Abstract - Imperial College London



054-2018.R1Systematic ReviewSystematic review of the literature regarding the Mmanagement of early pouch-related septic complications in ulcerative colitis: systematic reviewGuy H T Worley, Jonathan P Segal, Janindra Warusavitarne, Susan K Clark, Omar D FaizSt Mark's Hospital and Academic Institute, Harrow, Middlesex, UK and Department of Surgery and Cancer, Imperial College London, London, UKCorresponding author: Guy Worley guy.worley@ Guarantor of the article: Omar Faiz omar.faiz@ Keywords: ulcerative colitis, restorative proctocolectomy, ileal pouch, surgery, complications, sepsis, leakAbstract word count: 21620Word count: 2,9943Tables: 3Figures: 2Appendices: 1References: 26Date: 927th February May 2018AbstractIntroductionIt is well establishedreported that ileoanal pouch-related septic complications (PRSC) increase the risk of pouch failure. There are a number of publications that describe the management of early PRSC in ulcerative colitis (UC) in small series. This article aims to systematically review and summarise the relevant contemporary data on this subject and provide an algorithm for the management of early PRSC.MethodA systematic review was undertaken in accordance with PRISMA guidelines. Studies published between 2000 and 2017 describing the clinical management of PRSC in patients with UC within 30 days of primary ileoanal pouch surgery were included. A qualitative analysis was undertaken due to the heterogeneity and quality of studies included.Results1157 abstracts and 266 full text articles were screened. Twelve studies were included for analysis involving a total of 207 patients. The studies described a range of techniques including image-guided, endoscopic, surgical and endocavitational vacuum methods. Based on the evidence from these studies, an algorithm was created to guide the management of early PRSC.ConclusionThe results of this review case series included in this review suggest that although successful salvage of early pouch related septic complications is improving over time there is little information available relating to methods of salvage and outcomes. a paucity of research correlating the method used with functional outcome. Novel techniques may offer increased chance of salvage but comparative studies with longer follow-up are required.What does this paper add to the literature?This is a systematic review of the published literature regarding the management of short term pouch-related septic complications for patients with ulcerative colitis. The appropriate management of post-operative sepsis is crucial to give the best chance of avoiding pouch failure. We present an algorithm for management based on this review.IntroductionSince the first described publication in 1978, restorative proctocolectomy or the ileoanal pouch procedure has been frequently performed as an alternative to total colectomy and come a popular option for those patients requiring colectomy forpermanent ileostomy in patients with ulcerative colitis (UC). , avoiding the need for permanent ileostomy ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0007-1447 (Print)", "PMID" : "667572", "abstract" : "An operation has been developed that permits total removal of all disease-prone mucosa in ulcerative colitis but avoids the need for a permanent ileostomy. The colon and upper half of the rectum are excised and the remaining inflamed mucosa is stripped from the rectal stump down to the dentate line of the anal canal. A pouch is fashioned from a triplicated loop of terminal ileum. This is drawn down through the denuded rectum and an anastomosis created, via the per-anal approach, between the ileum just distal to the pouch and the mid-anal canal. A temporary ileostomy is made. Out of eight patients so treated, five were available for assessment, and four of them were highly satisfied with the result in improved health and function. The remaining three were awaiting closure of their ileostomies.", "author" : [ { "dropping-particle" : "", "family" : "Parks", "given" : "A G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nicholls", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British medical journal", "id" : "ITEM-1", "issue" : "6130", "issued" : { "date-parts" : [ [ "1978", "7" ] ] }, "language" : "eng", "page" : "85-88", "publisher-place" : "ENGLAND", "title" : "Proctocolectomy without ileostomy for ulcerative colitis.", "type" : "article-journal", "volume" : "2" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(1)", "plainTextFormattedCitation" : "(1)", "previouslyFormattedCitation" : "(1)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(1). The incidencerate of pelvic sepsis after ileoanal pouch formation approachesis up to 15%, and septic complications account for the majority of pouch failures. Many papers describe the rate and sequelae of early pouch related septic complications (PRSC) but very few empirical studies describe their clinical management in detail ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/j.1463-1318.2009.01816.x", "ISSN" : "14628910", "PMID" : "19226364", "abstract" : "OBJECTIVE: There is little information on the long-term failure and function after restorative proctocolectomy (RPC). The results of data submitted to a national registry were analysed. METHOD: The UK National Pouch Registry was established in 2004. By 2006, it comprised data collected from ten centres between 1976 and 2006. The long-term failure and functional outcome were determined. Trends over time were assessed using the gamma statistic or the Kruskal-Wallis statistic wherever appropriate. RESULTS: In all, 2491 patients underwent primary RPC over a median of 54 months (range 1 month to 28.9 years). Of these, 127 (5.1%) underwent abdominal salvage surgery. The incidence of failure (excision or indefinite diversion) was 7.7% following primary and 27.5% following salvage RPC (P < 0.001). The median frequency of defaecation/24 h was five including one at night. Nocturnal seepage occurred in 8% at 1 year, rising to 15.4% at 20 years (P = 0.037). Urgency was experienced by 5.1% of patients at 1 year rising to 9.1% at 15 years (P = 0.022). Stool frequency and the need for antidiarrhoeal medication were greater following salvage RPC. CONCLUSION: In patients retaining anal function after RPC, frequency of defaecation was stable over 20 years. Faecal urgency and minor incontinence worsened with time. Function after salvage RPC was significantly worse.", "author" : [ { "dropping-particle" : "", "family" : "Tekkis", "given" : "P P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lovegrove", "given" : "R E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tilney", "given" : "H S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smith", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sagar", "given" : "P M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shorthouse", "given" : "A J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mortensen", "given" : "N J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nicholls", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal Disease", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2010", "5" ] ] }, "language" : "eng", "page" : "433-441", "title" : "Long-term failure and function after restorative proctocolectomy - a multi-centre study of patients from the UK national ileal pouch registry", "type" : "article-journal", "volume" : "12" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/01.sla.0000082121.84763.4c", "ISSN" : "0003-4932", "author" : [ { "dropping-particle" : "", "family" : "Tulchinsky", "given" : "Hagit", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hawley", "given" : "Peter R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nicholls", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of Surgery", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "229-234", "title" : "Long-Term Failure After Restorative Proctocolectomy for Ulcerative Colitis", "type" : "article-journal", "volume" : "238" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1159/000085", "ISBN" : "0253-4886", "ISSN" : "0253-4886", "PMID" : "15838167", "abstract" : "Objective: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. Background: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. Methods: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. Results: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. Conclusions: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures. Copyright \u00a9 2005 S. Karger AG.", "author" : [ { "dropping-particle" : "", "family" : "Hueting", "given" : "W E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buskens", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tweel", "given" : "I", "non-dropping-particle" : "van der", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gooszen", "given" : "H G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Laarhoven", "given" : "C.J.H.M.", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "W.E.", "given" : "Hueting", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "E.", "given" : "Buskens", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "I.", "given" : "Van Der Tweel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "H.G.", "given" : "Gooszen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Digestive Surgery", "id" : "ITEM-3", "issue" : "1-2", "issued" : { "date-parts" : [ [ "2005" ] ] }, "note" : "Review article\nNo description of the management of short term PRSC", "page" : "69-79", "title" : "Results and complications after ileal pouch anal anastomosis: A meta-analysis of 43 observational studies comprising 9,317 patients", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1007/DCR.0b013e3181beb3f0", "ISSN" : "00123706", "PMID" : "19934918", "abstract" : "PURPOSE: This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. METHODS: Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. RESULTS: The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). CONCLUSION: Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.", "author" : [ { "dropping-particle" : "", "family" : "Forbes", "given" : "Shawn S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Charles Victor", "given" : "J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the Colon and Rectum", "id" : "ITEM-4", "issue" : "12", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "1975-1981", "title" : "Sepsis is a major predictor of failure after ileal pouch-anal anastomosis", "type" : "article-journal", "volume" : "52" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1097/01.sla.0000090940.39838.6a", "ISBN" : "0003-4932", "ISSN" : "0003-4932", "PMID" : "14530732", "abstract" : "OBJECTIVE: To identify risk factors associated with ileal pouch failure and to develop a multifactorial model for quantifying the risk of failure in individual patients. SUMMARY BACKGROUND DATA Ileal pouch anal anastomosis (IPAA) has become the treatment choice for most patients with ulcerative colitis and familial adenomatous polyposis who require surgery. At present, there are no published studies that investigate collectively the interrelation of factors related to ileal pouch failure, nor are there any predictive indices for risk stratification of patients undergoing IPAA surgery.\\n\\nMETHODS: Data from 23 preoperative, 7 intraoperative, and 10 postoperative risk factors were recorded from 1,965 patients undergoing restorative proctocolectomy in a single center between 1983 and 2001. Primary end point was ileal pouch failure during the follow-up period of up to 19 years. The \"CCF ileal pouch failure\" model was developed using a parametric survival analysis and a 70%:30% split-sample validation technique for model training and testing.\\n\\nRESULTS: The median patient follow-up was 4.1 year (range, 0-19 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.4-96.7). The following risk factors were found to be independent predictors of pouch survival and were used in the final multivariate model: patient diagnosis, prior anal pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture and separation. The model accurately predicted the risk of ileal pouch failure with adequate calibration statistics (Hosmer Lemeshow chi2 = 3.001; P = 0.557) and an area under the receiver operating characteristics curve of 82.0%.