Abstract
Background
Many different pouch failure (PF) indications and procedures are known. In literature, different types of PF are randomly classified and often stacked together due to complexity. Transanal minimally invasive surgery (TAMIS) is becoming increasingly popular for redo-surgery due to greater accessibility and visibility in complex pelvic surgery compared with the conventional abdominal approach. We aimed to evaluate the efficacy of TAMIS in patients with PF.
Methods
This retrospective study includes all consecutive patients over 18-year old with an ileal pouch-anal anastomosis (IPAA) and PF that were managed with TAMIS between July 2014 and July 2019. Patient characteristics, operative indications, perioperative outcomes and short-term follow-up (FU) are described using a suggested subclassification for surgical-related PF (Figure 1).
Results
Forty-six procedures were completed in 42 patients, predominantly male (66.7%) with a median age of 44.6 (range 22.0–70.8) years. Initial IPAA indications were familial adenomatous polyposis (n = 11), medical refractory ulcerative colitis (UC) (n = 29) or other (n = 2). Seven (24.1%) UC patients turned out to have Crohn’s disease (CD). Reasons for PF were septic complications (n = 18), retained rectum (n = 3), outlet problems (n = 8) (with megapouch: n = 5), inlet problems (n = 6), cuff problems (n = 8) and refractory pouchitis with unknown aetiology (n = 3). Twenty-three pouch redo’s (16 remodelling, 7 new pouches), 5 sleeve advancements, 4 cuff excisions, 1 posterior pouchpexy, and 13 pouch excisions were recorded. Five pouch excisions were performed in CD patients. Five procedures were fully completed transanally, and 41 were a combined transabdominal (with 32 open and 9 laparoscopic) and TAMIS approach. None were converted to an open procedure. Apart from the patients with a pouch excision, 9 ended up with a permanent ileostomy, although technical success was achieved in 4 of those. Six permanent ileostomies were in patients with a redo-pouch (3 remodelling, 3 new pouches), 2 after sleeve advancement and 1 after cuff excision. Major morbidity (Clavien-Dindo ≥3) occurred after 17 procedures (37.0%), 14 within 1 month after surgery with a median FU of 17.9 (0.9–41.6) months. There was no peri-operative mortality.
Conclusion
TAMIS for PF after IPAA is technically feasible with acceptable short-term outcomes. Peri-operative morbidity is high and reflects the complexity of these procedures. Success after PF procedures is difficult to interpret due to a wide range of possible outcomes such as technical success, conversion rate and number of patients with a permanent stoma. The PF subclassification makes the complex problem and surgical management of PF comprehensible.
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