The following is the summary of “Leaks From the Tip of the J-pouch: Diagnosis, Management, and Long-term Pouch Survival” published in January 2023 issue of Diseases of the Colon & Rectum by Holubar, et al.
Restorative proctocolectomy with ileal J-pouch is the gold standard for surgical therapy of ulcerative colitis. Although leaks at the J-tip pouches are well-known complications, the research on the topic could be more extensive. The report aims to detail their institution’s approach to diagnosing and treating leaks at the J-apex, as well as its long-term clinical outcomes for these patients. The design of this study was a retrospective analysis of data collected in a prospectively held pouch registry. The study was placed at a level-4 center for treating inflammatory bowel disease. Patients included those who had ileal J-pouches and were found to have leaks at the pouch’s apex.
The primary outcome measures were the rate of pouch salvage, the types of salvage operations used, and the long-term Kaplan-Meier survival of pouches. About 74 people had leaks at the J-opening. The majority of patients (68.1%) arrived with pain, followed by a pelvic abscess (40.9%), and just 10.8% with an acute abdomen. In 74.3% of cases, the leak was detected using imaging and/or endoscopy, while in 25.6% of cases, it was not found until the patient had a surgical investigation. About 63.5% of patients weren’t diagnosed until after their loop ileostomies were closed, whereas 32.4% were diagnosed beforehand. Pouchoscopy (31.1%) and gastrograffin enema (28.4%) were the most prevalent diagnostic procedures. The percentage of patients for whom a definitive nonoperative strategy was attempted is 48.6%. However, the percentage of patients for whom this technique was ultimately effective is 10.8%. In 89.2% of cases, surgical repair was attempted, whereas 4.5% of patients had their pouches removed.
The majority of the 63 successful salvage procedures involved suturing or stapling the J’s tip back together; 25% involved removal of the pouch and replacement with a neo-pouch; 9.5 % involved separation, repair, and reanastomosis of the pouch. The overall 5-year pouch survival rate was 86.3%, with 10 patients needing pouch excision (13.5%). The study’s limitations include its retrospective nature and the possibility of referral bias. Leaks at the J-apex pouches present themselves clinically in various ways, so a high index of suspicion is warranted. Most patients will need pouch salvage surgery, and this procedure has a high success rate.