\\n\\nCONCLUSIONS: The CCF ileal pouch failure model is a simple and accurate way of predicting the risk of ileal pouch failure in clinical practice on a longitudinal basis. It may play an important role in providing risk estimates for patients wishing to make informed choices on the type of treatment offered to them.", "author" : [ { "dropping-particle" : "", "family" : "Fazio", "given" : "Victor W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tekkis", "given" : "Paris P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Remzi", "given" : "Feza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lavery", "given" : "Ian C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Manilich", "given" : "Elena", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Connor", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Preen", "given" : "Miriam", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Delaney", "given" : "Conor P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of surgery", "id" : "ITEM-5", "issue" : "4", "issued" : { "date-parts" : [ [ "2003" ] ] }, "note" : "From Duplicate 2 (Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. - Fazio, Victor W; Tekkis, Paris P; Remzi, Feza; Lavery, Ian C; Manilich, Elena; Connor, Jason; Preen, Miriam; Delaney, Conor P)\n\nNo description of the management of short term PRSC\n\nFrom Duplicate 2 (Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. - Fazio, Victor W; Tekkis, Paris P; Remzi, Feza; Lavery, Ian C; Manilich, Elena; Connor, Jason; Preen, Miriam; Delaney, Conor P)\n\nComment in: Inflamm Bowel Dis. 2004 May;10(3):328-9; PMID: 15290933", "page" : "605-14; discussion 614-7", "title" : "Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery.", "type" : "article-journal", "volume" : "238" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(2\u20136)", "plainTextFormattedCitation" : "(2\u20136)", "previouslyFormattedCitation" : "(2\u20136)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(2–6). This systematic review of the literature aims to identify and summarise empirical studies describing the management of early PRSC.MethodThis systematic review was undertaken in adherence with the Preferred Reporting In Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane Handbook for Systematic Reviews of InterventionsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1371/journal.pmed.1000097", "ISBN" : "0031-9023", "ISSN" : "1549-1676", "PMID" : "19621072", "abstract" : "Registry", "author" : [ { "dropping-particle" : "", "family" : "Moher", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liberati", "given" : "a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tetzlaff", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Altman", "given" : "D G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grp", "given" : "Prisma", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical Therapy", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "873-880", "title" : "Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement (Reprinted from Annals of Internal Medicine)", "type" : "article-journal", "volume" : "89" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(7)", "plainTextFormattedCitation" : "(7)", "previouslyFormattedCitation" : "(7)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(7).Information sourcesMEDLINE (1946 to present), Embase (1974 to present) (both searched via Ovid), and Web of Science (1950 to present) were searched systematically as per the terminology in Appendix 1. The Cochrane Database of Systematic Reviews was searched by 'Topic' and articles were hand searched from the references and citing articles of papers which met the inclusion criteria. The last literature search was 21st November 2017.SearchAll databases were searched with the intention of high sensitivity and wide capture. The following terms were included as 'exploded' Medical Subject Headings (MeSH) or Keywords terms depending on database, and also as text word searches, using the suffix '.tw.'. These terms were then combined with the Boolean operators 'AND' or 'OR' as follows, and the search filtered by year (2000 to 2017 to focus on contemporary studies), by publication type (Journal Article) and to remove duplicates. No language filter was employed during the initial literature search but only abstracts in English were screened.Inclusion criteriaAll articles from peer-reviewed journals which described empirical studies on patients with UC after primary pouch surgery, with an abstract written in English, were included. Studies were required to describe techniques in managing pouch-related septic complications (i.e. anastomotic leak, abscess, sinus, fistula and peritonitis) within 30 days of the primary procedure. Exclusion criteriaReview articles, published abstracts, conference posters, audits, editorials and letters were excluded. Two researchers (GW and JPS) independently reviewed the articles retrieved by the search strategy and resolved disagreements by consensus.Data collection and abstractionData were extracted and tabulated in Microsoft Excel (Version 15.18). Data collected included: first author, institution city, year of publication, sample size, study design, gender, age, BMI, diagnosis, pouch configuration, anastomotic technique, operative stages, de-functioning ileostomy at pouch creation, categorisation of leak, diagnostic criteria for PRSC, signs and symptoms of PRSC, diagnostic imaging, diagnostic endoscopy, management techniques, time to diagnosis and treatment, duration of treatment, time to closure of defect, time to discharge, length of follow up and functional outcomes.Synthesis of resultsA descriptive synthesis was employed. Meta-analysis was not appropriate due to the extent of heterogeneity within the study designs and reported outcome variables.ResultsStudy selectionA total of 1155 results were obtained from the original database search, with duplicates removed as one of the search filters. Two results were obtained from hand searching. Of these 1157 screened abstracts 798 were excluded, leaving 339 for full text review. Further duplicates were removed from this selection in citation software (Mendeley v 1.14. 2008-2015) leaving 266 full text articles to be assessed for eligibility. After review 254 articles were excluded, leaving 12 for qualitative analysis (see PRISMA flow diagram, figure 1). When the studies are referred to in the results they are referenced in square brackets according to the numbers allocated in table 1, i.e. [2,5]. Other references are included in parentheses. Study characteristicsThe 12 included papers were published between 2007 and 2015. Six papers were from Europe and six from North America. Four papers were case reports of novel techniques [2,3,4,10], five were observational studies [5,8,9,11,12] and one was an interventional study [6]. Participants ranged from 1 to 141, with a total of 207 adult participants included across all studies (table 1).Synthesis of evidenceDiagnosis and InvestigationThe signs and symptoms associated with acute pouch sepsis were described in five papers [3-5,8,12]. Raval et al. stated that 130 of their series of 141 had symptomatic leaks, 67% exhibiting fever, 38% with abdominoperineal pain and 6% perineal abscess. Of 94 patients without a primary de-functioning ileostomy, high frequency of defaection was present in 29%. Kirat et al. reported fever in only 19% and abdominal pain in 56% of their 27 patients. One article [4] described the use of digital examination of the anal anastomosis in the diagnosis of pouch leaks.Mennigen et al. reported that three of 12 patients had very mild or absent symptoms, delaying diagnosis until 20, 26 and 50 days following surgery [11]. Raval et al reported 11 of 141 patients had asymptomatic leaks diagnosed on ‘pouchogram’ before ileostomy closure. Sagap et al. categorised symptoms as mild (clinical suspicion without prominent symptoms), moderate (prominent clinical and/or biochemical features) and severe (generalised peritonitis or shock requiring rapid surgery or ITU care).Computed tomography (CT) was the most common diagnostic imaging modality. Five studies [2,3,5,9,11] described using CT diagnosis and two [2,11] augmented CTs with contrast enemas. Three studies described routine use of water-soluble contrast enema radiography or 'pouchogram' to diagnose leaks [5,10,12]. Pouchoscopy was used to diagnose or confirm a leak in six studies [2,5,6,8,9,11]. Mennigen et al. reported routine pouchoscopy before discharge.Time from pouch formation to diagnosis of leak was presented in seven studies [2,4,9-12]. Three case studies [2,4,10] quoted 14, 10 and 5 days respectively, and the case series papers [1,9,11,12] presented medians of 25, 19, 14 and mean 11.5 days respectively. The mean time to diagnosis from these six papers was 18 days. Categorisation/site of leak Only Raval et al. presented a categorisation of leaks: either ileo-anal anastomosis (IAA) with (21%) or without (33%) abscess; pouch-cutaneous fistula (10%); pouch-vaginal fistula (12%); radiologic leak (8%) or pouch body leak (16%). Kirat et al reported larger abscesses in their group undergoing CT-guided percutaneous drainage (7.7cm) than those undergoing trans-anastomotic drainage (5.1cm). In Mennigen et al's series of 12, five had IAA dehiscence with associated abscess, three had pouch body leaks, two had fistulas and three had abscesses without evidence of leak. Kirat et al's series only described leaks from the 'tip' (blind end) of the J pouch, whereas the cumulative 22 patients from the Dutch trials [3,8,11] only dealt with low leaks, i.e. the IAA or just above.De-functioning ileostomy and pouch catheter useThe rate of primary de-functioning ileostomy varied between 26% and 100%. All of Kirat et al's 27 patients with leak from the blind end of the pouch were primarily de-functioned, compared to four of 15 in Gardenbroek et al's series of anastomotic leaks. Not all patients without a primary ileostomy were subsequently de-functioned: Raval et al. reported 63% of 141 patients were de-functioned with an ileostomy, but 42 of the remaining 47 leaks were managed with a pouch catheter and drainage. Five required an ileostomy and washout within 24 hours for generalised peritonitis. Gardenbroek et al. managed two patients with short-term Endo-SPONGE? treatment without de-functioning at all. In one of these patients the initial closure was successful, and the second required formation of an ileostomy and a second period of Endo-SPONGE? treatment before successful closure of the defect. Mennigen et al. managed one patient without ileostomy when there was an abscess but no leak present at abdominal washout.Percutaneous radiological drainagePercutaneous CT-guided drainage of peri-pouch abscess was reported in five papers. Thosani et al. described the use of CT-guided percutaneous drainage after primary closure of the anastomotic defect with an over the scope clip (OTSC). Kirat et al reported that two of 18 patients developed pouch-cutaneous fistula along the trans-gluteal CT drainage track. Both healed with conservative management and drainage of the associated sepsisTrans-anal drainageTrans-anastomotic drainage of peri-pouch abscesses was reported in three papers. Raval et al. stated the indication for trans-anastomotic drainage was anastomotic dehiscence. Only Varadarajulu et al. described peri-pouch abscess drainage endoluminally without a pre-existing anastomotic defect by endoscopic ultrasound guided drainage [9]. Kirat et al compared the non-randomised use of percutaneous vs trans-anastomotic drainage of abscesses and found no difference in outcome. Endo-cavitational vacuum therapyFive papers reported the use of vacuum therapy. All specified that this is only appropriate for low pelvic leaks due to technical limitations and to avoid exerting suction on abdominal small bowel. Two approaches were described – long and short term. The long-term method involved Endo-SPONGE? change every three to four days, reducing sponge size until a very small cavity remained, often with a persisting sinus. The median time from diagnosis to closure was 70 days. Gardenbroek et al. and Verlaan et al's short-term technique (three to six sponge changes to clean and encourage healing before early surgical closure of the defect) resulted in a time of 48 (from diagnosis) and 14 days (from start of treatment) to resolution [8,11].Abdominal re-operationFive studies described re-operation within 30 days [4,5,11,12], excluding surgery only to form a de-functioning ileostomy. The indication for abdominal salvage was peritonitis, abscess not amenable to radiological drainage or high leak [2,7]. Maruthachalam et al. described an initial ileostomy formation and pelvic drainage which failed, so the IAA was disconnected and pouch brought out as a mucus fistula [4]. The pouch was re-connected 12 months later and the technique resulted in good anorectal physiology at 18 months follow-up. Kirat et al. reported the rate of intervention required after failed local drainage. Trans-anal drainage failed in 13 patients (24.5%) of whom three had a re-do pouch, one had their pouch mobilised and an ileostomy formed, and six had their pouches excised. Of three failed CT-guided drainages (17%), two had a subsequent re-do pouch performed.Sagap et al. reported that abdominal re-operation was significantly associated with failure on univariate logistic regression, demonstrating 41% failure rate. Fifty-five of 157 patients required a laparotomy, either after failed drainage or as a primary procedure in 22. None of the studies described pouch excision within 30 days of the primary procedure.Quality of life and functional outcomeNine studies stated their length of follow-up (table 2). Three papers reported functional outcomes [4,5,11]. Mennigen et al's paper reported no statistically significant difference in ?resland, SIBDQ and GIQLI functional scores. The median frequency in the PRSC group was seven, compared to six for controls. Kirat et al's article also reported no significant difference in frequency, urgency, incontinence, seepage or pad use; neither was there significance difference between Cleveland Clinic scores, quality of health or sexual function. Maruthachalam et al's case report on pouch salvage by mucus fistula resulted in good capacity and compliance.Pouch failureSix papers presented failure rate [1,2,5-7,11]. Sagap et al. reported 75.8% of pouches were salvaged. On multivariate analysis – fistula, trans-anal drainage, delayed ileostomy closure, new ileostomy diversion and hypertension were associated with failure. Based on these factors they developed a predictive score.Raval et al. reported 84% with a functioning pouch from their sample, using multiple treatment techniques. Stapled anastomoses fared better than hand-sewn (93% vs 72% salvaged). There was no statistically significant difference in outcome between patients who had no ileostomy when PRSC was diagnosed, or those who had PRSC diagnosed before or after ileostomy closure (83%, 85%, 85% respectively). They reported improved rates of salvage from 67% between 1981 to 1984 to 88% between 2001 to 2003.Of Kirat et al’s series of 27 patients with leaks from the blind end of the J pouch, one patient had excision and ileostomy, one patient was still awaiting stoma closure and the remaining 25 had functioning pouches at 3.2 year mean follow-up.Mennigen et al. reported four pouch failures out of 12 patients with PRSC. Each had at least three procedures before failure and three had abdominal salvage attempts. Kirat et al. reported 75.5% and 83% success for trans-anal and percutaneous CT-guided drainage respectively, with a mean follow-up of 3.1 years. In Gardenbroek et al’s comparison of short-term Endo-SPONGE? treatment 14 of 15 patients had a functional pouch compared with 24 of 28 with the long-term technique. The median follow-up in their intervention group was significantly shorter at 25 compared to 104 months.DiscussionIt is well established that PRSC increases the risk of pouch dysfunction and failure ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/j.1463-1318.2009.01816.x", "ISSN" : "14628910", "PMID" : "19226364", "abstract" : "OBJECTIVE: There is little information on the long-term failure and function after restorative proctocolectomy (RPC). The results of data submitted to a national registry were analysed. METHOD: The UK National Pouch Registry was established in 2004. By 2006, it comprised data collected from ten centres between 1976 and 2006. The long-term failure and functional outcome were determined. Trends over time were assessed using the gamma statistic or the Kruskal-Wallis statistic wherever appropriate. RESULTS: In all, 2491 patients underwent primary RPC over a median of 54 months (range 1 month to 28.9 years). Of these, 127 (5.1%) underwent abdominal salvage surgery. The incidence of failure (excision or indefinite diversion) was 7.7% following primary and 27.5% following salvage RPC (P < 0.001). The median frequency of defaecation/24 h was five including one at night. Nocturnal seepage occurred in 8% at 1 year, rising to 15.4% at 20 years (P = 0.037). Urgency was experienced by 5.1% of patients at 1 year rising to 9.1% at 15 years (P = 0.022). Stool frequency and the need for antidiarrhoeal medication were greater following salvage RPC. CONCLUSION: In patients retaining anal function after RPC, frequency of defaecation was stable over 20 years. Faecal urgency and minor incontinence worsened with time. Function after salvage RPC was significantly worse.", "author" : [ { "dropping-particle" : "", "family" : "Tekkis", "given" : "P P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lovegrove", "given" : "R E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tilney", "given" : "H S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smith", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sagar", "given" : "P M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shorthouse", "given" : "A J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mortensen", "given" : "N J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nicholls", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal Disease", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2010", "5" ] ] }, "language" : "eng", "page" : "433-441", "title" : "Long-term failure and function after restorative proctocolectomy - a multi-centre study of patients from the UK national ileal pouch registry", "type" : "article-journal", "volume" : "12" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/01.sla.0000082121.84763.4c", "ISSN" : "0003-4932", "author" : [ { "dropping-particle" : "", "family" : "Tulchinsky", "given" : "Hagit", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hawley", "given" : "Peter R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nicholls", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of Surgery", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "229-234", "title" : "Long-Term Failure After Restorative Proctocolectomy for Ulcerative Colitis", "type" : "article-journal", "volume" : "238" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1159/000085", "ISBN" : "0253-4886", "ISSN" : "0253-4886", "PMID" : "15838167", "abstract" : "Objective: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. Background: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. Methods: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. Results: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. Conclusions: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures. Copyright \u00a9 2005 S. Karger AG.", "author" : [ { "dropping-particle" : "", "family" : "Hueting", "given" : "W E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buskens", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tweel", "given" : "I", "non-dropping-particle" : "van der", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gooszen", "given" : "H G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Laarhoven", "given" : "C.J.H.M.", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "W.E.", "given" : "Hueting", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "E.", "given" : "Buskens", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "I.", "given" : "Van Der Tweel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "H.G.", "given" : "Gooszen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Digestive Surgery", "id" : "ITEM-3", "issue" : "1-2", "issued" : { "date-parts" : [ [ "2005" ] ] }, "note" : "Review article\nNo description of the management of short term PRSC", "page" : "69-79", "title" : "Results and complications after ileal pouch anal anastomosis: A meta-analysis of 43 observational studies comprising 9,317 patients", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1007/DCR.0b013e3181beb3f0", "ISSN" : "00123706", "PMID" : "19934918", "abstract" : "PURPOSE: This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. METHODS: Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. RESULTS: The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). CONCLUSION: Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.", "author" : [ { "dropping-particle" : "", "family" : "Forbes", "given" : "Shawn S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Charles Victor", "given" : "J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the Colon and Rectum", "id" : "ITEM-4", "issue" : "12", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "1975-1981", "title" : "Sepsis is a major predictor of failure after ileal pouch-anal anastomosis", "type" : "article-journal", "volume" : "52" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1097/01.sla.0000090940.39838.6a", "ISBN" : "0003-4932", "ISSN" : "0003-4932", "PMID" : "14530732", "abstract" : "OBJECTIVE: To identify risk factors associated with ileal pouch failure and to develop a multifactorial model for quantifying the risk of failure in individual patients. SUMMARY BACKGROUND DATA Ileal pouch anal anastomosis (IPAA) has become the treatment choice for most patients with ulcerative colitis and familial adenomatous polyposis who require surgery. At present, there are no published studies that investigate collectively the interrelation of factors related to ileal pouch failure, nor are there any predictive indices for risk stratification of patients undergoing IPAA surgery.\\n\\nMETHODS: Data from 23 preoperative, 7 intraoperative, and 10 postoperative risk factors were recorded from 1,965 patients undergoing restorative proctocolectomy in a single center between 1983 and 2001. Primary end point was ileal pouch failure during the follow-up period of up to 19 years. The \"CCF ileal pouch failure\" model was developed using a parametric survival analysis and a 70%:30% split-sample validation technique for model training and testing.\\n\\nRESULTS: The median patient follow-up was 4.1 year (range, 0-19 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.4-96.7). The following risk factors were found to be independent predictors of pouch survival and were used in the final multivariate model: patient diagnosis, prior anal pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture and separation. The model accurately predicted the risk of ileal pouch failure with adequate calibration statistics (Hosmer Lemeshow chi2 = 3.001; P = 0.557) and an area under the receiver operating characteristics curve of 82.0%.\\n\\nCONCLUSIONS: The CCF ileal pouch failure model is a simple and accurate way of predicting the risk of ileal pouch failure in clinical practice on a longitudinal basis. It may play an important role in providing risk estimates for patients wishing to make informed choices on the type of treatment offered to them.", "author" : [ { "dropping-particle" : "", "family" : "Fazio", "given" : "Victor W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tekkis", "given" : "Paris P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Remzi", "given" : "Feza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lavery", "given" : "Ian C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Manilich", "given" : "Elena", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Connor", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Preen", "given" : "Miriam", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Delaney", "given" : "Conor P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of surgery", "id" : "ITEM-5", "issue" : "4", "issued" : { "date-parts" : [ [ "2003" ] ] }, "note" : "From Duplicate 2 (Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. - Fazio, Victor W; Tekkis, Paris P; Remzi, Feza; Lavery, Ian C; Manilich, Elena; Connor, Jason; Preen, Miriam; Delaney, Conor P)\n\nNo description of the management of short term PRSC\n\nFrom Duplicate 2 (Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. - Fazio, Victor W; Tekkis, Paris P; Remzi, Feza; Lavery, Ian C; Manilich, Elena; Connor, Jason; Preen, Miriam; Delaney, Conor P)\n\nComment in: Inflamm Bowel Dis. 2004 May;10(3):328-9; PMID: 15290933", "page" : "605-14; discussion 614-7", "title" : "Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery.", "type" : "article-journal", "volume" : "238" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(2\u20136)", "plainTextFormattedCitation" : "(2\u20136)", "previouslyFormattedCitation" : "(2\u20136)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(2–6). However, these complications are not homogenous and neither is the clinical management. Only one study reported included here described presented a categorisation of the nature of pouch leaks. Such a classification might ; a widely adopted categorisation of leaks may significantly improve the quality of reporting and homogeneity in the literature for pouch surgery. The International Study Group of Rectal Cancer categorisation of leaks is inadequate for ileoanal pouches as it does not account for the anatomic site, which guides the approach to treatment, albeit the vast majority are from the pouch-anal anastomosis ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.surg.2009.10.012", "author" : [ { "dropping-particle" : "", "family" : "Rahbari", "given" : "Nuh N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "339-351", "title" : "Definition and grading of anastomotic leakage following anterior resection of the rectum : A proposal by the International Study Group of Rectal Cancer", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(8)", "plainTextFormattedCitation" : "(8)", "previouslyFormattedCitation" : "(8)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(8).The definition of early sepsis is either Whether defining early sepsis as within 30 days, or until planned closure of ileostomy, (i.e. 3 months),. bBoth definitions refer to sepsis that is a direct result of the operative procedure. This is in comparison, compared