Afferent limb obstruction complicating ileal pouch-anal anastomosis

Abstract

PURPOSE: Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb at the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy. METHODS: Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database of all patients who have undergone IPAA since 1980. Records of patients who were identified as having afferent limb obstruction as a cause of bowel obstruction after IPAA were reviewed. RESULTS: A total of 567 patients had undergone total proctocolectomy and ileoanal J-pouch at time of the study. Of 122 patients with one or more episodes of obstruction after IPAA, 48 required operative intervention. Afferent limb obstruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruction (4 of 6 patients). Contrast small-bowel series and enemas were suggestive of obstruction in four of six patients, the most consistent radiographic finding being small-bowel dilation to the level of the pouch inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterior to the pouch, causing acute angulation at the pouch inlet. Rather than risk injury to the pouch or its mesentery, the obstruction was bypassed by side-to-side anastomosis of the afferent limb to the pouch (enteroenterostomy) in five of six patients. One patient underwent ileostomy only because of technical considerations. Two patients required re-exploration and pexy of the afferent limb to the pelvic sidewall (pouchopexy) to relieve recurrent afferent limb obstruction. CONCLUSION: Afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from distal ileum to the pouch is safe and effective treatment. Because of the risk of recurrent afferent limb angulation, concurrent pouchopexy should be considered.