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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 22-23

The hanging pouch


1 Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
2 Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Vitaliy Y Poylin
330 Brookline Ave., 6th Floor, Boston
MA 02215, USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_9_18

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  Abstract 


Ileoanal pouch reconstruction can be complicated intraoperatively by the inability for the pouch to reach the anus in a tension-free manner. Here, a case is presented where standard “mesentery lengthening” procedures did not allow the pouch to reach the anus and thus the pouch was left hanging in situ resulting in pouch lengthening over several months and a successful anastomosis at a later date.

Keywords: Difficult to reach, hanging pouch, ileoanal pouch anastomosis


How to cite this article:
Wong DJ, Tran MQ, Poylin VY. The hanging pouch. World J Colorectal Surg 2019;8:22-3

How to cite this URL:
Wong DJ, Tran MQ, Poylin VY. The hanging pouch. World J Colorectal Surg [serial online] 2019 [cited 2019 Oct 14];8:22-3. Available from: http://www.wjcs.us.com/text.asp?2019/8/1/22/254040


  Introduction Top


Since its first description in 1978, restorative proctocolectomy with ileoanal pouch anastomosis (RP-IPAA) has become the preferred approach in appropriate patients with refractory ulcerative colitis and familial adenomatous polyposis to avoid a stoma and preserve the anal route of defecation.[1],[2] It is critical that the ileal pouch reaches the anus so that a tension-free anastomosis can be made.[3] Due to patient anatomy or previous surgery, a rare (1.8%–7.8%) but consistently reported technical difficulty is the inability for the ileal pouch to reach the anus.[4],[5] In this circumstance, a number of intraoperative maneuvers geared toward “lengthening” the mesentery can be made including further mobilization of the mesentery, division of the peritoneum over the mesentery, division of mesenteric arteries where adequate collateralization is present, and even interposition vein grafting.[6],[7],[8],[9],[10] Additional options include conversion of the pouch to a Kock pouch or upstream ileostomy creation and leaving the pouch unattached with the option of reoperation at a later date.[3] Here, we report a successful case of leaving an unattached pouch in situ with subsequent successful restoration.


  Case Report Top


A 24-year-old female was admitted to the hospital with steroid-refractory ulcerative colitis. Despite salvage infliximab therapy, she continued to be symptomatic and underwent laparoscopic-assisted total abdominal colectomy with end ileostomy during her index admission. Of note, her body mass index at the time of admission was 17. Her postoperative course was uneventful.

Four months later, she presented for completion proctectomy and ileoanal pouch reconstruction. Intraoperatively, there was tension noted when the terminal ileum was stretched into the pelvis. Multiple maneuvers were attempted to make the ileum reach the anus including further mobilization of the proximal mesentery and mesenteric fenestration; however, due to concern for inadequate blood supply, no vessels were taken. A stapled J-pouch was created, wrapped in Seprafilm, and tacked to the presacral fascia and a diverting loop ileostomy was created [Figure 1]. Her postoperative course was significant for prolonged ileus requiring nasogastric tube decompression, and she was discharged on postoperative day 10.
Figure 1: The hanging pouch. Despite mobilization of the proximal mesentery and fenestration, inability to have J-pouch reach anus was treated by tacking pouch to the presacral fascia with plans for reexploration later

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Ten months after the pouch creation, the patient returned to the operating room for reexploration. Following a brief lysis of adhesions, her pouch was found in situ in the pelvis and to have been distended with mucus such that it could now reach the pelvis. Of interest, it appeared that the pouch growth and distension rather than a lengthening of the mesentery was responsible for the added length. A hand-sewn anastomosis was performed to the anus, and the diverting ileostomy left in place. Her postoperative course was notable for readmission for oral intolerance and leukocytosis, but no leak or abscess was identified. The patient underwent unremarkable ileostomy takedown 3 months later.


  Discussion Top


A variety of mesenteric lengthening procedures have been reported in the literature as a solution for difficult to reach pouch without apparent negative consequences as long as pouch perfusion is preserved.[10],[11] There have been reports of alternative techniques when these lengthening strategies are inadequate such as mesenteric arterial division and vein grafting as well as J-pouch to W-pouch conversion, creation of an S-pouch, leaving a slightly longer rectal cuff, and creating a Kock pouch instead.[3],[8] Each of these approaches has potential drawbacks that should be considered by the surgeon intraoperatively. There is some evidence that preoperative computed tomography may help the surgeon anticipate a difficult to reach pouch.[12]

Here, we present the often discussed but rarely, if ever, reported approach of leaving the pouch in situ and reoperation at a subsequent date. Of note, in this case, it appeared that interval pouch growth rather than mesenteric stretch was responsible for the added length and ability to complete a tension-free anastomosis.

