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The majority of re-do ileal pouch anal anastomoses (IPAA) are constructed with J-pouch formation. In situations where bowel reach to the pelvis is not limited, J-pouch construction, compared to H- or S-pouch formation, is technically less demanding and allows for intestinal continuity. Inability to bring bowel/mesentery down to the pelvis due to increased body mass index, complex pelvic anatomy after multiple operations, prior small bowel resections and/or prior ileostomy may prevent J pouch formation and leave patients with a permanent ileostomy. Specialized centers can uniquely offer redo J-pouch construction and have the proficiency to create redo S- or H-pouch if needed to restore intestinal continuity in cases where mesenteric reach to the pelvis is limited. In this video, we aimed to show our technique with redo S- and H-pouches. This article is protected by copyright. All rights reserved.

Indocyanine green (ICG)-enhanced fluorescence has recently been used to assist in identifying perfusion of bowel and a healthy anastomosis. Feasibility of ICG for many colorectal procedures has been shown, however use of ICG in complex inflammatory bowel disease (IBD) operations is not well-known [1-5]. This article is protected by copyright. All rights reserved.

Introduction: Minimally invasive ileal pouch-anal anastomosis (MI-IPAA) are becoming more commonly utilized. However, the outcomes in re-do IPAA after a failed MI-IPAA are not well studied. This study aims to compare short- and long-term outcomes of re-do IPAA surgery in patients who had a failed minimally invasive or open IPAA creation.
Method(s): Patients undergoing transabdominal re-do surgery for a failed MI vs open IPAA by single surgeon between September 2007-September 2017 were case-matched 1:1 fashion based on primary diagnosis, indication for re-do IPAA, age and body mass index(BMI). Patient characteristics, short- and long-term outcomes were compared between two groups.
Result(s): Forty-two patients undergoing MI-IPAA were matched with 42 open counterparts. Patient characteristics were comparable. The time between index and re-do IPAA surgery was shorter in patients who had MI-IPAA(median, 28.5 months vs 56 months, p=0.03). A long rectal stump (>2 cm) was more common after MI-IPAA (26% vs 10%, p=0.046). Stapled re-do IPAA was more common in MI-IPAA group (26% vs 10%, p=0.046). Although short-term morbidity was similar, abscess formation (7% vs 24%, p=0.035) was more frequent in patients who had index open IPAA. After median 26 months of follow-up, survival was comparable between two groups.
Conclusion(s): A retained rectum leading to pouch failure is more common during MI-IPAA compared to open IPAA. While leaving a long rectal stump during MI-IPAA is a major technical drawback resulting failure, the long remnant rectum may allow for appropriate transection with a linear stapler. This allows for a double-stapled re-do IPAA which was associated with less septic complications.
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INTRODUCTION/BACKGROUND:The vacuum-assisted drainage has many applications in managing complex wound healing. It quickens the recovery period by its hyperemic effect on the exposed zone, decreasing bacterial colonization, preventing tissue edema, and promoting granulation of the wound. However, its use in anastomotic leak after IPAA is scarcely studied, especially because a proprietary endoluminal vacuum-assisted closure system was removed from the US market. TECHNIQUE/METHODS:We applied a hand-crafted endoluminal vacuum-assisted closure system using the existing standard wound vacuum-assisted closure supplies to 2 patients who developed an anastomotic leak with a presacral abscess after completion proctectomy with J-pouch construction. RESULTS:We changed the endoluminal vacuum-assisted closure drain every 2 to 3 days, and both patients had substantial improvements in their abscess cavity after the seventh and ninth applications. CONCLUSIONS:Anastomotic leak at the IPAA traditionally takes up to a year to heal, which causes a significant toll on the psychosocial life of the patient and delayed stoma closure. Therefore, we believe that facilitating the healing process by using our hand-crafted endoluminal vacuum-assisted closure drain might provide a great value to patients' quality of life.

