AFFERENT LIMB VOLVULUS POST IPAA

Aims Patients operated with total colectomy and ileal pouch anal anastomosis (IPAA) for refractory ulcerative colitis often present with episodes of small bowel obstruction after different period of time post surgically. We present two cases of patients presented with afferent limb obstruction of the pouch.

Methods The first patient is a pregnant female with episodes of intermittent ileal obstruction since the 25^th week of gestation. Initially she was faced with total parenteral nutrition and cesarean delivery and surgical dissolution of adhesions at the 35^th week. Due to worsening of symptoms she underwent endoscopic (pouchoscopy) and imaging study which revealed volvulus of the efferent limb of the pouch.

The second patient due to severe abdominal pain and vomiting she underwent endoscopic and imaging study which revealed complete obstruction of the efferent limb of the pouch and had an operation on emergency basis.

Results The first patient was operated with open laparotomy which showed an incomplete volvulus of the efferent limb due to adhesions of the named loop with the right ovary and fallopian tube as a result of uterus growing size.

The second patient had an emergency operation which showed a complete volvulus of the efferent limb around the mesenteric vessels with concomitant severe ischaemic lesions. After limb volvulus resolution the tissue oxygenation remained enough satisfactory to prevent us for any segmental enterectomy.

Conclusions Small bowel volvulus (efferent limb of the pouch) could be one of the causes for recurrent obstructive episodes in patients operated with IPAA. High level of suspicion and suitable imaging and endoscopic tools will lead to the correct diagnosis. Premature surgical treatment could prevent us from unnecessary small bowel resection.