A 31-year-old woman was referred to the Inflammatory Bowel Disease (IBD) Center from an outside hospital 10 years after she had received a 2-stage total proctocolectomy with ileal pouch–anal anastomosis (IPAA) and diverting loop ileostomy, for ulcerative pancolitis that was unresponsive to medical management.
Patient Sought Surgical Option to Preserve Failed IPAA
The patient, having developed abdominal pelvic septic complications and IPAA-related recurrent strictures, required at least 15 dilatations over 10 years. Her quality of life had diminished and was marked by dietary restrictions, straining with bowel movements, and continuous drainage that necessitated wearing a pad. She had increased abdominal pain and bleeding, diarrhea, and a weight loss of more than 30 pounds. Later in her course of treatment, she also developed perineal fistulas, at which point she was diagnosed as having Crohn’s disease.
Her condition did not improve after treatment with two different biologics. The perineal fistulas were drained with seton insertion, and her strictures required continued dilatation. Having received a recommendation to pursue a pouch excision and end ileostomy, she decided to get a second opinion at NYU Langone.
Restorative proctocolectomy with IPAA is the gold standard procedure in patients with ulcerative colitis. Removal of the colon and the rectum creates a reservoir out of the small bowel, reestablishes gastrointestinal continuity, and provides improved quality of life and functionality, with minimal restrictions. However, the failure rates can range from 4 to 15 percent, according to various study series (Remzi et al., 2017; see Esen et al., 2019, for further reading). Additionally, 2 to 7 percent of the patients who receive the ileal pouch procedure for ulcerative colitis may have their diagnosis convert to Crohn’s disease in the long term.
For patients whose failure occurs within one year of the original surgery, the failure is likely due to a mechanical or technical problem related to the procedure itself rather than the Crohn’s disease. But if the patient has had an uneventful surgical course of treatment, followed by great outcomes for several years, and then develops symptoms later in their journey, the diagnosis is likely Crohn’s disease. When failures occur, redo pouch surgery is the only option to preserve gastrointestinal continuity for patients unwilling to live with a permanent stoma and ileostomy. At NYU Langone, a dedicated infrastructure is in place to address these complex problems.
Niche Surgical Expertise Expands Options
The patient was experiencing a significant amount of restrictions and poor quality of life when she was seen by Feza Remzi, MD, professor in the Department of Surgery and director of NYU Langone’s IBD Center. Dr. Remzi, a leader in the field of complex IBD and re-operative abdominal pelvic surgery, says the collective experience accrued daily in a high-volume quaternary care center plays a key factor when tackling the most complex redo cases. The IBD Center offers expertise in pelvic pouch reconstruction and a multidisciplinary approach to patient assessment and perioperative planning. This allows the center to offer innovative treatment options to patients who are turned away by other institutions for complex revision procedures after failed ileal pouch surgery. IPAA allows patients who have a severe aversion to living with a permanent stoma to establish their gastrointestinal continuity.
After their initial assessment, Dr. Remzi and colorectal surgeon Tarik Kirat, MD, clinical assistant professor of surgery, offered the patient a three-stage plan. This 3-stage strategic approach, historically, has had a more than 80 percent success rate in 10 years (Remzi et al., 2015; see Remzi et al., 2019, for further reading). Highly motivated to avoid a permanent ileostomy, the patient understood the risks and benefits and proceeded with the planned three-stage procedure.
Multistep Plan Ultimately Leads to Ileostomy Reversal
After the initial workup of gastrografin enema, pelvic MRI, and exam under anesthesia in which a flexible pouchoscopy was done, the pouch was revealed to be twisted 180 degrees. The exam under anesthesia revealed a severe IPAA stricture with multiple fistulas. The pouch was also severely dilated due to years of obstructive defecation related to the chronic IPAA stricture. At the first stage of the three-stage procedure, a laparoscopic loop ileostomy was created. A segment of the ileum (distal small bowel) was brought up as an ileostomy proximal to the pouch to create a diversion.
This strategy paved the way for a normal life and rehabilitated her so she could be physically, mentally, and psychologically prepared for the second stage of the procedure. The patient met with the stoma therapist before the ileostomy creation and throughout the nine months, where she required the ileostomy. She also spoke to several patients who underwent a similar experience in the center to hear about the process and outcomes from the patient perspective.
During the second stage, which was six months after the ileostomy creation, the surgeons planned exploratory laparotomy and J-pouch revision. Entry into the abdominal cavity revealed severe adhesions. This was further complicated by the serious abdominal pelvic infection due to years of ongoing phlegmonous changes related to the chronic obstruction, secondary to the anastomotic stricture. After lysis of multiple adhesions, the ileostomy was taken down. The twisted pouch was untwisted after the disconnection, and it was found to be still usable for the new anastomosis. Multiple severe strictures at the anastomosis in the pelvis were encountered and resected, including the perianal fistulas.
The chronic pelvic infection was addressed with excision, the pouch was revised, and a new hand-sewn IPAA (in the presence of diverting ileostomy) was created. “This procedure was very complicated from beginning to the end,” Dr. Remzi notes. “A team approach and meticulous dissection were needed to clean the chronic infection.”
As part of the third stage, and before the loop ileostomy closure six months later, a water-soluble contrast enema was performed and showed anastomosis without any leaks or obstruction. The ileostomy reversal was successfully completed without major complications, and the patient tolerated the procedure well. She has been doing great, and her one-year follow-up revealed no major issues.
For the ongoing care of her pouch, the patient has seen pouch specialist and gastroenterologist Shannon Chang, MD, assistant professor in the Department of Medicine within the Division of Gastroenterology and Hepatology. At a multidisciplinary center such as NYU Langone’s, outcomes are optimized through a coordinated continuum of care provided by a team that works side by side to meet the unique needs of patients living with the complexities of IBD.
Esen E … Remzi FH. Primary pouch preservation vs new pouch creation during re-do surgery for failed ileal pouches: Are the outcomes comparable? J Am Coll Surg. 2019. DOI.
Remzi FH … Pachter HL. Complex re-do IPAA and index IPAA surgery: Equivalent short-term outcomes in specialized high-volume center. J Am Coll Surg. 2019. DOI.
Remzi FH … Church JM. Restorative proctocolectomy: An example of how surgery evolves in response to paradigm shifts in care. Colorectal Dis. 2017. DOI.
Remzi FH … Shen B. Transabdominal redo ileal pouch surgery for failed restorative proctocolectomy: Lessons learned over 500 patients. Ann Surg. 2015. DOI.