Overview
Definition:
Redo ileal pouch surgery refers to a secondary surgical procedure performed after an initial restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) to address complications such as chronic pouchitis or anastomotic stricture.
Epidemiology:
Pouch failure rates vary, with chronic pouchitis reported in 15-30% and strictures in 5-10% of patients undergoing IPAA over time
Redo surgery is less common, typically reserved for refractory cases.
Clinical Significance:
Failure of the ileal pouch significantly impacts quality of life for patients with inflammatory bowel disease
Understanding the indications, techniques, and outcomes of redo surgery is crucial for managing these complex cases and preparing for surgical examinations.
Indications For Redo Surgery
Refractory Pouchitis:
Chronic, antibiotic-refractory pouchitis unresponsive to maximal medical management, leading to significant symptoms and functional impairment.
Symptomatic Stricture:
An anastomotic stricture causing obstructive symptoms such as abdominal pain, nausea, vomiting, or inability to pass stool/flatus, and not amenable to endoscopic dilatation.
Fistula Formation:
Development of a fistula involving the pouch or anastomosis that does not heal with conservative management or endoscopic intervention.
Dehiscence Or Leak:
Occult or overt leak from the pouch or anastomosis not amenable to less invasive salvage procedures.
Diagnostic Approach
History Taking:
Detailed history of initial surgery, symptoms of pouchitis (diarrhea, urgency, tenesmus, abdominal pain), or obstruction (nausea, vomiting, distension)
Assess prior treatments and their efficacy
Inquire about systemic symptoms.
Physical Examination:
Abdominal examination for tenderness, distension, or masses
Perianal inspection for fistulas, abscesses, or signs of inflammation
Digital rectal examination may reveal strictures or induration.
Investigations:
Laboratory tests: Complete blood count (anemia, leukocytosis), inflammatory markers (CRP, ESR), fecal calprotectin
Imaging: Contrast-enhanced CT or MRI abdomen/pelvis to assess pouch, anastomosis, and surrounding structures for inflammation, strictures, abscesses, or fistulas
Endoscopy: Flexible sigmoidoscopy or colonoscopy with biopsies to assess pouch mucosa and rule out malignancy
Contrast pouchogram to evaluate for strictures or leaks.
Differential Diagnosis:
Infectious colitis, C
difficile infection, medication side effects, Crohn's disease recurrence (if not diagnosed initially), bacterial overgrowth, afferent loop syndrome, malabsorption syndromes, radiation proctitis.
Surgical Management
Surgical Options:
Options include salvage ileal pouch-anal anastomosis (if feasible), conversion to a permanent ileostomy, or rarely, reconstruction of a new pouch if the original is unsalvageable.
Preoperative Preparation:
Optimizing nutrition, managing dehydration and electrolyte imbalances
Aggressive antibiotic therapy for active pouchitis or infection
Bowel preparation as per standard surgical practice
Preoperative contrast studies to delineate the pathology.
Techniques For Redo Ipaa:
Meticulous dissection to mobilize the pouch and bowel segments
Careful division of the strictured anastomosis or inflamed pouch
Creation of a new ileoanal anastomosis, often with a hand-sewn or stapled technique
Consideration for temporary diverting ileostomy to protect the new anastomosis.
Management Of Pouchitis During Redo:
If pouchitis is the primary issue, aggressive antibiotic treatment preoperatively and intraoperatively
Biopsies taken for culture and histology
Wide excision of inflamed tissue
Consideration for pouch advancement or flap repair if local tissue is compromised.
Management Of Strictures During Redo:
Wide excision of the fibrotic strictured segment
Careful mobilization of adjacent bowel
Reconstruction with healthy bowel
Tension-free anastomosis is paramount
Use of steroid eluting stents or biodegradable stents may be considered in select cases.
Postoperative Care
Diversion Management:
Management of temporary diverting ileostomy: stoma care, monitoring for output, electrolyte balance
Timely reversal of ileostomy based on radiographic and clinical assessment.
Monitoring For Complications:
Close monitoring for signs of anastomotic leak (fever, abdominal pain, tachycardia, peritonitis), bleeding, ileus, and sepsis
Fluid and electrolyte balance
Pain management.
Nutritional Support:
Early enteral feeding as tolerated
Nutritional assessment and supplementation if malabsorption or prolonged recovery is anticipated
Management of diarrhea and electrolyte abnormalities.
Long Term Follow Up:
Regular clinical review, including sigmoidoscopy and biopsies, to monitor pouch function and detect early signs of recurrence of pouchitis or stricture
Patient education on diet, lifestyle, and signs of complications.
Complications Of Redo Surgery
Early Complications:
Anastomotic leak or dehiscence, fistula formation, pelvic abscess, wound infection, bleeding, ileus, sepsis, stoma-related complications (necrosis, retraction, skin irritation).
Late Complications:
Recurrence of pouchitis, anastomotic stricture, infertility, sexual dysfunction, incisional hernia, adhesions leading to bowel obstruction, chronic abdominal pain.
Prevention Strategies:
Meticulous surgical technique, avoiding tension on the anastomosis, adequate bowel preparation, judicious use of diverting ileostomy, prompt recognition and management of leaks or abscesses, aggressive management of pre-existing inflammation.
Prognosis
Factors Affecting Prognosis:
The underlying etiology (Crohn's disease vs
ulcerative colitis), extent of disease, surgical technique, quality of the surrounding tissues, patient's overall health, and adherence to postoperative care all influence outcomes.
Outcomes:
Successful salvage of the pouch can restore good quality of life, but outcomes are generally less predictable than primary IPAA
Some patients may still require eventual diversion
Recurrence of pouchitis or stricture is possible.
Follow Up Recommendations:
Lifelong surveillance is recommended
This typically includes annual clinical review and endoscopic assessment (flexible sigmoidoscopy with biopsies) to monitor pouch health and detect recurrence
Monitoring inflammatory markers and fecal calprotectin can also be useful.
Key Points
Exam Focus:
Understand the indications for redo IPAA, the distinct surgical approaches for pouchitis vs
stricture, and the critical role of a diverting ileostomy
Know the common complications and their management strategies.
Clinical Pearls:
In cases of refractory pouchitis, consider rare causes like infections or atypical IBD
For strictures, ensure complete excision of fibrotic tissue and a tension-free anastomosis
Always consider the possibility of Crohn's disease masquerading as pouchitis.
Common Mistakes:
Inadequate preoperative assessment, insufficient bowel mobilization, tension on the anastomosis, failure to utilize a diverting ileostomy when indicated, and undertreatment of active inflammation during the redo procedure.