Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.
Dis Colon Rectum. 2019 Aug;62(8):1014-1019. doi: 10.1097/DCR.0000000000001403.
A restorative proctocolectomy with an IPAA is the surgical treatment of choice for medically refractory ulcerative colitis. Until now, a pouch volvulus has been considered a rare complication, only described in case reports and small case series. The aim of this technical note was to develop a standardized approach to allow a minimally invasive treatment.
First, an endoscopic decompression of the pouch is attempted. Subsequently, an exploratory laparoscopy is performed. If the endoscopic decompression was successful, a complete laparoscopic reduction is feasible. Once the integrity of the pouch is confirmed, a bilateral pouchopexy is performed, using multifilament interrupted sutures. Finally, the pouch patency is tested by pouchoscopy.
Between December 2010 and December 2018, 151 minimally invasive restorative proctocolectomies with an IPAA were performed. Eighty-nine IPAAs were constructed with the mesentery positioned anteriorly, 35 posteriorly, and 27 on the right side. Three patients were diagnosed with an IPAA volvulus. All 3 of the patients were in the anterior group (3.4%) compared with 0 patients in the nonanterior group. One patient (33%) was treated laparoscopically, after a successful endoscopic reduction. In the other 2 cases, conversion to a laparotomy was needed because an endoscopic decompression could not be achieved.
An endoscopic decompression was required to allow a laparoscopic treatment, and a bilateral pouchopexy was needed to avoid recurrence. This standardized approach might be a good treatment option, and we are awaiting additional follow-up to determine its long-term durability. In addition to the already described risk factors (minimally invasive technique, female sex, and low BMI), an anterior positioning of the pouch mesentery might be a potential risk factor as well for pouch volvulus. However, these observations should be carefully interpreted, considering the small number of cases.
回肠贮袋肛管吻合术（IPAA）是对药物治疗无效的溃疡性结肠炎的首选手术治疗方法。到目前为止，贮袋扭转被认为是一种罕见的并发症，仅在病例报告和小病例系列中有所描述。本技术说明的目的是制定一种标准化的方法，以便进行微创治疗。
首先，尝试对贮袋进行内镜减压。随后进行探查性腹腔镜检查。如果内镜减压成功，则可行完全腹腔镜复位。一旦确认贮袋完整，就使用多股间断缝线行双侧贮袋固定术。最后，通过贮袋镜检查测试贮袋通畅性。
2010 年 12 月至 2018 年 12 月，共进行了 151 例微创 IPAA 直肠切除术。89 例 IPAA 采用前位肠系膜，35 例采用后位肠系膜，27 例采用右侧肠系膜。3 例患者诊断为 IPAA 扭转。所有 3 例均在前位组（3.4%），而非前位组无 1 例（0%）。1 例（33%）患者经内镜减压后成功行腹腔镜治疗。另外 2 例因内镜减压无法实现而需要转为开腹手术。
需要内镜减压以允许腹腔镜治疗，需要双侧贮袋固定术以避免复发。这种标准化的方法可能是一种很好的治疗选择，我们正在等待更多的随访结果以确定其长期耐久性。除了已经描述的风险因素（微创技术、女性、低 BMI）之外，贮袋系膜的前位定位也可能是贮袋扭转的潜在危险因素。然而，考虑到病例数量较少，这些观察结果应谨慎解释。