Introduction: Re-do pelvic pouch surgery is a safe and feasible option to maintain intestinal continuity in patients with failed ileal pouch-anal anastomosis (IPAA). The decision to preserve (or augment) the primary pouch or create a new pouch is typically made intraoperatively. Our aim was to define factors associated with primary-pouch preservation/pouch augmentation in patients undergoing re-do IPAA surgery.
Method(s): Patients undergoing transabdominal re-do IPAA surgery between June 2016 and February 2019, in an inflammatory bowel disease center, were included. Full abdomino-pelvic pouch mobilization of the primary pouch was made in all cases. Indications, patient characteristics, and short-term (<=30 days) outcomes were evaluated and compared depending on preservation vs excision of the index pouch.
Result(s): Sixty-nine re-do IPAA patients were included. A new pouch was created in 42 (61%) patients. Most common indications for a new pouch creation were chronic infection (38%) and small pouch (36%) (Table ). Although patients having a new pouch were older (45 +/- 13 vs 32 +/- 13, p < 0.001), patients whose index pouches were preserved underwent a re-do IPAA surgery earlier (median, 120 vs 53 months, p < 0.001). A re-do, hand-sewn IPAA was more commonly performed when the primary pouch was excised and a new pouch needed to be created (88% vs 54%, p = 0.003). Postoperative short-term morbidity was similar between the 2 groups (52% vs 48%, p = 0.73). There were no re-operations or mortality.
Conclusion(s): Re-do IPAA surgery provides acceptable outcomes regardless of preserving or excising the primary pouch. Hand-sewn IPAA is more commonly performed when creating a new pouch during re-do IPAA. Index pouch preservation seems achievable in younger patients undergoing timely salvage operation. [Figure presented]
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Introduction: Ileal pouch-anal anastomosis (IPAA) failure is most commonly associated with pouch excision and permanent ileostomy. Motivated patients may choose to undergo a complex series of operations to attempt a re-do IPAA. We hypothesized that the outcomes of re-do IPAA are comparable to index IPAA.
Method(s): Patients undergoing index and redo IPAA at a specialized inflammatory bowel disease center between September 2016 and February 2019 were included. Operative and short-term outcomes were compared.
Result(s): There were 200 patients (index, n = 100 ; redo, n = 100). Eighty patients in the index and 70 in the redo group had their IPAA. Eight and 72 patients underwent 2 and 3-stage index IPAA surgery, respectively. Outside hospital system referrals were common for the cohort of redo operations (63% vs 29%, p < 0.001). Age, sex, BMI, American Society of Anesthesiologists (ASA) score, and primary diagnosis were comparable between the groups. Redo IPAA was associated with increased intraoperative bleeding (median, 200 vs 300 mL, p = 0.02), operative time (median, 223 vs 258 min, p = 0.001), and length of stay (median, 5 vs 6.5 days, p = 0.008). Thirty-day morbidity (41% vs 54%, p = 0.11), readmission (26% vs 24%, p = 0.78), and reoperation (1% vs 0, p = 1) were similar. One patient in the index group and 2 in the redo group had pouch failure with a median follow-up of 14 months.
Conclusion(s): In specialized high-volume centers, complex redo IPAA can safely be performed, with equivalent perioperative morbidity, when compared with index IPAA creation. Though redo IPAA was associated with greater blood loss, longer operative times, and length of stay, short-term morbidity was not significant.
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Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC). The most common type of IPAA is a J-pouch. If despite all other mobilization maneuvers, inadequate mesenteric reach prevents a tension free anastomosis with J-pouch, a good alternative is S-pouch creation, which can provide an additional 2 to 4 cm of length (1). This article is protected by copyright. All rights reserved.

PURPOSE/OBJECTIVE:Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. METHODS:Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. RESULTS:60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. CONCLUSION/CONCLUSIONS:Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

BACKGROUND: The efferent limb on the S-pouch fits well into the anal canal while the body of the pouch lies on the levators. In contrast, the blunt end of a J-pouch may be distorted as it is forced into the muscular tube of the stripped anus. OBJECTIVE: The aim of this study is to compare the clinical outcomes and quality of life between patients with S- and J-pouches with a handsewn IPAA. DESIGN: This study was retrospective. SETTING: This study was conducted at a high-volume tertiary referral center. PATIENTS: Patients undergoing a primary handsewn IPAA from 1983 to 2012 were identified. MAIN OUTCOMES MEASURES: Demographics, operative details, functional outcomes, and quality of life were abstracted. RESULTS: A total of 502 patients, including 169 patients with an S-pouch (33.7%) and 333 patients with J-pouch (66.3%), met our inclusion criteria; 55.8% (n = 280) were men. Mean age at pouch construction was 37.8 +/- 12.5 years. Patients with an S-pouch were younger (p = 0.004) and had a higher BMI (p = 0.035) at pouch surgery. There was no significant difference between patients with S- or J-pouches in other demographics. The frequencies of short-term complications in the 2 groups were similar (p > 0.05), but pouch fistula or sinus (p = 0.047), pelvic sepsis (p = 0.044), postoperative partial small-bowel obstruction (p = 0.003), or postoperative pouch-related hospitalization (p = 0.021) occurred in fewer patients with an S-pouch. At a median follow-up of 12.2 (range, 4.3-20.1) years, patients with an S-pouch were found to have fewer bowel movements (p < 0.001), less frequent pad use (p = 0.001), and a lower fecal incontinence severity index score (p = 0.015). The pouch failed in 62 patients (12.4%), but neither univariate nor multivariate analysis showed a significant association with pouch configuration. LIMITATIONS: The use of data from a single tertiary referral center was a limitation of this study. CONCLUSION: We recommend using an S-pouch when constructing an IPAA with a handsewn technique.