title: Permanent ostomy after ileoanal pouch failure:  pouch in situ or pouch excision?
abstract: BACKGROUND
  The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized.
  
  
  OBJECTIVE
  This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure.
  
  
  METHODS
  This study is a retrospective review of prospectively gathered data.
  
  
  METHODS
  This investigation was conducted at a tertiary center.
  
  
  METHODS
  Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study.
  
  
  METHODS
  The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires.
  
  
  RESULTS
  One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer.
  
  
  CONCLUSIONS
  This study was limited by its retrospective nature.
  
  
  CONCLUSIONS
  Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. kiranp@ccf.org
authors.forename: Ravi P
authors.initials: RP
authors.lastname: Kiran
authors.forename: Hasan T
authors.initials: HT
authors.lastname: Kirat
authors.forename: Matteo
authors.initials: M
authors.lastname: Rottoli
authors.forename: Xhileta
authors.initials: X
authors.lastname: Xhaja
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: Victor W
authors.initials: VW
authors.lastname: Fazio
mesh_terms: D011125:Adenomatous Polyposis Coli / Q000601:surgery*; D000328:Adult; D039021:Colonic Pouches; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D015212:Inflammatory Bowel Diseases / Q000601:surgery*; D008297:Male; D011183:Postoperative Complications; D016737:Proctocolectomy, Restorative; D011788:Quality of Life; D012086:Reoperation; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome