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Abdominal Radiology

, Volume 44, Issue 3, pp 845–866 | Cite as

Judging the J pouch: a pictorial review

  • Shannon P. SheedyEmail author
  • David J. Bartlett
  • Amy L. Lightner
  • Steven W. Trenkner
  • David H. Bruining
  • Jeff L. Fidler
  • Wendaline M. VanBuren
  • Christine O. Menias
  • Joshua D. Reber
  • Joel G. Fletcher
Pictorial essay
  • 193 Downloads

Abstract

Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.

Keywords

J pouch Ileoanal anastomosis Ileal pouch-anal anastomosis Proctocolectomy Enterography Ulcerative colitis 

Notes

Acknowledgements

The authors acknowledge the assistance of Sonia Watson, PhD, in preparation of the manuscript.

Compliance with ethical standards

Funding

None

Conflict of interest

The authors have no conflicts of interest to declare

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Supplementary material

261_2018_1786_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 16 kb)

References

  1. 1.
    Brown CJ, Maclean AR, Cohen Z, et al. (2005) Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum 48:1542–1549.  https://doi.org/10.1007/s10350-005-0059-z CrossRefGoogle Scholar
  2. 2.
    Yu CS, Pemberton JH, Larson D (2000) Ileal pouch-anal anastomosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 43:1487–1496CrossRefGoogle Scholar
  3. 3.
    Fazio VW, Ziv Y, Church JM, et al. (1995) Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 222:120–127CrossRefGoogle Scholar
  4. 4.
    Hahnloser D, Pemberton JH, Wolff BG, et al. (2007) Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 94:333–340.  https://doi.org/10.1002/bjs.5464 CrossRefGoogle Scholar
  5. 5.
    Hueting WE, Buskens E, van der Tweel I, Gooszen HG, van Laarhoven CJ (2005) Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients. Dig Surg 22:69–79.  https://doi.org/10.1159/000085356 CrossRefGoogle Scholar
  6. 6.
    Simchuk EJ, Thirlby RC (2000) Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg 24:851–856CrossRefGoogle Scholar
  7. 7.
    Kirat HT, Remzi FH (2010) Technical aspects of ileoanal pouch surgery in patients with ulcerative colitis. Clin Colon Rectal Surg 23:239–247.  https://doi.org/10.1055/s-0030-1268250 CrossRefGoogle Scholar
  8. 8.
    Wu XR, Kiran RP, Mukewar S, Remzi FH, Shen B (2014) Diagnosis and management of pouch outlet obstruction caused by common anatomical problems after restorative proctocolectomy. J Crohns Colitis 8:270–275.  https://doi.org/10.1016/j.crohns.2013.08.012 CrossRefGoogle Scholar
  9. 9.
    Johnston D, Williamson ME, Lewis WG, et al. (1996) Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis. Gut 39:242–247CrossRefGoogle Scholar
  10. 10.
    Wade AD, Mathiason MA, Brekke EF, Kothari SN (2009) Quality of life after ileoanal pouch: a comparison of J and W pouches. J Gastrointest Surg 13:1260–1265.  https://doi.org/10.1007/s11605-009-0884-9 CrossRefGoogle Scholar
  11. 11.
    Lovegrove RE, Constantinides VA, Heriot AG, et al. (2006) A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg 244:18–26.  https://doi.org/10.1097/01.sla.0000225031.15405.a3 CrossRefGoogle Scholar
  12. 12.
    Miller R, Lewis GT, Bartolo DC, Cervero F, Mortensen NJ (1988) Sensory discrimination and dynamic activity in the anorectum: evidence using a new ambulatory technique. Br J Surg 75:1003–1007CrossRefGoogle Scholar
  13. 13.
    Alfisher MM, Scholz FJ, Roberts PL, Counihan T (1997) Radiology of ileal pouch-anal anastomosis: normal findings, examination pitfalls, and complications. Radiographics 17:81–98; discussion 98–89. 10.1148/radiographics.17.1.9017801Google Scholar
  14. 14.
