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Abnormal Pouchogram Predicts Pouch Failure Even in Asymptomatic Patients

Sossenheimer, Philip H., B.A.1; Glick, Laura R., B.A.1; Dachman, Abraham H., M.D.2,3; Skowron, Kinga B., M.D.2,4; Rubin, Michele A., A.P.N.2,4; Umanskiy, Konstantin, M.D.2,4; Smith, Radhika, M.D.2,4; Cannon, Lisa M., M.D.2,4; Hurst, Roger D., M.D.2,4; Cohen, Russell D., M.D.2,5; Hyman, Neil H., M.D.2,4; Rubin, David T., M.D.2,5

Diseases of the Colon & Rectum: April 2019 - Volume 62 - Issue 4 - p 463–469
doi: 10.1097/DCR.0000000000001285
Original Contributions: Inflammatory Bowel Disease
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BACKGROUND: Anastomotic complications after restorative total proctocolectomy with IPAA for ulcerative colitis alter functional outcomes and quality of life and may lead to pouch failure. Routine contrast enema of the pouch assesses anastomotic integrity before ileostomy reversal, but its clinical use is challenged.

OBJECTIVE: The purpose of this research was to assess the relationship among preoperative clinical characteristics, abnormal pouchography, and long-term pouch complications.

DESIGN: This was a retrospective chart review.

SETTINGS: The study was conducted at a tertiary care center between 2000 and 2010.

PATIENTS: Ulcerative colitis patients with IPAA undergoing pouchography before ileostomy closure were included.

MAIN OUTCOME MEASURES: Patient demographics, incidence of pouch-related complications, and findings on pouchogram were recorded. Primary outcome was pouch failure, defined as excision or permanent diversion of the ileoanal pouch. Independent predictors of pouch failure were determined by multivariate regression.

RESULTS: A total of 262 patients with ulcerative colitis were included. Contrast extravasation was seen in 27 patients (10.3%): 14 (51.9%) were clinically asymptomatic at the time of pouchogram. Six (22.2%) of 27 patients with extravasation developed pouch failure despite normalization of the pouchogram before ileostomy closure. Forty patients (15.3%) were found to have pouch-anal anastomotic stenosis; only 1 developed pouch failure. Pre-IPAA serum albumin and hemoglobin levels were inversely associated with contrast extravasation (serum albumin: OR = 0.42; hemoglobin: OR = 0.77; p < 0.05). Contrast extravasation was associated with delayed takedown operation (average = 67 d), increased risk (OR = 5.25; p < 0.01), and shorter time (median = 32.0 vs 72.5 mo; HR = 5.88; p < 0.05) to pouch failure, as well as increased risk of pouch-related complications (p < 0.05).

LIMITATIONS: The study was limited by its retrospective nature and small number of patients who developed pouch failure.

CONCLUSIONS: Pouchography before ileostomy takedown is useful in identifying patients with ulcerative colitis at risk for postoperative complications. Radiologic resolution of IPAA-related leak does not reliably predict healing; caution is warranted in this subgroup. See Video Abstract at http://links.lww.com/DCR/A818.

1 Pritzker School of Medicine, University of Chicago, Chicago, Illinois

2 Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois

3 Department of Radiology, University of Chicago, Chicago, Illinois

4 Department of Surgery, University of Chicago, Chicago, Illinois

5 Department of Medicine, University of Chicago, Chicago, Illinois

Funding/Support: This work was supported by the Short Term Training Health Professional Students grant (T35 DK062719).

Financial Disclosure: None reported.

Correspondence: David T. Rubin, M.D., 5841 S Maryland Ave, MC 4076, Chicago, IL 60637. E-mail: drubin@uchicago.edu

© 2019 The American Society of Colon and Rectal Surgeons