failures

Akershus University Hospital
Salvage surgery
Arne Engebreth Færden, Ph.d
Department of Digestive Surgery, Akershus University
Hospital, Faculty of Medicine, University of Oslo
Pouch failure; pouch removed or disconnected
with a proximal stoma
Failure rates after IPAA
Author
n
Fazio
1965
5
4.4
Farouk
1386
8
9
Tulschinsky
634
5
10
9
13
Lepistö
486
10
7
Hueting
9317
>5
(Cleveland
(Mayo Clinic)
(St Marks)
(Helsinki)
(metaanalysis)
The British pouch
registry
2491
follow-up(years)
5 (10)
failure %
8.5
9 (16,1)
Kalblom
(Uppsala)
188
5 (10)
5,4 (6,9)
Hahnloser
Sveits
1885
5 (20)
3,7 (8)
Risk of pouch failure
Hahnloser et al,2007
Risk of pouch failure
S. Kørsgren, M.R.B. Keighley: causes of failure and life expectancy of the ilioanal
pouch.
Int J Colorectal Dis (1997) 12:; 4-8
Major causes of pouch failure*
pelvic sepsis >50 %
”poor function” 30 %
pouchitis ca 5-10 %
Crohn´s disease
*Tulchinsky H, Ann Surg 2003; 238(2):229-234.
Risk for septic complications
Odo A. Heuschen, Annals of Surgery 2002. Vol 235 , no 2. 207-216
Septic complications
Level 1: Upper and middle
part of the puoch n=13
Level 2. The rectal Cuff
N=41
Level 3: Pouch anal
anastomosis n=66
Odo A. Heuschen, Annals of Surgery 2002. Vol 235 , no 2. 207-216
Odo A. Heuschen,,. B.J.S 2002, 89,194-200
Diagnosis
Digital Exmination
Pouch endoscopy
CT Scan
Contrast pouchography
MRI
Control sepsis
•
•
•
•
Drain abscess
Internal
Percutanes drainage
Seton
• Diverting stoma?
11
Salvage Surgery
• Pasients wishes?
• Is salvage possible?
12
Minor surgery?
Ann Surg. 1998 October; 228(4): 588–597.
V W Fazio, J S Wu, and I C Lavery
13
Cleveland Clinic Florida*
67 patients with pouch failure
28 patients local operations;success rate
75% (mean number of operations 2,1)
Transperianal advancement
Graciles muscle interposition
Seton
Drainage
Shawki S, Dis Colon Rectum 2009; 52(5):884-890.
Mount Sinai Hospital
Minor surgey
Local procdures n=19 Sucess rate n=2
(10,5%)
Fibrin glue n=2 (0%)
Sutur closing n=1 (0%)
Transvaginal flap n=1 (0%)
Transanal flap n=5 (20%)
Ileal Advancment Flap n= 9 (12%)
Gracils flap interposition n=1 (0%)
.
Pouch vaginal fistula
16
Pouch-vaginale fistula. 3,3%-15,8%
Publication
year
Number of
operated
women
Patients with
PVF
Fonkalsrud
1987
76
3
3,9
Schoetz et al
1988
79
2
3,7
Wexner et al
1989
304
27
6,9
Groom et al
1993
161
22 (17+5)
10,6
O`Kelly et al
1994
50
7
12
Neilly et al
1999
98
5
5,6
Maclean
2002
57
9
15,8
Shah et al
2003
993
60(33+27)
3,3
1809
136(113+33)
6,3
Total
Incidens (%)
St. Marks Hospital*
68 pasients with pouch vaginal fistula (Chrohn 8, UC 49, FAP
10, Indeterminate colitis 1)
14 pouch excision or permanent diversion with pouch in situ
45 operated
37 transvaginal (35%)
2 perianal pouch revision (50%)
6 abdominal pouch revision REDO (67%)
*Heriot AG. Diseases of the Colon & Rectum. 48(3):451-8, 2005 Mar. St. Mark`s Hospital
CLEVELAND CLINIC, OHIO*
60 pasents with PVF,
UC 53, FAP1, Indeterminate colitis 6
Ileal advancment Flap 22 out of 63 with success(33% )
Redo restorative proctolectomi 10 out of 16 with sucess (62,5%)
Total 31 out of 60 (52%) success
Non Crohn 27 out of 36 (75%)
Crohn 4 out of 24 (17%)
*Shah NS. Diseases of the Colon & Rectum. 46(7):911-7, 2003 Jul.