towith a second peak of PRSC in patients who develop de novo sepsis several years after pouch formation. Some of these cases are attributed to Crohn’s disease, but recent literature suggests that this diagnosis is over used ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "", "ISSN" : "1530-0358", "abstract" : "BACKGROUND: After IPAA, 8% of patients with ulcerative colitis are later diagnosed with Crohn's disease of the pouch, associated with an increased rate of pouch failure. No study has reported on how often the clinical diagnosis is correlated with histologic findings of Crohn's disease in the excised pouch., OBJECTIVE: The purpose of this study was to determine whether the clinical diagnosis is consistent with pathologic confirmation at pouch excision., SETTINGS: The study was conducted at a tertiary IBD referral center., PATIENTS: Patients with chronic ulcerative colitis who underwent pouch excision for presumed Crohn's disease of the pouch were included., MAIN OUTCOME MEASURES: Preoperative evaluation and pathologic variables at the time of pouch excision were measured., RESULTS: A total of 35 patients underwent pouch excision for Crohn's disease of the pouch based on a combination of clinical, radiographic, and endoscopic findings. Seven (20%) had surgical pathology consistent with Crohn's disease at pouch excision. There were no differences in those 7 patients and the remaining 28 in terms of diagnosis at colectomy, primary pouch symptoms, prepouch inflammation, ulceration, or granulomas at endoscopy. In the nonpathology-confirmed Crohn's disease, 40% (n = 11) had an anastomotic leak at time of IPAA versus 0% in the Crohn's disease group, and 86% (n = 24) had symptoms of pouch dysfunction within 5 months of ileostomy reversal versus 13 months in the Crohn's disease group. Of 28 without pathology-confirmed Crohn's disease, 100% (n = 28) were treated with antibiotics, 68% (n = 19) with steroids, 59% (n = 16) with immunomodulators, and 57% (n = 15) with biologic therapy for Crohn's disease of the pouch., LIMITATIONS: The study was limited by its single-center scope and lack of an established definition for Crohn's disease of the pouch., CONCLUSIONS: Pathologic confirmation of Crohn's disease was given to only one fifth of patients who underwent pouch excision for Crohn's disease of the pouch. Given the histologic variability in Crohn's disease, it may be unreasonable to expect histologic confirmation in every case; still, the diagnosis of Crohn's disease of the pouch may be overly ascribed, resulting in unnecessary immunosuppressive medications and exclusion from consideration for pouch reconstructive surgery. See Video Abstract at .", "author" : [ { "dropping-particle" : "", "family" : "Lightner", "given" : "Amy L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fletcher", "given" : "Joel G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pemberton", "given" : "John H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mathis", "given" : "Kellie L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Raffals", "given" : "Laura E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smyrk", "given" : "Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "11", "issued" : { "date-parts" : [ [ "2017" ] ] }, "page" : "1201-1208", "publisher-place" : "United States", "title" : "Crohn's Disease of the Pouch: A True Diagnosis or an Oversubscribed Diagnosis of Exclusion?.", "type" : "article-journal", "volume" : "60" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(9)", "plainTextFormattedCitation" : "(9)", "previouslyFormattedCitation" : "(9)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(9).Many factors influence the As described by Raval et al, there may be varying degrees of the magnitude of the pouch septic insult. These include the , depending on time to time to diagnosis of the leak, leak diagnosis,the presence or otherwise of a defunctioning ileostomy, anatomical site and size. A leak from the tip of the J is generally a very different clinical scenario to a leak from the IAA. Further studies are required to follow up cases of PRSC with prospective data on different sepsis characteristics and management to accurately assess the correlation with outcome. The rate of successful salvage has improved over time, and now ranges between 75 and 85% ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/SLA.0b013e31814539b1", "ISBN" : "0003-4932", "ISSN" : "0003-4932", "PMID" : "17968167", "abstract" : "OBJECTIVE: To assess the clinical presentation, management, and outcome of leaks after the ileal pouch-anal anastomosis (IPAA) procedure., METHODS: Of 1424 IPAA procedures performed at Mount Sinai Hospital from 1981 to 2003, 141 patients experienced leaks (9.9%). Data were reviewed retrospectively from the Inflammatory Bowel Disease database and clinic and hospital charts. Statistical comparisons were performed with the chi2 test., RESULTS: There were 81 men and 60 women with a median age of 36 years (12-69). Indication for surgery was ulcerative colitis in 93% of patients. Twenty-three leaks (16.3%) originated from the pouch whereas 118 (84.1%) arose from the ileoanal anastomosis. Of ileoanal anastomosis leaks, 24.6% were associated with and 38.1% without an abscess, 12.7% were associated with a pouch-cutaneous fistula, 15.3% were associated with a pouch-vaginal fistula, and 9.3% were diagnosed radiologically. Of the 130 patients who developed symptoms, 67% had fever, 38% had abdominoperineal pain, and 6% had perineal abscess. Twenty-nine percent of those who did not have an ileostomy had increased stool frequency. Nonoperative treatment was attempted initially in 100 patients with an 80% success rate. An operative procedure was performed in 59 patients (including those who failed nonoperative treatment), including transanal repair in 34 patients with a success rate of 66%; laparotomy with direct suture repair in 7 with a success rate of 57% and combined abdominoperineal pouch reconstruction in 18 with a success rate of 72%. Overall, 119 patients (84%) have a functioning pouch. Pouch salvage after a leak increased from 67% in 1981-1984 to 88% in 2001-2003 (P = 0.0004, chi2)., CONCLUSIONS: A high rate of ileal pouch salvage can be achieved after leaks associated with the IPAA procedure if management is individualized. Improved salvage rate over time is likely a reflection of increased experience with the management of complications as well as the strategy of individualized management.", "author" : [ { "dropping-particle" : "", "family" : "Raval", "given" : "Manoj J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnitzler", "given" : "Margaret", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.J.", "given" : "Raval", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.", "given" : "Schnitzler", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B.I.", "given" : "O'Connor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Z.", "given" : "Cohen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R.S.", "given" : "McLeod", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Raval", "given" : "Manoj J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnitzler", "given" : "Margaret", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O\u02bcConnor", "given" : "Brenda I.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of surgery", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "From Duplicate 2 (Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis. - Raval, Manoj J; Schnitzler, Margaret; O'Connor, Brenda I; Cohen, Zane; McLeod, Robin S)\n\nExcellent paper", "page" : "763-770", "title" : "Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis.", "type" : "article-journal", "volume" : "246" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(10)", "plainTextFormattedCitation" : "(10)", "previouslyFormattedCitation" : "(10)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(10). The need for laparotomy or trans-anal drainage, however, was consistently associated with failure in this review.The clinical burden of insidious leaks is unknown. not yet known. Patients who are asymptomatic until reversal of stoma ileostomy may well have had ongoing low-grade sepsis. Roughly 8% of Raval et al’s series were asymptomatic, with an abnormal pouchogram before reversal of ileostomy. It is not known how many of their patients developed sepsis after ileostomy closure with a normal pouchogram, but it has been demonstrated in other studies that pouchogram has poor sensitivity for the detection of anastomotic leaks ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-9260", "abstract" : "A series of ileal pouchograms from 25 consecutive patients has been analysed retrospectively. Ileal pouchography may demonstrate abnormalities which delay closure of the covering ileostomy. The aim was to determine whether disruption of the ileoanal anastomosis and/or leak at pouchography correlated with pelvic sepsis after ileostomy closure. Disruption of the stapled ileoanal anastomosis is a sensitive (88%) but not specific predictor (57%) for subsequent pelvic sepsis. The predictive value of a negative test is high (89%). Leak of contrast from the anastomosis is specific (81%) but not sensitive (56%) for pelvic sepsis. No significant relationship was demonstrated between width of the presacral space and the presence of pelvic sepsis. No significant relationship was demonstrated between diameter of the ileoanal anastomosis and symptoms of stricture. The presence of anastomotic disruption or leak at pouchography prior to ileostomy closure are useful predictors of potential pelvic sepsis.", "author" : [ { "dropping-particle" : "", "family" : "Malcolm", "given" : "P N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bhagat", "given" : "K K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chapman", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Davies", "given" : "S G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Williams", "given" : "N S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Murfitt", "given" : "J B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical radiology", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "1995" ] ] }, "page" : "613-617", "title" : "Complications of the ileal pouch: is the pouchogram a useful predictor?.", "type" : "article-journal", "volume" : "50" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "1462-8910", "abstract" : "INTRODUCTION: Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis., METHODS: All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed., RESULTS: Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients., CONCLUSION: Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.", "author" : [ { "dropping-particle" : "", "family" : "Silva", "given" : "G M", "non-dropping-particle" : "da", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wexner", "given" : "S D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gurland", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gervaz", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "Do", "family" : "Moon", "given" : "Seong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Efron", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nogueras", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weiss", "given" : "E G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vernava", "given" : "A M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zmora", "given" : "O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "117-120", "title" : "Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?.", "type" : "article-journal", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(11,12)", "plainTextFormattedCitation" : "(11,12)", "previouslyFormattedCitation" : "(11,12)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(11,12). Only Mennigen et al’s paper describes the routine use of endoscopy to review the integrity of the pouch before discharge. Only one study describes the use of routine imaging in the early post-operative period before discharge, as opposed to before ileostomy closure. Chronic low grade sepsis can be asymptomatic or misdiagnosed as chronic pouchitis ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/codi.13536", "ISSN" : "1463-1318 (Electronic)", "PMID" : "27688067", "abstract" : "AIM: Chronic peri-pouch sepsis (CPPS) may be mistaken for antibiotic-dependent or refractory primary idiopathic pouchitis (ADRP), but requires different treatment such as drainage. The study aimed to identify the prevalence of CPPS in patients thought to have ADRP. The secondary aims were to identify any specific features on pouchoscopy suggesting CPPS and to determine the results of treatment for CPPS. METHOD: The records of patients who had been treated for ADRP between March 2006 and June 2015 were reviewed retrospectively. Only those with endoscopic evidence of pouch inflammation who had also undergone MRI of the pelvis were included. The findings on pouchoscopy and the outcome of treatment were determined. RESULTS: Sixty-eight patients (43 men, 