AFFERENT LIMB OBSTRUCTION COMPLICATING ILEAL POUCH-ANAL ANASTOMOSIS

PURPOSE: Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb a t the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy. METHODS: Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database o f 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. RESULTS: A total of 567 p atients had undergone total proctocolectomy and ileoanal J-pouch at ti me of the study. Of 122 patients with one or more episodes of obstruct ion after IPAA, 48 required operative intervention. Afferent limb obst ruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruct ion (4 of 6 patients). Contrast small-bower series and enemas were sug gestive of obstruction in four of six patients, the most consistent ra diographic finding being small-bower dilation to the level of the pouc h inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterio r to the pouch, causing acute angulation at the pouch inlet. Rather th an risk injury to the pouch or its mesentery, the obstruction was bypa ssed by side-to-side anastomosis of the afferent limb to the pouch (en teroenterostomy) in five of six patients. One patient underwent ileost omy only because of technical considerations. Two patients required re exploration and pexy of the afferent limb to the pelvic sidewall (pouc hopexy) to relieve recurrent afferent limb obstruction. CONCLUSION: Af ferent 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 ris k of recurrent afferent limb angulation, concurrent pouchopexy should be considered.