Surgical Management of an Ileal J-Pouch-Anal Anastomosis Volvulus

A restorative proctocolectomy with an IPAA is the surgical treatment of choice for medically refractory ulcerative colitis. Until now, a pouch volvulus has been considered a rare complication, only described in case reports and small case series. The aim of this technical note was to develop a standardized approach to allow a minimally invasive treatment.

First, an endoscopic decompression of the pouch is attempted. Subsequently, an exploratory laparoscopy is performed. If the endoscopic decompression was successful, a complete laparoscopic reduction is feasible. Once the integrity of the pouch is confirmed, a bilateral pouchopexy is performed, using multifilament interrupted sutures. Finally, the pouch patency is tested by pouchoscopy.

Between December 2010 and December 2018, 151 minimally invasive restorative proctocolectomies with an IPAA were performed. Eighty-nine IPAAs were constructed with the mesentery positioned anteriorly, 35 posteriorly, and 27 on the right side. Three patients were diagnosed with an IPAA volvulus. All 3 of the patients were in the anterior group (3.4%) compared with 0 patients in the nonanterior group. One patient (33%) was treated laparoscopically, after a successful endoscopic reduction. In the other 2 cases, conversion to a laparotomy was needed because an endoscopic decompression could not be achieved.

An endoscopic decompression was required to allow a laparoscopic treatment, and a bilateral pouchopexy was needed to avoid recurrence. This standardized approach might be a good treatment option, and we are awaiting additional follow-up to determine its long-term durability. In addition to the already described risk factors (minimally invasive technique, female sex, and low BMI), an anterior positioning of the pouch mesentery might be a potential risk factor as well for pouch volvulus. However, these observations should be carefully interpreted, considering the small number of cases.