63%) were identified with apparent ADRP between March 2006 and June 2015. MRI of the pelvis showed CPPS in 26 (38%). In those with CPPS, the inflammation was more often located in the upper pouch alone (15%) compared with patients without CPPS (0%) (P = 0.0184). Examination under anaesthesia was performed in 13 of those with CPPS. In five a collection was identified and drained; symptoms improved in only one (4%). Eighteen patients (69%) remained on antibiotics and seven (27%) had a defunctioning stoma or underwent pouch excision. CONCLUSION: In patients thought to have ADRP, 38% had CPPS on MRI. There was no clinically relevant specific feature on pouchoscopy suggestive of CPPS. The possibility of CPPS should be considered early in patients with apparent ADRP and pelvic MRI performed. This might lead to earlier detection of CPPS and appropriate treatment.", "author" : [ { "dropping-particle" : "", "family" : "Ploeg", "given" : "V A", "non-dropping-particle" : "van der", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maeda", "given" : "Y", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faiz", "given" : "O D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hart", "given" : "A L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Clark", "given" : "S K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2017", "9" ] ] }, "language" : "eng", "page" : "827-831", "publisher-place" : "England", "title" : "The prevalence of chronic peri-pouch sepsis in patients treated for antibiotic-dependent or refractory primary idiopathic pouchitis.", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(13)", "plainTextFormattedCitation" : "(13)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(13), and it may be appropriate to incorporate early prophylactic pouch imaging to detect silent leaks, with the intention of acute anastomotic repair or vacuum therapy to prevent the influence of insidious septic exposure on the pouch. There is very little mention of the routine examination of pouches in the post-operative period, and the sensitivity of digital examination to detect ileo-anal anastomotic defects in pouches is not known. Managing PRSC without a diverting ileostomy continues to be a contentious. issue. It is becoming more popular to undertake pouch surgery without a de-functioning ileostomy ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/ecco-jcc/jjv201", "ISSN" : "1873-9946", "author" : [ { "dropping-particle" : "", "family" : "Sahami", "given" : "Saloomeh", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buskens", "given" : "Christianne J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fadok", "given" : "Tonia Young", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tanis", "given" : "Pieter J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buck van Overstraeten", "given" : "Anthony", "non-dropping-particle" : "de", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wolthuis", "given" : "Albert M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bemelman", "given" : "Willem a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "D\u2019Hoore", "given" : "Andr\u00e9", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Crohn's and Colitis", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "jjv201", "title" : "Defunctioning Ileostomy is not Associated with Reduced Leakage in Proctocolectomy and Ileal Pouch Anastomosis Surgeries for IBD", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(14)", "plainTextFormattedCitation" : "(14)", "previouslyFormattedCitation" : "(13)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(14) and several of the studies included in this review even describe the successful management of PRSC without a de-functioning stoma [2, 6, 10]. As with selecting patients for primary pouch formation without ileostomy, the management of leaks without a de-functioning ileostomy must be assessed on a case by case basis, taking in to account patient factors (no steroid use, good nutritional status, non-smoker) and operative factors (tension free anastomosis, good perfusion etc). One of the arguments in favour of forming an ileal pouch without de-functioning is that a leak is likely to be more clinically apparentobvious, and thereby manifested earlier. The current progression of techniques towards trans-anal dissection, single circular stapled anastomosis and the use of Endo-SPONGE? for leak control go hand in hand with the ‘modern two-stage’ approach to pouch formation; i.e. colectomy with ileostomy followed by proctectomy and pouch formation without ileostomy. The novel use of the Endo-SPONGE? device to clean the cavity and promote healing before closure in Dutch studies shows promising results in terms of early healing, but as yet there are no published follow up data describing functional outcomes. Further studies are required to investigate the subsequent functional outcome depending on the time taken to resolve sepsis and the technique used. As stated previously, a published categorisation of pouch leaks would add homogeneity to future research.Based on the evidence collated here and the experience of our own institution we present an algorithm for the management of early PRSC (figure 2). Trans-gluteal image guided drainage should be avoided if possible because of potential fistulation along the drain tract. For a pelvic abscess cavity without a visible staple line defect or communicating sinus, controversy exists as to the best management. If transcutaneous drainage is performed in the context of a communication with the pouch this may result in an extrasphincteric fistula and should be avoided. If a small communication is found, it is possible to slightly dilate it and introduce an Endo-SPONGE?. Algorithms have been published previously following review of the techniques for all pouch complications, but they either do not focus specifically on early PRSC or do not include the use of Endo-SPONGE? therapy ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jamcollsurg.2014.10.016", "ISSN" : "18791190", "author" : [ { "dropping-particle" : "", "family" : "Theodoropoulos", "given" : "George E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Choman", "given" : "Eran N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wexner", "given" : "Steven D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the American College of Surgeons", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "225-242.e1", "publisher" : "American College of Surgeons", "title" : "Salvage procedures after restorative proctocolectomy: a systematic review and meta-analysis", "type" : "article-journal", "volume" : "220" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/SLA.0b013e31814539b1", "ISBN" : "0003-4932", "ISSN" : "0003-4932", "PMID" : "17968167", "abstract" : "OBJECTIVE: To assess the clinical presentation, management, and outcome of leaks after the ileal pouch-anal anastomosis (IPAA) procedure., METHODS: Of 1424 IPAA procedures performed at Mount Sinai Hospital from 1981 to 2003, 141 patients experienced leaks (9.9%). Data were reviewed retrospectively from the Inflammatory Bowel Disease database and clinic and hospital charts. Statistical comparisons were performed with the chi2 test., RESULTS: There were 81 men and 60 women with a median age of 36 years (12-69). Indication for surgery was ulcerative colitis in 93% of patients. Twenty-three leaks (16.3%) originated from the pouch whereas 118 (84.1%) arose from the ileoanal anastomosis. Of ileoanal anastomosis leaks, 24.6% were associated with and 38.1% without an abscess, 12.7% were associated with a pouch-cutaneous fistula, 15.3% were associated with a pouch-vaginal fistula, and 9.3% were diagnosed radiologically. Of the 130 patients who developed symptoms, 67% had fever, 38% had abdominoperineal pain, and 6% had perineal abscess. Twenty-nine percent of those who did not have an ileostomy had increased stool frequency. Nonoperative treatment was attempted initially in 100 patients with an 80% success rate. An operative procedure was performed in 59 patients (including those who failed nonoperative treatment), including transanal repair in 34 patients with a success rate of 66%; laparotomy with direct suture repair in 7 with a success rate of 57% and combined abdominoperineal pouch reconstruction in 18 with a success rate of 72%. Overall, 119 patients (84%) have a functioning pouch. Pouch salvage after a leak increased from 67% in 1981-1984 to 88% in 2001-2003 (P = 0.0004, chi2)., CONCLUSIONS: A high rate of ileal pouch salvage can be achieved after leaks associated with the IPAA procedure if management is individualized. Improved salvage rate over time is likely a reflection of increased experience with the management of complications as well as the strategy of individualized management.", "author" : [ { "dropping-particle" : "", "family" : "Raval", "given" : "Manoj J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnitzler", "given" : "Margaret", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.J.", "given" : "Raval", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.", "given" : "Schnitzler", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B.I.", "given" : "O'Connor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Z.", "given" : "Cohen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R.S.", "given" : "McLeod", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Raval", "given" : "Manoj J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnitzler", "given" : "Margaret", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O\u02bcConnor", "given" : "Brenda I.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of surgery", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "From Duplicate 2 (Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis. - Raval, Manoj J; Schnitzler, Margaret; O'Connor, Brenda I; Cohen, Zane; McLeod, Robin S)\n\nExcellent paper", "page" : "763-770", "title" : "Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis.", "type" : "article-journal", "volume" : "246" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "", "ISSN" : "1463-1318", "abstract" : "AIM: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the operation of choice for ulcerative colitis (UC) and some cases of familial adenomatous polyposis (FAP). Although it offers improvement in quality of life and high patient satisfaction, pouch surgery is also associated with significant morbidity. The aim of this study was to describe the management of patients referred to a tertiary centre with pouch dysfunction., METHOD: All patients referred with pouch dysfunction from other institutions between October 2006 and November 2014 were included in this retrospective study. Information regarding initial diagnosis before RPC, type of procedure, symptoms leading to referral, relation of the appearance of symptoms to the ileostomy closure, investigations, final diagnosis, treatment and follow-up was reviewed., RESULTS: One hundred and twenty-one patients were included, having had RPC mostly for UC (94%), and with diverting ileostomy (83%). The most frequent reasons for referral were high frequency of defaecation in 83 (69%) patients, abdominal pain and incontinence in 45 (37%) each and perianal pain in 44 (36%). The principal investigations performed were pouchoscopy in 97 (80%) patients, examination under anaesthesia (EUA) in 62 (51%), pelvic magnetic resonance imaging (MRI) in 56 (46%) and contrast radiology of the pouch (pouchogram) in 45 (35%). The commonest diagnoses were pouchitis (primary and secondary) in 24 (21%) patients and anastomotic leakage in 26 (22%). After full investigation a cause for the symptoms could not be found in 24 (20%) patients, resulting in the diagnosis of exclusion of 'irritable pouch syndrome' or functional disorder. The treatments given were long-term antibiotic therapy in 29 (25%) patients, ileostomy in 19 (16%), use of a Medena catheter to promote anal evacuation in 17 (15%) and dilatation of a stenosis under anaesthetic in 12 (10%). Six (5%) patients underwent major revision surgery of the pouch with a defunctioning ileostomy and the pouch was excised in another six (5%)., CONCLUSION: Patients with ileoanal pouch dysfunction often have multiple symptoms. This study shows that a wide range of investigations and treatment modalities need to be available to manage such patients, with a specialized approach in a multidisciplinary setting.Copyright Colorectal Disease \u00a9 2016 The Association of Coloproctology of Great Britain and Ireland.", "author" : [ { "dropping-particle" : "", "family" : "Ouro", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thava", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaikh", "given" : "I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Clark", "given" : "S K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland", "id" : "ITEM-3", "issue" : "12", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "1167-1171", "publisher-place" : "England", "title" : "Management of pouch dysfunction in a tertiary centre.", "type" : "article-journal", "volume" : "18" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(10,15,16)", "plainTextFormattedCitation" : "(10,15,16)", "previouslyFormattedCitation" : "(10,14,15)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(10,15,16). The limitations of this review lie with the quality of the studies reported. The relative lack of published data available in this area should prompt future research aiming to establish the most effective management of early PRSC by correlating interventions with outcome measures.ConclusionThe results of this review case series included in this review suggest that although successful salvage of early pouch related septic complications is improving. However, over time there is a paucity of research investigating salvage techniques and outcomes. correlating the method used with functional outcome. Novel techniques may offer an increased chance of salvage but comparative studies with longer follow-up are required. Author ContributionsGW conceived the study, performed the literature search, extracted and analysed the data, drafted the manuscript and approved the final version for publication. JS performed the literature search, extracted and analysed the data, critically appraised the manuscript and approved the final version for publication. JW and SKC critically appraised the manuscript and approved the final version for publication. ODF conceived the study, critically appraised the manuscript and approved the final version for publication.Conflicts of InterestNoneReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978 Jul;2:85–88. 