Endoscopic Reduction of Ileal J Pouch Volvulus With Laparoscopic Pexy

Abstract

FigureIntroduction: Surgical management of chronic ulcerative colitis includes restorative proctocolectomy with ileal pouch anal anastomosis. The reconstruction is a technically demanding operation and most complications that occur include small bowel obstructions, pouch leak, anatomic strictures, and pelvic abscesses. Restorative proctocolectomy poses unique anatomic consideration especially in the case of post-operative bowel obstruction. Methods: A 70 year old male with past medical history of ulcerative colitis underwent proctocolectomy with ileal J pouch anal anastomosis in 2010. His post-operative course was complicated by recurrent partial small bowel obstructions. Non-operative management as well as operative lysis of adhesions proved unsuccessful in definitely treating the obstructive manifestation. Imaging studies included a CT scan and a contrasted enema, which were suggestive of a potential volvulus of the small bowel pouch within the pelvis. In order to determine this, the patient was taken to the operating room for laparoscopy with intraoperative endoscopy. Laparoscopy revealed that the J-limb pouch was volvulized about the mesentery. Intra-operative endoscopy displayed twisting of the afferent limb of the pouch. Endoscopic insufflation coupled with laparoscopic manipulation of the J-pouch allowed for the reduction of the volvulus. Laparoscopic pexy of the small bowel pouch was then performed with endoscopic confirmation of a patent pouch. Results: A rare complication of ileal pouch anal anastomosis is volvulus of the pouch and should be considered in patients that have recurrent small bowel obstructions. Diagnostic imaging such as barium enema and CT with contrast can be obtained for early operative intervention and prevention of necrosis. Conclusion: Endoscopic reduction along with laparoscopic pexy is the best management in early diagnosis of ileal pouch anal anastomosis volvulus. Initial consideration, along with diagnostic imaging can salvage the J pouch.