Reconstruction for chronic dysfunction of ileoanal pouches

Objective A retrospective review was performed to determine the results after surgica l reconstruction for chronic dysfunction of ileal pouch-anal procedures for ulcerative colitis and familial colonic polyposis at a university medical center. Methods During the 20-year period from 1978 to 1998, 601 patients underwent colecto my and ileal pouch-anal anastomosis. (IPAA) for ulcerative colitis, familia l colonic polyposis, or Hirschsprung's disease. A J pouch was used for 351 patients, a lateral pouch for 221, an S pouch for 6, and a straight pull-th rough for 23. Acute complications after pouch construction have been detail ed in previous publications and are not included in this study. Chronic pou ch stasis with diarrhea, frequency, urgency, and soiling gradually became m ore severe in 164 patients (27.3%), associated with pouch enlargement, an e longated efferent limb, and obstruction to pouch outflow, largely related t o the pouch configuration used during the authors' early clinical experienc e. These patients were sufficiently symptomatic to be considered for recons truction (mean 68 months after IPAA). Transanal resection of an elongated I PAA spout was performed on 58 patients; abdominoperineal mobilization of th e pouch with resection and tapering of the lower end (AP reconstruction) an d ileoanal anastomosis on 83; pouch removal and new pouch construction on 7 ; and conversion of a straight pull-through to a pouch on 16. Results Good long-term results (mean 7.7 years) with improvement in symptoms occurr ed in 98% of transanal resections, 91.5% of AP reconstructions, 86% of new pouch constructions, and 100% of conversions of a straight pull-through to a pouch. The average number of bower movements per 24 hours at 6 months was 4.8. Complications occurred in 11.6% of reconstructed patients. Five of th e 164 patients (3.1%) required eventual pouch removal and permanent ileosto my. The high rate of pouch revision in this series of patients undergoing I PAA is due to a policy of aggressive correction when patients do not experi ence an optimal functional result, or have a progressive worsening of their status. Conclusions Although occasionally a major undertaking, reconstruction of ileoanal pouch es with progressive dysfunction due to large size or a long efferent limb h as resulted in marked improvement in intestinal function in >93% of patient s and has reduced the need for late pouch removal.