2. Tekkis PP, Lovegrove RE, Tilney HS et al. Long-term failure and function after restorative proctocolectomy - a multi-centre study of patients from the UK national ileal pouch registry. Color Dis. 2010 May;12:433–441. 3. Tulchinsky H, Hawley PR, Nicholls J. Long-Term Failure After Restorative Proctocolectomy for Ulcerative Colitis. Ann Surg. 2003;238:229–234. 4. Hueting WE, Buskens E, van der Tweel I et al. Results and complications after ileal pouch anal anastomosis: A meta-analysis of 43 observational studies comprising 9,317 patients. Dig Surg. 2005;22:69–79. 5. Forbes SS, O’Connor BI, Charles Victor J, Cohen Z, McLeod RS. Sepsis is a major predictor of failure after ileal pouch-anal anastomosis. Dis Colon Rectum. 2009;52:1975–81. 6. Fazio VW, Tekkis PP, Remzi F et al. Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. Ann Surg. 2003;238:605-14-7. 7. Moher D, Liberati a, Tetzlaff J, Altman DG, Grp P. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement (Reprinted from Annals of Internal Medicine). Phys Ther. 2009;89:873–880. 8. Rahbari NN. Definition and grading of anastomotic leakage following anterior resection of the rectum?: A proposal by the International Study Group of Rectal Cancer. 2010;339–351. 9. Lightner AL, Fletcher JG, Pemberton JH, Mathis KL, Raffals LE, Smyrk T. Crohn’s Disease of the Pouch: A True Diagnosis or an Oversubscribed Diagnosis of Exclusion?. Dis Colon Rectum. 2017;60:1201–1208. 10. Raval MJ, Schnitzler M, O’Connor BI et al. Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis. Ann Surg. 2007;246:763–770. 11. Malcolm PN, Bhagat KK, Chapman MA, Davies SG, Williams NS, Murfitt JB. Complications of the ileal pouch: is the pouchogram a useful predictor?. Clin Radiol. 1995;50:613–617. 12. da Silva GM, Wexner SD, Gurland B, Gervaz P, Moon S Do, Efron J, et al. Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?. Colorectal Dis. 2004;6:117–120. 13. van der Ploeg VA, Maeda Y, Faiz OD, Hart AL, Clark SK. The prevalence of chronic peri-pouch sepsis in patients treated for antibiotic-dependent or refractory primary idiopathic pouchitis. Colorectal Dis. 2017 Sep;19:827–831. 14. Sahami S, Buskens CJ, Fadok TY et al. Defunctioning Ileostomy is not Associated with Reduced Leakage in Proctocolectomy and Ileal Pouch Anastomosis Surgeries for IBD. J Crohn’s Colitis. 2016 Jul; 10: 779-78515. Theodoropoulos GE, Choman EN, Wexner SD. Salvage procedures after restorative proctocolectomy: a systematic review and meta-analysis. J Am Coll Surg. 2015;220:225–24216. Ouro S, Thava B, Shaikh I, Clark SK. Management of pouch dysfunction in a tertiary centre. Colorectal Dis. 2016;18:1167–1171. 17. Sagap I, Remzi FH, Hammel JP, Fazio VW. Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) - A multivariate analysis. Surgery. 2006;140:691–704. 18. Van Koperen PJ, Van Berge Henegouwen MI, Slors JFM, Bemelman WA. Endo-sponge treatment of anastomotic leakage after ileo-anal pouch anastomosis: report of two cases. Colorectal Dis. 2008;10:943–944. 19. Maruthachalam K, Kumar R, Hainsworth P. Parking the Pouch: Pouch Salvage After Anastomotic Leak Following Restorative Proctocolectomy. Report of a Case. Dis Colon Rectum. 2008;51:1724–1726. 20. Kirat HT, Kiran RP, Oncel M, Shen B, Fazio VW, Remzi FH. Management of Leak From the Tip of the ‘J’ in Ileal Pouch-Anal Anastomosis. Dis Colon Rectum. 2011;54:454–459. 21. Mennigen R, Senninger N, Bruewer M, et al. Pouch function and quality of life after successful management of pouch-related septic complications in patients with ulcerative colitis. Langenbeck’s Arch Surg. 2012;397:37–44. 22. Kirat HT, Remzi FH, Shen B, Kiran RP. Pelvic abscess associated with anastomotic leak in patients with ileal pouch-anal anastomosis (IPAA): transanastomotic or CT-guided drainage? Int J Colorectal Dis. 2011;26:1469–1474. 23. Verlaan T, Bartels S a. L, van Berge Henegouwen MI et al. Early, minimally invasive closure of anastomotic leaks: a new concept. Color Dis. 2011;13(SUPPL. 7):18–22. 24. Varadarajulu S. Endoscopic ultrasound-guided drainage of a pelvic abscess via a J-pouch. Endoscopy. 2012;44:E92–3. 25. Srinivasamurthy D, Wood C, Slater R et al. An initial experience using transanal vacuum therapy in pelvic anastomotic leakage. Tech Coloproctol. 2013;17:275–281. 26. Gardenbroek TJ, Musters GD, Buskens CJ et al. Early reconstruction of the leaking ileal pouch-anal anastomosis: a novel solution to an old problem. Colorectal Dis. 2015;17:426–432. 27. Thosani N, Sethi S, Hovsepian D, Kochar R, Welton M, Banerjee S. Rendezvous EndoSeel Technique for Non-operative Closure of Anastomotic Leak After Ileoanal Pouch Operation. Dig Dis Sci. Springer US; 2015;60:3545–3548. Table 1 Study Characteristics. If the study included more than one pathology, then the number of patients with UC is included in parenthesis.Author CountryYear of PublicationPatients studied (n)Female Gender (%)Average AgeStudy summaryAverage Follow Up (Months) Functional outcomes reported?Quality of life outcome reported?1.Sagap ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.surg.2006.07.015", "ISBN" : "0039-6060", "ISSN" : "00396060", "abstract" : "Background: Pelvic sepsis is known to cause a detrimental outcome after ileal pouch-anal anastomosis (IPAA). The aim of this study was to examine potential factors associated with failure in managing pelvic sepsis after IPAA. Methods: We performed univariate and multivariate logistic regression analysis on 2518 IPAA patients between 1983 and 2005. Failure was defined as pouch failure, the need for a permanent ileostomy, or mortality as a result of sepsis. There were 157 patients (6.2%) with pelvic sepsis after IPAA. These involved anastomotic leak 34% (54/157) and fistula 25% (40/157). There were 5 mortalities related to sepsis. Mean age at surgery was 38.1 +/- 14.4 years and mean follow-up was 5.5 +/- 4.7 years. Results: Pouches were saved in 75.8% patients. Univariate analysis identified early sepsis (P = .040), preoperative steroid use (P = .007), and need for percutaneous drainage (P = .004) as significant factors associated with treatment success. Factors associated with failure were hypertension (P = .026), hand-sewn anastomosis (P = .038), associated fistula (P = .0003), need for transanal drainage (P = .0002), need for laparotomy to control septic complications (P < .0001), delayed ileostomy closure (P = .0003), and need for a new diverting ileostomy (P < .0001). By using multivariate analysis with selected covariates, significant factors associated with failure were associated fistula (P = .0013), need for transanal drainage (P = .003), delayed ileostomy closure (P = .022), need for a new ileostomy diversion (P = .004), and hypertension (P = .039). We developed a predictive scoring system for failure to use in management plans and decision-making for the treatment of septic complications of IPAA. Conclusions: Pelvic sepsis after IPAA has a significant impact on pouch failure. This predictive model for failure may play an important role in providing risk estimates for successful outcomes. \u00a9 2006 Mosby, Inc. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Sagap", "given" : "Ismail", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Remzi", "given" : "Feza H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hammel", "given" : "Jeffrey P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fazio", "given" : "Victor W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgery", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2006" ] ] }, "note" : "From Duplicate 1 (Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) - A multivariate analysis - I., Sagap; F.H., Remzi; J.P., Hammel; V.W., Fazio)\n\nNo article. Available in library in print\n\nFrom Duplicate 2 (Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) - A multivariate analysis - Sagap, Ismail; Remzi, Feza H.; Hammel, Jeffrey P.; Fazio, Victor W.)\n\nFrom Duplicate 1 (Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) \u2013 A multivariate analysis - Sagap, Ismail; Remzi, Feza H.; Hammel, Jeffrey P.; Fazio, Victor W.)\n\nGood paper for systematic review of PRSC but no indication of time before 30 days\n\nFrom Duplicate 2 (Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) - A multivariate analysis - I., Sagap; F.H., Remzi; J.P., Hammel; V.W., Fazio)\n\nNo article. Available in library in print\n\nFrom Duplicate 3 (Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) \u2013 A multivariate analysis - Sagap, Ismail; Remzi, Feza H.; Hammel, Jeffrey P.; Fazio, Victor W.)\n\nGood paper for systematic review of PRSC but no indication of time before 30 days", "page" : "691-704", "title" : "Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) - A multivariate analysis", "type" : "article-journal", "volume" : "140" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(17)", "plainTextFormattedCitation" : "(17)", "previouslyFormattedCitation" : "(17)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(17)USA2006157 (85 UC + 24 I/UC)4138Factors associated with failure in managing pouch sepsis66NoNo2.Raval ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/SLA.0b013e31814539b1", "ISBN" : "0003-4932", "ISSN" : "0003-4932", "PMID" : "17968167", "abstract" : "OBJECTIVE: To assess the clinical presentation, management, and outcome of leaks after the ileal pouch-anal anastomosis (IPAA) procedure., METHODS: Of 1424 IPAA procedures performed at Mount Sinai Hospital from 1981 to 2003, 141 patients experienced leaks (9.9%). Data were reviewed retrospectively from the Inflammatory Bowel Disease database and clinic and hospital charts. Statistical comparisons were performed with the chi2 test., RESULTS: There were 81 men and 60 women with a median age of 36 years (12-69). Indication for surgery was ulcerative colitis in 93% of patients. Twenty-three leaks (16.3%) originated from the pouch whereas 118 (84.1%) arose from the ileoanal anastomosis. Of ileoanal anastomosis leaks, 24.6% were associated with and 38.1% without an abscess, 12.7% were associated with a pouch-cutaneous fistula, 15.3% were associated with a pouch-vaginal fistula, and 9.3% were diagnosed radiologically. Of the 130 patients who developed symptoms, 67% had fever, 38% had abdominoperineal pain, and 6% had perineal abscess. Twenty-nine percent of those who did not have an ileostomy had increased stool frequency. Nonoperative treatment was attempted initially in 100 patients with an 80% success rate. An operative procedure was performed in 59 patients (including those who failed nonoperative treatment), including transanal repair in 34 patients with a success rate of 66%; laparotomy with direct suture repair in 7 with a success rate of 57% and combined abdominoperineal pouch reconstruction in 18 with a success rate of 72%. Overall, 119 patients (84%) have a functioning pouch. Pouch salvage after a leak increased from 67% in 1981-1984 to 88% in 2001-2003 (P = 0.0004, chi2)., CONCLUSIONS: A high rate of ileal pouch salvage can be achieved after leaks associated with the IPAA procedure if management is individualized. Improved salvage rate over time is likely a reflection of increased experience with the management of complications as well as the strategy of individualized management.", "author" : [ { "dropping-particle" : "", "family" : "Raval", "given" : "Manoj J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnitzler", "given" : "Margaret", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.J.", "given" : "Raval", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.", "given" : "Schnitzler", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B.I.", "given" : "O'Connor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Z.", "given" : "Cohen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R.S.", "given" : "McLeod", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Raval", "given" : "Manoj J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnitzler", "given" : "Margaret", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Brenda I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O\u02bcConnor", "given" : "Brenda I.