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Pouch volvulus-why adhesions are not always the enemy.
Beatrice Dionigi1, Christopher Prien1, Olga Lavryk1
1Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
Summary
Minimally invasive surgery for ileal pouch anal anastomosis can lead to pouch volvulus. Urgent surgical intervention is crucial for pouch salvage, but pouch survival remains a concern.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Pelvic Surgery
Background:
- Minimally invasive proctocolectomy with ileal pouch anal anastomosis (IPAA) is standard care, reducing adhesion complications.
- However, reduced pelvic adherence can increase pouch mobility and risk of volvulus, potentially compromising pouch viability.
Purpose of the Study:
- To describe the institutional experience with pouch volvulus following IPAA.
- To analyze the characteristics, management, and outcomes of patients diagnosed with pouch volvulus.
Main Methods:
- A retrospective review of patients undergoing IPAA from 1983 to 2020 was conducted.
- Pouch volvulus was defined as reducible J-pouch rotation on its mesenteric axis with a correctly oriented ileo-anal anastomosis.
- Six patients met the criteria, with data collected from a pelvic pouch registry and electronic medical records.
Main Results:
- Six cases of pouch volvulus were identified among 5760 IPAA procedures.
- The mean time from pouch construction to volvulus was 2.36 years, with all cases occurring after laparoscopic techniques.
- Surgical intervention included reduction and pexy or pouch excision with reconstruction/ileostomy; 50% pouch survival was observed at 9-month follow-up.
Conclusions:
- Minimally invasive techniques may increase the risk of pouch volvulus due to decreased adhesion formation.
- A high index of suspicion is necessary for patients presenting with obstructive symptoms.
- CT imaging can aid diagnosis, and prompt surgery is vital for potential pouch salvage.
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