Total coloproctectomy with ileoanal J pouch anastomosis (IPAA) is actually the gold standard therapy for patients with familial adenomatous polyposis (FAP) or ulcerative colitis. It’s associated with an acceptable life quality and a satisfying long-term outcome. However, several complications may be seen. One of these is the ileal J pouch prolapse, which is an extremely rare event. A review of the literature, grouping approximately 25000 restorative coloprotectomies, identified only 11 cases [1] with an incidence less than 0,5 %. Presenting symptoms include external rectal prolapse, incontinence or seepage, impaired evacuation and anal pain [2]. Surgery should be proposed: either a transanal excision of the prolapsed mucosa or a transabdominal fixation of the pouch on the promontory [3].

AIM: Report a new case of an ileoanal J pouch prolapse.


OBSERVATION

It’s a 38 year old male who underwent a stapled restorative coloproctectomy with IPAA for a drug-resistant ulcerative colitis in 2004. The ileostomy reversal was made 3 months later. He made good progress and was followed up regularly. However, within 18 months, he presented a pelvic pain and a sensation of bulging following each bowel movement. A full-thickness prolapse of his J-pouch (figure 1) was diagnosed. The pouch prolapse was confirmed by a poucho-MRI (figure 2) and was found to have an external component that measured 5 cm. It mainly affected the anterior wall of the pouch but was circumferential with a small posterior component. The “take-off” point was approximately at 12 cm from the anus on the anterior wall of the pouch. Endoscopy revealed edematous mucosa without evidence of pouchitis. The patient was operated with middle incision. After adhesions release, surgical correction with a trans-abdominal approach was performed. The J pouch was sufficiently mobilized then fixed
to the sacrum by using a non-absorbable mesh. Our operative salvage technique is based on the procedure commonly used for rectal prolapse. After a nine-months follow-up, he reported an excellent response with no further episodes of pouch prolapse.

FIGURES LEGEND

Figure 1: Clinical exam showing the ileal pouch prolapse.

Figure 2: Pelvic MRI. A: Ileal pouch with a thickened wall. B: Ilealpouchprolapse.

1. S. Galandiuk, N.A. Scott, R. R. Dozois et al. Ileal pouch-anal anastomosis: reoperation for pouch-related complications. Annals of Surgery. 1990;212:446–54.
2. M. Ehsan, R. Billingham, BF Warren. Prevalence and management of prolapse of the ileo-anal pouch. Dis Colon Rectum. 2002;45:6.
3. M. Ehsan, J.T. Isler, M.H. Kimmins, R.P. Billingham. Prevalence and management of prolapse of the ileoanal pouch. Dis Colon Rectum. 2004;47:885–8.