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Hello, behind the knife listeners. We are so excited to be back with you for another clinical challenges in colon and rectal surgery with the Leahy colorectal surgery team.

Yet again, we have another very, very special guest who's joining us today and we'll introduce them shortly. So I'll just recap some of our prior episodes that we talked about in case you missed them endoscopic management of advanced colorectal polyps, the role of total new adjuvant therapy for locally advanced rectal cancer, surgical management of rectal prolapse, use of biologic medications in patients with Crohn's disease, requiring ileocolic resections, Structuroplasties and Crohn's disease, horseshoe abscesses, and anal dysplasias.

Very nice smorgasbord of colorectal surgery. And so today, we're going to tackle perhaps one of the more technically challenging aspects of colorectal surgery. And that is the ileal pouch anal anastomosis creation and management of complications. So once again, we have with

us again, Dr. Peter West, Marcello, and Dr.

Tess Hannah Alet. So say hi again. Hey guys, it's Peter, happy to be back on again. for another episode. I just came back from the Midwest colorectal meeting in Tahoe, California. It was phenomenal. Great meeting as always because you interact with many others. And with us, we had Dr. Matthew Mutch. He graduated in our current ASC program.

And I just got to tell you this. Matt is a phenomenal skier. I skied with him for 20 years. He was doing double blacks going down the chutes. So when you see the president at the national meeting, ask him, how's the skiing going? Nice. I tried to FaceTime you guys. I tried to FaceTime you guys on the ski lift.

It doesn't, yeah, we saw it. We're like, chute instead.

Things are good. Things are good. I'm Almost cooking 37 and a half weeks. So, almost at the end of my journey here. And you'll have to do all the skiing for me this this season. So you get a few

more. Can you tell the listeners, is it a boy or a girl? Do we know it's a girl? Yeah.

Nice. Oh, congratulations. Great. Thank you. Yeah, things are good though. All right. And today we have, as I said, a very, very special guest who's going to be joining us. So I'm honored to introduce Dr. Philip Fleschner. So Dr. Fleschner is the chair in colorectal surgery at Cedars Sinai. He completed his general surgery residency at Mount Sinai Medical Center in New York City.

Dr. Fleschner. And then he completed his co octal fellowship at the Leahy Clinic. What was it called then? The Leahy Clinic? The Leahy Clinic. Not Hitchcock or, yeah, okay. He then took a job at Cedars Sinai in L. A. and remains there to this day. And the main clinical and research interests of Dr. Fleschner are directed towards optimizing outcomes and techniques in the surgical management of Crohn's disease and ulcerative colitis.

He has over 200 publications, numerous

awards throughout his illustrious career, and we are thrilled to have him join us on Behind the Knife. Peter, any additional comments you'd like to make about Well y'all, so Phil was a fellow in 90 1991, and his year was like an all star year. He had Jose Guillem, who's been on the program before, and Dr.

Tom Stahl, who is down in Washington, D. C. A great year. Phil, a phenomenal surgeon and invited me out to Cedar Sinai and put me up at the Beverly Hills Hotel. And if you want to hear some good stories, whenever you see me, I'll give you some good stories about that. Great trip and a great innovator and just our understanding and thoughts regarding surgery for Crohn's in UC.

So really a pleasure to have Phil on board. Great to be here, guys. And listen, as an ex Lahey graduate, funnest year of my surgical training by far was getting those great oatmeal cookies in the cafeteria. I don't know if they have those anymore, but those oatmeal cookies were

absolutely unbelievable to this day.

I still remember them. All right, John, let's get rolling. Let's do it. All right. So like our prior clinical challenges episodes we're just going to talk about one case. All right. And then we're going to take a deep dive about some complex medical and surgical decision making. And so a reminder, you can follow along with us on the Behind the Knife YouTube channel for some relevant images.

Alright, so this is a 20 year old male you're seeing him in your clinic as a second opinion. He was diagnosed with medically refractory ulcerative colitis in 2019, and initially underwent a total abdominal colectomy with an ileostomy. He recovered well, and then three months later, he underwent a takedown of the ileostomy, completion proctectomy, with a pouch rectal anastomosis.

