VM8 - Pouch Inlet Transposition: A Novel Approach for Recurrent Small Bowel Volvulus from Pouch Inlet Twists

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Location: ASCRS Connect Lounge, Hall B1/B2, Ground Level

Video Presentation(s)

Stefan D. Holubar, MD, MS, FACS, FASCRS

Director of Research
Cleveland Clinic
Cleveland, Ohio, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no relevant relationships with ineligible companies.

Author(s)

OL

Olga Lavryk, MD, PhD

Staff, IBD Surgery Section
Cleveland Clinic
Cleveland, Ohio, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
IK

Imran Khan, MD

Research Fellow
Cleveland Clinic
Cleveland, Ohio, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
GK

George Kereselidze, MD

Surgery Resident
Cleveland Clinic
Cleveland, Ohio, United States

Disclosure information not submitted.
Michael Goldenshluger, MD

Clinical Associate
Cleveland Clinic
Cleveland clinic
Cleveland, Ohio, United States

Disclosure information not submitted.
GA

Gilad Alon, MD

Clinical Associate
Cleveland Clinic
Cleveland, Ohio, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.

Stefan D. Holubar, MD, MS, FACS, FASCRS: This individual has no relevant relationships with ineligible companies.

Olga Lavryk, MD, PhD: This individual has no financial relationships with ineligible companies.

Imran Khan, MD: This individual has no financial relationships with ineligible companies.

Gilad Alon, MD: This individual has no financial relationships with ineligible companies.

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Purpose/Background: Recurrent small bowel volvulus (SBV) after ileoanal pouch (IPAA) is a devastating complication, which left untreated may result in small bowel necrosis. SBV after IPAA may be related to the pouch fixed in a lateral position resulting in a pouch inlet twist, a subtype of twisted pouch syndrome. SBV after IPAA is distinct from volvulus of the pouch itself. In this report, we describe pouch inlet transposition for recurrent SBV from pouch inlet twists.

Methods/Interventions: Patients with pouch inlet twists, specifically 90° counterclockwise twists, may have normal pouch function between SBV episodes. However, as the pouch elongates over time, they may develop recurrent SBV immediately proximal to the pouch inlet and undergo multiple operations and adhesiolysis without success. In these cases, the tip of J is anterior, inlet posterior, linear staples lateral, and pouch mesentery to the right. The pathophysiology of SBV after IPAA is related to the mesentery crossing midline from left-to-right, resulting in mesenteric axial torsion. Pouch mobilization and pexy may result in 90° pouch outlet twist.

Results/Outcomes: Pouch inlet transposition involves swapping positions of the pouch inlet and tip of J. The bowel is transected posteriorly at the prior pouch inlet (which becomes the new tip of J), and the afferent limb and sleeve of mesentery brought over the pouch mesentery clockwise and re-implanted (handsewn or stapled) anteriorly into the prior tip of J. When the afferent limb and its mesentery are mobilized, mesenteric torsional forces on the proximal bowel are attenuated, thereby preventing SBV recurrence.

Conclusion/Discussion: In conclusion, pouch inlet transposition appears to be a safe and effective treatment for recurrent SBV secondary to pouch inlet twists, without the need to mobilize the entire pouch, redo IPAA, or a diverting ileostomy. Pouch inlet transposition may be considered in IPAA patients with recurrent SBV secondary to pouch inlet twists.