QS206 - Pouch Failure Is Often Caused by Remnant Mesorectum or Long Rectal Cuff

Purpose/Background: Etiology of pouch failure can be categorized as mechanical, conversion to Crohn’s disease (CD). Mechanical issues such as long rectal cuff and remnant mesorectum can cause pouch dysfunction, obstructive defecation and result in leak, septic complications like perianal fistula and pelvic abscess formation. Furthermore, these patients are often labeled as CD and treated with biologics for years despite the underlying cause is mechanical and require a redo ileal pouch anal anastomosis (IPAA). In addition to these, symptomatology of these patients may take years to become evident rather than presenting in the immediate postoperative setting after the ileostomy closure.
Therefore, the aims of our study are to determine the rates of the remnant mesorectum, long rectal cuff as a reason for pouch failure and report the management, postoperative outcomes in patients who underwent a redo IPAA surgery for pouch failure at our IBD center.

Methods/Interventions: Patients who underwent a redo IPAA after pouch failure between 9/2016 and 9/2023 were identified from our prospectively maintained database. Data regarding demographics, preoperative biologic usage, perioperative findings and postoperative outcomes as well as pouch retention rates were retrospectively analyzed.

Results/Outcomes: There were 245 patients who underwent a redo IPAA. Out of 245, 98 (40%) patients had remnant mesorectum, long rectal cuff or both. While 77 (78.5%) patients had long rectal cuff and remnant mesorectum, 21 (21.5%) patients had only remnant mesorectum. Median time from initial pouch surgery to redo IPAA surgery was 7 years (range: 3-12). Fifty-eight (59%) patients had their index surgery with a minimally invasive approach (46 laparoscopic, 12 robotic). Forty-seven (48%) patients had a history of biologic use after index pouch surgery until they presented for their redo surgery. All patients had diverting loop ileostomy before re-do IPAA for at least 6 months which is our routine 3-stage redo IPAA surgical practice. Forty-seven (48%) and 33 (34%) patients presented with associated pelvic sepsis and perianal fistula that was also encountered at the time of the redo IPAA surgery. Only 9 (9.1%) patients had CD diagnosis and 5 (5.1%) patients had indeterminate colitis. A new pouch was created in 49 (50%) of the patients, and 43 (44%) of the patients had handsewn anastomosis with mucosectomy. Twenty (20.4%) patients had septic complications after redo IPAA. Among 98, 83 patients underwent ileostomy closure. Of 15 out of 98 patients who did not undergo ileostomy reversal, 12 patients are waiting for reversal and 3 patients underwent a re-redo IPAA surgery since their initial IPAA has failed and required a re-redo IPAA surgery before their ileostomy closure. Out of 98, 3 patients have a pouch failure as their final outcome where 2 patients were rediverted, and 1 patient’s pouch was excised. In summary, after excluding 12 out of 98 patients who are waiting for ileostomy closure, 80 out of 83 patients who underwent ileostomy reversal had a functioning pouch with a 96.4% success rate during a median follow-up of 24 months.

Conclusion/Discussion: A long rectal cuff and remnant mesorectum are preventable risk factors for pouch failure. Redo IPAA is successful management option in patients with pouch failure resulting from mechanical complications. Majority of the patients received unnecessary biologic therapy for mechanical issues rather than the CD. These patients may benefit from early from referral to specialized surgical IBD centers to maintain gastrointestinal continuity.