Presented as a poster at the Digestive Disease Week, New Orleans, LA, May 1–5, 2010.
Diagnosis and management of afferent limb syndrome in patients with ileal pouch-anal anastomosis†
Article first published online: 26 OCT 2010
Copyright © 2010 Crohn's & Colitis Foundation of America, Inc.
Inflammatory Bowel Diseases
Volume 17, Issue 6, pages 1287–1290, June 2011
How to Cite
Kirat, H. T., Kiran, R. P., Remzi, F. H., Fazio, V. W. and Shen, B. (2011), Diagnosis and management of afferent limb syndrome in patients with ileal pouch-anal anastomosis. Inflamm Bowel Dis, 17: 1287–1290. doi: 10.1002/ibd.21503
- Issue published online: 10 MAY 2011
- Article first published online: 26 OCT 2010
- Manuscript Accepted: 24 AUG 2010
- Manuscript Received: 30 JUL 2010
- Key Words;
- afferent limb;
- ileal pouch-anal anastomosis;
- restorative proctocolectomy
Distal small bowel obstruction following ileal pouch-anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent limb syndrome (ALS). The aim of this study is to report our experience in diagnosis and management of ALS in patients with IPAA.
All patients with ALS after IPAA were identified from prospectively maintained databases. Demographic, clinical, endoscopic, and radiographic features together with its management and outcome were studied.
Eighteen patients (12 female) were included. The mean age was 35.6 ± 14.3 years. Most patients presented with intermittent obstructive symptoms. Fifteen patients were diagnosed by pouch endoscopy with features of angulation of the pouch inlet and difficulty in intubating the afferent limb; 12 patients had kinking or narrowing of the pouch inlet identified with abdominal imaging. The median follow-up was 1.3 (range, 0.14–16.1) years. Nine patients underwent empiric balloon dilatation of the afferent limb/pouch inlet. Of nine, four needed repeat dilatations. One patient with repeat dilatation ultimately had pouch excision; another has been scheduled for surgery after failed repeat dilatations. Eight patients underwent surgery, resection of angulated bowel (n = 3), pouchopexy (n = 2), pouch mobilization with small bowel fixation (n = 1), and pouch excision (n = 2). One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy.
ALS was characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive. (Inflamm Bowel Dis 2011;)
Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with ulcerative colitis (UC) who require surgery and some patients with familial adenomatous polyposis (FAP). Small bowel obstruction is one of the common complications after IPAA.1–5 In addition to the adhesions and strictures, distal small bowel obstruction can be caused by afferent limb obstruction. Read et al6 studied six patients with afferent limb obstruction and recommended that afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from the distal ileum to the pouch has been attempted. Due to risk of recurrent afferent limb angulation, pouchopexy may also be considered. However, this study included small number of patients and there has been no other study specifically reporting outcomes in patients with afferent limb syndrome (ALS), which has been defined by Shen et al7 as distal small-bowel obstruction caused by an acute angulation, prolapse, or intussusceptions of the afferent limb at the junction to the pouch. There are no specific studies in the literature on the clinical features and management strategies for patients with ALS. Therefore, we aimed to report our experience regarding presentation and management of ALS in patients with IPAA.
PATIENTS AND METHODS
All patients who had obstructive symptoms and diagnosed with ALS after primary IPAA performed at our institution or elsewhere and were treated in the Pouchitis Clinic and Department of Colorectal Surgery at the Cleveland Clinic were identified and the study was approved by the Cleveland Clinic Institutional Review Board.
Inclusion and Exclusion Criteria
ALS patients with an acute angulation, prolapse, or intussusception of the afferent limb at the junction to the pouch diagnosed by endoscopic or radiologic means were included. Those with IPAA presenting with obstructive symptoms due to adhesions, intraluminal strictures, or fibrostenotic Crohn's disease (CD) were excluded.
Definition of Afferent Limb Syndrome and Diagnostic Modality
Afferent limb syndrome was defined as distal small-bowel obstruction caused by an acute angulation, prolapse, or intussusception of the afferent limb at the junction to the pouch (Fig. 1), in the absence of intraluminal mucosa-associated strictures. Data were abstracted from Pouch Clinic and Pouchitis Clinic databases as well as patients' electronic medical records.
Demographic and clinical variables were evaluated, including age, gender, details of primary IPAA, symptoms due to partial small bowel obstruction, and endoscopic and radiological findings. Radiographic findings to diagnose ALS were acute angulation or prolapse at the level of distal afferent limb or pouch inlet with or without proximal small bowel dilation. Diagnosis of ALS was also made on endoscopy when it was found to be difficult to intubate the afferent limb, because of the sharp angulation between the afferent limb and pouch.
