Volvulus of an ileal J-pouch

Successful treatment of recurrent volvulus in the afferent limb of the pouch following proctocolectomy for ulcerative colitis: a case report

Background

Pouch volvulus after proctocolectomy for ulcerative colitis is a very rare postoperative complication. The common site of pouch volvulus has been reported to be the ileal pouch–anal anastomosis and the middle part of the pouch, but no reports on pouch volvulus in the afferent limb of the pouch have been observed. Here, we report the case of a patient with afferent limb volvulus who underwent afferent limbpexy, but required reoperation 7 months later.

Case presentation

A 38-year-old man with refractory ulcerative colitis had undergone open proctocolectomy 10 years ago at another hospital. He had been aware of lower abdominal pain and bowel movement difficulty for 2 years. After repeated bowel obstruction, he was referred to our hospital for surgery. Based on the radiographic findings, we diagnosed a pouch volvulus and performed an operation. Laparoscopically, counterclockwise rotation of the afferent limb of the pouch was recognized. Moreover, the ileal mesentery was adhered and fixed to the presacral space 20 cm from the oral side of the pouch. The antimesenteric side of the afferent limb was fixed using interrupted stiches on the left peritoneal wall of the pelvis. He was discharged uneventfully 18 days after surgery, and defecation improved immediately. However, he was readmitted 7 months after surgery with the same abdominal pain and defecation difficulty. A similar finding was found and diagnosed as recurrent volvulus. Therefore, we performed a laparoscopic surgery. The same volvulus as in the previous surgery was confirmed. The site fixed during the previous surgery showed scars, but the afferent limb was free. The dilated ileum that contained the volvulus was excised only on the oral side of the pouch and an intraluminal anastomosis was performed on the anterior wall of the pouch. He had a good postoperative course and was discharged.

Conclusion

Proper diagnosis of volvulus based on the characteristic imaging findings is important. In principle, bilateral row fixation of the rotated ileum is the basic procedure for volvulus. However, fixation with this technique is sometimes difficult. Therefore, this procedure is one of the useful options for the fixation of difficult or recurrent cases.

Volvulus of the ileal pouch-anal anastomosis: a meta-narrative systematic review of frequency, diagnosis, and treatment outcomes

Background

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA.

Methods

A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018.

Results

The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%).

Conclusion

Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.

Surgical Management of an Ileal J-Pouch-Anal Anastomosis Volvulus

BACKGROUND

A restorative proctocolectomy with an IPAA is the surgical treatment of choice for medically refractory ulcerative colitis. Until now, a pouch volvulus has been considered a rare complication, only described in case reports and small case series. The aim of this technical note was to develop a standardized approach to allow a minimally invasive treatment.

TECHNIQUE

First, an endoscopic decompression of the pouch is attempted. Subsequently, an exploratory laparoscopy is performed. If the endoscopic decompression was successful, a complete laparoscopic reduction is feasible. Once the integrity of the pouch is confirmed, a bilateral pouchopexy is performed, using multifilament interrupted sutures. Finally, the pouch patency is tested by pouchoscopy.

RESULTS

Between December 2010 and December 2018, 151 minimally invasive restorative proctocolectomies with an IPAA were performed. Eighty-nine IPAAs were constructed with the mesentery positioned anteriorly, 35 posteriorly, and 27 on the right side. Three patients were diagnosed with an IPAA volvulus. All 3 of the patients were in the anterior group (3.4%) compared with 0 patients in the nonanterior group. One patient (33%) was treated laparoscopically, after a successful endoscopic reduction. In the other 2 cases, conversion to a laparotomy was needed because an endoscopic decompression could not be achieved.

CONCLUSION

An endoscopic decompression was required to allow a laparoscopic treatment, and a bilateral pouchopexy was needed to avoid recurrence. This standardized approach might be a good treatment option, and we are awaiting additional follow-up to determine its long-term durability. In addition to the already described risk factors (minimally invasive technique, female sex, and low BMI), an anterior positioning of the pouch mesentery might be a potential risk factor as well for pouch volvulus. However, these observations should be carefully interpreted, considering the small number of cases.

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses

INTRODUCTION

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch.

PRESENTATION OF CASE

A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done.

DISCUSSION

The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.

CONCLUSION

The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.

Recurrent volvulus of an ileal pouch requiring repeat pouchopexy: a lesson learnt

Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed.

How I do it: the stapled ileal J pouch at restorative proctocolectomy

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) following proctocolectomy is the preferred option for patients with medically refractory ulcerative colitis, indeterminate colitis, and familial adenomatous polyposis. However, it remains a procedure associated with morbidity and mortality. Pelvic sepsis, pouch fistulae, and anastomotic dehiscence predispose to pouch failure. We report our experience with an adaptation for the formation of the stapled ileal J pouch using the GIA™ 100 stapling device (Covidien, Mansfield, Massachusetts, USA). When creating the J pouch, we remove the bevelled plastic protector from the thin fork of the stapling device, allowing the staple line to be completed to the tip of the stapled efferent limb of the pouch, thereby minimizing potential blind ending in the efferent limb and injury to the transverse staple line.

METHODS

Patients undergoing elective IPAA at our institution over a 5-year period using this adapted stapling technique for creation of the ileal J pouch were reviewed. Data were collected from a prospectively maintained inflammatory bowel disease database, theater records, and patient chart review.

RESULTS

Forty-one patients underwent IPAA using this technique at our institution during the study period. Postoperative morbidity was encountered in 11 of 41 patients including pelvic sepsis, pouch fistulae, anastomotic stricture, or leak. There was no morbidity observed related to a blind efferent limb or transverse staple line disruption. No mortality was observed in this series.

CONCLUSION

Maximizing the length of the efferent fork of the GIA stapling device can reduce the length of redundant efferent J limb of the ileal J pouch. This may reduce the incidence of torsion, volvulus, distension, fistulae/sinuses, and pelvic sepsis/anastomotic leak following IPAA.