Management of Leak From the Tip of the J in Ileal Pouch-Anal Anastomosis

BACKGROUND: Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. OBJECTIVE: The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: Data were obtained from a prospectively maintained single-institution pelvic pouch database. PATIENTS: Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. MAIN OUTCOME MEASURES: The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. RESULTS: There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 +/- 1.9 years. LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.