Successful treatment of recurrent volvulus in the afferent limb of the pouch following proctocolectomy for ulcerative colitis: a case report

Abstract

Background Pouch volvulus after proctocolectomy for ulcerative colitis is a very rare postoperative complication. The common site of pouch volvulus has been reported to be the ileal pouch–anal anastomosis and the middle part of the pouch, but no reports on pouch volvulus in the afferent limb of the pouch have been observed. Here, we report the case of a patient with afferent limb volvulus who underwent afferent limbpexy, but required reoperation 7 months later. Case presentation A 38-year-old man with refractory ulcerative colitis had undergone open proctocolectomy 10 years ago at another hospital. He had been aware of lower abdominal pain and bowel movement difficulty for 2 years. After repeated bowel obstruction, he was referred to our hospital for surgery. Based on the radiographic findings, we diagnosed a pouch volvulus and performed an operation. Laparoscopically, counterclockwise rotation of the afferent limb of the pouch was recognized. Moreover, the ileal mesentery was adhered and fixed to the presacral space 20 cm from the oral side of the pouch. The antimesenteric side of the afferent limb was fixed using interrupted stiches on the left peritoneal wall of the pelvis. He was discharged uneventfully 18 days after surgery, and defecation improved immediately. However, he was readmitted 7 months after surgery with the same abdominal pain and defecation difficulty. A similar finding was found and diagnosed as recurrent volvulus. Therefore, we performed a laparoscopic surgery. The same volvulus as in the previous surgery was confirmed. The site fixed during the previous surgery showed scars, but the afferent limb was free. The dilated ileum that contained the volvulus was excised only on the oral side of the pouch and an intraluminal anastomosis was performed on the anterior wall of the pouch. He had a good postoperative course and was discharged. Conclusion Proper diagnosis of volvulus based on the characteristic imaging findings is important. In principle, bilateral row fixation of the rotated ileum is the basic procedure for volvulus. However, fixation with this technique is sometimes difficult. Therefore, this procedure is one of the useful options for the fixation of difficult or recurrent cases.

Recurrent Pouch Volvulus Following Ileoanal J-Pouch Anastomosis: A Case Report

“…The patient's primary volvulus was treated by endoscopic decompression and a unilateral pexy after which she recovered uneventfully. The patient was said to have "a free-floating pouch without any adhesions between the pouch and the sacral hollow" [15], an observation also reported by all of the seven cases that we found in the literature [10][11][12][13][14][15][16]. One year later, the patient was diagnosed with a further volvulus for which she underwent a pouchoscopy and exploratory laparoscopy.…”

“…Lastly, Itabashi et al [ 12 ] suggested other factors that may predispose individuals to pouch volvulus, including the role of a prophylactic pouch pexy and the configuration of the pouch (the choice of J, S, or W pouch thus affecting pouch volume). Finally, the tension placed on the small bowel mesentery during manipulation upon creation of the IPAA may also contribute to the occurrence of volvulus.…”

“…To our knowledge, there is a dearth of case reports on patients with recurrent pouch volvulus after undergoing a total proctocolectomy and IPAA surgery. After an extensive PubMed search, we found only seven other cases that presented with recurrent pouch volvulus [10][11][12][13][14][15][16]. In five out of these seven cases, the initial volvulus was treated by decompression and a unilateral pouch pexy; however, this pexy did not suffice as the patient re-presented with a further volvulus [10,11,[14][15][16].…”

Recurrent pouch volvulus treated with robotic ventral graft pouch‐pexy

“…Pouch volvulus following ileal‐pouch anal anastomosis (IPAA) is a rare, but recognized event, with incidence rates estimated at 0.18% 2 . Rates of recurrent volvulus are even more rare, with only a handful of case‐reports in the literature 3–5 . Volvulus is typically a rare occurrence, as sufficient adhesions form between the IPAA and the sacrum, preventing rotation of the pouch.…”

“…2 Rates of recurrent volvulus are even more rare, with only a handful of case-reports in the literature. [3][4][5] Volvulus is typically a rare occurrence, as sufficient adhesions form between the IPAA and the sacrum, preventing rotation of the pouch.…”