WB, Fazio VW. Functional comparison between double and triple ileal loop pouches. Dis Colon Rectum 1991;34:17–21.
O'Connell PR, Pemberton JH, Brown ML, Kelly KA. Determinants of stool frequency after ileal pouch-anal anastomosis. Am J Surg 1987;153:157–64.
Beart RW Jr, Dozois RR, Wolff BG, Pemberton JH. Mechanisms of rectal continence: lessons from the ilealanal procedure. Am J Surg 1985;149:31–4.
Harms BA, Pahl AC, Starling JR. Comparison of clinical and compliance characteristics between S and W ileal reservoirs. Am J Surg 1989;159:34–40.
Taylor BM, Beart RW Jr, Dozois RR, Kelly KA, Phillips SF. Straight ileoanal anastomosisversus ileal pouch-anal anastomosis after colectomy and mucosal proctectomy. Arch Surg 1983;118:696–701.
Rabau MY, Percy JP, Parks AG. Ileal pelvic reservoir: a correlation between motor patterns and clinical behaviour. Br J Surg 1982;69:391–5.
Harms BA, Pellet JR, Starling JR. Modified quadrupleloop (W) ileal reservoir for restorative proctocolectomy. Surgery 1987;101:234–7.
Goes R, Beart RW Jr. Physiology of ileal pouch-anal anastomosis: current concepts. Dis Colon Rectum 1995;38:996–1005.
Taylor BM, Cranley B, Kelly KA, Phillips DF, Beart RW Jr, Dozois RR. A clinicophysiologic comparison of ileal pouch-anal and straight ileoanal anastomosis. Ann Surg 1983;198:462–8.
Nasmyth DG, Johnston D, Godwin PG, Dixon MF, Smith A, Williams NS. Factors influencing bowel function after ileal pouch-anal anastomosis. Br J Surg 1986;73:469–73.
Farouk R, Duthie GS, Bartolo DC. Recovery of the internal anal sphincter and continence after restorative proctocolectomy. Br J Surg 1994;81:1065–8.
Author information
Authors and Affiliations
Additional information
Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.
About this article
Cite this article
Klas, J., Myers, G.A., Starling, J.R. et al. Physiologic evaluation and surgical management of failed ileoanal pouch. Dis Colon Rectum 41, 854–861 (1998). https://doi.org/10.1007/BF02235365
Issue Date:
DOI: https://doi.org/10.1007/BF02235365