LigaSure-Assisted Transanal Division of a Pouch Septum: A Stapler is Not Always the Answer

Background:
For medically refractory ulcerative colitis (UC), total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical intervention of choice. A rare complication of ileoanal pouch creation is a pouch septum, which results from incomplete firing of the stapler during initial pouch construction. This rarity has thus far been managed with division by a surgical stapler or endoscopic needle knife therapy in the literature.
Methods:
This is a case report of a patient who presented with ileoanal pouch septum that was treated with LigaSure-assisted transanal division of the septum.
Results:
We present the case of a 73-year-old male with history of medically refractory UC who underwent 2-stage proctocolectomy and IPAA in 1988. He presented to our institution 35 years later with an 8-month history of intermittent obstructive symptoms, prolapse, fecal incontinence and blood per rectum. Pouchoscopy at his home institution showed pouch body prolapse and a mucosal bridge in the distal pouch, which were thought the cause of his pouch dysfunction. CT enterography showed a severely dilated pouch with narrowing by the pouch outlet. 3D pouchography and defecography demonstrated hypermotility of the dilated pouch, anastomotic narrowing that impaired pouch emptying, and an area of contrast extravasation concerning for a defect in the pouch. Anorectal manometry indicated above average resting and squeeze pressures consistent with high pelvic floor tension. An in-office pouchoscopy at our institution showed pouch septum and otherwise a tight sphincter without stricture. He was admitted shortly after presentation and was planned for anorectal examination under anesthesia and operative exploration. Intraoperatively, the proximal and distal aspects of the pouch septum were identified easily, but the EndoGIA stapler (Covidien, Medtronic, USA) was unable to be advanced past the small aperture of the anus. No stricture was present at the anus or ileoanal anastomosis. We instead used the LigaSure device (Covidien, Medtronic, USA) to divide the pouch septum, and any exposed defects in the muscularis propria were closed with resolution clips (15 total were used). Subsequently an exploratory laparotomy, lysis of adhesions and diverting loop ileostomy was performed. Postoperative recovery was uneventful. Gastrografin enema 6 months later showed no leak or obstruction, and his ileostomy was reversed without complication. On most recent follow up 7 months from septum division, his pouch function is excellent with drastic improvements in pouch emptying and continence.
Conclusions:
We present a novel method for the division of pouch septum that is feasible and safe, if a surgical stapler is not an option. As the incidence of pouch septum increases with more long-term follow up on IPAA patients, LigaSure-assisted transanal division of pouch septum is a strategy available in the ileoanal pouch surgeon’s toolbox.