Surgical solutions for refractory J‐pouch inlet obstruction

Abstract

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.

The Surgical Management of Ileal Pouch Strictures

“…All patients retained their pouches after a median follow-up of 36.5 months, concluding that, in patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with a pouch salvage procedure. 29…”

“…Fumery et al 30 reported their experience with 1 patient with an inlet stricture that failed endoscopic balloon dilation, an excision of the stricture at the prepouch ileum, and reanastomosis to the pouch inlet successfully performed as evaluated after 3 years of follow-up. As mentioned above, all patients in the series from Sellers et al 29 who had inlet strictures that were resected and primarily anastomosed retained their pouches after a median follow-up of 36.5 months.…”

“…A literature review of afferent limb/inlet stricture surgical management options is shown in Table 2. 6,[27][28][29][30] Options include strictureplasty, bypass (proximal afferent limb stricture bypass or afferent to efferent bypass), or resection and reanastomosis.…”

“…The authors found that bypass of the obstructed segment from the distal ileum to the pouch was safe and effective treatment, and they recommended concurrent pouchopexy due to the risk of recurrence. 6 Sellers et al 29 reported on 6 patients who had inlet strictures or acute angulations, which were either bypassed or resected and primarily anastomosed. All Copyright © The American Society of Colon & Rectal Surgeons, Inc.…”

Complications of the Pelvic Pouch

“…The causes of ALS were initially thought to include only a displacement of the pre-pouch ileum posterior to the pouch causing obstructive symptoms; but a more contemporary understanding of ALS has shown a growing number of potential abnormalities of this portion of the bowel, many of which can be difficult to identify on initial evaluation. For example, a fibrotic stricture causing ALS may be easily seen during pouchoscopy, but angulation of the afferent limb due to adhesions or an inappropriate rotation of the small bowel mesentery is sometimes only identified at laparotomy with findings of partial or complete obstruction [18].…”