Stenosis of Pouch Anal Anastomosis

Ogunbiyi's study [9] on 198 PRs reports nine cases of OO due to stenosis of the pouch-anal anastomosis in four, LEL in two, prolapse of the pouch in one and stenosis of the remaining ileum above the pouch in two cases. All patients with stenosis of the pouchanal anastomosis underwent a reconstruction of the reservoir with success in three patients out of four. A pouchpexy was performed with success in the patient with prolapse of the pouch. In the two patients with LEL, the efferent limb was successfully removed. In the two cases of stenosis above the pouch, one patient showed no improvement of clinical conditions after the construction of a pouch-anal anastomosis L/L, while for the other patient who was diagnosed with Crohn's disease after the construction of the reservoir, the resulting strictureplasty was successful.

A stenosis of the pouch-anal anastomosis, requiring a single dilatation, is described in the literature in a variable percentage from 4-40% of cases [1, 13, 25-31]. This event is more frequent in patients with UC [13, 28, 29] compared to those with FAP and shows a double incidence regarding mechanical anastomosis compared to those made by hand [29]. Senapati [31] in a study of 266 patients who underwent PR, reported stenosis in 14.2 and 39% of the patients, depending on whether the procedure had been carried out via manual or mechanical anastomosis. The first therapeutic approach to stenosis of the pouch-anal anastomosis, is dilatation under anaesthesia. With this procedure Senapati [31] reports a success rate of 26%, while Galandiuk [13] at a 31-month follow-up (range 1-98) reports a relapse rate of 59% with failure in 16% of the cases. The same author reports satisfactory results after repeated dilatations in more than 50% of cases (23 patients out of 42). In particular, in the case of a short stenosis, a posterior strictureplasty can be indicated. Stenosis of 2 cm of length can be corrected by an exclusive transanal approach. In the case of a long stenotic segment, on the other hand, a combined abdominoper-ineal approach is recommended [32, 33].

According to Dehni's [23] study of 23 patients who underwent transanal surgery, 4 because of fibrous stricture, the combined abdominoperineal conversion is mandatory. The transanal approach with removal of the stenosis and distal advancement of the pouch is particularly indicated in cases with concomitant vaginal fistula [32].

The remaining therapeutic options consist of the removal of the pouch with definitive ileostomy, which was necessary in 2.5-15% of the cases, or by abdominal salvage surgery, with removal of the pouch, removal of the fibrotic ring and reconstruction of the pouch-anal anastomosis restoring the proximal portion of pouch [24].

Maclean [34] of the Mount Sinai Hospital of Toronto, comparing patients who underwent rescue of the pouch through an abdominal approach in cases of pelvic sepsis or OO, reported a minor incidence of complications (33.3 vs. 61.5%, p=0.047) in patients with OO. This emphasises, moreover, that there was a greater risk of malfunction in those cases where it was necessary to refashion a new pouch then where it was possible to modify the old reservoir, depending on whether there was insufficient compliance due to fibrosis and a reservoir lacking in volume with a subsequent increase of evacuation frequency.

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  • cora
    What is pouchanal stenosis?
    6 years ago

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