Long-term results of salvage surgery for septic complications after restorative proctocolectomy: does fecal diversion improve outcome?

PURPOSE: Septic complications related to the ileal pouch-anal anastomosis after restorative proctocolectomy have been reported in up to 16 percent of patients in major series. Management strategies are not well established. The aim of this study was to evaluate the results of salvage surgery and to assess the impact diversion had on the outcome.
METHODS: Patients who developed ileal pouch-anal anastomosis-related septic complications after restorative proctocolectomy were identified from a prospectively maintained database. Surgical procedures and follow-up data were obtained at the time of hospital and office visits. Successful salvage was defined as the absence of clinical evidence of fistula, sinus, or abscess at least three months after salvage surgery or closure of ileostomy.
RESULTS: Fifty-one patients with ileal pouch-anal anastomosis-related sepsis were identified. All patients had sinus or fistulous tracts from pouch-anal anastomoses. Eighty-nine salvage procedures were performed among these 51 patients (range, 1-4 procedures per patient). Forty-eight transanal anastomotic revisions were performed in nondiverted patients. Thirty-seven transanal revisions and four abdominoperineal revisions were performed in diverted patients. At a median follow-up of 65.2 (range, 3 to 166) months after salvage surgery or closure of the diverting stoma, 21 patients (41 percent) had complete resolution of their septic problems. Bowel frequency and continence for these patients were similar to patients who had not had ileal pouch-anal anastomotic problems. Eleven (29.7 percent) of 37 transanal procedures with diversion succeeded, whereas 10 (20.8 percent) of 48 nondiverted procedures succeeded. This difference was not significant (11/37 vs. 10/48; P = 0.448). None of the four abdominoperineal revisions succeeded. Of 51 patients, 34 (66.7 percent) retained their pouches and 21 (41.2 percent) were successfully revised. Seventeen patients (33.3 percent) had pouch excision. Five (9.8 percent) had persistent fistulas and remained diverted, and 8 (15.7 percent) had persistent fistulas and were not diverted. Thus, pouch function was retained in 29 patients (56.9 percent).
CONCLUSIONS: This study shows that anastomotic failure after restorative proctocolectomy is associated with a high rate of pouch failure. Ileal pouch-anal anastomosis-related fistula or sinus warrants an aggressive surgical approach in selected, highly motivated patients because acceptable functional results are possible. Multiple procedures may often be necessary to achieve complete healing. Successful repair can be achieved after one or more unsuccessful attempts. Repeat procedures can be performed safely without adversely affecting ultimate outcome.