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.
Similar content being viewed by others
References
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
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
Sandborn WJ (1994) Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment. Gastroenterology 107(6):1856–1860
Parks AG, Nicholls R (1978) Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 2(6130):85–88
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
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)
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
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):120–127
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
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
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
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
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)
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
Khanna R, Shen B (2012) Adverse metabolic sequelae following restorative proctocolectomy with an ileal pouch. Gastroenterol Hepatol (N Y) 8(5):322–326
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
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)
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
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):234–239
Simchuk EJ, Thirlby RC (2000) Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg 24(7):851–856
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
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)
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
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):203–210
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):525–529
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
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
Ogilvie WH (1987) William Heneage Ogilvie 1887–1971. Large-intestine colic due to sympathetic deprivation. A new clinical syndrome. Dis Colon Rectum 30(12):984–987
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
Hull TL, Faizo VW, Schroeder T (1995) Paradoxical puborectalis contraction in patients after pelvic pouch construction. Dis Colon Rectum 38(11):1144–1146
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
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
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
Shen B, Lashner B (2006) Diagnosis and treatment of ileal pouch diseases in patients with underlying ulcerative colitis. Curr Treat Options Gastroenterol 9(1):3–12
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
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
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
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
Fonkalsrud EW, Bustorff-Silva J (1999) Reconstruction for chronic dysfunction of ileoanal pouches. Ann Surg 229(2):197–204
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
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.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Preeti Shashi and Bo Shen have no conflicts of interest or financial ties to disclose.
Rights and permissions
About this article
Cite this article
Shashi, P., Shen, B. Characterization of megapouch in patients with restorative proctocolectomy. Surg Endosc 33, 2293–2303 (2019). https://doi.org/10.1007/s00464-018-6523-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-018-6523-3