VM22 - Implications of Intra-Mesenteric Dissection in the Setting of Pouch Surgery

Purpose/Background: A restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is used for patients with medically refractory ulcerative colitis, leading to improved quality of life and functional outcomes. Research indicates that there is a 4.3-8.5% rate of pouch failure. In the last seven years, the IBD Center at NYU has performed 235 primary pouch surgeries and 226 redo pouch surgeries.

Methods/Interventions: Pouch redo is undergone in three steps. The first step involves creating a thoughtful ileostomy, 15-20cm upstream of the current pouch, which may act as the enterotomy for the new pouch anal anastomosis at the time of eventual redo. Since the mesentery has lengthened over time, this loop of bowel can easily be flipped into the pelvis with adequate reach. At the second stage, the pouch is redone or revised and a diverting loop ileostomy is created. The third stage is reversal of the ileostomy.

Results/Outcomes: If an intramesenteric dissection is performed, and the mesorectum is left behind, there is limited space in the pelvis. External compression of the pouch can result in symptoms of obstructive defecation, stricturing, and/or fistulizing disease. These patients are often labeled as having Crohn's disease when the problem is, in fact, mechanical. Stasis and bacterial overgrowth can also lead to pouchitis. We find residual mesorectum in ~25% of our redo patients. This video highlights two examples of such patients.

Conclusion/Discussion: Intramesenteric dissection was initially described in the pediatric surgery literature and is now being reintroduced in the setting of transanal pouch surgery. We believe that this technique can cause complications and favor a total or near total mesorectal dissection.