Advertisement

Surgical Endoscopy

, Volume 33, Issue 7, pp 2293–2303 | Cite as

Characterization of megapouch in patients with restorative proctocolectomy

  • Preeti Shashi
  • Bo ShenEmail author
Article

Abstract

Background

Megapouch is a rare functional complication of restorative proctocolectomy with ileal pouch-anal anastomosis characterized by pouch ± small bowel dilatation with no evidence of obstruction on endoscopy and imaging. Little is known about clinical characteristics and outcomes of this entity.

Methods

We included all patients diagnosed with megapouch at our institution, identified from a pouch database. Data on baseline characteristics, management, and outcomes were documented and analyzed from electronic medical records. Appropriate statistical measures were used. p < 0.05 was considered significant.

Results

Twenty-three patients with megapouch were identified. The mean age was 40.7 years; 95.6% had underlying ulcerative colitis; most common indication for colectomy was medically refractory disease (56.5%). Abdominal pain (82.6%) and bloating (52.2%) were most common presenting symptoms. Most common finding on pouchoscopy was pouch dilatation (81.8%), while barium or gastrografin enemas and MRI/CT mostly revealed dilatation of pouch and/or small bowel. Fourteen (66.7%) patients required some forms of surgery—six patients required pouch excision and three required either pouch redo or revision. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically versus those managed medically (p = 0.007 and 0.024, respectively), while need for escalation of IBD-therapy was comparable between the groups (p = 0.133). No deaths were reported and no patient had recurrence of megapouch. IPAA revision or redo did not lead to more IBD-related morbidity.

Conclusions

Majority of our patients with megapouch required surgery. In selected patients, redo pouch offered cure. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically.

Keywords

Ileal-anal pouch anastomosis Megapouch Pouch redo Pouch revision Pouch failure 

Notes

Acknowledgements

Dr. Bo Shen has been holder of the Ed and Joey Story Endowed Chair at the Digestive Disease & Surgery Institute, Cleveland Clinic, established in 2007.

