A technique of extending small-bowel mesentery for ileal pouch-anal anastomosis: report of a case

Intraoperative Techniques for Gaining Ileoanal Pouch Reach

Ileal pouch-anal anastomosis allows for reestablishing gastrointestinal continuity in patients after proctocolectomy. The technical elements of pouch creation and gaining reach into the pelvis are demanding and require a variety of surgical maneuvers to achieve a tension-free anastomosis. We present a brief review of the literature discussing various approaches aimed at improving ileal pouch reach into the low pelvis. Although these techniques are used with different frequencies, they serve as important adjuncts to the gastrointestinal surgeons' armamentarium.

Fluorescence angiography after vascular ligation to make the ileo-anal pouch reach

The two most essential technical aspects of any gastrointestinal anastomosis are adequate perfusion and sufficient reach. For ileal pouch-anal anastomosis (IPAA), a trade-off exists between these two factors, as lengthening manoeuvers to avoid tension may require vascular ligation. In this technical note, we describe two cases in which we used indocyanine green (ICG) fluorescence angiography (FA) to assess perfusion of the pouch after vascular ligation to acquire sufficient reach. In both cases, FA allowed us to distinguish better between an arterial inflow problem and venous congestion than white light assessment. Both pouches remained viable and no anastomotic leakage occurred. Our results indicate that ICG FA is of great value after vascular ligation to obtain reach during IPAA.

Mesenteric lengthening during pouch surgery: technique and outcomes in a tertiary centre

Anastomotic complications after ileal pouch-anal anastomosis (IPAA) are often associated with excessive tension and poor blood supply. Carrying out a tension-free IPAA might prove difficult in a proportion of cases, especially if mucosectomy and hand-sewn anastomosis are necessary. The aim of the study was to analyse the outcomes of mesenteric lengthening in patients undergoing IPAA in a tertiary centre. Consecutive patients who required mesenteric lengthening during IPAA surgery between 2000 and 2019 were retrospectively included. Short and long-term outcomes were analyzed. Chi square, Fisher's exact test and Wilcoxon rank sum test were used as appropriate. Kaplan-Meier analysis was carried out to report the long-term rate of pouch failure. Some 131 patients (78 UC, three indeterminate colitis, 50 FAP) were included. The need for mesenteric lengthening, due to short mesentery or intraoperative complications, was unpredictable in 15 patients. The rate of surgical complications was 20.6%; eight patients required a reoperation, two of them experienced postoperative pouch ischemia. After a median follow-up time of 9.4 years, the risk of pouch failure in FAP and UC patients was 7.2% and 13% at 10 years. Despite the indication to mucosectomy has been reducing over the years, mesenteric lengthening is still required in a significant proportion of UC and FAP patients, also because of unforeseeable intraoperative conditions necessities.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Comparison of Mesenteric Lengthening Techniques in IPAA: An Anatomic and Angiographic Study on Fresh Cadavers

BACKGROUND

The IPAA technique restores anal functionality in patients who have had the large intestine and rectum removed; however, 1 of the most important reasons for pouch failure is tension on the anastomosis.

OBJECTIVE

The aim of this study was to compare technical procedures for mesenteric lengthening used for IPAA to reduce this tension.

DESIGN

After randomization, 4 different techniques for mesenteric lengthening were performed and compared on fresh cadavers.

SETTING

This was a cross-sectional cadaveric study.

MAIN OUTCOME MEASURES

In the first group (n = 5), stepladder incisions were made on the visceral peritoneum of the mesentery of the small intestine. In the second and third groups, the superior mesenteric pedicle was divided, whereas the ileocolic pedicle (n = 7) or marginal vessels (n = 6) were preserved during proctocolectomy. In the fourth group (n = 7), the superior mesenteric pedicle was cut without preserving any colic vessels. Mesenteric lengthening was analyzed. Angiography was performed to visualize the blood supply of the terminal ileum and pouch after mesenteric lengthening.

RESULTS

Average mesenteric lengthening was 5.72 cm (± 1.68 cm) in group 1, 3.63 cm (± 1.75 cm) in group 2, 7.03 cm (± 3.47 cm) in group 3, and 7.29 cm (± 1.73 cm) in group 4 (p = 0.011 for group 2 when compared with the others).

LIMITATIONS

The study was limited by nature of being a cadaver study.

CONCLUSIONS

Stepladder incisions through superior mesenteric pedicle trace are usually sufficient for mesenteric lengthening. In addition, division of the superior mesenteric pedicle with either a preserving marginal artery or without preserving ileocolic and marginal arteries leads to additional mesenteric lengthening.

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

BACKGROUND AND AIMS

Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres.

METHODS

The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate.

RESULTS

In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery.

