IPAA Surgical Revision: Lessons Learned from > 500 Patients

Ileal pouch-anal anastomosis (IPAA) failure rates are reported to range from 3 percent to 15 percent, mainly due to technical or inflammatory conditions. Surgical revision is the only option in patients with a failed IPAA to avoid a permanent stoma.

Because redo pouch surgery for failed IPAA is a complex and difficult procedure, data regarding its durability and long-term surgical, functional and quality of life (QOL) outcomes have been limited: Until now.

Leaders from Cleveland Clinic’s Department of Colorectal Surgery shared their large single-center experience with IPAA redos at the recently concluded 135th Annual Meeting of the American Surgical Association— and the news was encouraging.

“With the largest experience in IPAA redos both nationally and internationally and a marked increase in referral cases over the past several years, our analysis of more than 500 patients found that 82.4 percent had a functional IPAA at 10-year follow-up,” says Feza H. Remzi, MD, Chairman of Cleveland Clinic’s Department of Colorectal Surgery.

Table 1: Largest Worldwide IPAA Redo Experience at Cleveland Clinic

Study highlights

The study evaluated 502 patients (43 percent male; median age of 38 years; median BMI of 24 kg/m2) who underwent transabdominal redo surgery for failed IPAA between 1983 and 2014 at Cleveland Clinic, based on a prospectively maintained institutional registry.

Surgeons created a new pouch in 41 percent of patients, while 59 percent underwent revisions to their original pouch. Prior pouch types were J (81 percent), S (18 percent) and W (0.3 percent).

Table 2: Indications for Re-Do Surgery (N = 502)

“Pouchitis is most often due to a septic or inflammatory problem — and most of the time we can fix it,” Dr. Remzi says. “It’s when there’s no known etiology that it’s toughest to handle.”

Dr. Remzi notes that a diagnosis of Crohn’s disease was not a predictive factor for failure of the redo pouch, which essentially meant that some of the redo patients had been misdiagnosed as having Crohn’s disease when they in fact may have experienced complications from the initial surgery. “These patients were told they would need a permanent bag for the rest of their lives, but we were able to help more than 80 percent of them by giving them GI continuity,” he says.

Twenty percent of patients had redo IPAA failure, with pelvic sepsis developing after redo surgery as the primary indicator of pouch failure (P < 0.0001). A second transabdominal redo IPAA was performed in 16 patients after redo IPAA surgery, and the pouch was salvaged in 13 of the cases. Based on Kaplan-Meier estimates, 5-year and 10-year pouch survival after redo surgery were 90 percent and 82.4 percent, respectively.

Postoperative mortality for the redo pouch surgeries was 0 percent and morbidity was 53 percent. The short-term anastomotic leak rate was 8 percent. Median length of stay following surgery was seven days, and the readmission rate was 13 percent.

“Overall, we found that patients with a failed ileoanal pouch who underwent redo pouch surgery at our center had a high likelihood of success in terms of function and quality of life,” Dr. Remzi says.

Patient satisfaction, QOL

Of the patients [n = 261] who answered a Cleveland Global Quality of Life questionnaire, 92 percent said they would undergo the redo surgery again, and 93 percent said they would recommend it to others. Acceptable QOL measures included number of bowel movements, seepage and pad usage; and dietary, social, work and sexual restrictions.

“Most patients are very happy with their outcomes,” Dr. Remzi says. “However, the process needs to be dictated and driven by patient — if patients want to live with an ileostomy and move on, it’s up to them.” He notes that the pouch redo process from beginning to end takes about nine months, but patients are so grateful to have an alternative to a permanent stoma that they are willing to make the commitment.

High referral rate

Around 80 percent of the IPAA redo cases were referred from outside institutions by surgical or medical colleagues (and sometimes by the patients themselves). “Our referral base for redo surgeries includes nearly every state in the country, and we also receive international referrals that have included countries such as Brazil, Australia, Serbia and Turkey,” Dr. Remzi says.

He says the outcomes data should be viewed in the big-picture context: Patients referred to Cleveland Clinic are some of the most difficult cases in the country, and they are often referred late, rather than early, following an IPAA failure. The study found the shortest referral time was three years and the longest was 29 years. Dr. Remzi would like to see that change.

“Patients should not be ping-ponged from one doctor to another,” he says. “Many of the cases we see are sad and even tragic. These patients need to be referred to the right center, and early rather than late.”

The study found that there had been an attempt to repair at least 25 percent to 30 percent of the pouches from the bottom and 10 percent from the top prior to the cases being referred to Cleveland Clinic. “The more that’s done before these cases are referred, the higher chance there is that the redo surgery won’t be successful,” Dr. Remzi says.

Ileal Pouch Center: A multidisciplinary approach

Since 2002, most of Cleveland Clinic’s IPAA redos have been coordinated through its Ileal Pouch Center, the world’s first and largest multidisciplinary pouch center. Surgeons at the center see the highest volumes in the country of both initial and reoperative J-pouch cases, including pouches that have failed either from disease or complications related to prior surgical procedures. Cleveland Clinic has one of the lowest pouch failure rates reported by any institution nationwide.

“There are times when we need to push the limits to clear infection,” Dr. Remzi says. “If we don’t fully clear it, our efforts will be futile because the issues will come back. Our multidisciplinary infrastructure gives us more latitude to push those limits. While we rarely need to call them in, we do have urologists or vascular surgeons that can collaborate with us whenever needed.”

Dr. Remzi points out that the majority of initial IPAA surgeries are nonemergent, and as such, patients should always be referred to Cleveland Clinic or another center of excellence from the outset. “I don’t want to be doing re-dos for the rest of my life,” he says. “I used to do a redo pouch surgery once a month, and for the past two years, I have been doing them twice a week on average. If the initial surgeries are performed in the right hands, we would have far fewer redos to do.”

He adds: “It’s a complex colorectal surgery, and you always have to stay three to four steps ahead. If the surgery is successful the first time, it prevents the nightmares of suffering some of these patients have gone through when a failure occurs. We are here to serve our patients and referring physicians by pushing the limits with our collective ‘act as a unit’ model, to deliver the best care available.”

Suggested Reading

Remzi FH, Aytac E, Ashburn J, Gu J, Hull TL, Dietz DW, Stocchi L, Church JM, Shen B. Trans-abdominal redo ileal pouch surgery for failed restorative proctocolectomy lessons learned over 500 patients [Abstract]. Presented at: American Surgical Association’s 135th Annual Meeting; April 23−25, 2015; San Diego, CA. http://meeting.americansurgical.org/abstracts/2015/30.cgi. Accessed July 16, 2015.

Remzi FH, Aytac E, Ashburn J, Gu J, Hull TL, Dietz DW, Stocchi L, Church JM, Shen B. Trans-abdominal redo ileal pouch surgery for failed restorative proctocolectomy lessons learned over 500 patients. Ann Surg. In press [2015].

To refer a patient to the Department of Colorectal Surgery, call 855.REFER.123. Dr. Remzi can be reached at 216.445.5020 or remzif@ccf.org.