Compliance with ethical standards

Disclosures

Preeti Shashi and Bo Shen have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Tekkis PP, Lovegrove RE, Tilney HS, Smith JJ, Sagar PM, Shorthouse AJ, Mortensen NJ, Nicholls RJ (2010) Long-term failure and function after restorative proctocolectomy—a multi-centre study of patients from the Uk National Ileal Pouch Registry. Colorectal Dis 12(5):433–441.  https://doi.org/10.1111/J.1463-1318.2009.01816.X CrossRefGoogle Scholar
  2. 2.
    Shen B, Fazio VW, Remzi FH, Brzezinski A, Bennett AE, Lopez R, Hammel JP, Achkar JP, Bevins CL, Lavery IC, Strong SA (2006) Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis. Clin Gastroenterol Hepatol 4(1):81–89 (quiz 82–83).  https://doi.org/10.1016/J.Cgh.2005.10.004 CrossRefGoogle Scholar
  3. 3.
    Sandborn WJ (1994) Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment. Gastroenterology 107(6):1856–1860CrossRefGoogle Scholar
  4. 4.
    Parks AG, Nicholls R (1978) Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 2(6130):85–88CrossRefGoogle Scholar
  5. 5.
    Melton GB, Fazio VW, Kiran RP, He J, Lavery IC, Shen B, Achkar JP, Church JM, Remzi FH (2008) Long-term outcomes with ileal pouch-anal anastomosis and Crohn’s disease: pouch retention and implications of delayed diagnosis. Ann Surg 248(4):608–616.  https://doi.org/10.1097/Sla.0b013e318187ed64 Google Scholar
  6. 6.
    Marcello PW, Roberts PL, Schoetz DJ, Coller JA, Murray JJ, Veidenheimer MC (1993) Long-term results of the ileoanal pouch procedure. Arch Surg 128(5):500–503 (discussion 503–504)CrossRefGoogle Scholar
  7. 7.
    Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR (2007) Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 94(3):333–340.  https://doi.org/10.1002/Bjs.5464 CrossRefGoogle Scholar
  8. 8.
    Fazio VW, Ziv Y, Church JM, Oakley JR, Lavery IC, Milsom JW, Schroeder TK (1995) Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 222(2):120–127CrossRefGoogle Scholar
  9. 9.
    Fazio VW, Kiran RP, Remzi FH, Coffey JC, Heneghan HM, Kirat HT, Manilich E, Shen B, Martin ST (2013) Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg 257(4):679–685.  https://doi.org/10.1097/Sla.0b013e31827d99a2 CrossRefGoogle Scholar
  10. 10.
    Shen B, Remzi FH, Lavery IC, Lashner BA, Fazio VW (2008) A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 6(2):145–158.  https://doi.org/10.1016/J.Cgh.2007.11.006 CrossRefGoogle Scholar
  11. 11.
    Muir AJ, Edwards LJ, Sanders LL, Bollinger RR, Koruda MJ, Bachwich DR, Provenzale D (2001) A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis. Am J Gastroenterol 96(5):1480–1485.  https://doi.org/10.1111/J.1572-0241.2001.03801.X CrossRefGoogle Scholar
  12. 12.
    Li Y, Shen B (2012) Evaluating pouch problems. Gastroenterol Clin N Am 41(2):355–378.  https://doi.org/10.1016/J.Gtc.2012.01.013 CrossRefGoogle Scholar
  13. 13.
    Fazio VW, O’riordain MG, Lavery IC, Church JM, Lau P, Strong SA, Hull T (1999) Long-term functional outcome and quality of life after stapled restorative proctocolectomy. Ann Surg 230(4):575–584 (discussion 584–576)CrossRefGoogle Scholar
  14. 14.
    Shen B, Fazio VW, Remzi FH, Lashner BA (2005) Clinical approach to diseases of ileal pouch-anal anastomosis. Am J Gastroenterol 100(12):2796–2807.  https://doi.org/10.1111/J.1572-0241.2005.00278.X CrossRefGoogle Scholar
  15. 15.
    Khanna R, Shen B (2012) Adverse metabolic sequelae following restorative proctocolectomy with an ileal pouch. Gastroenterol Hepatol (N Y) 8(5):322–326Google Scholar
  16. 16.
    Shen B, Fazio VW, Remzi FH, Delaney CP, Bennett AE, Achkar JP, Brzezinski A, Khandwala F, Liu W, Bambrick ML, Bast J, Lashner B (2005) Comprehensive evaluation of inflammatory and noninflammatory sequelae of ileal pouch-anal anastomoses. Am J Gastroenterol 100(1):93–101.  https://doi.org/10.1111/J.1572-0241.2005.40778.X CrossRefGoogle Scholar
  17. 17.
    Hurst RD, Molinari M, Chung TP, Rubin M, Michelassi F (1996) Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy. Arch Surg 131(5):497–500 (discussion 501–492)CrossRefGoogle Scholar
  18. 18.
    Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH (1998) J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 85(6):800–803.  https://doi.org/10.1046/J.1365-2168.1998.00689.X CrossRefGoogle Scholar
  19. 19.
    Penna C, Dozois R, Tremaine W, Sandborn W, Larusso N, Schleck C, Ilstrup D (1996) Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Gut 38(2):234–239CrossRefGoogle Scholar
  20. 20.
    Simchuk EJ, Thirlby RC (2000) Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg 24(7):851–856CrossRefGoogle Scholar
  21. 21.
    Copley PC, Tyler R, Alvi A (2016) Excision of a distended chronic non-functional large ileoanal pouch. BMJ Case Rep.  https://doi.org/10.1136/Bcr-2015-213662 Google Scholar
