Revisions Underutilized When an Ileal Pouch Fails

When an ileal pouch fails, patient quality of life often deteriorates quickly and a surgical intervention becomes necessary. But there is little published evidence to guide clinicians in weighing the benefits of revision versus excision.

That is, until now. Colorectal surgeon Stefan D. Holubar, MD, MS, and colleagues in the Cleveland Clinic Department of Colon & Rectal Surgery took a big data approach ― assessing 907,146 colon and rectal procedures nationwide in the American College of Surgeon’s National Surgical Quality Improvement Project (NSQIP) database. Among these, they identified 594 major procedures to surgically repair pouch failures from 2005 to 2016.

“The major result of the study is we didn’t find any difference in short-term outcomes or complications between the patients who had revisions versus excisions,” says Dr. Holubar. “There was some difference in patient selection, but we did statistically propensity matching and, even then, there was no significant difference in the short-term [30-day] surgical outcomes ― meaning they were equally safe.”

The findings were presented at the 13th Congress of the European Crohn’s and Colitis Organisation (ECCO) in Vienna, Austria.

Even though short-term safety did not differ, the study revealed the vast majority, 87 percent, of the 594 interventions in the study were surgical excisions ― meaning only 13 percent were pouch revisions. That was one of the “most striking things we found,” Dr. Holubar says, and points to a need to refer more patients to expert centers, like the Cleveland Clinic, with its extensive pouch revision experience.

In general, following a pouch failure, surgeons have three main options to intervene:

1. Construct a new ileostomy, also known as a ‘rediversion.’
2. Redo the pouch. “This is uncommonly done outside of large referral centers like Cleveland Clinic,” Dr. Holubar says.
3. Excise the pouch, or surgical removal followed by conversion to an end-ileostomy.

“It’s a very important topic for patients who have ulcerative colitis because long-term data from Cleveland Clinic suggests that approximately 92 percent of the time, pouches will work,” Dr. Holubar says. For the remaining 8 percent of patients, choice of intervention can carry quality of life implications.

Figure. Illustration of common IPAA complications. Left panel, 1 = presacral sinus, 2 = leak from tip of the J-pouch, 3 = leak from body of the J-pouch, 4 = pouch-anal anastomotic leak with transphincteric fistula-in-ano, 5 = pouch-vaginal fistula. Right panel illustrates, from top to bottom, afferent limb stricture, pouchitis with aphthous ulcerations and a pouch-anal anastomosis stricture.

Patient quality of life

“One of the messages is, regardless of what you do, patients need to have something done when a pouch fails. Studies indicate that someone with a bad pouch has a poor quality of life,” Dr. Holubar says. “So both the pouch excision and the pouch revision should improve the patient’s quality of life.”

The decision to excise or revise has to be individualized, he adds. “Some patients are very averse to having a permanent ileostomy, and for that subgroup, if they can have a pouch revision, then their relativistic quality of life is going to be better. Other patients have suffered so much they say: ‘Go ahead with excision. I don’t even want to try a redo.’”

Dr. Holubar says that realistically surgeons sometimes find a lot of scarring and adhesions during a planned redo procedure and have to switch to pouch removal mid-procedure, so its important for doctors and patients to be familiar with the anticipated outcomes of both. Patients at Cleveland Clinic are aware of this possibility through the informed consent process.

When to consider referral

Patients who have a poor quality of life because of pouch complications, those with dysfunctional pouches, and patients without Crohn’s disease who develop fistulas, in addition to primary pouch failure are potential candidates for referral to Cleveland Clinic, Dr. Holubar says. In addition, people with Crohn’s disease and a failing pouch can be more complicated to manage and could benefit from expert evaluation.

Dr. Holubar and his research associates plan to further explore their findings by assessing national trends in pouch revision using other large national data sets and to the vast experience of the Department of Colon & Rectal Surgery at Cleveland Clinic.