The surgical decision-making in a medically refractory ulcerative colitis female patient of childbearing age in the biologic age is not automatic. While RP-IPAA is broadly considered the gold standard for reconstruction in this patient, the surgeon must consider the risks and benefits of a two-stage or three-stage procedure, the potential for long-term pouch dysfunction if complications are encountered as well as the influence of IPAA creation on fertility.[13],[14],[15] Adding to the complexities of these decisions is the problem of a difficult to reach pouch. We report that a conservative strategy of leaving an unattached pouch in situ was successful in avoiding potential infectious or ischemic complications associated with further attempts to make the pouch reach at the time of the first IPAA attempt and allowed for eventual anastomoses 10 months later.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978;2:85-8.  Back to cited text no. 1
    
2.
Sofo L, Caprino P, Sacchetti F, Bossola M. Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: A narrative review. World J Gastrointest Surg 2016;8:556-63.  Back to cited text no. 2
    
3.
Milsom J. Restorative proctocolectomy with ileoanal anastomosis. In: Michelassi F, Milsom JW, editors. Operative Strategies in Inflammatory Bowel Disease. New York: Springer Science; 1999. p. 326-37.  Back to cited text no. 3
    
4.
Chun HK, Smith LE, Orkin BA. Intraoperative reasons for abandoning ileal pouch-anal anastomosis procedures. Dis Colon Rectum 1995;38:273-5.  Back to cited text no. 4
    
5.
Browning SM, Nivatvongs S. Intraoperative abandonment of ileal pouch to anal anastomosis – The Mayo clinic experience. J Am Coll Surg 1998;186:441-5.  Back to cited text no. 5
    
6.
Thirlby RC. Optimizing results and techniques of mesenteric lengthening in ileal pouch-anal anastomosis. Am J Surg 1995;169:499-502.  Back to cited text no. 6
    
7.
Chu DI, Tognelli J, Kartheuser AH, Dozois EJ. Strategy for the difficult-to-reach ileal pouch-anal anastomosis: Technical steps of anin vivo application of a mesenteric-lengthening technique. Tech Coloproctol 2015;19:705-9.  Back to cited text no. 7
    
8.
Metcalf DR, Nivatvongs S, Sullivan TM, Suwanthanma W. A technique of extending small-bowel mesentery for ileal pouch-anal anastomosis: Report of a case. Dis Colon Rectum 2008;51:363-4.  Back to cited text no. 8
    
9.
Kirat HT, Remzi FH. Technical aspects of ileoanal pouch surgery in patients with ulcerative colitis. Clin Colon Rectal Surg 2010;23:239-47.  Back to cited text no. 9
    
10.
Martel P, Majery N, Savigny B, Sezeur A, Gallot D, Malafosse M, et al. Mesenteric lengthening in ileoanal pouch anastomosis for ulcerative colitis: Is high division of the superior mesenteric pedicle a safe procedure? Dis Colon Rectum 1998;41:862-6.  Back to cited text no. 10
    
11.
Araki T, Parc Y, Lefevre J, Dehni N, Tiret E, Parc R, et al. The effect on morbidity of mesentery lengthening techniques and the use of a covering stoma after ileoanal pouch surgery. Dis Colon Rectum 2006;49:621-8.  Back to cited text no. 11
    
12.
Ohira G, Miyauchi H, Narushima K, Kagaya A, Mutou Y, Saitou H, et al. Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: Investigation of a simple predictive method using computed tomography. Colorectal Dis 2017;19:O34-8.  Back to cited text no. 12
    
13.
Fazio VW, Tekkis PP, Remzi F, Lavery IC, Manilich E, Connor J, et al. Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. Ann Surg 2003;238:605-14.  Back to cited text no. 13
    
14.
Sagap I, Remzi FH, Hammel JP, Fazio VW. Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA) – A multivariate analysis. Surgery 2006;140:691-703.  Back to cited text no. 14
    
15.
Cornish JA, Tan E, Teare J, Teoh TG, Rai R, Darzi AW, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: A systematic review. Dis Colon Rectum 2007;50:1128-38.  Back to cited text no. 15
    


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