Management and Outcome
Once ALS was diagnosed, endoscopic balloon dilation therapy was performed. All dilatation procedures were performed by one investigator (B.S.) who has extensive experience in endoscopy using a GIF scope. Typical through-the-scope balloon size was 20 mm with or without guidewire. We performed endoscopic dilation without fluoroscopy. Balloon was inflated for 5–10 seconds. Postprocedure findings to suggest benefit was opening of the neoterminal ileum and inlet. Details of endoscopic therapy and operations for ALS and pouch survival were evaluated.
Categorical variables were summarized as frequencies and percentages. Quantitative variables were reported as mean ± SD or median (range).
Demographic and Clinical Presentation of Afferent Limb Syndrome
There were a total of 18 UC patients with ALS after IPAA. During the study period the pouchitis database included 931 patients with IPAA. Therefore, the frequency of this condition was 1.9% (18/931). Twelve were female. The median age was 34.5 (range, 16–60) years at the time of IPAA. Precolectomy diagnosis was UC in 17 patients and inflammatory bowel disease unclassified in 1. The median duration of disease was 18 (range, 5–38) years. Extent of disease was extensive colitis in 12 and left-sided colitis in six. One patient had concurrent primary sclerosing cholangitis. Ten patients had primary IPAA constructed elsewhere. Twelve patients had a 2-stage IPAA, while six patients underwent 3-stage IPAA. Pouch configuration was “J” in 14 and “S” in 4 patients. Information on type of anastomosis was available in 13 patients (stapled IPAA = 9, hand-sewn IPAA = 4). The median time from construction IPAA to last follow-up was 5.3 (range, 2.5–19.9) years.
Patients presented with intermittent obstructive symptoms including recurrent intermittent abdominal pain (n = 15), bloating (n = 4), constipation (n = 4), and perianal pain (n = 1). Some patients had more than one symptom (Table 1).
|Total number of patients||18|
|Median age, years||34.5 (range, 16–60)|
|Referred from other institutions||10|
|Recurrent intermittent abdominal pain||15|
|Constipation or dyschezia||4|
|Small bowel series||1|
Diagnosis of Afferent Limb Syndrome
In 15 patients, angulation of pouch inlet and difficulty in intubating the afferent limb was detected at pouchoscopy. In 12 patients kinking or narrowing of the pouch inlet were identified using water-contrasted pouchogram (n = 10), defecography (n = 1), or small bowel series (n = 1) (Table 1). In two patients, radiographic examination did not show ALS despite the finding at pouchoscopy. In 10 patients the afferent limb obstruction was diagnosed using both radiologic examination and pouchoscopy.
Management of Afferent Limb Syndrome
Of 18 patients, 9 underwent balloon dilatation. Size of the balloon used was 20 mm. Median number of sessions for dilatation was 1 (range, 1–4). Of the nine undergoing dilatation, four needed repeat dilatations. One patient with dilatation was lost to follow-up. One patient with repeat dilatation ultimately had pouch excision per patient's preference; another has been scheduled for surgery due to failure after repeat dilatations. Median follow-up for the six patients with successful dilatation was 1.03 (range, 0.14–2.5) years (Table 2).
|Resection of angulated bowel||3|
|Pexy of the pouch||2|
|Pouch excision with end ileostomy||2|
|Mobilization of pouch with small bowel fixation||1|
Eight patients needed surgery including resection of angulated bowel (n = 3), pexy of the pouch (n = 2), pouch excision with end ileostomy (n = 2), and mobilization of pouch with small bowel fixation (n = 1) at the time of stoma closure (Table 2). In patients with bowel resection and those with pexy of the pouch, lysis of extensive adhesions in the pelvis was also performed. One patient with a bowel resection had loop end ileostomy at the time of surgery for ALS and later on underwent closure of end ileostomy. Both the pouch excisions were performed as per patient preference due to persistent obstructive symptoms. After excluding two patients with pouch excision, six patients who underwent surgery for ALS did not develop recurrence of the symptoms after a median follow-up of 2.7 (range, 1.3–16.1) years. One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy. The last patient diagnosed with ALS was lost to follow-up.
Small bowel obstruction has been reported as one of the most common complications after IPAA.1–5 Distal small bowel obstruction can be caused by afferent limb syndrome. Herein, we described our experience regarding presentation and management of ALS in 18 patients with UC undergoing IPAA at our institution or elsewhere.
