Afferent limb obstruction complicating ileal pouch-anal anastomosis

Complications following ileal pouch-anal anastomosis in pediatric ulcerative colitis

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for reconstruction after total proctocolectomy in pediatric patients with ulcerative colitis. 30-60 % of patients undergoing IPAA will experience a postoperative complication. The primary objective of this article is to address the most common complications specific to IPAA in the pediatric population and provide an up-to-date review of their presentation, risk factors, workup, and management. We also share our preferred approaches to management and prevention of complications, where relevant. We intend to provide a concise review on the topic aimed at pediatric surgeons and healthcare providers involved in the care of this population with the goal of contributing to improved outcomes and patient quality of life.

The Surgical Management of Ileal Pouch Strictures

BACKGROUND

Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn's disease. Pouch stricture is a common complication after IPAA.

OBJECTIVE

This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm.

DATA SOURCES

A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed.

STUDY SELECTION

Randomized controlled trials, cohort studies, observational studies, and case reports were considered.

INTERVENTIONS

Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included.

MAIN OUTCOMES

Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques' including resection and reconnection, strictureplasty, or bypass.

RESULTS

Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection' or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience.

LIMITATIONS

Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.

Pelvic Pouch Failure: Treatment Options

Up to 30% of patients with ulcerative colitis (UC) will require surgical management of their disease during their lifetime. An ileal pouch-anal anastomosis (IPAA) is the gold standard of care, giving patients the ability to be free from UC's bowel disease and avoid a permanent ostomy. Despite surgical advancements, a minority of patients will still experience pouch failure which can be debilitating and often require further surgical interventions. Signs and symptoms of pouch failure should be addressed with the appropriate workup and treatment plans formulated according with the patient's wishes. This article will discuss the identification, workup, and treatment options for pouch failure after IPAA.

Reporting Templates for MRI and Water-Soluble Contrast Enema in Patients With Ileal Pouch-Anal Anastomosis: Experience From a Large Referral Center

Ileal pouch-anal anastomosis (IPAA) surgery is the reference standard surgical procedure for treatment of ulcerative colitis and most patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of workup for pouch dysfunction. The purpose of this article is to propose structured reporting templates for MRI and water-soluble contrast enema (WSCE), based on our referral pouch center's experience, in patients who have undergone IPAA surgery. We review salient surgical technique, pouch anatomy, and imaging protocols, with an emphasis on a systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting templates for MRI and WSCE.

Afferent limb syndrome after total proctocolectomy and ileal pouch-anal canal anastomosis

Background

Small bowel obstruction (SBO) is a common postoperative complication of ulcerative colitis (UC). There have been a few recent reports of afferent limb syndrome (ALS) as a rare occurrence in cases of SBO. We present a case of ALS with recurrent SBO that was successfully managed surgically.

Case presentation

When this male patient was 55 years old, he underwent laparoscopy-assisted anus-preserving total proctocolectomy, the creation of a J-type ileal pouch, ileal pouch-anal canal anastomosis (IPAA), and creation of ileostomy for intractable UC. Three months later, ileostomy closure was performed. The first onset of SBO was observed 5 months after ileostomy closure. SBO occurred repeatedly, and the patient was hospitalized nine times in approximately 2 years. Each SBO was improved by non-surgical treatment. A computed tomography (CT) scan revealed that the afferent limb was narrowing and twisted, and gastrografin enema confirmed narrowing at the proximal portion of the pouch inlet. Endoscopy showed a sharp angulation at the pouch inlet. We suspected ALS and decided on a surgical policy and performed pouchopexy and ileopexy to the retroperitoneum by suturing with excision of the remaining blind end of the ileum. Endoscopy 3 days after surgery showed neither twist nor stricture in the fixed ileal pouch or the afferent limb. At the time of writing, the patient remains free of SBO symptoms.

Conclusion

Clinicians should consider ALS when examining a patient with recurrent intermittent SBO after IPAA surgery. When ALS is suspected, the patient is indicated for surgery such as surgical pexy.

Lower peripouch fat area is related with increased frequency of pouch prolapse and floppy pouch complex in inflammatory bowel disease patients

BACKGROUND

Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC.

METHODS

Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images.

RESULTS

Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0-16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3-18.5) vs. 27.6 (11.0-46.2)cm², P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4-20.6) vs. 27.6 (11.0-46.9)cm², P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC.

CONCLUSIONS

A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.

Endoscopy in Postoperative Patients with Crohn's Disease or Ulcerative Colitis. Does It Translate to Better Outcomes?

