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Management of the Problem Pouch

Management of the Problem Pouch. Bruce George Oxford University Hospitals. Pouch surgery – the agony. Long Term Failure Rates from St Mark’s. Karoui Cohen and Nicholls DCR 2004. Indications for Pouch Excision at St Mark’s. Karoui, Cohen, and Nicholls DCR 2004. Causes of Pouch Failure.

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Management of the Problem Pouch

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  1. Management of the Problem Pouch Bruce George Oxford University Hospitals

  2. Pouch surgery – the agony

  3. Long Term Failure Rates from St Mark’s Karoui Cohen and Nicholls DCR 2004

  4. Indications for Pouch Excision at St Mark’s Karoui, Cohen, and Nicholls DCR 2004

  5. Causes of Pouch Failure 49 (8.8%) of 551 pouches failed 9 (1.6%) defunctioned - 21 (39%) anastomotic leak - 13 (23%) poor function - 7 (12%) pouchitis - 7 (12%) pouch leakage - 7 (12%) perianal disease - 3 (5%) various MacRae et al Dis Col Rect 1997

  6. For every failed pouch, there are a few injured

  7. History of poor function Always bad Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy Stool culture Phase 1assessment of poor pouch function

  8. Acute pouchitis ciprofloxacin Pouch-anal anastomotic stricture EUA + gentle dilatation Cuffitis topical steroids or mesalazine Common problems

  9. Inside Flexible pouchoscopy + biopsy pouchogram Outside CT or MR pelvis Below Sphincter physiology and ultrasound Pouchogram EUA, pouch and cuff biopsies Above MRE endoscopy Emptying the pouch Dynamic evacuating “proctography” Phase 2Assessment of persistent poor pouch function

  10. INSIDE THE POUCH • Chronic pouchitis • Irritable pouch • Small volume/non compliant pouch • Ischaemia • Cmv/c diff • Collagenous pouchitis

  11. OUTSIDE THE POUCH • Pelvic abscess/induration • Fistula • Unrelated pathology • Fibroid, desmoid

  12. Below the pouch • Stenosis/induration at anastomosis • Pouch-vaginal fistula • Sphincter weakness • Cuffitis • Long rectal cuff

  13. ABOVE THE POUCH • Adhesions • Bacterial overgrowth • Crohn’s disease • Pre-pouch ileitis • NSAIDs • coeliac

  14. EMPTYING THE POUCH • Intussusception/prolapse • Anismus

  15. Treatment • Dependant on identification of cause of poor pouch function

  16. Phase 3the really failing pouch • Septic • Peri-pouch fistulae • Strictured, indurated pouch-anal anastomosis • Long retained rectal cuff • Severe pouchitis • Mechanical • Small pouch • Long blind end • Long efferent spout • intussusception • Suspicion of Crohn’s disease • Chronic resistant pouchitis

  17. Surgical options for the failing pouch • Indefinite diversion • with pouch excision • with pouch left in-situ • Re-do pouch reconstruction • Kock pouch

  18. operative procedure

  19. operative procedure

  20. operative procedure

  21. operative procedure

  22. operative procedure

  23. operative procedure

  24. operative procedure

  25. Summary • Structured approach to poor pouch function • Joint with gastroenterologists • Probably main argument for large volume units • Avoid salvage surgery if possible

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