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Recurrent volvulus of an ileal pouch requiring repeat pouchopexy: a lesson learnt.

Myrelid P, Druvefors P, Andersson P - Case Rep Surg (2014)

Bottom Line: At follow-up after five months she was free of symptoms.Conclusion.Several rows seem to be needed.

View Article: PubMed Central - PubMed

Affiliation: Unit for Colorectal Surgery, Department of Surgery, County Council of Östergötland, 581 85 Linköping, Sweden ; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, 581 83 Linköping, Sweden.

ABSTRACT
Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed.

No MeSH data available.


Related in: MedlinePlus

CT-scan showing volvulus of the pelvic pouch apparent by twisting of the posterior staple line 270 degrees just above the level of the ileoanal anastomosis (arrow).
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fig1: CT-scan showing volvulus of the pelvic pouch apparent by twisting of the posterior staple line 270 degrees just above the level of the ileoanal anastomosis (arrow).

Mentions: A 58-year-old woman operated with proctocolectomy and an ileal J-pouch 11 years earlier due to ulcerative colitis complicated by colonic cancer presented at a local hospital because of abdominal pain and failure of faecal evacuation. There was a previous history of similar but short and self-resolving episodes of obstruction without clear explanation. A CT-scan aroused suspicion of twisting of the pouch along its longitudinal axis causing an obstruction at the ileoanal anastomosis. An intestinal tube was passed into the pouch for decompression which resulted in relief of symptoms lasting also the day after removal of the tube. She was therefore discharged and referred to our hospital for follow-up with pouchoscopy. However, on the same day as she had been discharged, she presented as an emergency case at our hospital with identical symptoms of obstruction and was admitted to a surgical ward after the application of a tube into the pouch for deflating. Repeated CT-scans at presentation and after application of the tube showed again volvulus of the pouch, which resolved after tube insertion as did the symptoms (Figure 1). Endoscopy of the pouch including 50 cm of the afferent loop was easily done with no signs of ischemia or obvious twisting. The following day a laparotomy was done in order to fixate the pouch to prevent further episodes of twisting. The pouch was found to be enlarged but in its regular position without twisting and not surprisingly there were no adhesions, either in the pelvis or in the abdomen, which made the pouch completely mobile. A loop of the distal ileum was also found to be twisted behind the mesentery of the afferent loop of the pouch as a remaining part of the volvulus (Figure 2). After reduction of the distal ileum a pouchopexy was made with one row of multiple interrupted nonabsorbable monofilament sutures (Prolene) to the presacral fascia as well as closure of the open space behind the mesentery of the afferent loop in the same manner. The postoperative course was uneventful and the patient was discharged.


Recurrent volvulus of an ileal pouch requiring repeat pouchopexy: a lesson learnt.

Myrelid P, Druvefors P, Andersson P - Case Rep Surg (2014)

CT-scan showing volvulus of the pelvic pouch apparent by twisting of the posterior staple line 270 degrees just above the level of the ileoanal anastomosis (arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4109119&req=5

fig1: CT-scan showing volvulus of the pelvic pouch apparent by twisting of the posterior staple line 270 degrees just above the level of the ileoanal anastomosis (arrow).
Mentions: A 58-year-old woman operated with proctocolectomy and an ileal J-pouch 11 years earlier due to ulcerative colitis complicated by colonic cancer presented at a local hospital because of abdominal pain and failure of faecal evacuation. There was a previous history of similar but short and self-resolving episodes of obstruction without clear explanation. A CT-scan aroused suspicion of twisting of the pouch along its longitudinal axis causing an obstruction at the ileoanal anastomosis. An intestinal tube was passed into the pouch for decompression which resulted in relief of symptoms lasting also the day after removal of the tube. She was therefore discharged and referred to our hospital for follow-up with pouchoscopy. However, on the same day as she had been discharged, she presented as an emergency case at our hospital with identical symptoms of obstruction and was admitted to a surgical ward after the application of a tube into the pouch for deflating. Repeated CT-scans at presentation and after application of the tube showed again volvulus of the pouch, which resolved after tube insertion as did the symptoms (Figure 1). Endoscopy of the pouch including 50 cm of the afferent loop was easily done with no signs of ischemia or obvious twisting. The following day a laparotomy was done in order to fixate the pouch to prevent further episodes of twisting. The pouch was found to be enlarged but in its regular position without twisting and not surprisingly there were no adhesions, either in the pelvis or in the abdomen, which made the pouch completely mobile. A loop of the distal ileum was also found to be twisted behind the mesentery of the afferent loop of the pouch as a remaining part of the volvulus (Figure 2). After reduction of the distal ileum a pouchopexy was made with one row of multiple interrupted nonabsorbable monofilament sutures (Prolene) to the presacral fascia as well as closure of the open space behind the mesentery of the afferent loop in the same manner. The postoperative course was uneventful and the patient was discharged.

Bottom Line: At follow-up after five months she was free of symptoms.Conclusion.Several rows seem to be needed.

View Article: PubMed Central - PubMed

Affiliation: Unit for Colorectal Surgery, Department of Surgery, County Council of Östergötland, 581 85 Linköping, Sweden ; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, 581 83 Linköping, Sweden.

ABSTRACT
Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed.

No MeSH data available.


Related in: MedlinePlus