This article discusses the use of endoscopy in patients with Crohn disease and ulcerative colitis in the postoperative setting. Endoscopy is the most sensitive and validated tool available in the diagnosis of recurrence of Crohn disease in the postoperative setting. It is also the most effective diagnostic modality available for evaluating complications of pouch anatomy in patients with ulcerative colitis. In addition to diagnosis, management postoperatively can be determined through endoscopy.

Surgical solutions for refractory J-pouch inlet obstruction

AIM

Many surgeons consider total proctectomy with ileal pouch-anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients.

METHODS

A retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal-pouch anastomosis for J-pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra-operative findings, type of surgical intervention and postoperative outcomes.

RESULTS

Surgical interventions were performed on eight patients with J-pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarily anastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow-up of 36.5 months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred.

DISCUSSION

J-pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J-pouches being performed, awareness of novel surgical techniques is important.

Characterization of risk factors for floppy pouch complex in ulcerative colitis

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis can be associated with a variety of complications, including floppy pouch complex (FPC). FPC is defined as the presence of pouch prolapse, afferent limb syndrome, enterocele, redundant loop, and folding pouch on pouchoscopy or contrasted pouchogram. The main symptoms of patients with FPC are dyschezia, incomplete evacuation, and bloating. The aims of the study were to evaluate the relative frequency of each disorder of FPC and to characterize its risk factors.

METHODS

This case-control study included all eligible patients with FPC from our prospectively maintained, IRB-approved Pouchitis Registry from 2011 to 2017. The control group included the patients without any of the above conditions. Univariate and multivariate analyses were performed.

RESULTS

A total of 437 eligible patients were analyzed including 97 (22.2%) with FPC and 340 (77.8%) without FPC, 188 (43.0%) being female, 360 (82.4%) being Caucasians, and 66 (15.1%) having a family history of inflammatory bowel disease (IBD). There were 427 patients (97.7%) having J pouches and 10 (2.2%) having S pouches and the median duration from pouch construction to data sensor was 6.0 years (interquartile range 0.962-1.020). In the whole cohort, 64 (66.0%) patients had pouch prolapse, 38 (39.2%) patients had afferent limb syndrome, 10/42 (23.8%) patients had redundant loop, and 3/42 (7.1%) had folding pouch. In multivariable analysis, lower body weight (odds ratio [OR] 0.944; interquartile range; 95% confidence interval [CI] 0.913-0.976, P = 0.001) and the presence of family history of IBD (OR 4.098; 95% CI 1.301-12.905, P = 0.013) were associated with a higher risk of FPC.

CONCLUSION

We found that pouch prolapse and afferent limb syndrome are the most common forms of FPC. A lower body weight as well as family history of IBD was found to be risk factors for FPC. The findings will have implications in both diagnosis and investigation of etiopathogenesis of this group of challenging disorders.

Diagnosis and management of floppy pouch complex

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with refractory ulcerative colitis, colitis-associated dysplasia or familial adenomatous polyposis. There are various pouch disorders and associated complications. Floppy pouch complex is defined as the presence of pouch prolapse, afferent limb syndrome, enterocele, redundant loop and folding pouch on pouchoscopy, gastrografin pouchogram or defecography. Common clinical presentation includes dyschezia, bloating, abdominal pain, straining or the sense of incomplete evacuation. Each disorder has its own unique endoscopic, radiographic and manometry findings. A range of therapeutic options are available for the management of the various causes of a pouch.

Complications in children with ulcerative colitis undergoing ileal pouch-anal anastomosis

Total colectomy with ileal pouch-anal anastomosis (IPAA) is considered the standard procedure for the surgical management of ulcerative colitis. Despite the widespread utility of the procedure, as many as 75% of patients who undergo IPAA, experience at least 1 complication. This review highlights difficult intraoperative scenarios and complications of pouch surgery in children, including intraoperative, postoperative, and functional complications. Intraoperative scenarios include insufficient mesenteric length and positive leak tests. Postoperative complications include surgical site infection, anastomotic leak, stricture, fistula, pouchitis, small bowel obstruction, and pouch failure. Less common complications include afferent limb syndrome, pouch prolapse, and superior mesenteric artery syndrome. Functional complications include incontinence, impaired quality of life, infertility, and sexual dysfunction. Despite complications, most patients are satisfied with their outcomes and report an improvement in their lifestyle.

