The Failing Pouch

Neil Mortensen, John Radcliffe Hospital, Oxford

Powerpoint File

Pouch excision or indefinite retention of a defunctioning stoma defines failure. Institutional pouch failure rates have notably fallen during the past 20 years presumably following improvements in patient selection and surgical technique. The rate of failure for 2 separate halves of a 22-year study from St. Marks were 16.5% and 8.3%, respectively. Annual failure rates at the Cleveland Clinic have fallen from 15% to 2% during an 18-year period, with similar trends reported from Toronto.

Experience plays a key role in both pouch construction and the treatment of postoperative complications. The Cleveland Clinic group examined how operator experience, determined by previous number of IPAA operations, influenced long-term pouch failure rates using a technique that sought to compensate for mixed case loads. Surgeons were grouped according to experience with 2 seniors who had performed IPAA operations since the mid-1980s and 10 juniors who had completed an average of 67 IPAA cases each. Half of the juniors demonstrated a learning curve of 23 cases for this procedure as determined by their pouch failure rate. The initial learning curve for senior staff had been ~40 cases. Notably, pouch failure following hand-sewn anastomosis was significantly higher for junior staff when compared with their senior colleagues, although both groups performed stapled anastomosis equally well.

In general, 2 types of pouch failure have been considered. Early failure arises from complications of the primary procedure or from technical difficulties experienced at this time. Late failure is more likely to reflect poor function of the pouch reservoir. A consistent theme that emerges from the large institutional series is that early pouch failure is closely associated with the occurrence of perioperative pelvic sepsis, whereas that occurring later is often secondary to poor function or after an unexpected diagnosis of Crohn's disease. Most failures occur beyond the first year, and a steady rate of attrition occurs up to 10 years.

Bach S, Mortensen NJ Revolution and Evolution: 30 Years of Ileoanal Pouch Surgery Inflamm Bowel Disease Volume 12(2), February 2006, pp 131-145