When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it's happening, and the treatments needed.

[BACKGROUND] Patients with an ileal pouch have a new system of defecation. The expulsive peristalsis of the rectum is replaced by the inertia of the pouch. Defecation becomes dependent on gravity and patients are prone to inefficient pouch-emptying. Several factors can impact pouch emptying and here we review a series of patients to illustrate these factors and their variable presentations.

[METHODS] This is a retrospective, descriptive study of a series of patients who had undergone total proctocolectomy with ileal pouch anal anastomosis and presented with pouch dysfunction. Patients underwent investigations including, pouchoscopy, pouchography and anorectal physiology testing.

[RESULTS] There were 34 patients, 18 men, mean age 48.4 years. Thirty-one had a J-pouch and 3 an S-pouch. Twenty-eight had a stapled and 6 a hand-sewn anastomosis. Presenting complaints included difficulty emptying the pouch (n = 17), high stool frequency (n = 8), clinical bowel obstruction (n = 7), and nocturnal incontinence (n = 3). Diagnoses were anal stenosis (11), afferent-limb syndrome (n = 7), pouch twist (n = 4), paradoxical puborectalis contraction (n = 7), efferent-limb spasm/stenosis (n = 2), mega-pouch (n = 3), pouch prolapse (n = 1), and pouch-rectal anastomosis (n = 1). Treatments included anal dilation (n = 11), disimpaction (n = 2), biofeedback (n = 2), pouch excision (n = 2), laparotomy with lysis of adhesions (n = 6), Botox injection into puborectalis (n = 6), catheter drainage (3), and miralax (n = 11). All patients with a stenosis had some improvement after dilation, and surgery restored pouch function.

[CONCLUSIONS] Accurate diagnosis and effective treatment of pouch dysfunction is based on an appreciation of pouch physiology, correction of anatomic abnormalities that impair emptying, and management of stool consistency.