背景:回肠袋-肛门吻合术(IPAA)被认为是溃疡性结肠炎和家族性腺瘤性息肉病患者需要直肠结肠切除术的首选修复性手术方法。不幸的是,术后渗漏仍然是一种并发症,可能会产生重大影响。本研究旨在对评价进行全面的描述,管理,以及主要IPAA程序后的泄漏结果。
方法:在1995年至2022年之间,克利夫兰诊所共进行了4058例主要IPAA手术。根据一份前瞻性维护的邮袋登记册,我们回顾性分析了237例患者的资料,这些患者是由护理中心就诊的.其中,114(3%)在我们的诊所接受了指数IPAA程序(从头病例),而123例患者的指数IPAA在其他地方进行。43名患者的数据缺失,最终导致194名患者。
结果:我们的队列平均年龄为41岁(范围,16-76)在泄漏诊断时。总的来说,55.2%为男性,平均体重指数为24.4kg/m2,疼痛是最常见的症状(61.8%),其次是发烧(34%)。141例通过诊断检测证实了泄漏,而术中检测到27.3%。最常见的初始诊断是盆腔脓肿(47.4%)和肠瘘(26.8%),包括皮肤(9.8%),阴道(7.2%),膀胱瘘(3.1%)。按位置,泄漏发生在“J”的尖端(52.6%),在袋-肛门吻合部位(35%),和小袋体内(12.4%)。最初在49.5%的病例中尝试了非手术治疗方法,包括抗生素治疗,排水,endoclip,和endo-海绵,成功率为18.5%。81.4%的患者最终需要手术,包括(1)缝合或钉合袋修复(52.5%),在抢救手术之前或期间,这些病例中有87.9%进行了转移;(2)用neo-IPAA进行的囊袋切除术(22.7%),包括第一组的9名患者;和(3)囊袋断开,修复,再吻合(9.3%)。袋失效发生率为8.4%,囊切除(11.1%)或永久改道(4.5%)。最终,12.4%的患者(194人中有24人)需要永久改道,所有都需要眼袋切除。在抢救手术后的30天随访中,38.7%的患者出现短期并发症.观察到的最常见的并发症是肠梗阻,盆腔脓肿/败血症,和发烧。
结论:初次IPAA手术后的泄漏是罕见的,然而具有挑战性,并发症。尽管尝试了非手术管理,成功率是有限的。挽救手术与高的囊保留率相关,强调其在IPAA后泄漏管理中的重要性。
BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures.
METHODS: Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients.
RESULTS: Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4 kg/m2, and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the \"J\" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever.
CONCLUSIONS: Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.