Salvage surgery for ileal pouch outlet obstruction

Sixteen patients with ileal pouch outlet mechanical obstruction had major abdominal revision of the ileoanal anastomosis. Before operation all had severe difficulty in evacuation which required catheterization in 11. Eleven patients had a long efferent limb and/or long anorectal cuff, and five had a persistent stricture at the ileoanal anastomosis, None had pouchitis, The pouch was fully mobilized abdominally and the obstructing lesion resected, A new handsewn ileoanal anastomosis was formed. In two cases pouch volume was increased by incorporating an additional loop of ileum, All anastomoses but one were covered by a loop ileostomy, There were no deaths. Major complications occurred in two patients. Function was assessed in 15 patients; in one the ileostomy had not been closed, Median (interquartile range) frequency of defaecation per 24 h fell from 15 (7.3-19.5) to 6 (4.5-6.0) (P= 0.0033). Of the 11 patients who required a catheter before operation six evacuated spontaneously, three were improved but intubated on some occasions and two were unchanged after revisional surgery. Of the ten incontinent patients, five became continent, four were improved and one remained unchanged, There was a new continence disturbance in four (minor nocturnal in three) of the remaining five patients, One patient underwent further abdominal salvage surgery and another required establishment of an ileostomy because of poor function. Combined abdominoanal salvage surgery for outlet mechanical obstruction was successful in averting an ileostomy in 13 of 16 patients, and significantly improved pouch function in 12 of 15.