Laparoscopic ileopexy for afferent limb syndrome after ileal pouch‐anal anastomosis

Afferent limb syndrome (ALS) is caused by an obstruction of the afferent intestinal limb after ileal pouch‐anal anastomosis. Here, we describe the first case of ALS to be successfully treated by a laparoscopic approach. A 27‐year‐old man underwent ileal pouch‐anal anastomosis for ulcerative colitis. He was subsequently diagnosed with ALS and underwent ileopexy with laparotomy at 33 years old. Then, 21 months after the first ileopexy, he underwent laparoscopic ileopexy for ALS recurrence. The operative findings revealed a shortened fixed portion of the afferent limb adhering to the right pelvic retroperitoneum, which was regarded as the cause of the acute angulation. The portion of the afferent limb fixed to the abdominal wall was extended under laparoscopic visualization by suturing above the level of the iliac crest. At the 12‐month follow‐up, the patient remained free of symptoms of obstruction. Laparoscopic ileopexy should be the procedure of choice for patients with ALS.     

Restorative proctocolectomy: morphological and functional study with coronal CT

Background: Restorative proctocolectomy with ileal pouch has become the surgical treatment of choice for patients with ulcerative colitis (UC) and familial polyposis of the colon. Defecography is the radiological technique commonly employed to obtain detailed information on function and morphology of the ileal pouch; it allows the direct visualization of the ileal pouch and the anal canal, but it does not provide the visualization of the pelvis. Methods: In all patients, computed tomography (CT) on coronal planes was performed to determine its possibilities as an alternative to defecography; 10 patients with UC submitted to restorative proctocolectomy and were examined. Results: Coronal CT images provided a panoramic vision of the pelvis and demonstrated the morphology of the ileal pouch, the thickness of its walls, and its correlation with the surrounding tissues. Coronal CT also allowed the evaluation of the continence of ileo-anal and ileo-ileal anastomosis and the functional changes of the perineal muscles at rest and during squeezing. Conclusion: CT images acquired on coronal planes allows an easy and clear detection of the major postoperative complications, such as stenosis or dehiscences of the anastomosis, pelvic phlogosis, and fistulae. Received: 29 December 1994/Accepted: 5 February 1995     

Laparoscopic versus open proctocolectomy with ileal pouch-anal anastomosis.

In recent years laparoscopic proctocolectomy with ileal pouch-anal anastomosis has been used as an alternative to conventional open techniques. Since many published series on proctectomy and ileal pouch-anal anastomosis are based on open experience, in this paper we compare our laparoscopic experience on 21 patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) to 25 patients who had undergone open proctocolectomy with ileal pouch-anal anastomosis. The median operative time in the laparoscopic group was significantly longer than that in the open group (325 min vs. 220 min). However, blood loss was less (115 ml vs.240 ml), bowel function returned earlier (2 days vs.4 days), and hospitalization time was shorter (9 days vs.11 days) in the laparoscopic group (all p<0.05). Early postoperative complications were encountered in five patients of the laparoscopic group and in seven patients of the open group. The median follow-up time was 15 months (range 6-34) in both groups. Late postoperative complications were encountered in three patients of the laparoscopic group and in three patients of the open group. In conclusion, laparoscopic proctocolectomy with ileal pouch-anal anastomosis is technically feasible. The technique described in this study provides the advantages of less blood loss, shorter hospitalization, quicker return of bowel function and more favorable cosmetic results when compared to the open technique.     

Surgical treatment for ulcerative colitis--recent advances

Surgical indication for ulcerative colitis is fulminant colitis, intractability, cancer or dysplasia. New surgical indication should be established because new medical treatment such as leucocytoapheresis or intravenous cyclosporine treatment developed. Standard surgical procedure is ileal pouch anal anastomosis with rectal mucosal stripping and stapled ileal pouch anal anastomosis. Postoperative bowel function and QOL are satisfactory in both of them. Surgical treatment should be performed without any delay for the patients who do not respond medical treatment.     

Robotic-assisted laparoscopic surgery for restorative proctocolectomy with ileal J pouch-anal anastomosis

Abstract

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for chronic ulcerative colitis (CUC). Robotic-assisted laparoscopic surgery (RALS) has been shown to have its greatest merits in colorectal procedures involving the pelvis. The aim of this study was to evaluate the safety and feasibility of RP with IPAA using an innovative robotic technique. A total of five consecutive patients underwent RALS RP with IPAA between August 2008 and February 2010. Patient demographics, intraoperative parameters, and postoperative outcomes were tabulated and assessed. Surgery was indicated for medically intractable CUC in three patients (60%), CUC-related dysplasia in one patient (20%) and CUC-related adenocarcinoma in one patient (20%). An ileal pouch-anal anastomosis was successful in all five cases. The mean operative time was 330 min and estimated blood loss was 200 cc. There were no intraoperative complications or conversions. The mean length of hospital stay was 5.6 days and no patients developed major postoperative complications. RALS is an innovative technique offering technical and visual advantages to the colorectal surgeon and can be offered for those who are seeking restorative proctolectomy for chronic ulcerative colitis.     