So, just some details here. The rectum and operative rapport was noted to be transected at the level of the levators using an endo GIA 60 millimeter purple cartridge stapler by Covidien.

Two firings were needed to come across the rectum. The J pouch was made from 12. 5 centimeter limbs and then a 31 millimeter EEA stapler was used.

For the anastomosis, no proximal diversion. All right, so let's stop there. Dr. Fleschner, if we can ask you to summarize some of your ideal approaches to how you create an ileopouch anal anastomosis in patients with medically refractory ulcerative colitis. And so I think our listeners would love to hear just your general thoughts.

Two stage, three stage, key technical steps of the pouch creation. role of proximal fecal diversion, and then, your historical perspective on how this has changed over time. Well, historically, certainly, I mean, certainly also what I learned in Leahy, because I did a lot of them there, is we used to do these all via open incisions.

I think with the advent of laparoscopy now, most of us now are doing it that way because it's less invasive and certainly easier on the patient. Many of these patients are young and it's a good cosmetic effect. you know, cosmesis after. In terms of

the procedure itself, I do laparoscopy pretty much exclusively now in these patients to try to do it.

I'm a big believer of fecal diversion. I think that routine fecal diversion is important in these. And the main reason I think I say that, even though there are some people out there that tend not to do that, we can potentially talk about that. I really do believe you get one shot. to do that pelvis well.

And I think if you end up miscalculating, yes, it's a stoma. Yes, stomas have their own risks and stoma closures have their own risk and patients don't like them, et cetera. But if you gamble wrong, you literally have a lifetime of problem as opposed to two months of a potential problem with a stoma. So that's the reason why I generally believe in it.

We routinely used to do these in two stages. Now, most of them are, quite frankly, done in three phases. Mainly because of the role of biologics. Although there's a lot of data out there that shows that it does not influence surgical morbidity. But I think a lot of us have sort of just become comfortable in doing it that way.

I certainly will do two stage procedures in patients who are on no

medication, like dysplasia example, if they're on this, you know, if you're getting a colectomy for dysplasia, but I think in general, three phases now based on what we're doing. I used to do all of my procedures using mucosectomies.

I think I've changed that now. Most of them now are done double staple technique. So I do retain a small amount, but it's very important. to remember that you're not going to do an ileal pouch rectal anastomosis in this. And this is one of the caveats that you have to be careful of when you're doing laparoscopy because as much as you think you're getting down to the pelvic floor and the elevators, and potentially in this case, there's no way that they went down to, to the elevators.

And I can tell you that mainly because of what you said. They said they're at the lator, but yet they have to have two firings of a stapler. As all of you know, the rectum is very, very large, but it narrows down to the anal canal. So that by the top of the levators, it's basically a short tube. Literally what you would think of the anuses.

So literally when you

staple these you know, when you're doing your distal transection, you should be seeing a short tube, not something that requires two staplers. And beside the fact that obviously we all know that multiple firings on the rectum is not good because it increased leak rate.

But This is another problem which I think that you've sort of described in your report right here, which should be a red flag in terms of what's going to be happening to this patient. Phil, that's a good summary. Who gets a mucosectomy now? What do you think the top three reasons that somebody might get it?

I do mucosectomy still for patients who have the pre op diagnosis of dysplasia, particularly it's in the rectum or cancer, obviously, if you're doing one, for example, with an upper rectal cancer where you have some. Ability to get below the tumor in a good way.

I'll still be doing dysplasia where I have a technical problem. If I have a patient, for example, what I'm putting in the stapler and it rips through the, the distal side, I almost always will do it in that scenario. Yeah, but those are the main reasons nowadays that I'll do a two stage.

And the other thing that I do them routinely on right now,

quite frankly, are the pouch revisions are the ones that have, you know, that ever, whatever they need, they have some almost always those patients are going to have a mucosectomy and a very ultra low if you want to call it pouch anal anastomosis.

And I agree with a hundred percent on the rectum transsection. I think if you're going to do a double stable technique, it's going to be, you know, one to two centimeters of cuff. I like to use still a fan steel incision. Both for extraction, and I like the TA30 stapler across the low rectum as my preference as my primary treatment.

