Pouch Excision vs. Redo IPAA After a Failed Pouch

Abstract

Failure of the ileoanal pelvic pouch (IPAA) is an uncommon but disastrous situation for patients motivated to preserve intestinal continuity after restorative proctocolectomy [1]. Patients with IPAA dysfunction unresponsive to local corrective measures have historically been faced with the limited option of permanent fecal diversion +/− excision of the failed pelvic pouch [2]. However, advancements in the understanding of pouch failure have opened avenues for surgical revision of the failed pouch in some instances as an alternative to permanent ileostomy. Carefully selected patients who are decidedly motivated to avoid permanent conventional ileostomy may be considered for surgical pouch salvage, with a high likelihood of safely creating a durable, functional result similar to a de novo pouch [3–6]. Whether to pursue pouch salvage vs. redo IPAA is a challenging decision that is best approached in a multi-disciplinary, patient-centered fashion with input from both patient and experienced IPAA clinicians for best results (Table 44.1).