title: Outcomes of salvage surgery for ileal pouch complications and dysfunctions. the experience of a referral centre and review of literature.
abstract: OBJECTIVE
  Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction.
  
  
  METHODS
  We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre- and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3).
  
  
  RESULTS
  Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003).
  
  
  CONCLUSIONS
  Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction.
authors.affiliation: Unit of General Surgery, Second University of Naples, Naples, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Pellino
authors.affiliation: Unit of General Surgery, Second University of Naples, Naples, Italy fselvaggi@hotmail.com.
authors.forename: Francesco
authors.initials: F
authors.lastname: Selvaggi
mesh_terms: D000038:Abscess / Q000209:etiology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057868:Anastomotic Leak / Q000209:etiology / Q000601:surgery; D002648:Child; D039021:Colonic Pouches / Q000009:adverse effects* / Q000473:pathology / Q000502:physiology*; D003251:Constriction, Pathologic / Q000209:etiology / Q000601:surgery; D003672:Defecation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016737:Proctocolectomy, Restorative; D012086:Reoperation / Q000379:methods; D016879:Salvage Therapy; D017211:Treatment Failure; D014624:Vaginal Fistula / Q000209:etiology / Q000601:surgery*; D055815:Young Adult
keywords: Surgery; pouch; ulcerative colitis