Endoscopy‐assisted transanal repair of afferent limb obstruction and long efferent limb with ileopexy after ileal J‐pouch‐anal anastomosis

Afferent limb obstruction can be a persistent complication after restorative proctocolectomy with ileal pouch‐anal anastomosis. We present a case of afferent limb obstruction complicated by a long efferent limb of the ileal pouch that we successfully treated with side‐to‐side anastomosis of the afferent and efferent limbs. The procedure involved using a transanal endoscopic stapling device assisted by transanal endoscopy with a thin intestinal video endoscope. This allowed reliable, safe visualization of the lesion from the tight pouch‐anal anastomosis and facilitated repair with an endoscopic stapling device. Because the technique was performed without enterotomy, it reduced the risks of contamination and leakage from transabdominal small bowel anastomosis. Laparotomy view also prevented of injury to the pouch itself and entrapment of the mesentery of the afferent and efferent limbs of the pouch between the stapler anvils.     

Judging the J pouch: a pictorial review

Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.

     

Transanal total mesorectal excision for restorative coloproctectomy in an obese high-risk patient with colitis-associated carcinoma

Transanal total mesorectal excision (TaTME) offers great potential for the treatment of malign and benign diseases. However, laparoscopic-assisted TaTME in ulcerative colitis has not been described in more than a handful of patients. We present a 47-year-old highly comorbid female patient with an ulcerative colitis–associated carcinoma of the ascending colon and steroid- refractory pancolitis. A two-stage restorative coloproctectomy including right-sided complete mesocolic excision was conducted. The second step consisted of a successful nerve-sparing TaTME and a handsewn ileal pouch–anal anastomosis. TaTME may extend the possible treatment options in inflammatory bowel disease, especially for high-risk patients.     

One‐stage completely laparoscopic restorative proctocolectomy for ulcerative colitis complicated with sigmoid colon cancer – a case report

Recent advances in laparoscopic surgery have made it possible to perform restorative proctocolectomy (RP) for ulcerative colitis (UC) or familial adenomatous polyposis (FAC). However, most of these procedures are performed as two‐stage operations with the creation of diverting ileostomy. Furthermore, they are performed with a small abdominal incision from 4 to 8cm in length. We describe the first case of ulcerative colitis that underwent a single‐stage completely laparoscopic restorative proctocolectomy without an abdominal incision. The patient also underwent lymph node dissection since he had a sigmoid colon cancer. The postoperative course was uneventful and the functional outcome was satisfactory. Considering the improved cosmetic as well as functional results achieved by this procedure, the present technology can be applied for selected patients, especially young UC or FAP patients needing RP who seek for a superior cosmetic result.     

Total proctocolectomy and ileoanal pouch: the role of contrast studies for evaluating postoperative leaks

Background: To assess the role of contrast enemas for the evaluation of leaks in symptomatic and asymptomatic patients after the first stage of restorative proctocolectomy. Methods: We reviewed the findings of 59 contrast enemas in 40 patients who underwent total proctocolectomy with creation of an ileoanal pouch and a proximal diverting ileostomy. Thirty-seven patients initially underwent routine contrast studies of the ileoanal pouch, and three underwent contrast studies because of suspected fistulas or obstruction. Medical records were also reviewed to determine the clinical presentation and course of these patients. Results: Of 37 patients who underwent routine postoperative contrast enemas, 33 (89%) had normal studies, three (8%) had clinically silent leaks (including two blind-ending tracks from the ileoanal anastomosis and one from the pouch), and one (3%) had pouchitis. In all three patients with unsuspected leaks, ileostomy closure was delayed. In two other patients with abdominal pain and fever, contrast enemas revealed leaks from the ileoanal pouch and distal ileum, respectively. The remaining patient had a contrast enema because of abdominal pain and distention; this patient had a distal ileal obstruction due to adhesions. Conclusions: Routine postoperative contrast studies revealed clinically silent leaks from the ileal J pouch or ileoanal anastomosis in three of 37 patients (8%) after the first stage of restorative proctocolectomy. Our findings suggest that routine contrast enema can detect clinically silent leaks after this surgery. Received: 31 January 1997/Accepted: 5 March 1997     

One-stage completely laparoscopic restorative proctocolectomy for ulcerative colitis complicated with sigmoid colon cancer--a case report.

Recent advances in laparoscopic surgery have made it possible to perform restorative proctocolectomy (RP) for ulcerative colitis (UC) or familial adenomatous polyposis (FAC). However, most of these procedures are performed as two-stage operations with the creation of diverting ileostomy. Furthermore, they are performed with a small abdominal incision from 4 to 8 cm in length. We describe the first case of ulcerative colitis that underwent a single-stage completely laparoscopic restorative proctocolectomy without an abdominal incision. The patient also underwent lymph node dissection since he had a sigmoid colon cancer. The postoperative course was uneventful and the functional outcome was satisfactory. Considering the improved cosmetic as well as functional results achieved by this procedure, the present technology can be applied for selected patients, especially young UC or FAP patients needing RP who seek for a superior cosmetic result.     