How do you handle the rectal stump for transection? I totally agree with what you said. Now, in a, for example a skinny female with a wide pelvis where you can go all the way down. And you know you're at the levators and you put your finger in and it literally is like a centimeter and a half, two centimeters above the dente line.

I have no problem just taking a TX60, I'm sorry, a TA60 and going across that. But if you're in a scenario where even if you've had the intent to do that, and you're running into a problem here, do a fan and

seal incision. You're going to end up being for a fan and seal incision for I keep saying, you know, you have a lot, many of these patients are young, they have their whole lives ahead of them for a little fan and seal incision guys, and you get so much more ability.

And I totally agree because it sort of gets back to what I said before, the anus, the rectum, if you want to call it at that level is very narrow and a TA 30 will go across that easily. Tess you're now, you're coming three years of clinical practice. Tell us about your POUCH experience what you've done and what they do in the practice.

And what do you think recent grads need to know who are coming out of fellowship about that? And what about the role of diversion? So, I have not had a ton of experience. I have been able to do a few, in my first few years of practice. My first year at UMass worked with Dr.

Makel as a clinical associate and we were able to do quite a few together. At UMass, we are doing quite a bit of TATME and have kind of

utilized this approach for the, second stage completion proctectomy And I think in terms of what we're kind of getting at, the benefit of the TATME is you're Able to really define that distal transection of the rectum using the trans anal approach to fight some of the challenges that we're kind of describing and that narrow male pelvis where you're, not really the angle of the stapler might be challenging if you're trying to do it laparoscopically Obviously, coming from Leahy, I love a fan in steel and the TA30 as you already brought up, Dr.

Marcello but that's one of the things at UMass that I think I didn't see as much of as Othello, and I think does definitely have its benefits. There's different sizes to the Trans anal platform. So, you don't want to pick the biggest size because you want to make sure that you're actually getting that short rectal cuff and not leaving a long stump with the trans anal platform.

And so you can also,

depending on the platform, I've seen, some of my partners like trim it afterwards to if you need to get a little bit lower, but then you're really set up for, good Trans anal view of everything. I 100 percent believe in diversion. I think there's a theme here, everybody, from Leahy, but I think one of the things that stuck with me as a fellow Dr Marcello is you kind of hammering.

Home this idea of, the creation of a pouch being, quality of life operation. And, you know, we get one shot as Dr Flesher has already pointed out. And so we want to do it well and. We know that from a lot of the literature, pouches that suffer a leak have higher rates of failure, quality of life, and function is not as good, and so if we're doing this to give patients the best quality of life and function, why gamble with that?

And so, so far my stances divert with an ileostomy for that reason. All right, so let's

continue with the case. And so, as you can probably tell from our conversation and based on our prior cases the story is not going to end with a perfect pouch, right, called anastomosis.

So, unfortunately, this patient did have a fairly poor pouch function was having at least 15 bowel movements per day. Up multiple times at night. And so now he's seeing you in clinic six months after his pouch creation. Like we said, it's a second opinion. You do a pouchoscopy yourself and that reveals a fairly long rectal cuff at about five centimeters from the dentate line.

And there's severe inflammation with erosions and ulcerations in the rectal cuff. You know, the pouch itself is normal. And so again, we just remind you if you want to follow along with YouTube, you'll see some endoscopic images. Of the rectal cuff here. So, Dr. Fleschner, how do you approach a patient like this who shows up at your clinic, both medically and surgically?

One of the first things I would do, like I just mentioned before, is go to the op report, because this is going to give you clues as to what happened. That's number one. Number two, obviously, you see

this. So, this is basically an Incomplete proctectomy. This is basically still residual colitis.

And I presume the patient was severe enough, obviously to require a colectomy. Obviously, their inflammation was bad enough that they went to surgery. You can throw medication until the cows come home on this. This needs surgery. And there's really no other way to get around this. You're going to have to go back in that pelvis.

You're going to have to take out the residual rectum and perform an ileal pouch anal, not ileal pouch rectal. Like this is an ileal pouch anal anastomosis. And that's what I would recommend in this patient. Yeah, I agree. I think here the goal is you got to get rid of that disease piece and that's what we we talked about.

