Redo Pouches: Salvaging of Failed Ileal Pouch-Anal Anastomoses Gilberto Poggioli, M.D., Floriano Marchetti, M.D., Simonetta Selleri, M.D., Silvio Laureti, M.D., Luca Stocchi, M.D., Giuseppe Gozzetti, M.D., F.A.C.S. From the Clinica Chirurgica II, University of Bologna, Bologna, Italy From October 1, 1984 to December 31, 1991 at the Clinica Chirurgica II of the University of Bologna, 140 patients submitted to ileal pouch-anal anastomosis for ulcerative colitis (UC) and familial adenomatous poly- posis (FAP). Nineteen patients (13.5 percent) developed septic complications. Of these, 11 patients (7.8 percent) had pelvic sepsis. Eight patients required further surgical intervention. Five patients underwent the redo pouch procedure. Another redo pouch was performed in a pa- tient who had previously, in another hospital, had an ileal pouch-anal anastomosis placed and then removed be- cause of ischemic necrosis of the reservoir. No deaths are reported in the reoperated patients. Currently, five of the six patients who underwent the redo pouch procedure have a well-functioning ileoanal anastomosis. The redo pouch procedure should always be attempted prior to the establishment of pelvic fibrosis. [Key words: Ileal pouch- anal anastomosis; Pelvic sepsis; Redo pouch] Poggioli G, Marchetti F, Selleri S, Laureti S, Stocchi L, Gozzetti G. Redo pouches: salvaging of failed ileal pouch- anal anastomoses. Dis Colon Rectum 1993;36:492-496. I leoanal anastomosis is currently the surgical treatment carried out worldwide for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The operation radically cures both diseases and provides excellent quality of life. Despite this, the procedure has a higher rate of surgical complications than do proctocolectomy with permanent ileostomy and ileorectal anasto- mosis. In the literature, the rate of complications de- creases as surgical experience improves. Neverthe- less, pelvic sepsis remains a dreadful complication because of its evolution into pelvic fibrosis, which leads to ileal pouch failure. The presence of complicated pelvic sepsis does not mandate the removal of the reservoir and the placement of a permanent ileostomy. It is possible in some cases to reconstruct the reservoir and perform the so-called "redo pouch" procedure. The authors report on six redo pouches. Their personal experience and a review of the literature define the possibilities and limits of this procedure. Address reprint requests to Dr. Gozzetti: Clinica Chirurgica II, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy. MATERIALS AND METHODS From October 1, 1984 to December 31, 1991, 140 patients submitted to an ileoanal procedure: 122 for UC and 18 for FAP. In all patients with FAP, mucosectomy and a hand-sewn anastomosis were carried out. Of the remaining 122 patients who underwent surgery for UC, 56 had a hand-sewn anastomosis fashioned and 68 had a stapled anastomosis. Nineteen patients (13.5 percent) developed sep- tic complications. Of these, eight (5.7 percent) had intra-abdominal sepsis located well above the sac- ral promontory. All patients recovered, seven with surgery and one with antibiotic therapy. Of the 11 patients with pelvic sepsis (7.8 per- cent), three were successfully treated with antibi- otics and/or lavages. The remaining eight patients (5.7 percent) had pelvic sepsis complicated with a fistula of the reservoir and required further surgical intervention. Four patients submitted to a redo pouch procedure, in three cases successfully with a well-functioning pouch. One case was later con- verted to a permanent ileostomy. The remaining patients with complicated pelvic sepsis were repeatedly treated with surgery and eventually developed pelvic fibrosis. All of them were converted to a permanent ileostomy. In one case, it was only temporarily possible to close the ileostomy because of the poor functional results that ultimately compelled the authors to remove the reservoir. Overall, five patients (3.5 percent) had their reservoir removed. Redo Pouches: Personal Histories Case 1. Approximately two weeks postopera- tively, this 23-year-old female presented with in- termittent cramps and fever. A contrast x-ray showed a rotation of the pouch around its longi- tudinal axis. That in turn brought about ischemia and a fistula of the upper part of the pouch. We proceeded to the resection of this part and then carried out a small J-pouch with the ileum proximal 492