Current status of sphincter-saving operations for chronic ulcerative colitis

When surgery is demanded by the course of a patient with ulcerative colitis, the sphincter mechanism can be spared. The straight ileoanal anastomosis without a reservoir has not been satisfactory for adults because of frequent diarrheal stools. The ileorectal anastomosis has the advantage of minimal morbidity, but the patient is not totally cured, because the diseased rectum is still in place. The pouch pull-through procedure has an increased morbidity, but the patient is cured of ulcerative colitis. The anastomotic stricture rate is 7% to 15% and the failure rate, 2% to 6%. Inflammation of the pouch or reservoir occurs in 5% to 19%. There have been no deaths in the reviewed series. As the details of the pouch pull-through procedure are refined, this operation will become the choice for treatment of ulcerative colitis.     

Juvenile polyposis syndrome: A case report

Juvenile polyposis syndrome (JPS) is an autosomal dominant disease that is characterized by multiple hamartomatous polyps. Patients with JPS are at increased risk for developing colorectal and gastric cancer. JPS was diagnosed by endoscopy and histology, and the patient underwent surgery, total proctocolectomy and ileal pouch–anal anastomosis.     

Endoscopy in the management of patients after ileal pouch surgery for ulcerative colitis

Pouchitis is the most common complication following ileal pouch-anal anastomosis in patients with ulcerative colitis. However, there are several other inflammatory and noninflammatory conditions that can mimic pouchitis, and endoscopy with biopsies is essential for distinguishing these various conditions. This paper will review the differential diagnosis of pouchitis and the role of endoscopy in the diagnosis and management of disorders of the ileal pouch.     

Thirty years of the ileal-anal pouch and beyond

Still referred to as a new surgical procedure, the ileal-anal pouch or restorative proctocolectomy is now in its 30th year. Over this time the procedure has become the standard of care for patients with ulcerative colitis and familial adenomatous polyposis who require surgery. For many patients it not only eradicates disease, but also preserves the anal sphincter, therefore enabling the patient to defecate in the normal way. Much research over the years has explored optimum surgical techniques, pouch function/capacity, pouch failure and pouch satisfaction and its long-term follow-up. This article reviews literature relating to the ileal-anal pouch and traces its journey through the past three decades, providing an overview of how the pouch has evolved and considers its future development.     

全结肠或全结直肠切除回肠J袋直肠或肛管吻合术(附13例报告)

目的 探讨全结肠或结直肠切除后，回肠J袋直肠或肛管吻合术的效果及经验。方法 回顾性分析13例全结肠或结、直肠切除后回肠J袋直肠或肛管吻合术的临床资料。结果 手术经过顺利，1例于术后第3天出现肺部感染，其余均顺利恢复，无手术死亡，肛门排便功能经3个月逐步改善；6个月后随访，大便多已成形，每天平均4、5次。结论 该手术能保持良好的排便功能，术后患者生活质量满意，是全结肠或结、直肠切除后的一种有效而理想的肠道重建方式。     

Recommended follow-up for ileo-anal pouch patient

One of the greatest advances in colorectal surgery over the past 30-years has been the development of restorative proctocolectomy with ileal pouch-anal anastomosis for patients suffering with ulcerative colitis and selected patients with familial adenomatous polyposis. This has coincided with a proliferation of new and exciting advanced clinical roles for nurses in the United Kingdom and subsequently has led to an increase in the responsibilities and professional status of nurses. Staff development is necessary to maintain the unique contribution that nurses make to health care in the terms of practice, education and research. Nurse specialists in gastroenterology are taking their place alongside medical specialists, and more importantly establishing themselves as the principle carer in many diverse roles. However, as these nursing roles expand, a recognized framework needs to be designed, which takes into account the educational, ethical and legal issues related to accountability of running nurse-led clinics, offering support, advice and follow-up for patients. This article provides nursing staff with research-based recommendations and practical guidance on running a successful nurse-led pouch clinic and follow-up service in collaboration with the consultant surgeon, gastroenterology teams and nursing staff involved specifically with the ileo-anal pouch patient.     

A case of familial adenomatous polyposis with protein-losing enteropathy treated by laparoscopic total colorectal resection: A literature review

Familial adenomatous polyposis (FAP) with protein-losing enteropathy is a rare disorder and is difficult to treat medically. A 74-year-old female patient was referred to our hospital with a chief complaint of anorexia. Lower gastrointestinal endoscopy showed multiple adenomas from the ascending colon to the rectum and adenocarcinoma in the sigmoid colon and descending colon. Laboratory findings showed hypoalbuminemia (albumin 1.6 mg/dl). Protein leak scintigraphy using 99mTc-HSAD found a protein leak from the colon. Although hypercaloric infusion was administered, the nutritional status was not improved and albumin transfusion was required. The patient underwent laparoscopic total proctocolectomy, ileal pouch-anal anastomosis, and temporary ileostomy. She had a good postoperative course and the hypoalbuminemia normalized in a few weeks. The patient underwent temporary ileostomy reversal. Here we report a case of FAP with protein-losing enteropathy who underwent laparoscopic total proctocolectomy, which resulted in improvement of the protein leak as well as cancer treatment.