Unique surgical approach to a twisted ileal-anal pouch

Abstract

Total proctocolectomy with ileal pouch-anal anastomosis can restore gastrointestinal continuity in patients requiring colectomy for ulcerative colitis, however, it can be associated with high morbidity. Reoperation for pouch-related complications is technically challenging and often leads to deterioration of pouch function or need for permanent stoma. We report a case of acute on chronic small bowel obstruction secondary to a 360-degree twist in the small bowel introduced during creation of the ileal-anal pouch. Our novel approach at repair has not been reported in past literature which included resection and re-anastomosis of the small bowel proximal to the pouch allowing for pouch salvage with return to function.

Endoscopic management of obstructing pouch twist

“…Twisted pouch and volvulus are rare complications of IPAA with few cases being reported in the literature [ 4 , 5 , 7–9 ]. Pouch twist is believed to result from poor orientation of the mesentery or adhesions.…”

“…Diagnosis of this condition typically requires a high degree of suspicion, CT, and gastrografin enema. The patients reported in the literature have been managed surgically with adhesiolysis and derotation and fixing the pouch with or without revision of the ileorectal anastomosis [ 5 , 6 , 8 , 9 ]. Twists can be managed with an endoscopic approach, which avoids the need for a large open surgical procedure that can be technically challenging due to severe adhesions and might lead to increased complications and prolonged hospital stay.…”