Redo IPAA After a Failed Pouch In Patients With Crohn's Disease: Is It Worth Trying?

BACKGROUND In selected patients with ulcerative colitis and pelvic pouch failure, redo pouch is an option. However, it is unknown whether selected patients with Crohn's disease should be offered a chance to avoid permanent diversion after failure of IPAA. OBJECTIVE The objective was to compare the outcomes of redo pouch for ulcerative colitis and Crohn's disease. DESIGN This was a retrospective analysis of a prospectively maintained pouch database (1983-2017). SETTINGS The setting was the Cleveland Clinic. PATIENTS This study included patients who underwent redo pouch with a primary surgical specimen diagnosis of ulcerative or Crohn's colitis at the time of initial pouch. MAIN OUTCOME MEASURES Pouch failure was defined as either pouch excision or indefinite pouch diversion. Patient characteristics, perioperative and functional outcomes, pouch survival, and quality of life were compared according to the diagnosis. RESULTS Of 422 patients, 392 had ulcerative colitis and 30 had Crohn's disease. Age and sex were comparable. The most common indications for redo pouch included anastomotic separation and fistulas (220 (56.1%) in ulcerative colitis and 21 (70%) in Crohn's disease). The majority of redo pouches required mucosectomy with handsewn anastomosis (310 (79%) in ulcerative colitis and 30 (100%) in Crohn's disease; p = 0.23). A new pouch was constructed in 160 patients (41%) with ulcerative colitis and repair of old pouch in 231 patients (59%) compared with 25 (83%) in Crohn's disease, who had creation of new pouch; only in 5 (17%) was the old pouch re-anastomosed. Stool frequency, seepage, and fecal urgency were comparable between groups. Cumulative 5-year pouch survival was longer in ulcerative colitis versus Crohn's disease (88% vs 55%; p = 0.008). Major causes of redo failure in Crohn's disease were pouch fistulas and/or strictures occurring after ileostomy closure. These were more common in Crohn's disease than in ulcerative colitis (p < 0.001). LIMITATIONS This was a retrospective design. CONCLUSIONS Redo pouch can be offered to selected patients with colonic Crohn's disease diagnosed at the time of their primary pouch. See Video Abstract at http://links.lww.com/DCR/B206. REHACER LA ANASTOMOSIS ILEOANAL CON RESERVORIO DESPUeS DE UN RESERVORIO ILEAL FALLIDO EN PACIENTES CON ENFERMEDAD DE CROHN: ?VALE LA PENA INTENTARLO?: En pacientes seleccionados con colitis ulcerativa y falla del reservorio pelvico, rehacer el reservorio es una opcion. Sin embargo, se desconoce si en los pacientes seleccionados con enfermedad de Crohn se deberia ofrecer la oportunidad de evitar la derivacion permanente despues de la falla de la anastomosis ileoanal con reservorio ileal.El objetivo fue comparar los resultados de reservorios re-hechos en colitis ulcerosa y la enfermedad de Crohn.El escenario fue la Cleveland Clinic.Analisis retrospectivo de una base de datos de reservorios ileales mantenida prospectivamente (1983-2017).Este estudio incluyo a pacientes que se sometieron a cirugia para rehacer el reservorio ileal con un diagnostico en el especimen quirurgico primario de colitis ulcerosa o de Crohn en el momento del reservorio inicial.La falla del reservorio se definio como la escision del reservorio o la derivacion indefinida del reservorio. Las caracteristicas del paciente, los resultados perioperatorios y funcionales, la supervivencia del reservorio y la calidad de vida se compararon de acuerdo con el diagnostico.De 422 pacientes, 392 tenian colitis ulcerativa y 30 tenian enfermedad de Crohn. La edad y el genero fueron comparables. Las indicaciones mas comunes para rehacer el reservorio incluyeron dehiscencia anastomotica y fistulas [220 (56,1%) en colitis ulcerosa y 21 (70%) en la enfermedad de Crohn]. La mayoria de los reservorios rehechos requirieron mucosectomia con anastomosis manual [310 (79%) en colitis ulcerosa y 30 (100%) en la enfermedad de Crohn, p = 0.23]. Se construyo un nuevo reservorio en 160 (41%) pacientes con colitis ulcerativa y se reparo el reservorio antiguo en 231 (59%) pacientes, en comparacion con 25 (83%) en la enfermedad de Crohn, que requirieron creacion de un nuevo reservorio, y solo 5 (17%) donde el reservorio antiguo se volvio a anastomosar. La frecuencia de las evacuaciones, el manchado fecal y la urgencia fecal fueron comparables entre grupos. La supervivencia acumulada del reservorio a 5 anos fue mayor en la colitis ulcerativa frente a la enfermedad de Crohn (88% frente a 55%, p = 0.008). Las principales causas de falla del reservorio rehecho en la enfermedad de Crohn fueron las fistulas del reservorio y / o las estenosis que ocurrieron despues del cierre de ileostomia. Estas fueron mas comunes en la enfermedad de Crohn que en la colitis ulcerativa (p