Read T E, Schoetz D J, Marcello P W, Roberts P L, Coller J A, Murray J J, Rusin L C
Department of Colon and Rectal Surgery, Lahey Hitchcock Medical Center, Burlington, Massachusetts 01805, USA.
Dis Colon Rectum. 1997 May;40(5):566-9. doi: 10.1007/BF02055380.
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.
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.
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.
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.
小肠梗阻是回肠储袋肛管吻合术（IPAA）后常见的并发症。部分需要剖腹手术的患者中，输入袢在储袋入口处急性成角是梗阻的原因。
从Lahey诊所回肠肛管储袋登记处识别患者，该登记处是一个前瞻性计算机数据库，收录了自1980年以来所有接受IPAA的患者。回顾了被确定为因IPAA后输入袢梗阻导致肠梗阻的患者记录。
在研究时，共有567例患者接受了全直肠结肠切除术和回肠肛管J形储袋手术。在122例IPAA后发生一次或多次梗阻的患者中，48例需要手术干预。6例患者（12%）被确定为输入袢梗阻是梗阻原因。最常见的表现是复发性部分梗阻（6例患者中的4例）。6例患者中有4例的小肠造影和灌肠提示梗阻，最一致的影像学表现是小肠扩张至储袋入口水平。所有患者均因梗阻未缓解而接受剖腹手术。术中发现输入袢在储袋后方粘连，导致储袋入口处急性成角。为避免损伤储袋或其系膜，6例患者中有5例通过将输入袢与储袋侧侧吻合（肠肠吻合术）绕过梗阻。1例患者仅因技术考虑接受了回肠造口术。2例患者需要再次探查并将输入袢固定于盆腔侧壁（储袋固定术）以缓解复发性输入袢梗阻。
IPAA后反复梗阻的患者应怀疑有输入袢梗阻。将梗阻段从回肠远端绕过至储袋进行旁路手术是一种安全有效的治疗方法。由于存在输入袢反复成角的风险，应考虑同时进行储袋固定术。
