Elsevier

Surgery

Volume 145, Issue 5, May 2009, Pages 568-572
Surgery

Brief Clinical Reports
Interposition of a gastric pouch between ileum and anus after proctocolectomy: Long-term results in 3 patients

https://doi.org/10.1016/j.surg.2008.12.014Get rights and content

Background

After proctocolectomy, ileal pouch-anal anastomosis may not be feasible, especially in the case of desmoid tumor or after failed ileal pouch-anal anastomosis requiring excision of the pouch. We designed a gastric pouch interposed between the terminal ileum and the anus to avoid a permanent ileostomy for these patients. Long-term results and quality of life with this technique remain unknown.

Methods

After proctocolectomy, ileal pouch-anal anastomosis was not feasible or had failed in 3 patients (2 with familial adenomatous polyposis and 1 with ulcerative colitis; 40, 49, and 50 years of age, respectively). Of these patients, 2 had undergone end ileostomy 7 and 8 years previously. A pouch was created using the left half of the gastric fundus, supplied through the right gastroepiploic vessels; the pouch was anastomosed proximally to the terminal ileum and distally to the anus. Diverting ileostomy was performed in all patients.

Results

After a mean follow-up of 6 years, all 3 patients were highly satisfied with the operation and described their quality of life as good. The median stool frequency during the day and night were 6 and 1, respectively. No patient reported incontinence or urgency. Of the 3 patients, 2 had minimal soiling with gastric juice; 1 patient had anastomotic ulcers with bleeding requiring resection with reanastomosis. All of the patients needed long-term proton pump inhibitor therapy and topical perianal treatment to prevent skin burning.

Conclusion

Inter-ileoanal gastroplasty is a surgical salvage technique that can avoid a permanent ileostomy. The procedure provides a good quality of life for patients with unfeasible or failed ileal pouch.

Section snippets

Operative technique

A midline xyphopubic laparotomy was performed. The gastrocolic and the gastrosplenic ligaments were cut carefully to avoid injuries to the right gastroepiploic vessels; the gastrophrenic ligament was preserved. The right gastroepiploic vessels were carefully dissected from the greater gastric curve, starting at their origin and then cephalad until a point located 15 cm from their end (the upper gastric branches of the gastroepiploic artery were thus preserved). The left half of the stomach was

Technique and postoperative period

The pouch was feasible in all 3 patients, and there were no technical complications. No residual rectal mucosa was found, and mucosectomy was not required. The pouch reached the dentate line with an average excess length of 10 cm. The median operation time was 255 minutes. The postoperative period was uneventful, and all patients were discharged within 10 days after the operation on a regular diet. The pouch was tested with a postoperative barium enema at 1 month; no fistulae were found (Fig 2

Discussion

The early postoperative course was uneventful in all 3 patients. There were no fistulae or septic complications. We believe the risk of leakage is low: The anastomosis between the ileum and the gastric pouch is as safe as gastroenteroanastomosis; the mechanical stapling and transection of the stomach is safe (and reinforced by continuous absorbable sutures); and the gastric pouch-anal anastomosis has a good blood supply and is tension free (excess length of the pouch is about 10 cm). There was

References (13)

  • B.T. Gemlo et al.

    Functional assessment of ileal pouch-anal anastomotic techniques

    Am J Surg

    (1995)
  • M. Prudhomme et al.

    Causes and outcomes of pouch excision after restorative proctocolectomy

    Br J Surg

    (2006)
  • W.E. Hueting et al.

    Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients

    Dig Surg

    (2005)
  • N. Dehni et al.

    Salvage reoperation for complications after ileal pouch-anal anastomosis

    Br J Surg

    (2005)
  • P.P. Tekkis et al.

    Long-term results of abdominal salvage surgery following restorative proctocolectomy

    Br J Surg

    (2006)
  • M. Raval et al.

    Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis

    Ann Surg

    (2007)
There are more references available in the full text version of this article.

Cited by (2)

Presented in part at the 108th National Congress of Surgery of the French Association of Surgeons (AFC), October 2–6, 2006, Paris, France, and to the 15th World Congress of The International Association of Surgeons, Gastroenterologists (and Oncologists), May 25–28, 2006, Madrid, Spain.

View full text
Copyright © 2009 Mosby, Inc. All rights reserved.