Laparoscopic ileopexy for afferent limb syndrome after ileal pouch-anal anastomosis

Afferent limb syndrome (ALS) is caused by an obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis. Here, we describe the first case of ALS to be successfully treated by a laparoscopic approach. A 27-year-old man underwent ileal pouch-anal anastomosis for ulcerative colitis. He was subsequently diagnosed with ALS and underwent ileopexy with laparotomy at 33 years old. Then, 21 months after the first ileopexy, he underwent laparoscopic ileopexy for ALS recurrence. The operative findings revealed a shortened fixed portion of the afferent limb adhering to the right pelvic retroperitoneum, which was regarded as the cause of the acute angulation. The portion of the afferent limb fixed to the abdominal wall was extended under laparoscopic visualization by suturing above the level of the iliac crest. At the 12-month follow-up, the patient remained free of symptoms of obstruction. Laparoscopic ileopexy should be the procedure of choice for patients with ALS.

Endoscopy-assisted transanal repair of afferent limb obstruction and long efferent limb with ileopexy after ileal J-pouch-anal anastomosis

Afferent limb obstruction can be a persistent complication after restorative proctocolectomy with ileal pouch-anal anastomosis. We present a case of afferent limb obstruction complicated by a long efferent limb of the ileal pouch that we successfully treated with side-to-side anastomosis of the afferent and efferent limbs. The procedure involved using a transanal endoscopic stapling device assisted by transanal endoscopy with a thin intestinal video endoscope. This allowed reliable, safe visualization of the lesion from the tight pouch-anal anastomosis and facilitated repair with an endoscopic stapling device. Because the technique was performed without enterotomy, it reduced the risks of contamination and leakage from transabdominal small bowel anastomosis. Laparotomy view also prevented of injury to the pouch itself and entrapment of the mesentery of the afferent and efferent limbs of the pouch between the stapler anvils.

Clinical features and management of afferent limb syndrome after ileal pouch-anal anastomosis for ulcerative colitis

PURPOSE

Afferent limb syndrome (ALS) is a type of small bowel obstruction (SBO) caused by obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis (IPAA). The aim of this study was to reveal the clinical features and management of ALS.

METHODS

Of 320 patients undergoing IPAA for ulcerative colitis, we analyzed data from patients presenting with SBO.

RESULTS

Six of 19 patients with SBO were diagnosed with ALS. All patients with ALS presented with recurrent intermittent obstructive symptoms before admission, whereas 15 % of patients without ALS presented with these symptoms (P < 0.0005). Among the six patients with ALS, four patients required surgery, although they underwent transanal decompression for each episode of obstruction. The proportion of surgery was higher in the ALS group (P < 0.01). Acute angulation of the afferent limb was recognized in four cases and followed by fixation of the afferent limb. No further surgery was required in any patient following the last fixation.

CONCLUSIONS

SBO after IPAA may be caused by acute angulation of the afferent limb of the ileal J-pouch. Most patients with ALS may eventually require fixation of the afferent limb due to acute angulation of the afferent limb.

A unique variant of afferent limb syndrome after ileal pouch-anal anastomosis: a case series and review of the literature

BACKGROUND

Afferent limb syndrome is a relatively rare cause of small bowel obstruction after restorative total proctocolectomy with ileal pouch-anal anastomosis for patients with ulcerative colitis or familial adenomatous polyposis.

DISCUSSION

This report describes three patients who developed recurrent small bowel obstruction after ileal pouch-anal anastomosis. The bowel obstruction was caused by torsion of the ileum at the inlet of the ileal J-pouch, which was thought to be a variant of afferent limb syndrome. This variant of afferent limb syndrome is characterized by a flexible afferent limb of the pelvic pouch due to the lack adhesion of the ileum in the abdominal cavity. Preoperative diagnosis required multiple series of contrast small bowel enemas. Strictureplasty and ileopexy effectively resolved the recurrent bowel obstruction caused by this variant of afferent limb syndrome.

Diagnosis and management of afferent limb syndrome in patients with ileal pouch-anal anastomosis

BACKGROUND

Distal small bowel obstruction following ileal pouch-anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent limb syndrome (ALS). The aim of this study is to report our experience in diagnosis and management of ALS in patients with IPAA.

METHODS

All patients with ALS after IPAA were identified from prospectively maintained databases. Demographic, clinical, endoscopic, and radiographic features together with its management and outcome were studied.

