Dionigi Beatrice, Prien Christopher, Lavryk Olga, Lightner Amy L, Holubar Stefan D, Hull Tracy
Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
Colorectal Dis. 2022 Oct;24(10):1192-1196. doi: 10.1111/codi.16195. Epub 2022 Jun 3.
Minimally invasive approaches to proctocolectomy with ileal pouch anal anastomosis have become the standard of care with one benefit being the reduced risk of adhesion-related complications. However, a lack of pouch adherence to the pelvis can lead to increased mobility as well as volvulization, placing pouch viability at risk. We aimed to describe our institutional experience with pouch volvulus.
Patients who presented with pouch volvulus from 1983 to 2020 were identified through a search of our pelvic pouch registry and enterprise-wide electronic medical record. Pouch volvulus was defined as a reducible rotation of the J-pouch on its mesenteric axis with evidence of a properly oriented ileo-anal anastomosis. Patients with 'twisted pouches' were excluded.
In total, 5760 patients underwent ileal pouch anal anastomosis from 1983 to 2020. Six patients (five women) were identified with a diagnosis of 'pouch volvulus' consistent with our definition. The six pouches were constructed utilizing laparoscopic techniques and the mean time from construction to volvulus was 2.36 years. All patients underwent urgent surgery, with a paucity of adhesions noted in five. Reduction and pouch pexy was performed in three and pouch excision in three, with immediate pouch reconstruction in two and end ileostomy creation in one. At a median follow-up of 9 months, pouch survival was 50%.
Pelvic pouches constructed using minimally invasive techniques may be at risk of volvulus due to reduced adhesion development. A high index of suspicion is warranted in pouch patients with obstructive symptomatology. CT imaging may be diagnostic, and prompt surgical intervention may facilitate pouch salvage.
采用回肠储袋肛管吻合术的微创直肠结肠切除术已成为标准治疗方法，其一个优点是粘连相关并发症的风险降低。然而，储袋与骨盆缺乏粘连会导致活动度增加以及肠扭转，使储袋的存活受到威胁。我们旨在描述我们机构处理储袋扭转的经验。
通过检索我们的盆腔储袋登记册和全企业范围的电子病历，确定1983年至2020年期间出现储袋扭转的患者。储袋扭转定义为J形储袋围绕其肠系膜轴的可复位旋转，且有方向正确的回肠肛管吻合的证据。“扭转储袋”患者被排除。
1983年至2020年期间，共有5760例患者接受了回肠储袋肛管吻合术。6例患者（5名女性）被确诊为符合我们定义的“储袋扭转”。这6个储袋均采用腹腔镜技术构建，从构建到扭转的平均时间为2.36年。所有患者均接受了急诊手术，5例患者粘连较少。3例行复位和储袋固定术，3例行储袋切除术，2例立即进行储袋重建，1例进行末端回肠造口术。中位随访9个月时，储袋存活率为50%。
由于粘连形成减少，采用微创技术构建的盆腔储袋可能有扭转风险。对有梗阻症状的储袋患者应保持高度怀疑。CT成像可能具有诊断价值，及时的手术干预可能有助于挽救储袋。