  22. 22.
    Dayton MT (2000) Redo ileal pouch-anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy? Am J Surg 180(6):561–564 (discussion 565)CrossRefGoogle Scholar
  23. 23.
    Maddireddy VK, Shorthouse A, Goodfellow P, Katory M (2007) Intermittent torsion of a megapouch: report of a case. Dis Colon Rectum 50(12):2244–2246.  https://doi.org/10.1007/S10350-006-0861-2 CrossRefGoogle Scholar
  24. 24.
    Vanek VW, Al-Salti M (1986) Acute pseudo-obstruction of the colon (Ogilvie’s syndrome). An analysis of 400 cases. Dis Colon Rectum 29(3):203–210CrossRefGoogle Scholar
  25. 25.
    Johnston G, Vitikainen K, Knight R, Annest L, Garcia C (1992) Changing perspective on gastrointestinal complications in patients undergoing cardiac surgery. Am J Surg 163(5):525–529CrossRefGoogle Scholar
  26. 26.
    Sreter KB, Barisic B, Popovic-Grle S (2017) Pharmacogenomics and tailored polypharmacy: an 80-year-old lady with Rosuvastatin-associated rhabdomyolysis and Maprotiline-related Ogilvie’s syndrome. Int J Clin Pharmacol Ther 55(5):442–448.  https://doi.org/10.5414/Cp202784 CrossRefGoogle Scholar
  27. 27.
    Jayaram P, Mohan M, Lindow S, Konje J (2017) Postpartum acute colonic pseudo-obstruction (Ogilvie’s Syndrome): a systematic review of case reports and case series. Eur J Obstet Gynecol Reprod Biol 214:145–149.  https://doi.org/10.1016/J.Ejogrb.2017.04.028 CrossRefGoogle Scholar
  28. 28.
    Ogilvie WH (1987) William Heneage Ogilvie 1887–1971. Large-intestine colic due to sympathetic deprivation. A new clinical syndrome. Dis Colon Rectum 30(12):984–987CrossRefGoogle Scholar
  29. 29.
    Manilich E, Remzi FH, Faizo VW, Church JM, Kiran RP (2012) Prognostic modeling of preoperative risk factors of pouch failure. Dis Colon Rectum 55(4):393–399.  https://doi.org/10.1097/Dcr.0b013e3182452594 CrossRefGoogle Scholar
  30. 30.
    Hull TL, Faizo VW, Schroeder T (1995) Paradoxical puborectalis contraction in patients after pelvic pouch construction. Dis Colon Rectum 38(11):1144–1146CrossRefGoogle Scholar
  31. 31.
    Silva-Velazco J, Hull TL, Stocchi L, Gorgun E (2015) Is it really small-bowel obstruction. Patients With Paradox After Ipaa? Dis Colon Rectum 58(3):328–332.  https://doi.org/10.1097/Dcr.0000000000000264 CrossRefGoogle Scholar
  32. 32.
    Shen B, Haubert L (2017) Association between mechanical, inflammatory, and functional complications of the ileal pouch: another chicken-or-egg story. Clin Gastroenterol Hepatol 15(8):1202–1203.  https://doi.org/10.1016/J.Cgh.2017.03.024 CrossRefGoogle Scholar
  33. 33.
    Makkar R, Graff LA, Bharadwaj S, Lopez R, Shen B (2015) Psychological factors in irritable pouch syndrome and other pouch disorders. Inflamm Bowel Dis 21(12):2815–2824.  https://doi.org/10.1097/Mib.0000000000000552 CrossRefGoogle Scholar
  34. 34.
    Shen B, Lashner B (2006) Diagnosis and treatment of ileal pouch diseases in patients with underlying ulcerative colitis. Curr Treat Options Gastroenterol 9(1):3–12CrossRefGoogle Scholar
  35. 35.
    Tang L, Cai H, Moore L, Shen B (2010) Evaluation of endoscopic and imaging modalities in the diagnosis of structural disorders of the ileal pouch. Inflamm Bowel Dis 16(9):1526–1531.  https://doi.org/10.1002/Ibd.21199 CrossRefGoogle Scholar
  36. 36.
    Khanna R, Li Y, Schroeder T, Brzezinski A, Lashner BA, Kiran RP, Remzi RH, Shen B (2013) Manometric evaluation of evacuatory difficulty (Dyschezia) in ileal pouch patients. Inflamm Bowel Dis 19(3):569–575.  https://doi.org/10.1097/Mib.0b013e31827e78d6 CrossRefGoogle Scholar
  37. 37.
    Baixauli J, Delaney CP, Wu JS, Remzi FH, Lavery IC, Fazio VW (2004) Functional outcome and quality of life after repeat ileal pouch-anal anastomosis for complications of ileoanal surgery. Dis Colon Rectum 47(1):2–11.  https://doi.org/10.1007/S10350-003-0003-Z CrossRefGoogle Scholar
  38. 38.
    Remzi FH, Aytac E, Ashburn J, Gu J, Hull Tl, Dietz DW, Stocchi L, Church JM, Shen B (2015) Transabdominal redo ileal pouch surgery for failed restorative proctocolectomy: lessons learned over 500 patients. Ann Surg 262(4):675–682.  https://doi.org/10.1097/Sla.0000000000001386 CrossRefGoogle Scholar
  39. 39.
    Fonkalsrud EW, Bustorff-Silva J (1999) Reconstruction for chronic dysfunction of ileoanal pouches. Ann Surg 229(2):197–204CrossRefGoogle Scholar
  40. 40.
    Kiran RP, Kirat HT, Rottoli M, Xhaja X, Remzi FH, Faizo VW (2012) Permanent ostomy after ileoanal pouch failure: pouch situ or pouch excision? Dis Colon Rectum 55(1):4–9.  https://doi.org/10.1097/Dcr.0b013e3182312a8a CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Center for Inflammatory Bowel Disease, Digestive Disease Institute, Cleveland ClinicClevelandUSA

Personalised recommendations