Ileal Advancment Flap
Ileal Advancment Flap
Ileal Advancment Flap
Pouch vaginal fistula-colagen plug
Gonsalves S, Dis Colon Rectum 2009; 52(11):1877188
7 patients . Sucess rate 57% . Follow up 15 weeks
Mirnezami AH Tech Coloproctol 2009; 13(3):259-260.
7 patients. Sucess rate 57 %. Follow up 1 year
Gajsek U, Dis Colon Rectum 2011; 54(8):999-1002.
11 patients. Success rate 0%. Follow up 2 years.
24
REDO?
The surgical approch is
determned by the level of the
fistula, absess or sinus
If there is a significant lenght of anorectal stump
below the level of he fistula, abdominal pouch
advancment has a high change of success*
Tekkis PP,.Br J Surg 2006; 93(2):231-237.
25
Results of Redo IPAA for septic
complications
Author Year
Number of patients
Succes rate
Fazio 1998
22 UC
10 CD
95%
60%
Ogunbiyi 1997
8
70%
Dayton 2001
11
100%
Baixauli 2004
74
70%
MacLean 2002
57
70%
Heuschen 2002
74
71%
Tekkis 2006
117
5 år 70%
85% non septic
61% Septic
30
Konklusjon septiske komplikasjoner
Lokale inngrep hvor dette er mulig kan/bør forsøkes som 1.
behandlingsalternativ, men tilheling er relativ lav.
Hos pasienter hvor fistlel/sinus utgår fra anastomosen eller
ovenfor og det er nok plass distalt til å få mobilisert anastomosen
til å dekke fistlen/sinusen, bør abdominal tilgang med REDO
tilbys.
Transabdominal tilgang er ikke alternativ der hvor fistlen oppstår i
analkanalen, da det ikke er nok plass til å få sydd ny anastomose
nedenfor fistel/sinus.
Udiagnostisert Crohn har minimal sjanse for tilheling
Major causes of pouch failure*
pelvic sepsis >50 %
”poor function” 30 %
pouchitis ca 5-10 %
Crohn´s disease
*Tulchinsky H, Ann Surg 2003; 238(2):229-234.
Poor function
Low pouch volume
Inflamed ano-rectal mucosa below the anastomosis ”Cuffitis”
Outlet obstruction, long anorectal segment
Anastomotic strictures
Pouch prolapse
34
Poor function
Low pouch volume
Inflamed ano-rectal mucosa below the anastomosis ”Cuffitis”
Outlet obstruction, long anorectal segment
Anastomotic strictures
Pouch prolapse
Results of Redo IPAA
Author Year
Number of patients
Quality of
Life/Function
(Good or excelent)
Succesive Salvage
rate
Fonkalsrud 1999
164
94%
97%
Fazio 1998
35
57%
86%
Ogunbiyi 1997
16
50%
50%
Dayton 2001
16
50%
100%
Baixauli 2004
101
70%
70%
Mac Lean 2002
57
74%
70%
Heuschen
131
69%
Tekkis 2006
117
5 år 70%
85% non septic
61% Septic
38
Poor function
Low pouch volume
Inflamed ano-rectal mucosa below the anastomosis ”Cuffitis”
Outlet obstruction, long anorectal segment
Anastomotic strictures
Pouch prolapse
Pouch prolaps
40
Major causes of pouch failure*
pelvic sepsis >50 %
”poor function” 30 %
pouchitis ca 10 %
Crohn´s disease
*Tulchinsky H, Ann Surg 2003; 238(2):229-234.
