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A 36 years old female diagnosed with Gardner Syndrome underwent a proctocolectomy by laparoscopy with a J pouch for the treatment of colonic polyposis. Since then she has had three episodes of small bowel obstruction, the first one 5 years after surgery caused by adhesions and required surgical treatment by open approach. The second, 9 years after, due to herniation of the pouch through the mesentery, also solved by laparotomy with reduction of the hernia and fixation of the pouch to the retroperitoneum. The patient was asymptomatic for one year until she was admitted to the emergency room suffering from abdominal pain, distention and absence of bowel movements. There was little pain at physical examination and blood test were normal, the X-Ray showed a huge dilatation of the small bowel without gas at the pelvis (FIG. 1) . With a high suspicion of another episode of bowel obstruction a CT-Scan was performed demonstrating a volvulus with a twisted mesenterium and normal mucosa (FIG. 2, 3).
Minimally invasive treatment was attempted with a colonoscopy but failed for being unable to pass through the torsioned zone, the pouch was gigantic so surgical treatment was mandatory by laparotomy (FIG. 4). The pouch was twisted once again, a rectal tube was placed with the help of the surgeons that controlled the passage of the stenotic area achieving the decompression and relocation of the pouch, a running suture was performed at the mesenteric defect to prevent new herniation episodes.
Postoperative course was satisfactory and the patient left the hospital without complications. Last follow-up was two months after surgery and the patient tolerates her usual diet and has regular bowel movements, she was proposed to re-do the pouch in the case of a new episode of occlusion.
FIG 1. Rx Dilated Pouch.
FIG 2. Gauge Change.
FIG 3. Twisted mesentery.
FIG 4. Gigantic pouch found at surgery