We had an uneventful total colectomy and ileoanal J-pouch anastomosis for a 65 years old lady, who was a known case of Ulcerative colitis. She received medical treatment for more than 12 years and come with bleeding. She came back 12 weeks later with peritonitis and we found a 2 cm tear in the junction of ileum and pouch. What is the explanation for this? Is there anybody who have some experience with such cases?
Well I'm not a surgeon, but according to our resident surgeon that I should this, it could be that there was ischemic tissue caused by the J-pouch anastomosis leading to bleeding.
Thank you for response,but the perforation occurred 12 weeks later!!!!
No,but at operation we had a 2-3 cm tear with clean but not sharp margin.Pouch had good color.
Is this a type of back wash ileitis?Is there any report of pouch perforation with back wash ileitis?
1.)The perforation may be connected with anal sphincter hypertonicity. Has the patient chronic anal fissure? Did you measure anal sphincter pressure?
2.)He did not want to make the patient himself can defecation. This condition may increase intraluminal pressure . So perforation may be occured.
Please ask to the patient with telephone:
1. Do you have chronic anal fissure
2.When defecation request,did you block defecation? It may increase intraluminal bowel pressure.
Most of us do a loop ileostomy after ileal pouch anal anstamosis to divert the faecal stream thus reducing the chances of leak or ischemia and infection.where exactly was the perforation?If it is at anatamotic level likely cause is ischemia or it may be due to an abscess which gave way in to the pouch.I dont think that hypertonic sphincter is the cause,more over we do need a good continent sphincter in these patients otherwise their QOL becomes miserable.
I saw and examined the patient again this morning.She had not any problem in anus before,also I did not find and sign for chronic anal fissure.
Diverting ileostomy may not be essential in female patients but personaly I decidede to do diverting loop ileostomy for every body after that.
Is there any possibility this could be due to an assault? A clean tear at that pouch-ileal junction in a 3 month old pouch is extremely unusual. This will not be ischaemia as this area is quite proximal and the blood supply to it has not been tampered with. I have not seen increased intra-luminal pressure cause a perforation unless there is a closed loop, whcih she doea not appear to have. I think you need to gently enquire about the possibility of assault, or has she herself pushed anything into her pouch.
Is it a big J-pouch? I only do a 5 cm long pouch in my practice now to prevent pouchitis, since one of my patient developed a delayed perforation in a 10 cm J pouch after one year.
We asked about the assault ,but patient refused to had any type of anal intrusion. I can not understand Ischemic mechanism for the perforation after 2-3 months.
Our pouch had 10 cm length.Dear Dr. lee did you find the cause of perforation in your patient?Had your patient diarrhea for a longer time because of a smaller pouch?
I went in, closed the perforation and converted the pouch to smaller size. Path showed pouchitis and the patient recovered. No bowel frequency and he was fine ten years later. Now a day I would use one GIA and do a 5 cm pouch and after six months most patients do fine with their bowels.
In my Department (about 350 proctocolectomies at all) 3 cases of late perforation (>6 weeks) were occurred, no clear reason was found.
We hipotetized, that the potential risk factor can be tension of the pouch. Of course we need avoid of tension during anastomisis, but during healing processes (adhesions, fibrotic reaction, peristaltic activity) the tension is possible. Good confirmation how the fibrotic reaction can be severe can be stricture of anal-pouch anastomosis in some patients.
Of course when we exclude other factors as pathology in the wall, no full thickeness of the wall during stapling, ischemic leasions)
any sign of ileitis at that site? (pre-pouch ileitis, misdiagnosed CD ...). Was the loop angled?
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