Redo Pelvic Pouch Procedure: Indications, Pitfalls, Technique, and Outcomes

The procedure to redo a pelvic pouch is much more complicated than constructing the primary pouch. It is important to have a team-based approach to determine the etiology of the pouch problem. While not all pouches should be redone, some indications for the redo pouch procedure include chronic fistula or sepsis, stricture of anastomosis or afferent limb, torsion, neoplasia or dysplasia, and efferent outlet obstruction. Redo pouches have higher complication rates and should not be undertaken by casual pouch surgeons. In the preoperative setting, nutritional optimization and current imaging are required. All sepsis must be drained, and fecal diversion with a “thoughtful stoma” may be constructed to aid in sepsis control. Surgery is typically performed via an open approach and ureteric stents are utilized. Meticulous dissection is required, and intraoperatively, the decision must be made whether to repair the existing pouch or construct a new pouch. Rarely, with redo surgery can the ileal pouch anal anastomosis be stapled. Therefore, a mucosectomy and handsewn pouch anal anastomosis is needed. Long-term function and pouch retention depend on the initial diagnosis and etiology of the pouch problem. That said, improved quality of life and acceptable long-term function can be achieved for patients who undergo a redo pouch procedure.