We defined ALS as acute angulation, prolapse, or intussusceptions of the distal ileum just proximal to the pelvic pouch causing complete or high-grade partial obstruction. Therefore, we did not include patients with other pathologies such as stricture causing obstruction at the pouch inlet in this study.
It has been suggested that afferent limb obstruction occurs due to a loop of ileum just proximal to the pelvic pouch becoming trapped posteriorly between the sacrum and the pouch.6 Read et al6 reported six patients with ALS and stated that afferent limb obstruction should be suspected in patients with recurrent obstructive symptoms after IPAA. Similarly, most patients in our study presented with recurrent intermittent abdominal pain due to recurrent obstruction. Read et al found that contrast small bowel series and enemas were suggestive of the obstruction in four of six patients; the most common finding was small bowel dilatation to the level of the pouch. In our study, angulation of pouch inlet and difficulty in intubating the afferent limb was detected at pouchoscopy in most patients. In 12 patients, kinking or narrowing of the pouch inlet could be identified using pouchogram, defecography, or small bowel series.
There are scant data in the literature on diagnosis of ALS. Nakagoe et al8 described a technique using omental pedicle graft to fill the pelvic dead space to prevent small bowel obstruction and the subsequent afferent limb obstruction. They used this technique in four patients undergoing IPAA and none of these patients developed any signs of bowel obstruction after surgery. Therefore, they recommended this simple technique as safe adjunct to IPAA.
In terms of treatment, Tjandra and Fazio9 from our institution stated that pexy of the afferent limb and side-to-side anastomosis, when division of adhesions is extremely hazardous, are preferable techniques for patients with afferent limb obstruction following IPAA. Read et al6 also reported that all patients in their study underwent laparotomy for unresolved obstruction due to afferent limb obstruction. One patient underwent ileostomy only due to deep pelvis and dense adhesions, while the others had enteroenterostomy. Although they found that bypass of the obstructed segment from distal ileum to the pouch was safe and effective treatment, they suggested concurrent pouchopexy due to the risk of recurrent afferent limb angulation. Of note, they did not report the use of any endoscopic treatments prior to surgery. Although four patients needed repeat dilatations in the current study, one with dilatation ultimately underwent a pouch excision and another has been scheduled for surgery due to failure after dilatation, ultimately six patients had successful balloon dilatation of the afferent limb without the need for surgery. In theory, the endoscopic balloon dilation may only work in patients with intraluminal or intrinsic strictures. However, some of our patients with ALS responded to the endoscopic therapy. A possible explanation behind this could be disruption of intermittent intussusception or due to the unkinking of the bowel due to surgical adhesion bands outside the bowel lumen in the area of pouch inlet or distal pouch. Therefore, our results suggest that an endoscopic approach be applied before surgery is undertaken.
Eight patients had surgery including resection of angulated bowel, pexy of the pouch to the pelvic sidewall, pouch mobilization and small bowel fixation, and pouch excision with end ileostomy. Decision on pexy of the pouch versus resection of angulated bowel was based on surgeon's preference or severity of the inflammation and adhesion. During the study period, involvement of different surgeons might explain the differences in surgical techniques used. In two patients indication for pouch excision was patient preference. Although bypass of obstructed segment was not used in our study patients, it may be an option with good outcomes for patients with ALS when it is performed with concurrent pouchopexy.6 When dealing with a patient with ALS, we suggest that persistent obstructive symptoms, despite endoscopic therapy, would be the criteria for surgery.
There are limitations to our study. We have a biased patient population, as the vast majority of patients from the pouchitis clinic had some sort of pouch disorders. Also, this complication after IPAA is rare; therefore, our study included only 18 patients. However, considering that this series comprises the largest in the literature, the findings from this study could be helpful to diagnose and manage ALS in patients suffering from recurrent obstructive symptoms. Further studies reporting a larger number of patients with longer follow-up may be needed to evaluate long-term outcomes after therapy for this complication of IPAA.
In conclusion, ALS should be suspected in patients that present with persistent obstruction symptoms following IPAA. A combined assessment of endoscopy and abdominal imaging is essential to establish the diagnosis of ALS. Endoscopic or surgical intervention is often required.
- 9Complications of the ileoanal pouch. In: MazierWP, LuchtefeldMA, LevienDH, SenagoreAJ, eds. Surgery of the Colon, Rectum, and Anus. Philadelphia: WB Saunders; 1995: 893–903.,