CONCLUSIONS

Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

The Failed J Pouch

The development and refinement of proctectomy with ileal pouch-anal anastomosis (IPAA) since its introduction in the 1970s has made it the optimal procedure of choice in patients with chronic ulcerative colitis and patients with familial adenomatous polyposis. However, it is a procedure that can be associated with significant morbidity. Pouch failure due to infection, mechanical, or functional disability represents a challenge to both surgeon and patient. Practicing surgeons who deal with revisional pouch surgery face a variety of intraoperative, postoperative, and reoperative challenges. Success requires a strategy that includes critical planning, preparation, specialized surgical techniques, and experience to achieve long-term success, minimize the adverse consequences of IPAA-related complications, and ensure solutions and hope to patients.

Alternative ileal flap for bladder augmentation if mesentery is short

PURPOSE

To date the clam ileocystoplasty is the preferred method of bladder augmentation in children when the urodynamic problem is non-compliance and/or detrusor overactivity. The key to this technique is the incision of the bladder wall deep into the pelvis down to the trigone in order to avoid a diverticulum like neobladder and to provide adequate margin for augmentation. The detubularised ileum flap therefore has to reach to the bottom of the divided bladder on a reliable vascular pedicle without significant tension. A short ileal mesentery caused by previous surgery, peritonitis, peritoneal dialysis or ventriculo-peritoneal shunt may complicate surgery and compromise outcome. We hypothesized we can rely on the communication of the intramural vessels within the intestine and can detubularise the ileum adjacent to the mesentery rather than along the antimesenteric line and this could be combined with ligation of some vasa recta (VR) in order to create alternative ileum flaps, which reach further into the pelvis. Our aim was to assess the viability of the alternative flaps detubularised along the paramesenteric line and measure how many VR could be sacrificed beyond the tertiary arcades.

MATERIALS AND METHODS

After ethical approval adjacent ileal segments were detubulirased along the antimesenteric line (Group 1) and along the paramesenteric line (Group 2) in 5 minipigs in general anaesthesia. Ligation of 0,1,2,3 and 4 VR has been performed starting from the free end of the segments. The length of the ileal flaps was recorded. The microcirculation of flap edges was detected by in vivo microscopy using orthogonal polarising spectral imaging (Cytoscan A/R Cytometrics, PA, USA). Clam ileocystoplasty was performed with the ileum detubularised along the paramesenteric line without ligation of VR. Specimens of the augmented bladder were obtained after 4 weeks and stained with Hematoxilin + Eosin.

RESULTS

No alteration in capillary red blood cell velocity (RBCV) and perfusion rate (PR) was observed after paramesenteric detubularisation. The flaps in Group 2 reached 20.25 ± 0.5 mm longer vs.

CONTROL

This is 98% of the mean bowel width (20.5 ± 0.57 mm) measured in the animals. Ligation of each VR further increased the length of both flaps (mean: 10.59 ± 3.18 mm) however ligation of more than 2 VR gradually decreased the microcirculation in both groups. All animals augmented with alternative flap survived, there was no urine leak or suture break down. Histology confirmed viable bowel flaps.

CONCLUSION

Paramesenteric detubularisation of the ileum is fully tolerated and results in longer reaching ileal flap vs.

CONTROL

Only limited ligation of VR is tolerated.

DISCUSSION

This study showed the first time that clam ileocystoplasty is feasible with ileal flap detubularised along the paramesenteric line. The use of the animal model and the relative short postoperative observation are the main limitations of this study.

The impact of mesenteric tension on pouch outcome and quality of life in patients undergoing restorative proctocolectomy

AIM

The study aimed to establish a method for the measurement of mesenteric tension after ileal pouch-anal anastomosis (IPAA) and to evaluate the impact of tension on clinical outcome and quality of life.

METHODS

All consecutive patients undergoing an open IPAA from July 2008 to October 2009 were prospectively enrolled. After the creation of the anastomosis, mesenteric tension was estimated by the surgeon in the operating room on a 10-point scale (1, least tension; 10, most tension). The association was analysed between mesenteric tension defined as low (1-2), medium (3-7) and high (8-10) and postoperative complications and quality of life (Cleveland Clinic Global Scale).

RESULTS

A mesenteric tension score was obtained in 134 patients (71 men, 53.0%). Median age was 38.5 (29.3-47.0) years. Fifty-six patients (41.8%) had a low, 59 (44.0%) a medium and 19 (14.2%) a high degree of mesenteric tension. Patients with a high mesenteric tension had a shorter anal transitional zone, a longer distance from the upper border of the symphysis pubis to the apex of the small bowel loop designated for the ileoanal anastomosis, a thinner abdominal wall at the stoma site and a longer distance from the pouch to the ileostomy. The proportion of patients with high mesenteric tension was less after stapled anastomosis. On long-term follow-up, patients with high mesenteric tension were more likely to suffer from anastomotic stricture and pouch failure. Pouch function was not influenced by mesenteric tension.

CONCLUSION

High mesenteric tension after IPAA is adversely associated with postoperative complications and pouch survival.

Intraoperative, postoperative and reoperative problems with ileoanal pouches

BACKGROUND

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches.

METHODS

The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed.

RESULTS

Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation.

CONCLUSION

A structured management plan will minimize the adverse consequences of the problems associated with pouches.