I didn't think that medical therapy would be a benefit. And then it was a young male, so am I going to try double stapled if I can depending on what happens or mucosectomy, and that'll be an interrupt decision making. All right, great. So, let's come to the operating room nine months after his prior surgery for exploratory laparotomy, lice of adhesions.

We took down the pouch rectal

anastomosis, anastomosis, did a completion proctectomy, and then constructed an ileal anal or ileal pouch anal anastomosis with diverting glucoleostomy. I guess, Peter, maybe you want to give some comments then about intraoperative findings and some of your, thoughts when you were doing the case?

Yeah, I'll ask Bill the same thing, but the I start all, before I make a pouch, I just start with a flexible endoscopy Like right there, I'm making my decision. Am I going to do a double staple or a mucosectomy? And it really is on the state of that distal 2 centimeters of the rectal cuff. And while there was inflammation, I thought the cuff would be acceptable for stapling anastomosis.

And so, that was part of it. And then, of course, we'll talk about leak testing, which if I'm going to do a double staple, I'm going to leak test it. And so, I got rid of the diseased part. and took the rest out. Phil, how do you decide if you're going to do a mucosectomy Or a stapled?

Are there factors I would've done? Yeah, sure. I would've done a mucus acumen, this patient. And the main reason why is that this patient,

and again, it's not exactly a cuff, but it's a long cuff, and they've sort of described they've kind of declared themselves that they're gonna continue to have inflammation in the residual cuff that you're leaving.

So I would be very inclined to do a. Full mucus ectomy in this patient. Bring it down, get all that, that mucosa out because he's already, the, is a he's already defined his natural history, I think to some degree. So I would do an ileal pouch, anal mucus with a diverting low ileostomy. Well, I wish I'd listened to you, Phil.

Go ahead. Alright, so he with discharge home on postop day seven he was then readmitted with fevers and abdominal pain. So I'll show you just a screenshot of a, the CT scan. That showed a likely pelvic hematoma, some air adjacent to this so we took him back to the operating room wash out of a pelvic hematoma and then pouchoscopy.

We did find old hematoma in the pelvis, no gross purulence on the short rectal cuff side posteriorly, the mucosa had separated slightly at the staple line, but there was really no definitive true opening in the posterior midline. And

so at that time you sort of felt that it was possible there might've been a small breach of the anastomosis, and so we placed a 24 French malicot.

Into the pouch and then transabdominal drains anterior and posterior to the pouch. Comments then, Peter, about some of your thoughts about that? Yeah, and I'll ask Phil about his thoughts. He was very sick. I mean, he was toxic. So I felt that, I didn't think that non operative management with drain, percutaneous drainage was appropriate.

And I wanted to really, I saw this, the big collection. He was sick. And I wanted to make sure I could do the best I could to try to salvage the pouch. So I elected to reopen. I explored, washed things out, and then found the defect posteriorly. And in this scenario, what I learned from the past was communicate the abdominal and the transanal cavities.

In other words, Leave a malachite in from above and put a drain from below the two communicate together so that you try to create one natural cavity rather than sometimes drains.

It'll be off to the side and not to the malachite. So that's what we did. Put a 24 malachite. Yeah, I mean, my perspective on this is that this is an unusual scenario for someone who has a posterior leak like this.

In other words, to be so sick, the vast majority of these get walled off. Yeah, the patient has some fever. Usually they'll just present, I feel like I have a golf ball in my pelvis and you're kind of wondering what's going on. They don't have to have fever. They don't have to have a white count because most of them, at least in my experience, have an ileostomy.

So, I agree if the patient was sick, the patient needed a washout, obviously. Again, you also have to remember that. You're probably going to manipulate the pouch a little bit and pull on it, potentially make that leak that you have that defect a little bit larger. So you have to be careful with that.

And I understand the, or at least I understand the concept. I know some people try to do this abdominal pelvic communication, but it seems to me like doing an IR drain with a transgluteal, or even quite frankly, a transanal drain where you're

keeping the endoluminal might be potentially better, but again, I have no, there's no, obviously, trials looking at that my, my approach to this.

Yeah, go ahead. I'm sorry. My approach to, go ahead again. Sick. You need to go to, or no, no question. But they're not sick. I mean, that's the majority not right. Majority. So the message to the residents is if they're not that sick IR drainage or transanal drainage, yes, I do agree with that, that that's what I'd be doing.

