A rare case of refractory pouchitis requiring ileal J -pouch excision after total proctocolectomy for ulcerative colitis

Introduction: Pouchitis is a late-period complication after ileal pouch-anal (canal) anastomosis in pa- tients with ulcerative colitis (UC). Most pouchitis is controlled with the antimicrobial agents. However, some postoperative pouchitis does not respond to antimicrobial agents, and it is very dif ficult to treat cases of refractory and severe pouchitis. Presentation of case: A 66-year-old man underwent total proctocolectomy with ileal pouch-anal anas- tomosis 22 years ago. He repeatedly presented pouchitis over the last five years. The administration of antimicrobial agents had not been effective, and he sustainably suffered from stenosis symptoms at the ileal pouch-anal anastomosis site. Therefore, we decided to excise the diseased ileal pouch by permanent ileostomy according to technique of abdominoperineal resection. The postoperative course was un- eventful, and at 6 months after resection, there was no relapse of abdominal symptoms and he reported a better quality of life. Discussion: The cause of pouchitis is still unknown. Oral administration of antimicrobial agents, such as metronidazole and cipro floxacin are effective for almost pouchitis, but there are some patients of re- fractory pouchitis. In the cases of refractory pouchitis, the 5-ASA formulation, a steroid enema, immu- nomodulators, biologics, and plasma pheresis are used. But, despite attempts with these various treatments, there are rare cases that require surgical intervention to excise the diseased ileal pouch. Conclusions: We should consider surgical intervention for severe refractory pouchitis after ileal pouch- anal (canal) anastomosis for UC. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).