Is omitting pouchography before ileostomy takedown safe after negative clinical examination in asymptomatic patients with pelvic ileal pouch? An observational study

When restorative proctocolectomy (RPC) is performed, a temporary diverting loop ileostomy is often fashioned and usually closed 2-3 months later. Pouchography is used to assess pouch integrity, although its benefits have been questioned and no definitive data support its routine use. Our aim was to assess the utility of pouchography before ileostomy closure in patients with a negative clinical examination. We retrospectively reviewed our database of patients who underwent ileostomy takedown between 1987 and 2010. Two hundred and thirty-two patients were identified who underwent RPC with a W- or J-pouch for ulcerative colitis or familial adenomatous polyposis. Twenty-one patients underwent RPC without diversion. Twenty-four symptomatic patients were excluded from the study. Only asymptomatic patients with a normal clinical examination were enrolled. One patient was lost at follow-up. Hence, 186 patients were considered suitable for evaluation. Patients undergoing ileostomy closure without any radiological examination were assigned to Group A (n = 132); those operated on after a preoperative pouchography to Group B (n = 54). Pouchography was normal in 49 (90.7 %) Group B patients. None of the 5 (9.3 %) Group B patients with an abnormal radiographic examination experienced complications. Negative pouchography did not exclude future problems. Patients of both groups experienced similar early functional impairments. Failure occurred in 3 (2.3 %) Group A patients and in 2 (3.7 %) patients of the pouchography group. Pouchography may be safely omitted before ileostomy takedown if there is no clinical or endoscopic evidence of pelvic sepsis or ileo-anal anastomotic complications, even in very young patients, provided clinical and endoscopic follow-up is carefully performed. All anomalies detected were already suspected clinically.