The Feasibility of a Laparoscopic Approach to Re-operative Ileoanal J-pouch surgery

Sami Chadi, MD, Ido Mizrahi, MD, Steven D Wexner, MD, PhD, Hon. Cleveland Clinic Florida, Weston, FL

Introduction: Restorative proctocolectomy with ileal J-pouch-anal anastomosis is the current standard of care for reconstructive surgery in most patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The current available literature has described successful outcomes for re-operative surgery with both abdominal and perineal approaches. There are no previous series that have demonstrated the feasibility of a laparoscopic assisted approach to management of various pouch-related complications

Methods and Procedures: The objective of this single surgeon case series was to establish the feasibility of a laparoscopic assisted approach in patients presenting to a tertiary care center with pouch-related conditions necessitating re-operation. Patient demographics and outcomes were retrospectively collected from an IRB approved prospective database and from IRB approved chart review.  All procedures were performed by a single surgeon with extensive expertise in laparoscopy and pouch-related complications.

Results: Between 2013 and 2015, 9 reoperative pouch procedures were performed on 7 patients (1 FAP, 6 UC) with a mean age of 37 years and BMI of 25kg/m2 (20-32). The median time from the prior procedure was 532 (2-2438) days. Procedures included laparoscopic assisted pouch revision or repair (7/9), laparoscopic pouch excision (2/9). Mean operative time was 236 (107- 430) minutes. All 9 procedures were performed with 1 camera and 3 instrument ports. One pre-emptive conversion was made in this series due to the extent of pelvic fibrosis precluding safe dissection. Most (8/9) procedures were completed with placement of an intra-abdominal drain.  2 patients developed postoperative pelvic fluid collections, both of which were successfully drained through percutaneous imaging techniques. Median length of stay was 7 (3-24) days). All patients with an anastomosis were diverted with a loop ileostomy and stomas were eventually reversed in all 7 patients.

Conclusion: Reoperative pouch surgery is sometimes necessary to revise or resect a pouch. In cases of extensive inflammation, a laparoscopic approach may not be feasible.  To our knowledge, this is the first series to demonstrate the utility and feasibility of a laparoscopic approach in patients with pouch-related complications. 

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