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "Zane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLeod", "given" : "Robin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of surgery", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "From Duplicate 2 (Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis. - Raval, Manoj J; Schnitzler, Margaret; O'Connor, Brenda I; Cohen, Zane; McLeod, Robin S)\n\nExcellent paper", "page" : "763-770", "title" : "Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis.", "type" : "article-journal", "volume" : "246" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(10)", "plainTextFormattedCitation" : "(10)", "previouslyFormattedCitation" : "(10)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(10)Canada2007141(131 UC)43 36Individualised management of leaks36NoNo3.Van Koperen ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1463-1318", "abstract" : "OBJECTIVE: The endo-sponge was used in two patients in the treatment of anastomotic leakage following ileo-anal J-pouch reconstruction. Recently, local vacuum sponge treatment has shown to be effective to treat contained anastomotic leakage after low anterior anastomosis in rectal cancer patients., METHOD: Two patients (male, 18 years; female, 40 years) who underwent restorative proctocolectomy for ulcerative colitis developed localized anastomotic leakage without general peritonitis. This was endoscopically managed by transanal placement of an endo-sponge (B. Braun Medical B.V., Melsungen, Germany) after a diverting ileostomy was performed., RESULTS: The sponge was frequently replaced until resolution of the sinus was achieved in 35 and 56 days., CONCLUSION: Vacuum endo-sponge treatment can help anastomotic leakage after ileo-anal pouch surgery.", "author" : [ { "dropping-particle" : "", "family" : "Koperen", "given" : "P J", "non-dropping-particle" : "Van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berge Henegouwen", "given" : "M I", "non-dropping-particle" : "Van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Slors", "given" : "J F M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bemelman", "given" : "W A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "943-944", "title" : "Endo-sponge treatment of anastomotic leakage after ileo-anal pouch anastomosis: report of two cases.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(18)", "plainTextFormattedCitation" : "(18)", "previouslyFormattedCitation" : "(18)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(18)Holland20072 (2 UC)5034Long course Endo-SPONGE? therapyNRNoNo4.Maruthachalam ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s10350-008-9362-9", "ISSN" : "0012-3706", "author" : [ { "dropping-particle" : "", "family" : "Maruthachalam", "given" : "Karthik", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kumar", "given" : "Rohit", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hainsworth", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the Colon & Rectum", "id" : "ITEM-1", "issue" : "11", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "1724-1726", "title" : "Parking the Pouch: Pouch Salvage After Anastomotic Leak Following Restorative Proctocolectomy. Report of a Case", "type" : "article-journal", "volume" : "51" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(19)", "plainTextFormattedCitation" : "(19)", "previouslyFormattedCitation" : "(19)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(19)UK20081N/A59Interim pouch salvage as a mucus fistula18YesNo5.Kirat ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/DCR.0b013e31820481be", "ISSN" : "0012-3706", "author" : [ { "dropping-particle" : "", "family" : "Kirat", "given" : "Hasan T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kiran", "given" : "Ravi P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oncel", "given" : "Mustafa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shen", "given" : "Bo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fazio", "given" : "Victor W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Remzi", "given" : "Feza H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the Colon & Rectum", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "454-459", "title" : "Management of Leak From the Tip of the \u201cJ\u201d in Ileal Pouch-Anal Anastomosis", "type" : "article-journal", "volume" : "54" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(20)", "plainTextFormattedCitation" : "(20)", "previouslyFormattedCitation" : "(20)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(20)USA201127 (22 UC)4837Management of leaks from the tip of the J pouch38YesYes6.Mennigen ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00423-011-0802-y", "ISBN" : "1435-2443", "ISSN" : "1435-2451", "abstract" : "PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis is associated with pouch-related septic complications (PRSC) in 10% of patients. This study questioned if PRSC have a negative impact on pouch function and quality of life., PATIENTS AND METHODS: One hundred thirty consecutive patients undergoing IPAA for ulcerative colitis between 1997 and 2009 were reviewed. At 1-year follow-up, patients were asked to complete questionnaires including a pouch function score (Oresland score, 0-16 points, 0 optimum) and two quality of life scores [Short Inflammatory Bowel Disease Questionnaire (SIBDQ), 1-7 points, 7 optimum; Gastrointestinal Quality of Life Index (GIQLI), 0-144 points, 144 optimum]., RESULTS: Twelve out of 130 patients (9.2%) undergoing IPAA developed PRSC. These included anastomotic dehiscence (five), pouch leakage (three, one patient had a combined leak), peripouchal abscess (three), pouch-anal fistula (one), and pouch-vaginal fistula (one). Omission of diverting ileostomy was a risk factor for PRSC (OR 4.62, CI 1.17-18.4). PRSC led to four pouch failures (33%), whereas no failure occurred in the control group (p<0.001). Median 3 (range, 1-10) further operations were necessary until the pouch was salvaged or definitively lost. If the pouch was salvaged, functional Oresland score (8.2+/-1.3 vs. 6.6+/-0.5; p=0.127), SIBDQ (5.0+/-0.5 vs. 5.5+/-0.1; p=0.203), and GIQLI (95.8+/-8.4 vs. 107.3+/-2.6; p=0.119) were not significantly inferior to uncomplicated controls., CONCLUSIONS: In case of PRSC, even multiple surgical approaches are worthwhile as the outcome of salvaged pouches in terms of function and quality of life is not substantially inferior to patients without septic complications.", "author" : [ { "dropping-particle" : "", "family" : "Mennigen", "given" : "Rudolf", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Senninger", "given" : "Norbert", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bruewer", "given" : "Matthias", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rijcken", "given" : "Emile", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R.", "given" : "Mennigen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "N.", "given" : "Senninger", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.", "given" : "Bruewer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "E.", "given" : "Rijcken", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mennigen", "given" : "Rudolf", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Senninger", "given" : "Norbert", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bruewer", "given" : "Matthias", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rijcken", "given" : "Emile", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R.", "given" : "Mennigen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "N.", "given" : "Senninger", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.", "given" : "Bruewer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "E.", "given" : "Rijcken", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Langenbeck's Archives of Surgery", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "language" : "English", "note" : "From Duplicate 4 (Pouch function and quality of life after successful management of pouch-related septic complications in patients with ulcerative colitis - Mennigen, Rudolf; Senninger, Norbert; Bruewer, Matthias; Rijcken, Emile)\n\nExcellent paper. Detailed description of management of PRSC\n\n12 patients with septic complications of pouches. These included leaks, abscess, fistulas.\n\n33% pouch failure in septic complications compared to control.\n\nMedian 3 operations to salvage pouch.\n\nNo functional difference between salvaged pouches and primary.\n\nUsed Oresland Score\nShort Inflammatory Bowel Disease Questionnaire (SIBDQ)\nGastrointestinal Quality of Life Index (GIQLI)", "page" : "37-44", "title" : "Pouch function and quality of life after successful management of pouch-related septic complications in patients with ulcerative colitis", "type" : "article-journal", "volume" : "397" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(21)", "plainTextFormattedCitation" : "(21)", "previouslyFormattedCitation" : "(21)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(21)Germany201112 (12 UC)5034.5Function after successful management of PRSC23.5YesYes7.Kirat ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00384-011-1272-y", "ISSN" : "0179-1958", "author" : [ { "dropping-particle" : "", "family" : "Kirat", "given" : "Hasan Tarik", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Remzi", "given" : "Feza H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shen", "given" : "Bo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kiran", "given" : "Ravi P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International Journal of Colorectal Disease", "id" : "ITEM-1", "issue" : "11", "issued" : { "date-parts" : [ [ "2011" ] ] }, "note" : "? for inclusion in systematic review but no clear indication of whether this treatment is within 30 days of primary surgery.\n\n'Length of post-operative hospital stay' is an indication that drainages were performed in the immediate post-operative period and so this study is appropriate for inclusion.", "page" : "1469-1474", "title" : "Pelvic abscess associated with anastomotic leak in patients with ileal pouch-anal anastomosis (IPAA): transanastomotic or CT-guided drainage?", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(22)", "plainTextFormattedCitation" : "(22)", "previouslyFormattedCitation" : "(22)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(22)USA201171(61 UC post-op histology)3037CT vs trans-anastomotic drainage of pouch abscesses45YesYes8.Verlaan ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/j.1463-1318.2011.02775.x", "ISBN" : "1462-8910", "ISSN" : "14628910", "abstract" : "Chronic pelvic sepsis after ileoanal or coloanal anastomosis precludes ileostomy closure and, even if closure is ultimately possible, function of the neorectum is badly affected. Early closure of the anastomotic leak might prevent chronic pelvic sepsis and its adverse sequelae. In our experience of early closure in a consecutive group of six patients with a leaking low anastomosis (five with ileoanal pouch anastomosis and one after a low anterior resection), we were able to achieve anastomotic closure in five by means of initial endosponge therapy followed either by early suture (four patients) or endoscopic clip repair (one patient). Early minimally invasive closure of low anastomotic leaks is therefore possible provided that the para-anastomotic cavity is drained well prior to closure and the anastomosis is defunctioned.Copyright \u00a9 2011 The Authors. Colorectal Disease \u00a9 2011 The Association of Coloproctology of Great Britain and Ireland.", "author" : [ { "dropping-particle" : "", "family" : "Verlaan", "given" : "T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bartels", "given" : "S. a. L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berge Henegouwen", "given" : "M. I.", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tanis", "given" : "P. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fockens", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bemelman", "given" : "W. a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "T.", "given" : "Verlaan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "S.A.L.", "given" : "Bartels", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M.I.", "given" : "van Berge Henegouwen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "P.J.", "given" : "Tanis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "P.", "given" : "Fockens", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "W.A.", "given" : "Bemelman", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal Disease", "id" : "ITEM-1", "issue" : "SUPPL. 7", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "18-22", "title" : "Early, minimally invasive closure of anastomotic leaks: a new concept", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(23)", "plainTextFormattedCitation" : "(23)", "previouslyFormattedCitation" : "(23)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(23)Netherlands20116 (5 UC)1750Early closure of anastomotic defect after short course Endo-SPONGE? therapy4.5NoNo9.Varadarajulu ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1055/s-0030-1256946", "ISSN" : "0013-726X", "author" : [ { "dropping-particle" : "", "family" : "Varadarajulu", "given" : "S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Endoscopy", "id" : "ITEM-1", "issue" : "S 02", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "E92-E93", "title" : "Endoscopic ultrasound-guided drainage of a pelvic abscess via a J-pouch", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(24)", "plainTextFormattedCitation" : "(24)", "previouslyFormattedCitation" : "(24)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(24)USA20121NRNREUS guided drainage of pouch abscessNRNoNo10.Srinivasamurthy ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "1123-6337", "ISSN" : "1128-045X", "abstract" : "BACKGROUND: Treatment of the presacral cavity that forms after contained anastomotic leakage of a low pelvic anastomosis is challenging and often results in a permanent stoma. EndospongeTM therapy is a minimally invasive method of treating the presacral cavity which potentially avoids a permanent stoma. We report our initial experience of using EndospongeTM therapy., METHODS: All patients who underwent EndospongeTM treatment for low pelvic anastomotic leakage in our hospital over a 45-month period were identified and data collected from clinical, operative and endoscopic notes., RESULTS: Eight patients (seven males, one female) underwent EndospongeTM therapy for extraperitoneal pelvic anastomotic leak during the study period; all had had defunctioning ileostomies placed at their original surgery. Six out of eight patients had complete closure or a reduction in the size of the abscess cavity. Five patients have had their ileostomies reversed with good or reasonable bowel function after a median follow-up of 41 months and four of these patients had EndospongeTM therapy instituted within 6 weeks of initial surgery. One patient had EndospongeTM therapy abandoned and conversion to a permanent end colostomy after accidental intraperitoneal placement of the sponge., CONCLUSIONS: Early use of EndospongeTM therapy appears to offer a minimally invasive and effective way of closing the presacral cavity after a pelvic anastomotic leak, reducing the risk of permanent stoma and resulting in acceptable bowel function. EndospongeTM-specific complications can occur.", "author" : [ { "dropping-particle" : "", "family" : "Srinivasamurthy", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wood", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Slater", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garner", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "D.", "given" : "Srinivasamurthy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "C.", "given" : "Wood", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R.", "given" : "Slater", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Techniques in Coloproctology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2013" ] ] }, "note" : "One case describing managment", "page" : "275-281", "title" : "An initial experience using transanal vacuum therapy in pelvic anastomotic leakage.", "type" : "article-journal", "volume" : "17" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(25)", "plainTextFormattedCitation" : "(25)", "previouslyFormattedCitation" : "(25)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(25)UK20126 (1 UC)N/A50Endo-SPONGE? therapy in pelvic leaks41YesNo11.Gardenbroek ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/codi.12867", "ISBN" : "1462-8910", "ISSN" : "1463-1318", "PMID" : "25512241", "abstract" : "AIM: The study aimed to determine the effectiveness and direct medical costs of early surgical closure of the anastomotic defect after a short course of Endo-sponge\u00ae therapy of the presacral cavity, compared with conventional treatment in patients with anastomotic leakage after ileal pouch-anal anastomosis (IPAA).\\n\\nMETHOD: Patients with anastomotic leakage after IPAA undergoing early surgical closure of the anastomotic defect after a short Endo-sponge\u00ae treatment were prospectively followed and compared with a consecutive cohort of patients with an anastomotic leak treated by creation of a loop ileostomy and occasional drainage of the presacral cavity.\\n\\nRESULTS: A total of 15 patients were treated with early surgical closure and 29 were treated conventionally. In the early surgical closure group, the Endo-sponge\u00ae treatment was continued for a median of 12 days [interquartile range (IQR) 7-15 days] with a median of 3 (IQR 2-4) Endo-sponge\u00ae changes. Secondary anastomotic healing was achieved in all patients (n = 15) in the early surgical closure group compared with 52% (n = 16) in the conventional treatment group (P = 0.003). Closure of the anastomotic defect was achieved after a median of 48 (25-103) days in the early surgical closure group compared with 70 (IQR 49-175) days in the conventional treatment group (P = 0.013). A functional pouch was seen in 93% and 86% of the patients in each group. There was no significant difference in direct medical cost.\\n\\nCONCLUSION: Early surgical closure after a short period of Endo-sponge\u00ae treatment is highly effective in treating anastomotic leakage after IPAA without increasing cost.", "author" : [ { "dropping-particle" : "", "family" : "Gardenbroek", "given" : "T J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Musters", "given" : "G D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buskens", "given" : "C J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ponsioen", "given" : "C Y", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "D'Haens", "given" : "G R a M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dijkgraaf", "given" : "M G W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tanis", "given" : "P J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bemelman", "given" : "W a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "426-32", "title" : "Early reconstruction of the leaking ileal pouch-anal anastomosis: a novel solution to an old problem.", "type" : "article-journal", "volume" : "17" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(26)", "plainTextFormattedCitation" : "(26)", "previouslyFormattedCitation" : "(16)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(26)Netherlands201515 (9 UC)2037Early closure of anastomotic defect after short course Endo-SPONGE? therapy in comparison with standard treatment25NoNo12.Thosani ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s10620-015-3657-1", "ISSN" : "0163-2116", "author" : [ { "dropping-particle" : "", "family" : "Thosani", "given" : "Nirav", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sethi", "given" : "Saurabh", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hovsepian", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kochar", "given" : "Rajan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Welton", "given" : "Mark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Banerjee", "given" : "Subhas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Digestive Diseases and Sciences", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "3545-3548", "publisher" : "Springer US", "title" : "Rendezvous EndoSeel Technique for Non-operative Closure of Anastomotic Leak After Ileoanal Pouch Operation", "type" : "article-journal", "volume" : "60" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(27)", "plainTextFormattedCitation" : "(27)", "previouslyFormattedCitation" : "(26)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(27)USA20151N/A50Over the scope clip closure of anastomotic defect1.5NoNoTable 2 Functional OutcomesAuthorF/UScore UsedScore outcomeDaily Stool FrequencyUrgencyIn-continenceSeepagePadsDayNightDayNightMaruthachalam1.5y--NRNR‘complete continence’NRNRNRNRKiratTrans-anal DrainageMean 4y--7.6 3.67.5%2.5%35.1%NR17.9%NRCT DrainageMean 3y--7.9 3.36.2%6.2%31.2%NR37.5%NRMennigenSepsis1y?resland(0-16; 0 optimum)Mean 8.27NRNRNRNRNRNRControlsMean 6.66NRNRNRNRNRNRKiratSalvageMean 3.2 y--8.4 4.615.4%018.2%25%8.3%8.3%ControlsMean 5.6y--8.8 104.3%2.1%23.9%30.4%19.6%21.7%SrinivasamurthyNR--6NR‘remain[s] continent throughout an 8-h shift at work’NRNRNRNRTable 3 Quality of Life OutcomesAuthorSubgroupQuestionnaireOutcomeP ValueKiratTransanal DrainageCGQL0.7 0.20.9CT Drainage0.7 0.1MennigenSepsisSIBDQ(1-7; 7 optimum)5.00.20Controls5.5SepsisGIQLI(0-144; 144 optimum)95.80.12Controls107.3KiratSalvageCGQL0.8 0.30.67Controls0.8 0.2Figure 1: PRISMA flow diagramFigure 2. Algorithm for the management of early pouch sepsis. *See 'presentation' in results section. ?As per Gardenbroek et al ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/codi.12867", "ISBN" : "1462-8910", "ISSN" : "1463-1318", "PMID" : "25512241", "abstract" : "AIM: The study aimed to determine the effectiveness and direct medical costs of early surgical closure of the anastomotic defect after a short course of Endo-sponge\u00ae therapy of the presacral cavity, compared with conventional treatment in patients with anastomotic leakage after ileal pouch-anal anastomosis (IPAA).\\n\\nMETHOD: Patients with anastomotic leakage after IPAA undergoing early surgical closure of the anastomotic defect after a short Endo-sponge\u00ae treatment were prospectively followed and compared with a consecutive cohort of patients with an anastomotic leak treated by creation of a loop ileostomy and occasional drainage of the presacral cavity.\\n\\nRESULTS: A total of 15 patients were treated with early surgical closure and 29 were treated conventionally. In the early surgical closure group, the Endo-sponge\u00ae treatment was continued for a median of 12 days [interquartile range (IQR) 7-15 days] with a median of 3 (IQR 2-4) Endo-sponge\u00ae changes. Secondary anastomotic healing was achieved in all patients (n = 15) in the early surgical closure group compared with 52% (n = 16) in the conventional treatment group (P = 0.003). Closure of the anastomotic defect was achieved after a median of 48 (25-103) days in the early surgical closure group compared with 70 (IQR 49-175) days in the conventional treatment group (P = 0.013). A functional pouch was seen in 93% and 86% of the patients in each group. There was no significant difference in direct medical cost.\\n\\nCONCLUSION: Early surgical closure after a short period of Endo-sponge\u00ae treatment is highly effective in treating anastomotic leakage after IPAA without increasing cost.", "author" : [ { "dropping-particle" : "", "family" : "Gardenbroek", "given" : "T J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Musters", "given" : "G D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buskens", "given" : "C J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ponsioen", "given" : "C Y", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "D'Haens", "given" : "G R a M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dijkgraaf", "given" : "M G W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tanis", "given" : "P J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bemelman", "given" : "W a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "426-32", "title" : "Early reconstruction of the leaking ileal pouch-anal anastomosis: a novel solution to an old problem.", "type" : "article-journal", "volume" : "17" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(16)", "plainTextFormattedCitation" : "(16)", "previouslyFormattedCitation" : "(16)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(16). ?Percutaneous drains should be removed as quickly as possible.Appendix 1.Search strategy:1. exp Colitis, Ulcerative/2. ulcerative coliti*.tw.3. 1 or 24. exp Colonic Pouches/5. exp Proctocolectomy, Restorative/6. ("restorative proctocolectomy" or "RPC" or "ile* pouch anal anastomosis" or"IPAA" or "ile* pouch" or "j pouch" or "s pouch" or "w pouch" or "h pouch").tw.7. 4 or 5 or 68. 3 and79. exp Anastomotic Leak/10. exp Sepsis/11. exp Abscess/ or exp Abdominal Abscess/12. exp Postoperative Complications/13. ("leak*" or "collection" or "sac* collection" or "abscess" or "fistula*").tw.14. ("pouch related septic complications" or "PRSC").tw.15. "pouch sepsis".tw.16. 9 or 10 or 11 or 12 or 13 or 14 or 1517. 8 and 1618. remove duplicates from 1719. 18 and 2000:2017.(sa_year).20. 19 and "Journal: Article" [Publication Type] ................
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