Incidence and causes of failure in various anatomical pouch designs 20 years after surgical primary ileal-pouch anal anastomosis construction

Purpose Since the introduction of ileo-pouch anal anastomosis (IPAA) surgery, various pouch designs have been applied. Recently, there has been renewed interest in creating larger pouch designs to reduce defecation frequency after pouch surgery. The aim of this study was to assess chronic pouch failure (PF) rates and causes in alternative S or septated (SP) pouches when compared to J pouches and B- shaped adaptations. Methods This retrospective cohort study included patients that underwent primary IPAA construction surgery from 1978–2000. Pouch designs were subdivided in J and B (J/B), and larger pouches (S/SP). PF included need for a pouch excision, redo pouch procedure, revisional pouch surgery, or permanent ileostomy surgery. Outcomes of this study were incidence and causes for PF per pouch design group. Results Out of 200 patients who underwent IPAA surgery, 19 had an S/SP design and 181 had a J/B design. After a follow-up of 27.0 (IQR 23.3 – 29.0) years, 45/200 (22.5%) patients who underwent IPAA surgery between 1975–2000 developed PF. Some 78.9% of patients with an S/SP pouch developed PF, compared to 16.7% of patients with a J/B pouch (p < 0.01). Mechanical outlet issues occurred more often in S/SP pouches when compared to J/B (42.1% vs. 1.1%, p < 0.01), and were predominantly caused by septal- or pouch wall intussusception and efferent loop kinking (S-pouch). Conclusion Despite an inevitable proportion of bias, the current study revealed that S/SP pouches were characterized by an increased PF incidence due to emptying problems after long-term follow-up when compared to J/B pouches. Constructing an S pouch or large septated reservoir at index surgery should therefore be questioned because of a shorter longevity.