Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses.

INTRODUCTION: Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch. PRESENTATION OF CASE: A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done. DISCUSSION: The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.
CONCLUSION: The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.

Introduction

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy, first popularized by Parks AG et al., in the early 1980s is now the surgical procedure of choice in ulcerative colitis. Recurrent postoperative obstruction is a common complication after IPAA. Volvulus of the ileal pouch itself is extremely rare with only three cases reported in literature. We here report a case of volvulus of S-type ileal pouch, which is the first documentation of its type.

Case report

A 28 year old male presented to the emergency with colicky pain abdomen, distension and bilious vomiting for 3 days, and not passing flatus, motion for last 2 days.

On examination patient had tachycardia, hypotension and features of dehydration.

Abdomen showed the midline scar of previous surgery, was distended and tender.

Patient had a history of total proctocolectomy with ileal pouch anal anastomosis for refractory ulcerative colitis in 2009. There was no history of any other surgical procedure or any known medical comorbidity.

He had several episodes of constipation following the surgery but all were self-relieving.

Abdominal X-ray was suggestive of dilated bowel loops with multiple air fluid levels and a large loop of small bowel reaching up to left dome of diaphragm (Fig. 1).

Fig. 1

Abdominal radiograph showing multiple air fluid levels and a large dilated small bowel loop reaching up to the left dome of diaphragm.

Laboratory examinations revealed hemoglobin of 11.5 gm/dL, total leucocyte count 7200/cu mm. Blood sugar levels, serum urea/creatinine and liver function tests were within normal limits.

A diagnosis of acute post operative obstruction was made. Patient was resuscitated with intravenous fluids and nasogastric aspiration was done. Due to the deteriorating vital parameters of the patient an emergency laparotomy was planned.

Exploratory laparotomy with derotation of volvulus of ileal S-pouch with pouchpexy (anchoring the ascending and descending limbs of the S-pouch by seromuscular non absorbable polypropylene 2-0 sutures to the posterior pelvic wall/presacral fascia) and proximal loop ileostomy was done.

Intraoperative findings were that of massively dilated S-type ileal pouch rotated upon its axis with proximal bowel dilatation, with multiple inter loop and peritoneal adhesions (Figs. 2–4). Upon derotation the pouch was healthy with no signs of ischemia, thus pouch fixation to pelvic side wall was done. Proximal diversion ileostomy for decompression was made.

Patient became normotensive on post-operative day 2 and was discharged on post operative day 8. Gut continuity was restored with ileostomy closure after 2 months. The patient is in regular follow up and is asymptomatic for last 6 months since surgery.

Discussion

For patients with ulcerative colitis refractory to medical treatment, restorative proctocolectomy with ileal pouch anal anastomosis is the gold standard. Ileal pouch provides the benefit of improved continence by maintaining the anal sphincter function thereby decreasing the stool frequency.

Ileal pouch formation can have several variations including: the triple loop “S” pouch, double loop “J” pouch or quadruple loop “W” pouch. The type of pouch totally depends upon the surgeon expertise with the J-pouch being the most commonly performed.

Complications of IPAA are varied ranging from pouch leak, pelvic abscess/sepsis, and pouch bleeding, occurring in the early post operative period (30 days) to the delayed manifestations of obstruction, pouchitis, fistula formation, anastomotic stricture, urinary and sexual dysfunction.

Obstruction of the small bowel is one of the most common complications and is generally due to post operative adhesions.

Volvulus of the small bowel following IPAA is rare and to our knowledge only 6 cases have been reported in the literature with only 3 of them involving the ileal pouch itself (Table 1). Our case being the first documentation on volvulus of an S-type ileal pouch.

Table 1

Cases of ileal pouch volvulus reported in literature.

Reference	Type of pouch	Stapled/hand-sewn	Site of volvulus	Operative procedure done
Ullah et al. [10]	W pouch	Stapled	Pouch	Redo of pouch
Patel et al. [9]	??	??	Small bowel	Pouch take down with end ileostomy
Jain and Abbas et al. [8]	J pouch	Stapled	Pouch	Redo of pouch
Arima et al. [11]	J pouch	Stapled	Pouch	Pouchpexy

Patel et al. have described a case of ileal pouch necrosis due to volvulus of small bowel, thereby emphasizing the importance of early diagnosis and management in pouch salvage.

The CT findings of small bowel volvulus in a case of IPAA have been described by Catalano. He described signs of obstruction with a radial disposition of small bowel loops around the mesenteric root and an abnormal right sided position of the superior mesenteric artery and vein in an abdominal CT.

The usefulness of endoscopy in diagnosis or reduction of volvulus is doubtful with cases of unsuccessful attempts and even a perforation had been reported.

When the diagnosis is in doubt and patient still in obstruction, exploration should not be delayed; failing to do so can lead to necrosis and pouch loss. Upon exploration, if the pouch is viable after de-rotation and anastomotic site healthy, simple pouchpexy is all that is required. Presence of gangrene in the pouch or proximal bowel should warrant a redo of the pouch anastomosis with preferable proximal diversion ileostomy.

Role of post-operative follow-up endoscopy is not yet proven.

As in our case the patient's deteriorating general condition mandated early operative intervention, a CT or endoscopic evaluation/intervention could not be performed.

There were no technical issues with the pouch formation and ileoanal anastomosis during the original operation.

During the current surgery distal limb of the “S” type pouch containing the ileoanal anastomosis was found to be abnormally elongated. The elongation could have been the result of chronic repeated obstruction which might have led to the volvulus. But this conclusion cannot be definitively drawn due to the rarity of this complication. Also the occurrence of a pouch volvulus cannot attributed to a specific pouch type.

Conclusion

Volvulus of the ileal pouch is a very rare occurrence following IPAA for ulcerative colitis. It should always be included in the differential diagnosis of patients presenting with recurrent post operative obstruction due to its serious complications. In our case timely exploration and correction of the volvulus lead to the pouch salvage, hence preventing the patient from undergoing another major procedure and morbidity, thus emphasizing on the importance of early diagnosis and management of ileal pouch volvulus.

Conflicts of interest

The authors report that there are no conflicts of interest.

Funding

None.

Ethical approval

Written informed consents were obtained from the patient for publication of the case and accompanying images. A copy of the written consent is available for review by Editor-in-Chief of the journal on request.

Author contributions

Dr. Gaurav Tyagi—Study design, data acquisition, writing, article revision and data analysis.

Dr. Utsav Gupta—Study design, data analysis.

Dr. Ankit Verma—Article revision and writing.

Dr. Dhananjay Saxena—Writing.

Dr. Atul Mittal—Data acquisition.

Dr. Amit Goyal—Article revision.

Dr. Jeevan Kankaria—Design, article revision.

Dr. R.K. Jenaw—Data analysis, article revision and approval