V30 - Laparoscopic Management of J Pouch Volvulus and Perforation With Pexy and Diversion

CME Eligible

Purpose/Background: Ileal pouch-anal anastomosis (IPAA) surgery offers patients an alternative to permanent stoma but is not without risk of major complications. Pouch anatomy can create unique pathology that may elude precise diagnosis leading to poor function and, eventually, to excision if opportunities for salvage are missed. Pouch volvulus is a rare complication, and video demonstrations of laparoscopic management are sparse. We present a case of a young male with ulcerative colitis and primary sclerosing cholangitis who underwent three-stage surgery for medically refractory disease. One year after loop ileostomy reversal he was diagnosed with pouchitis and later chronic antibiotic resistant pouchitis requiring reinitiation of biologic therapy with improvement. He eventually presented with severe distension of the pouch, which was presumed to be chronic and attributed to IPAA stricture. This was managed with endoscopic decompression, and conversations regarding eventual pouch excision. He presented again two weeks later with peritonitis and evidence of hollow viscus perforation on CT imaging requiring surgical exploration.

Methods/Interventions: We performed diagnostic laparoscopy along with upper endoscopy and pouchoscopy. Small volume succus and fibrinous exudate were found in the deep pelvis along with 180-degree clockwise rotation of the pouch along its axis. This was laparoscopically reduced. Although intraoperative leak test was positive in the deep, posterolateral pelvis, we could not directly visualize a defect with concurrent pouchoscopy and laparoscopy. The pouch otherwise appeared healthy, so we performed pouch pexy between the sacral promontory and efferent limb mesentery using braided, absorbable suture. After copious irrigation, a closed suction drain was placed in the pelvis. The prior loop reversal anastomosis was brought up for diversion creating a double-barrel stoma. We secured a Malecot drain in the pouch for added decompresssion.

Results/Outcomes: The patient was maintained on broad-spectrum antibiotic therapy for four days while awaiting return of bowel function and resolution of sepsis. The pelvic drain and Malecot were discontinued prior to discharge home. He recovered well and will be undergoing repeat pouchoscopy and retrograde enema to evaluate the pouch-anal anastomosis . Our goal is for eventual reversal of the diversion for an attempt at pouch salvage.

Conclusion/Discussion: IPAA complications present unique and challenging management dilemmas. Volvulus of the pouch is a rare presentation that may be clouded by alternative diagnoses; thus, it must remain high on the differential. Laparoscopic reduction of pouch torsion with suture pexy, wide drainage and diversion provide an opportunity for pouch salvage with limited morbidity.