But again, a sick patient, listen, any sick patient, you go to the or. Okay? Iris, you can't rely on ir. IR is good, but they're not that good in a patient who's otherwise septic, of course. So, you know, he definitely recovered well from that operation. And then, prior to discharge, we did do a repeat exam under anesthesia.

We did confirm a small posterior pouch anal anastomotic leak about three to four millimeters in diameter. We were able to place a temperance catheter into this cavity. And so again, if you're following along, you can see the defect on our presentation. So Dr. Fletcher, you're going forward for a patient like

this.

What's your game plan? How do you talk about it with the patient and what the next steps are? Well, certainly the drain in place will obviously keep him well. One of the things that I would consider doing this is to enlarge it a little bit with a balloon and then to put a an endo endo sponge in there.

I've had some experience doing that. You know, the endo sponge is unfortunately not available commercially in this country. You kind of have to rig it yourself with an NG tube and the back drain that all of us know about in wounds. And the concept is Basically, you have to bring, it's very labor intensive, guys, don't get me wrong, you have to bring the patient back every three to four days for a back change.

You can't just do this at the bedside, it's anesthesia, etc. But it's an attempt to try to collapse the cavity. And there's some European data that suggests that the functional results might be better this way than doing an IR drain. But again, that's one thing to consider doing in this scenario. If you'd already done the the trans anal drain, most of the time, though, although I've had experience with endosponges, most of the time, I'll just leave the drain in, keep it in for about three to four weeks and then slowly advance it out and end up leaving yourself a

sinus, which you can then evaluate after that.

Either radiologically and or again with another scope to see whether or not you should incorporate this into the pouch and basically take that leak that he has and basically make it one cavity. But that's something you'll decide down the line, but you don't do that right away because there's, you know, you need this thing to mature and develop a fibrotic wall around it first.

Got it. So we ended up taking him a couple of weeks later for an exam under anesthesia and we were able to. perform a trans anal closure of the anastomotic leak. And so, good vascularity of the tissue, you know, no evidence of obvious Crohn's at that point. I guess, Peter, your thoughts and you describe your technique for our listeners about how you approach that.

Yeah. I want to go back to a second for Phil's, for the endo sponge. So basically you put a sponge in, put an NG tube in, suck on the sponge coming out and then change it and less sponge each time. Yeah, supposedly, I mean, it contracts, the space contracts that. It's just an,

you know, an anal vac is basically what we're talking about.

And I think the residents understand that concept. Here, and for those listeners who have YouTube and can see the image it was actually quality tissue and I still had the abdominal drain in. So, we've had experience here where we actually will try to suture it. And the trick, the tricks of the trade for suturing it is we use those plastic anus scopes that we used to have way back from Leahy.

There's a company in New Orleans that will make them. And I used a laparoscopic needle driver. And I used a couple of 3 O Vicryl on an RB needle. And I was able to drive through to bring the tissue together. Knowing that It's not perfectly sealed, and I still have the abdominal drain for any fluid they want to collect on the other side.

And this case, as you can see in the image, it didn't really favor itself to that sinus that you often see where there's sort of a longer erosion. It would look more like a flap. So I just closed the flap.

It's interesting how you did it down the line. I'm wondering why you didn't consider doing it right away at the time here if you already had an abdominal drain.

I thought that I wasn't sure if everything was going to settle down and I wanted to make him in better shape and let things soften a little bit. But get there before it gets too fibrotic, right? I mean, that's the hard phase when the fibrosis sets in. So, we did perform a water soluble enema six weeks later.

It did still reveal a persistent leak at the anastomosis. You know, we then actually repeated this procedure two months later with an additional transanal repair. And so, I guess at second repair, other comments about what you're looking for in terms of the tissue to guide.

Your operative decision making at that time. It's just really quality of tissue. And this, and they when I did the study, I was concerned that if I left it, that sinus was long and I worry about that happening behind, but I know Phil's got a huge experience

managing, you know, the leaks in the sinuses.