Pouchitis
• Pouchitis is no indication for salvage surgery
• BUT: Septic complications in IPAA patients may
mimic symptoms pauchitis; so called seconary
pouchitis*
*Heuschen UA, . Br.J Surg. 2002; 89:194-200
42
Bekken reservoar med fistler
rtg antegrad reservoar : kontrastfyllt reservoar og multiple fistler til
tynntarm + delvis framstilling av den perianale /transpinkteriske fistelen
Bekken reservoar med fistel dannelse, MR
Fistel i det perianale
fettvevet
Intersphinkterisk
abscess
sacrum
reservoar
Supralevatorisk
fistel
fistel
Sagital
Thank you
45
Afferent Limb Syndrome (2%*)
*Kirat HT Inflamm.Bowel.Dis. 2011; 17:1287-1290
46
Pouch dysfunction
Pouchitis
Pouch hypermotility laparotomy with
Low pouch volume pouch augmentatio
Afferent Limb Syndrom
Mucosal folds
Pouch prolapse
transanal excision
pouch-pexy
Anal canal dysfunction
Reduced anal pressures,
internal or external anal sphincter damage
stretch and/or denervation
Anflamed ano-rectal mucosa below the
anastomosis
Outlet obstruction, long anorectal segment
Anastomotic strictures
Small bowel dysfunction
Bacterial overgrowth
Coeliac disease
Lactose intolerance
Crohns disease
High volume output
etc
Consult the gastroenterologist!
Indications redo:
fistula from pouch or anastomosis to
the vagina or perineum
outlet obstruction, long outlet, severe
stenosis or severe postinflammatory
fibrosis at the anastomosis
Ileal Advancment Flap
52
Baixauli J. Delaney CP. Wu JS. Remzi FH. Lavery IC. Fazio VW.
Functional Outcome and Quality of Life after Repeat Ileal
Pouch-Anal Anastomosis for Complications of Ileoanal
Surgery.
Diseases of the Colon & Rectum. Vol. 47(1)(pp 2-11), 2004.
101 pasienter etter gjentatt IAA operasjon
88 fikk lagt ned sin avlastende stomi.
2 fikk ny iliostomi
13 fjernet resevoiret
5 års pouch overlevelse 74%
Antall tømninger mean 6,3 om dagen og 2 natt
Bind 50 dag, 69 natt.
97% ville evt gjenta prosedyren og 99% ville
anbefale det til andre
Summary; when a patient is facing pouch failure:
-if possible consider a local procedure.
-redo is often an alternative provided there is a functioning
sphincter and that failure is not due to pouchitis.
-conversion to a continent ileostomy may be an alternative
when there is no functioning sphincter.
These are major procedures with a considerable risk for
complications.The majority of patients will eventually have
functioning pouch.
a
-when the option is a permanent ileostomy the pouch may be left in situ for a
considerable time
55
Pouch dysfunction
Pouchitis
Pouch hypermotility laparotomy with
Low pouch volume pouch augmentatio
Afferent Limb Syndrom
Mucosal folds
Pouch prolapse
transanal excision
pouch-pexy
Ann Surg. 1998 October; 228(4): 588–597.
V W Fazio, J S Wu, and I C Lavery
58
59
Health related Quality of Life
Pouch ”failures”
SF-36
100
80
60
40
pouch "failures" = 26
referenspopulation = 156
20
0
PF
RP
BP
GH
VT
SF
RE
MH
Pouch-vaginale fistler. Forekomst
3,6%-12%
Lee PY. Fazio VW. Church JM. Hull TL. Eu KW. Lavery IC. Vaginal fistula
following restorative proctocolectomy. Diseases of the Colon &
Rectum. 40(7):752-9, 1997 Jul.
506 kvinner hvorav 19( 3,6%) utviklet Anovaginale fistler
Wexner SD. Rothenberger DA. Jensen L. Goldberg SM. Balcos EG.
Belliveau P. Bennett BH. Buls JG. Cohen JM. Kennedy HL. et al. Ileal
pouch vaginal fistulas: incidence, etiology, and management. Diseases
of the Colon & Rectum. 32(6):460-5, 1989 Jun.
304 kvinner hvorav 21 (7%) utviklet anovaginale fistler
Groom JS. Nicholls RJ. Hawley PR. Phillips RK. Pouch-vaginal fistula.
British Journal of Surgery. 80(7):936-40, 1993 Jul.
161 kvinner hvorav 17( 11%) utviklet Anovaginale fistler
Lolohea S. Lynch AC. Robertson GB. Frizelle FA.
Ileal pouch-anal anastomosis-vaginal fistula: A review. [ Review]
Diseases of the Colon & Rectum. Vol. 48(9)(pp 1802-1810), 2005.