3-Dimensional Pouchography: A Proof-of-Concept Study of a Novel Technique for Visualizing Ileoanal Pouch Anatomy & Morphology in Normal and Mechanical Pouch Complication Patients

BACKGROUND

Herein, we present a proof-of-concept study of 3-dimensional (3D) pouchography using virtual and printed 3D models of ileal pouch-anal anastomosis (IPAA) in patients with normal pouches and in cases of mechanical pouch complications.

MATERIALS & METHODS

We performed a retrospective, descriptive case series of a convenience sample of 10 pouch patients with or without pouch dysfunction who had CT scans appropriate for segmentation were identified from our pouch registry. The steps involved in clinician-driven automated 3D reconstruction are presented.

RESULTS

Three patients who underwent CT imaging and were found to have no primary pouch pathology, and seven patients with known pouch pathology identifiable with 3D reconstruction including pouch strictures, megapouch, pouch volvulus, and twisted pouches underwent 3D virtual modeling; one normal and one twisted pouch were 3D printed. We discovered that 3D pouchography reliably identified staple lines (pouch body, anorectal circular and transverse, and tip of J), the relationship between staple lines, and variations in pouch morphology, and pouch pathology.

CONCLUSIONS

Three-dimensional reconstruction of IPAA morphology is highly feasible using readily available technology. In our practice, we have found 3D pouchography to be an extremely useful adjunct to diagnose various mechanical pouch complications and improve planning for pouch salvage strategies. Given its ease of use and helpfulness in understanding the pouch structure and function, we have started to routinely integrate 3D pouchography into our clinical pouch referral practice. Further study is needed to formally assess to value of this technique to aid in the diagnosis of pouch pathology.

Ileoanal Pouch: Pelvic Sepsis and Poor Function-Now What?

Pelvic sepsis is a dreadful complication after ileal pouch creation. It is mostly treated conservatively, and the ileal pouch can be salvaged if sepsis is detected and treated in a timely manner. Even under the best circumstances, pelvic sepsis is often associated with poor functional outcomes. If pelvic sepsis becomes chronic, it could lead to pouch failure. Redo ileal pouch-anal anastomosis (IPAA) is a viable option in the setting of chronic pelvic sepsis to preserve gastrointestinal continuity in motivated patients. It is associated with similar surgical morbidity, acceptable functional outcomes, and good quality of life. Patients should be involved in the decision-making process after ileal pouch failure. In the setting of ileal pouch failure, surgeons with limited experience may not be comfortable offering patients redo IPAA. Redo IPAA requires subspecialization and patients with ileal pouch failure should be treated at specialized high-volume centers.