Diagnosis and management of pouch outlet obstruction caused by common anatomical problems after restorative proctocolectomy

BACKGROUND AND AIMS: Efferent limb syndrome (ELS) after S pouch and pouch-rectal anastomosis (PRA) after J pouch are common anatomical problems after restorative proctocolectomy that lead to pouch outlet obstruction. This study was aimed to evaluate the frequency, diagnosis and management of ELS and PRA. METHODS: Consecutive patients diagnosed with ELS or PRA at our Pouch Center from 2002 to 2011 were included. Demographic, clinical, endoscopic, and radiographic features together with its management and outcomes were studied. RESULTS: A total of 26 patients met the inclusion criteria, 17 (65.4%) were male. Eleven patients (42.3%) had ELS and 15 (57.7%) had PRA. The median length of the efferent limb/rectal stump for all patients was 6.0 (interquartile range [IQR]: 5.0-8.8) cm, 7.0 (IQR: 5.0-9.0) cm and 6.0 (IQR: 5.0-10.5) cm for S and J pouch patients, respectively (P=0.025). Dyschezia (n=15, 57.7%) was the most common presenting symptom, followed by bloating (n=9, 34.6%), abdominal pain (n=9, 34.6%), the sense of incomplete evacuation (n=7, 26.9%) and perianal discomfort (n=3, 11.5%). A greater number of patients in the ELS group had dyschezia compared to the PRA group (90.9% vs. 33.3%, P=0.005). More patients in the ELS group had a sense of incomplete evacuation than those in the PRA group (45.5% vs. 13.3%, P=0.10). Ten patients (90.9%) in the ELS group and 5 patients in the PRA group (33.3%) required surgical intervention (P=0.005). After a mean follow-up of 3.4 ± 1.4 years, 7 (87.5%) of the 8 patients, who underwent redo pouch construction with efferent limb/rectal stump excision, maintained a functional pouch. CONCLUSIONS: Patients with ELS or PRA often presented with debilitating symptoms. ELS occurred more frequently in S pouch patients than PRA in J pouch patients. Surgical intervention might be needed, especially for the ELS patients.