    Thoeni RF, Fell SC, Engelstad B, Schrock TB (1990) Ileoanal pouches: comparison of CT, scintigraphy, and contrast enemas for diagnosing postsurgical complications. AJR Am J Roentgenol 154:73–78.  https://doi.org/10.2214/ajr.154.1.2104730 CrossRefGoogle Scholar
  15. 15.
    Elsayes KM, Al-Hawary MM, Jagdish J, Ganesh HS, Platt JF (2010) CT enterography: principles, trends, and interpretation of findings. Radiographics 30:1955–1970.  https://doi.org/10.1148/rg.307105052 CrossRefGoogle Scholar
  16. 16.
    Fidler JL, Guimaraes L, Einstein DM (2009) MR imaging of the small bowel. Radiographics 29:1811–1825.  https://doi.org/10.1148/rg.296095507 CrossRefGoogle Scholar
  17. 17.
    Bruining DH, Zimmermann EM, Loftus Jr. EV, et al. (2018) Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s Disease. Radiology 286:776–799.  https://doi.org/10.1148/radiol.2018171737 CrossRefGoogle Scholar
  18. 18.
    Azizi L, Balu M, Belkacem A, et al. (2005) MRI features of mesenteric desmoid tumors in familial adenomatous polyposis. AJR Am J Roentgenol 184:1128–1135.  https://doi.org/10.2214/ajr.184.4.01841128 CrossRefGoogle Scholar
  19. 19.
    Shen B (2010) Diagnosis and management of postoperative ileal pouch disorders. Clin Colon Rectal Surg 23:259–268.  https://doi.org/10.1055/s-0030-1268252 CrossRefGoogle Scholar
  20. 20.
    Gold RH, Hawkins RA, Katz RD (1991) Bacterial osteomyelitis: findings on plain radiography, CT, MR, and scintigraphy. AJR Am J Roentgenol 157:365–370.  https://doi.org/10.2214/ajr.157.2.1853823 CrossRefGoogle Scholar
  21. 21.
    Pappou EP, Kiran RP (2016) The failed J pouch. Clin Colon Rectal Surg 29:123–129.  https://doi.org/10.1055/s-0036-1580724 CrossRefGoogle Scholar
  22. 22.
    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 6:145–158; quiz 124. 10.1016/j.cgh.2007.11.006Google Scholar
  23. 23.
    de Zeeuw S, Ahmed Ali U, Donders RA, et al. (2012) Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies. Int J Colorectal Dis 27:843–853.  https://doi.org/10.1007/s00384-011-1402-6 CrossRefGoogle Scholar
  24. 24.
    Shah NS, Remzi F, Massmann A, Baixauli J, Fazio VW (2003) Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy. Dis Colon Rectum 46:911–917.  https://doi.org/10.1097/01.DCR.0000074686.09871.9C CrossRefGoogle Scholar
  25. 25.
    Gorgun E, Remzi FH (2004) Complications of ileoanal pouches. Clin Colon Rectal Surg 17:43–55.  https://doi.org/10.1055/s-2004-823070 CrossRefGoogle Scholar
  26. 26.
    Arima K, Watanabe M, Iwatsuki M, et al. (2014) Volvulus of an ileal pouch-rectal anastomosis after subtotal colectomy for ulcerative colitis: report of a case. Surg Today 44:2382–2384.  https://doi.org/10.1007/s00595-013-0724-0 CrossRefGoogle Scholar
  27. 27.
    Landische RM, Knechtges PM (2018) Pouch volvulus in patients having undergone restorative prctocolectomy for ucertive coloitis: a case series. Dis Colon Rectum 61(6):713–718CrossRefGoogle Scholar
  28. 28.
    Warren C, O’Donnell ME, Gardiner KR, Irwin T (2011) Successful management of ileo-anal pouch volvulus. Colorectal Dis 13:106–107.  https://doi.org/10.1111/j.1463-1318.2010.02207.x CrossRefGoogle Scholar
  29. 29.
    Groves CJ, Beveridge G, Swain DJ, et al. (2005) Prevalence and morphology of pouch and ileal adenomas in familial adenomatous polyposis. Dis Colon Rectum 48:816–823.  https://doi.org/10.1007/s10350-004-0835-1 CrossRefGoogle Scholar
  30. 30.
    Tajika M, Nakamura T, Nakahara O, et al. (2009) Prevalence of adenomas and carcinomas in the ileal pouch after proctocolectomy in patients with familial adenomatous polyposis. J Gastrointest Surg 13:1266–1273.  https://doi.org/10.1007/s11605-009-0871-1 CrossRefGoogle Scholar
  31. 31.
