PHYSIOLOGICAL EVALUATION AND SURGICAL-MANAGEMENT OF FAILED ILEOANAL POUCH

BACKGROUND: Following proctocolectomy and ileal pouch-anal anastomosis , a small percentage of patients will have poor functional results att ributable to pouchitis or anastomotic or septic complications. Additio nally, functional failures can occur secondary to limited pouch capaci ty and compliance. We present five such patients managed with operativ e conversion to W-ileal pouch-anal anastomosis and examined physiologi c parameters important for improving functional results. METHODS: Five female patients (mean age, 30 (range, 24-39) years) with poorly funct ioning J-ileal pouch-anal anastomoses were referred for evaluation wit h symptoms of high stool frequency and incontinence problems. Three ha d severe nocturnal incontinence, and the remaining two patients experi enced minor nocturnal incontinence. Preoperative and postoperative eva luation included barium pouch studies, flexible sigmoidoscopy, anal ma nometry, evacuation volume, and pouch compliance. Pouch-to-anal pressu re gradients were calculated. To improve reservoir capacity and compli ance, all five patients underwent conversion to W-ileal pouch-anal ana stomoses. RESULTS: Twenty-four hour and nocturnal stool frequencies de creased from 13.8 +/- 1.7 and 3 +/- 1.3 to 5.8 +/- 0.3 and 0.3 +/- 0.2 postconversion (P < 0.05). Mean pouch evacuation Volume increased fro m 83 +/- 27 to 290 +/- 29 ml postoperatively (P < 0.05). Pouch complia nce increased from 2.7 +/- 0.5 mmHg/ml to 7.7 +/- 0.6 mmHg/ml postconv ersion (P < 0.05). Improvement in postconversion stool frequency corre lated with an increase in pouch evacuation volume (r = - 0.87). All pa tients reported improved day and nocturnal continence, despite no sign ificant change between preoperative and postoperative anal manometric pressures. Improved continence correlated with a significant widening of the pouch-to-anal pressure gradients, which increased from 5 to 25 mmHg at 150 ml following pouch conversion. CONCLUSIONS: Poorly functio ning ileal reservoirs secondary to limited capacity and compliance can be successfully managed with conversion to W-ileal pouch-anal anastom osis. The increased pouch capacity is associated with improvement in c ompliance and widening of the pouch-to-anal pressure gradients, provid ing excellent functional results.