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Baker ME, Hull T, Holubar S, Lightner A, Qazi T. Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch. Abdom Radiol (NY) 2023; 48:2913-2917. [PMID: 36334124 DOI: 10.1007/s00261-022-03723-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.
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Affiliation(s)
- Mark E Baker
- Imaging Institute, 9500 Euclid Ave/L10, Cleveland, OH, 44195, USA.
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
- Crohn's Disease Focus Panel of the Society of Abdominal Radiology, East Dundee, USA.
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Lightner
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Lekamalage BBW, Centauri SM, Arachchi A, Hulme-Moir M. Ileoanal J pouch construction. ANZ J Surg 2023; 93:687-688. [PMID: 36732916 DOI: 10.1111/ans.18301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023]
Affiliation(s)
| | | | - Asiri Arachchi
- General Surgery, North Shore Hospital, Auckland, New Zealand
| | - Mike Hulme-Moir
- General Surgery, North Shore Hospital, Auckland, New Zealand
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Dionigi B, Prien C, Lavryk O, Lightner AL, Holubar SD, Hull T. Pouch volvulus-why adhesions are not always the enemy. Colorectal Dis 2022; 24:1192-1196. [PMID: 35585780 DOI: 10.1111/codi.16195] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/11/2022] [Accepted: 05/13/2022] [Indexed: 12/13/2022]
Abstract
AIM Minimally invasive approaches to proctocolectomy with ileal pouch anal anastomosis have become the standard of care with one benefit being the reduced risk of adhesion-related complications. However, a lack of pouch adherence to the pelvis can lead to increased mobility as well as volvulization, placing pouch viability at risk. We aimed to describe our institutional experience with pouch volvulus. METHODS Patients who presented with pouch volvulus from 1983 to 2020 were identified through a search of our pelvic pouch registry and enterprise-wide electronic medical record. Pouch volvulus was defined as a reducible rotation of the J-pouch on its mesenteric axis with evidence of a properly oriented ileo-anal anastomosis. Patients with 'twisted pouches' were excluded. RESULTS In total, 5760 patients underwent ileal pouch anal anastomosis from 1983 to 2020. Six patients (five women) were identified with a diagnosis of 'pouch volvulus' consistent with our definition. The six pouches were constructed utilizing laparoscopic techniques and the mean time from construction to volvulus was 2.36 years. All patients underwent urgent surgery, with a paucity of adhesions noted in five. Reduction and pouch pexy was performed in three and pouch excision in three, with immediate pouch reconstruction in two and end ileostomy creation in one. At a median follow-up of 9 months, pouch survival was 50%. CONCLUSIONS Pelvic pouches constructed using minimally invasive techniques may be at risk of volvulus due to reduced adhesion development. A high index of suspicion is warranted in pouch patients with obstructive symptomatology. CT imaging may be diagnostic, and prompt surgical intervention may facilitate pouch salvage.
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Affiliation(s)
- Beatrice Dionigi
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Prien
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olga Lavryk
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Chen HLR, Chok AY, Cheng TEL, Tan KWE. Pouch volvulus after laparoscopic ileal pouch anal anastomosis: the Achilles heel? ANZ J Surg 2021; 92:2322-2323. [PMID: 34958164 DOI: 10.1111/ans.17432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/05/2021] [Accepted: 12/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Jawoosh M, Haffar S, Deepak P, Meyers A, Lightner AL, Larson DW, Raffals LH, Murad MH, Buttar N, Bazerbachi F. Volvulus of the ileal pouch-anal anastomosis: a meta-narrative systematic review of frequency, diagnosis, and treatment outcomes. Gastroenterol Rep (Oxf) 2019; 7:403-410. [PMID: 31857902 PMCID: PMC6911998 DOI: 10.1093/gastro/goz045] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/01/2019] [Accepted: 06/21/2019] [Indexed: 12/16/2022] Open
Abstract
Background Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA. Methods A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018. Results The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%). Conclusion Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.
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Affiliation(s)
- Muhammad Jawoosh
- Division of Gastroenterology and Hepatology, Dessau Municipal Hospital, Auenweg 38, Dessau-Rosslau, Germany
| | - Samir Haffar
- Digestive Center for Diagnosis and Treatment, Damascus, Syrian Arab Republic
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alyssa Meyers
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Laura H Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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