Surgical solutions for refractory J-pouch inlet obstruction

AimMany surgeons consider total proctectomy with ileal pouch-anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients. MethodsA retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal-pouch anastomosis for J-pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra-operative findings, type of surgical intervention and postoperative outcomes. ResultsSurgical interventions were performed on eight patients with J-pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarilyanastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow-up of 36.5months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred. DiscussionJ-pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J-pouches being performed, awareness of novel surgical techniques is important.