RESULTS

Eighteen patients (12 female) were included. The mean age was 35.6 ± 14.3 years. Most patients presented with intermittent obstructive symptoms. Fifteen patients were diagnosed by pouch endoscopy with features of angulation of the pouch inlet and difficulty in intubating the afferent limb; 12 patients had kinking or narrowing of the pouch inlet identified with abdominal imaging. The median follow-up was 1.3 (range, 0.14-16.1) years. Nine patients underwent empiric balloon dilatation of the afferent limb/pouch inlet. Of nine, four needed repeat dilatations. One patient with repeat dilatation ultimately had pouch excision; another has been scheduled for surgery after failed repeat dilatations. Eight patients underwent surgery, resection of angulated bowel (n = 3), pouchopexy (n = 2), pouch mobilization with small bowel fixation (n = 1), and pouch excision (n = 2). One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy.

CONCLUSIONS

ALS was characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive.

Robotic-assisted laparoscopic "salvage" rectopexy for recurrent ileoanal J-pouch prolapse

Total restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) has become the standard of care for the surgical treatment of ulcerative colitis. Despite its correlation with an excellent quality of life and favorable long-term outcomes, RP/IPAA has been associated with several complications. Prolapse of the ileoanal pouch is a rare and debilitating complication that should be considered in the differential diagnosis of pouch failure. Limited data exist regarding the prevalence and treatment of pouch prolapse. We present the case of a recurrent J-pouch prolapse treated with a novel minimally invasive “salvage” approach involving a robotic-assisted laparoscopic rectopexy with mesh.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Long-axis rotational volvulus in a W ileoanal pouch: an unusual but potentially preventable problem. Report of a case

PURPOSE

This study was designed to report long-axis rotational volvulus, an unusual long-term complication of restorative proctocolectomy.

METHODS

A MEDLINE search using the keywords, pouch volvulus, pouch complications, ileoanal pouch volvulus, restorative proctocolectomy volvulus, restorative proctocolectomy complications, W-pouch, and early and late complications, was performed and yielded no previous reports.

RESULTS

We describe pouch gangrene secondary to volvulus in a W-pouch four years after restorative proctocolectomy for ulcerative colitis. Early recognition by clinical features, pouchoscopy, and soluble contrast studies are crucial if pouch salvage by pouchpexy is to be successful.

CONCLUSIONS

Acute necrosis of the ileoanal pouch caused by long-axis rotational volvulus is an important, but uncommon, cause of life-threatening acute abdomen after restorative proctocolectomy. Prophylactic pouchpexy at the time of pouch construction or salvage pouchpexy after early diagnosis of the at-risk pouch are important considerations to avoid loss of the pouch.

Ileal pouch-anal anastomosis: the Australasian experience

OBJECTIVE

The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia.

METHOD

The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results.

RESULTS

Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005).

CONCLUSION

A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.

Proposed association between ileoanal j-pouch perforation and rapid consumption of a high-calorie, high-fiber meal: report of two cases

PURPOSE

We report two cases of ileoanal J-pouch rupture after rapid consumption of high-fiber, high-calorie meals.

METHOD

We review the food intake, presentation, laboratory and radiographic data, and course of two patients who developed ileoanal J-pouch perforation after rapid consumption of meals rich in fiber or calories or both. The potential association between food consumption and rupture is explored.

RESULTS

The authors propose that the rapid ingestion of a high-fiber, high-calorie meal may lead to an acute intraluminal pressure elevation or a closed-loop obstruction. These effects may be the basis for an association between food ingestion patterns and perforation at the distal transection site in an ileoanal J-pouch.

CONCLUSION

The authors hypothesize that the rapid ingestion of a high-fiber, high-calorie meal may be associated with J-pouch perforation. Further investigative efforts are needed to confirm this association and to evaluate whether a causal relationship is present. If causality is established, physicians may develop a higher index of suspicion for pouch rupture in patients who present with abdominal disturbances after the rapid ingestion of a high-fiber, high-calorie meal.

The use of an omental pedicle graft to prevent small-bowel obstruction after restorative proctocolectomy

Small-bowel obstruction remains one of the most frequent complications after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Of particular concern is small-bowel adhesion to the pelvic dead space that causes afferent limb obstruction, sometimes necessitating laparotomy. In this report, we describe a technique using an omental pedicle graft (OPG) to fill the pelvic dead space to prevent small-bowel obstruction and the resulting afferent limb obstruction after IPAA. The OPG is created from the left half of the omentum, while maintaining the blood supply from the left gastroepiploic vessels. The omentum is placed into the pelvis along the left paracolic gutter from where the colon has been resected. It is then passed over the pelvic brim and placed behind and along the bilateral sides of the ileal pouch, filling the space. This modified technique was employed in the treatment of four patients with chronic ulcerative colitis, none of whom developed any signs of small-bowel obstruction.