Association Between Mechanical, Inflammatory, and Functional Complications of the Ileal Pouch: Another Chicken-Or-Egg Story

Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch

For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.

Characterization of megapouch in patients with restorative proctocolectomy

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.