So Phil, give us some of your thoughts and philosophies regarding a standard, posterior abscess, leak, drainage. But the sinus and your thoughts regarding the sinus. Yeah, sure. By the way, I don't have a huge experience. The only leaks I ever see are other people's patients. They're not mine. I know that to be true.

Go ahead. Just everyone's clear about that. Well, I think the key is what you're saying is that obviously once you have drainage, In my experience, when I see when I'll do a gas, like a rogram at this patient, potentially they can start closing. What I'm looking for is, number one, what the patient's symptoms are like if the patient's asymptomatic, and the CT scan, which you'll hopefully has have as well reveals no evidence of residual, cavity space or infection behind it.

I'll close. And we've actually published on this to show that it's safe and the patients do okay down the line, but the key is that they have to be asymptomatic. And the concept, the reason that we think that works is that it's walled off

and it's basically just sitting there like a blind space. And if it's been there for a month or two or whatever, then you can just close it at that point.

The other thing that's very helpful to look at on your pouchogram is the anatomy of the leak. And what I mean by that are the, it's the angle that it takes. If it takes a 90 degree angle off and it goes directly posteriorly, those are the ones that are very difficult to manage. And those are the ones that I will clearly wait and and and see what happens.

The ones that are parallel to the pouch, literally. You could just take an endo GIA and literally slip it right through there and incorporate that, that defect that you have into the pouch itself to basically marsupialize it you know, basically into the J pouch. So that's another option to consider with the ones that are parallel to the pouch.

You can't do that on the ones that are perpendicular to the pouch anastomosis because obviously there's so much tissue in between. But the ones that are parallel, parallel, you can. That's why it's very important that you do a, a poutogram on these, not only to sense, you know, whether or not the thing is healed, but also the local

anatomy to try to guide out, you know, to guide therapy.

Yeah. So we're go ahead, John. And I was going to say, I mean, we're, we've made it very, very clear to our listeners, we're talking about posterior leaks. So perhaps I can just ask Tess, if we can just comment for a minute about anterior leaks. And so how is that different, better or worse for the patient, the surgeon?

So I'll just, put another, picture here of a screenshot of a patient who's six months after pouch creation and ileostomy and ostomy closure. And now this patient's presenting with pelvic pain. So, female, pelvic pain, fever, and anterior leak. So, Tess, what are your thoughts about a patient like that?

Yeah, so, and the male you have the prostate there and the female you have the vagina uterus. This slide on the screen shows a collection and tier to the pouch as you mentioned. You know, with the vagina is going to be right in front of there. So, ideally you kind of drain this depending on how sick the

patient is or how they're doing probably with IR, try to get that cavity to collapse down and hopefully you're not going to end up with a pouch to a vaginal fistula.

So. Anyone with a pouch and you're concerned about anterior leak making sure you really have that pelvic sepsis controlled, make sure you're looking for an abscess, and if they're having symptoms really investigate that before you have a, you know, big cavity and tons of inflammation sitting in that anterior cul de sac that's going to cause problems.

In my experience, the, I'm sorry, Peter, let me interrupt you. In my experience the anterior leaks are very rare. We see them, but they're very uncommon, and I'm not sure why they occur because it's certainly not a tension issue, and it's not an ischemic issue, which is why the vast majority of leaks that we see are posteriorly related to the two factors I mentioned.

So I quite frankly think it's going to be very difficult to get IR access into this

safely because of it, because what Ed with respect to the vagina and the prostate. I think this is exactly the one that you wanna do a transanal drain, keep it in place, and then probably maybe do sort of what you did, Peter a couple weeks later, sew it in.

And the vast majority of these, because they're not ischemic and because they're not in detention, these do very, very well, way better than, than the posterior ones because of the men, the reasons I mentioned. Yeah, I think the part of it also is the fact that there isn't that dead space. Like when you make a pouch anal anastomosis, there's always that space behind in the sacral hollow and that's where the posterior leaks occur.

An anterior leak, you've got at least vagina or prostate, like you've got tissue around it that will actually help. So I agree with, I think if I can get good drainage, most anterior leaks, I'll make sure they're diverted. They're fine. But Tess, what about on top of the J pouch leak? That's a different one, like a different beast, but that's sort of the third category.

