Third Re-do IPAA Resolves Complications and Vaginal Fistula, Restores Continence: A Case Study

By Tracy Hull, MD

Cleveland Clinic performs the highest volume of inflammatory bowel disease surgery in the country, and has particular experience managing patients sent with complications after surgery elsewhere. Overall mortality and morbidity scores are exemplary based on recent NSQIP datasets, even allowing for the high percentage of reoperative surgery performed at this institution.

Vignette:

A 43-year-old woman from another state had ulcerative colitis diagnosed 10 years prior. When medical therapy no longer kept her symptoms under control, her colon had to be removed.

After removing her colon, surgeons had constructed a pelvic pouch from her small bowel, connected it to her anal area, and formed a loop ileostomy. Her hospital course after surgery lasted nearly two months, because she developed a failure of the joining between the pouch and her anal sphincter muscles. They had thought this had healed, but the leak became evident again when her ileostomy was closed. She next underwent a redo pouch and loop ileostomy, again in her home state. When the ileostomy was done at the time her second pelvic pouch was closed, she started to have stool and gas from her vagina (i.e., she had a hole between the pouch and the vagina).

At this stage, she came to Cleveland Clinic. While reviewing her outside records, we noted a concern from a gynecologist regarding cystic masses in her ovaries so she was seen in conjunction with a gynecologist at Cleveland Clinic. A combined surgery was then performed, with the colorectal surgeon and the gynecologist operating together. The gynecologist removed her uterus, tubes and ovaries while the colorectal surgeons did a third redo pouch and loop ileostomy.

The patient stayed in the hospital for seven days after the surgery. The loop ileostomy was closed in December 2014 and she remains with good bowel function, no holes and no vaginal drainage. She has been able to return to her job as a teacher.

References:

1. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Fazio VW, Kiran RP, Remzi FH, Coffey JC, Heneghan HM, Kirat HT, Manilich E, Shen B, Martin ST. Ann Surg. 2013 Apr;257(4):679-85
2. Transabdominal Redo Ileal Pouch Surgery for Failed Restorative Proctocolectomy: Lessons Learned Over 500 Patients. Remzi FH, Aytac E, Ashburn J, Gu J, Hull TL, Dietz DW, Stocchi L, Church JM, Shen B. Ann Surg. 2015 Oct;262(4):675-82
3. Management and outcome of pouch-vaginal fistulas after IPAA surgery. Mallick IH, Hull TL, Remzi FH, Kiran RP. Dis Colon Rectum. 2014 Apr;57(4):490-6