Background: Many technical difficulties of the ileoanal reservoir operation have been overcome, allowing acceptable morbidity in the hands of both the frequent and less frequent operator. However, a minority of patients have persistently unsatisfactory pouch function, which can be a difficult problem to manage.
Methods: A Medline search was carried out to identify relevant papers published from November 1996 to January 1978. For clinical information more emphasis was given to recent publications with larger numbers. Where appropriate, information from other sources and some local data were included.
Results: Most patients empty the pouch four to eight times a day with perfect continence and no urgency, and are considered to have acceptable function with which they are satisfied. Patients who have poor function beyond an easily treated episode of pouchitis require the expertise of a multidisciplinary team offering some understanding of the anatomy, physiology and pathology of the gastrointestinal tract in general and of the ileal reservoir in particular. A thorough and persistent approach to difficult cases is often rewarded with a good outcome, with the exception of problems arising from postoperative sepsis. The temptation to use pouchitis as a waste-basket diagnosis for poorly understood dysfunction should be avoided. Problems causing poor function may originate in the pouch (including pelvic sepsis), the pouch outlet, or the small bowel above the pouch, and these areas need to be considered in each case.
Conclusion: To optimize the benefits of restorative pouch surgery, both patients and physicians need to understand aspects of fine tuning of pouch function, including diet, medication and lifestyle. In managing ileoanal reservoir dysfunction the temptation to procrastinate should be resisted; an approach that is systematic and sympathetic should be adopted.