    Tytgat GN, Gopinath N (1995) Recurrent polyps in the ileo-anal pouch or rectum in familial adenomatous polyposis. Eur J Cancer 31A:1154–1159CrossRefGoogle Scholar
  32. 32.
    Donati OF, Weishaupt D, Weber A, Hahnloser D (2010) Colonic transformation of ileal pouch-anal anastomosis and of the distal ileum: MRI findings. Br J Radiol 83:e185–e187.  https://doi.org/10.1259/bjr/72125476 CrossRefGoogle Scholar
  33. 33.
    Barton JG, Paden MA, Lane M, Postier RG (2001) Comparison of postoperative outcomes in ulcerative colitis and familial polyposis patients after ileoanal pouch operations. Am J Surg 182:616–620CrossRefGoogle Scholar
  34. 34.
    Shen B (2013) Pouchitis: what every gastroenterologist needs to know. Clin Gastroenterol Hepatol 11:1538–1549.  https://doi.org/10.1016/j.cgh.2013.03.033 CrossRefGoogle Scholar
  35. 35.
    Pardi DS, Sandborn WJ (2006) Systematic review: the management of pouchitis. Aliment Pharmacol Ther 23:1087–1096.  https://doi.org/10.1111/j.1365-2036.2006.02884.x CrossRefGoogle Scholar
  36. 36.
    Ben-Bassat O, Tyler AD, Xu W, et al. (2014) Ileal pouch symptoms do not correlate with inflammation of the pouch. Clin Gastroenterol Hepatol 12(831–837):e832.  https://doi.org/10.1016/j.cgh.2013.09.027 Google Scholar
  37. 37.
    Shen B, Achkar JP, Lashner BA, et al. (2001) Endoscopic and histologic evaluation together with symptom assessment are required to diagnose pouchitis. Gastroenterology 121:261–267CrossRefGoogle Scholar
  38. 38.
    Seggerman RE, Chen MY, Waters GS, Ott DJ (2003) Pictorial essay. Radiology of ileal pouch-anal anastomosis surgery. AJR Am J Roentgenol 180:999–1002.  https://doi.org/10.2214/ajr.180.4.1800999 CrossRefGoogle Scholar
  39. 39.
    Nadgir RN, Soto JA, Dendrinos K, et al. (2006) MRI of complicated pouchitis. AJR Am J Roentgenol 187:W386–W391.  https://doi.org/10.2214/AJR.05.1019 CrossRefGoogle Scholar
  40. 40.
    Liszewski MC, Sahni VA, Shyn PB, et al. (2012) Multidetector-row computed tomography enterographic assessment of the ileal-anal pouch: descriptive radiologic analysis with endoscopic and pathologic correlation. J Comput Assist Tomogr 36:394–399.  https://doi.org/10.1097/RCT.0b013e31825b878c CrossRefGoogle Scholar
  41. 41.
    Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF (1994) Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc 69:409–415CrossRefGoogle Scholar
  42. 42.
    Segal JP, Adegbola SO, Worley GHT, et al. (2018) A systematic review: the management and outcomes of ileal pouch strictures. J Crohns Colitis 12:369–375.  https://doi.org/10.1093/ecco-jcc/jjx151 CrossRefGoogle Scholar
  43. 43.
    Shen B, Plesec TP, Remer E, et al. (2010) Asymmetric endoscopic inflammation of the ileal pouch: a sign of ischemic pouchitis? Inflamm Bowel Dis 16:836–846.  https://doi.org/10.1002/ibd.21129 CrossRefGoogle Scholar
  44. 44.
    Tonelli F, Ficari F, Bargellini T, Valanzano R (2012) Ileal pouch adenomas and carcinomas after restorative proctocolectomy for familial adenomatous polyposis. Dis Colon Rectum 55:322–329.  https://doi.org/10.1097/DCR.0b013e318241e6f2 CrossRefGoogle Scholar
  45. 45.
    Kariv R, Remzi FH, Lian L, Bennett AE, Kiran RP, Kariv Y, Fazio VW, Lavery IC, Shen B (2010) Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology 139:806–812, 812 e801–802. 10.1053/j.gastro.2010.05.085Google Scholar
  46. 46.
    Kirat HT, Kiran RP, Remzi FH, Fazio VW, Shen B (2011) Diagnosis and management of afferent limb syndrome in patients with ileal pouch-anal anastomosis. Inflamm Bowel Dis 17:1287–1290.  https://doi.org/10.1002/ibd.21503 CrossRefGoogle Scholar
  47. 47.
    Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG (2017) MR imaging of perianal crohn disease. Radiology 282:628–645.  https://doi.org/10.1148/radiol.2016151491 CrossRefGoogle Scholar
  48. 48.
    Violi NV, Schoepfer AM, Fournier N, et al. (2014) Prevalence and clinical importance of mesenteric venous thrombosis in the Swiss Inflammatory Bowel Disease Cohort. AJR Am J Roentgenol 203:62–69.  https://doi.org/10.2214/AJR.13.12447 CrossRefGoogle Scholar
  49. 49.
    Baker ME, Remzi F, Einstein D, et al. (2003) CT depiction of portal vein thrombi after creation of ileal pouch-anal anastomosis. Radiology 227:73–79.  https://doi.org/10.1148/radiol.2271020032 CrossRefGoogle Scholar
  50. 50.
    Ball CG, MacLean AR, Buie WD, Smith DF, Raber EL (2007) Portal vein thrombi after ileal pouch-anal anastomosis: its incidence and association with pouchitis. Surg Today 37:552–557.  https://doi.org/10.1007/s00595-006-3470-8 CrossRefGoogle Scholar
  51. 51.
    Millan M, Hull TL, Hammel J, Remzi F (2007) Portal vein thrombi after restorative proctocolectomy: serious complication without long-term sequelae. Dis Colon Rectum 50:1540–1544.  https://doi.org/10.1007/s10350-007-0297-3 CrossRefGoogle Scholar
  52. 52.
    Remzi FH, Fazio VW, Oncel M, Baker ME, Church JM, Ooi BS, Connor JT, Preen M, Einstein D (2002) Portal vein thrombi after restorative proctocolectomy. Surgery 132:655–661; discussion 661–652Google Scholar
  53. 53.
    Sunde ML, Negard A, Oresland T, et al. (2018) MRI defecography of the ileal pouch-anal anastomosis-contributes little to the understanding of functional outcome. Int J Colorectal Dis 33:609–617.  https://doi.org/10.1007/s00384-018-3011-0 CrossRefGoogle Scholar
  54. 54.
    Joyce MR, Fazio VW, Hull TT, et al. (2010) Ileal pouch prolapse: prevalence, management, and outcomes. J Gastrointest Surg 14:993–997.  https://doi.org/10.1007/s11605-010-1194-y CrossRefGoogle Scholar
  55. 55.
    Changchien EM, Griffin JA, Murday ME, Bossart PW (2015) Mesh pouch pexy in the management of J-pouch prolapse. Dis Colon Rectum 58:e46–e48.  https://doi.org/10.1097/DCR.0000000000000337 CrossRefGoogle Scholar
  56. 56.
    Quinn KP, Tse CS, Lightner AL, et al. (2017) Nonrelaxing pelvic floor dysfunction is an underestimated complication of ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol 15:1242–1247.  https://doi.org/10.1016/j.cgh.2017.02.024 CrossRefGoogle Scholar
  57. 57.
    Mathis KL, Dozois EJ, Larson DW, et al. (2009) Outcomes in patients with ulcerative colitis undergoing partial or complete reconstructive surgery for failing ileal pouch-anal anastomosis. Ann Surg 249:409–413.  https://doi.org/10.1097/SLA.0b013e31819a697b CrossRefGoogle Scholar
  58. 58.
    Lightner AL, Dattani S, Dozois EJ, et al. (2017) Pouch excision: indications and outcomes. Colorectal Dis 19:912–916.  https://doi.org/10.1111/codi.13673 CrossRefGoogle Scholar
  59. 59.
    Braveman JM, Schoetz DJ Jr, Marcello PW, et al. (2004) The fate of the ileal pouch in patients developing Crohn’s disease. Dis Colon Rectum 47:1613–1619CrossRefGoogle Scholar
  60. 60.
    Garrett KA, Remzi FH, Kirat HT, et al. (2009) Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn’s disease. Dis Colon Rectum 52:1967–1974.  https://doi.org/10.1007/DCR.0b013e3181b77d1e CrossRefGoogle Scholar

Copyright information

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

Authors and Affiliations

  1. 1.Department of RadiologyMayo ClinicRochesterUSA
  2. 2.Department of Surgery, Division of Colon and Rectal SurgeryMayo ClinicRochesterUSA
  3. 3.Division of Gastroenterology and HepatologyMayo ClinicRochesterUSA
  4. 4.Department of RadiologyMayo ClinicScottsdaleUSA

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