Gastrointestinal: Ileo‐anal J‑pouch intraluminal bridge causing obstruction and bleeding

Abstract

Gastrointestinal: Ileo-anal J pouch intraluminal bridge causing obstruction and bleedingA 41-year-old patient with familial adenomatous polyposis underwent a total proctocolectomy, ileo-anal J-pouch creation, and formation of covering loop ileostomy. The patientˈs past history included end-stage renal failure from reflux nephropathy requiring hemodialysis and long-term smoking. Standard proctocolectomy was performed, and the rectum was divided at the anorectal junction with a TL 30 stapler (Ethicon, NJ, USA). The ileocolic vessels were preserved. The terminal ileum was divided with TLC 75 stapler, and a 15-cm long ileo-anal J pouch was created with a TLC 75 ™ stapler (Ethicon, NJ USA). The ileal pouch was successfully leak tested by distending it with 200 mL of betadine saline. A double-stapled ileal pouch anal anastomosis was created with an endo-anal circular stapler (ECS 29). The ileal J pouch was then endoscoped to ensure integrity of the pouch staple lines and pouchanal anastomosis. There were no intraoperative or postoperative problems.Six months postoperatively, the patient experienced rectal blood loss mixed with stool and tenesmus. There was no abdominal pain, perineal discomfort nor fever. Gastrograffin enema showed no leakage of contrast or abnormality within the ileal J pouch. Pouchoscopy found a 4 cm intraluminal epithelialized fibrous adhesion between the anterior and posterior wall in the middle third of the J pouch causing narrowing of the lumen of the J pouch. (Fig. 1) Endoscope at pouch anal anastomosis (Fig. 2). Endoscope looking into afferent limb of pouch. Deep biopsies of the intra pouch bridge showed inflamed tissue with no evidence of malignancy.The adhesion was successfully divided with a laparoscopic linear stapler (EndoGIA ™ , Covidien Minnesota) placed through the anus under endoscopic vision (Fig. 3). Figure 4 shows the bridge after division. The patientˈs symptoms resolved. The cause of the intraluminal adhesional bridge is not certain.There is no report in the English literature of an intraluminal adhesion within the J pouch. The inflammatory adhesion was along the staple line and one possibility of its etiology could be from episodic hypotension during dialysis. While the ileocolic vessels had been preserved, the hypotension associated with hemodialysis may have contributed to local ischemia.