Revisional ileoanal pouch surgery: a systematic literature review assessing outcomes over the last 40 years.

Aim: Failure of primary ileal pouch-anal anastomosis (IPAA) occurs in up to 15% of patients. Revision surgery may be offered to patients wishing to maintain gastrointestinal continuity. This paper explores the literature relating to IPAA revision surgery, focusing on pouch function after revision and factors associated with pouch failure.

Methods: Search of PubMed database was carried out for 'ileal pouch anal anastomoses', 'ileoanal pouch', 'restorative proctocolectomy', 'revision surgery', 'redo surgery', 'failure', 'refashion surgery', 'reconstruction surgery' and 'salvage surgery'. Papers were screened using the PRISMA literature review strategy. Studies of adults published after 1980 in English with an available abstract were included. Case reports and studies that were superseded using the same data were excluded.

Results: Nineteen papers (1424 patients) were identified. Bowel motion frequency doubled following revision surgery compared to primary IPAA although the increase was not always statistically significant. In patients failing primary IPAA, frequency of daytime bowel motions improved following revision in three studies but only reached significance in one (12.1 vs. 6.9, P = 0.021). Risk of pouch failure is increased in patients who develop pelvic sepsis after the primary procedure with the largest study demonstrating a four-fold increased risk (hazard ratio 3.691, P < 0.0001). A final diagnosis of Crohn's causes a four-fold increased risk of pouch failure (n = 81; OR 3.92, 95% CI 1.1-15.9, P = 0.04).

Conclusions: In patients undergoing revisional surgery, improved outcomes are observed but are inferior compared to primary IPAA patients. Pelvic sepsis after primary IPAA and a final diagnosis of Crohn's are associated with increased risk of pouch failure.