What are your thoughts about a top of the J pouch leak and what do you do there? Yeah.

So again, that's going to potentially, I think, be a little bit easier to drain trans abdominally. You're going to have a harder time dealing with that trans anally, I would think. And making sure that the patients diverted potentially, you know, source control and then whether or not that closes down might need.

A revision prior to reversal. Bill, have you seen leaks from the top of the J? I've seen the, I've seen the tip of the J leaks. I don't know why they occur. I don't know if it's our stitching or who knows localized ischemia, but one of the things that's really good for these is endoscopic clipping. This is exactly the patient where it might work very well.

Some of our IR, I'm sorry, our advanced GI guys actually even sewed them endoluminally. And as, as Tess said, almost, because I divert all these patients, you have The the luxury, so to speak, I'm not having a stool going by it. That's the best way to try to approach these initially. And if it doesn't work, then you've got to go back in transabdominally and close that leak and almost always it's very easy to close them.

But

particularly in the laparoscopy age, where kind of there's minimal adhesion formation, you can do it laparoscopically. But almost always I'll approach those at least endoluminally first. That's a great teaching point. Got it. Well, I'll just circle back around to the main case that we presented, and I'm thrilled to report a subsequent water soluble enema, showed no posterior leak.

We reversed his ostomy. As you might have caught, this was actually back in 2019, 2020, and so he was seen, you know, a few years post op and was doing quite well. about eight to 10 bowel movements a day. Good, good control. So happy, happy end to that story. But you'll notice that he doesn't have four to six bowel movements like you should have had if you didn't develop pelvic sepsis.

Although you basically you, you got rid of the permanent stoma potentially. But as, as we all know, pelvic sepsis is not good for long-term function as well. Yeah. A pouch leak, you know, is, it can be a problem. And I think, if we talk about SHA or test

said before about the operation shas always Dr.

David Shas mentor for Phil and I would say that the pouch operations and operation of functional preference and his other favorite saying was it's a calculated risk. We make all the calculations and the patient is taking all the risk. I remember those very, very well. Yeah, and they're good teaching points.

Great teaching points. Yeah, and I think I don't know that you'll find a 30 minute episode with more pearls in that, so I think this was awesome. So we are out of time, and so we're going to wrap up as we usually do with some of our takeaways, so Tess give us some Tess's teaching points.

Yeah, so, leaks, we've talked about result in decreased function of the pouch, so do everything you can to improve function and divert. And then, these are, can be challenging cases, so early on in your career, you know, ask for help and make sure you have a friend close by.

All

right. Marcello's must knows. All right. A lot of must knows. Make a pouch anal anastomosis, not a pouch rectal anastomosis, most importantly for function. Posterior leaks, drain and then manage and I think if you do it appropriately, you can salvage many of them, but it's complicated. So if you, if repair and divert and the best time is the first time to make a pouch.

Phil, anything else from you? No, I think these are very complicated procedures. Please don't do one or two a year of these. These should be sent to referral centers. If you see patients like this in the middle of the night with ulcerative colitis that's perforated, obviously don't do a PUSH. Do your total colectomy in the middle and send them off to a referral center if you don't feel comfortable doing it.

Because as you, as everyone said, these are, these can be very complicated procedures. Yeah, I mean, I'll just throw in there for my approach. I mean, I'm, you know, I'm one year ahead of tests, right? And so. We want to get experience. We want to be doing the pouches. And so, you know, but I would

say don't hesitate as in your early in your career.

Ask for help from a senior partner. And if you are going to reoperate, and this is pouch, no pouch leak, no leak. I think having a partner there to evaluate complications with you is actually quite helpful. And I am saying that from personal experience because I do have complications.

All right. Well, I don't. Great, Phil. All right. With that, we're going to wrap up. This is our ninth episode. So again, if you'd like to dive into the weeds consider joining us Sunday evenings for our colorectal surgery, virtual education series, and you can also check out our show notes for some details.

We're going to see you again in September. We're going to have a journal club review on diverticulitis. And please, if you enjoyed this session, do take a minute or two out of your hectic day and leave us a review. And it's behind the knife always says until the next time, everybody dominate today.

Thanks for having me guys. See you guys. Thank you. Thank

you.