Deep Infiltrating Endometriosis Affecting Ileoanal Anastomosis (J-Pouch): Surgical Approach

Study Objective

To review a patient case of deep infiltrating endometriosis of an ileoanal anastomosis.

Design

Case report.

Setting

Academic institution, Minimally Invasive Gynecologic Surgery and Colorectal combined procedure.

Patients or Participants

38-year-old with history of ulcerative colitis status post ileoanal anastomosis (J-pouch) with deep infiltrating endometriosis.

Interventions

Robotic-assisted total laparoscopic hysterectomy with bilateral salpingectomy, left oophorectomy, excision of deep infiltrating endometriosis of J-pouch, ureteral ICG injection, and pouchoscopy.

Measurements and Main Results

Patients with endometriosis are at increased risk of co-morbid inflammatory bowel disease. Ileoanal anastomosis is indicated in patients with disease affecting the entire colon and rectum such as ulcerative colitis. The J-pouch is created with an anastomosis of folded terminal ileum following total resection of the colon and rectum. An enterotomy of the pouch and anal anastomosis are then completed, forgoing the need for ileostomy. The primary vascular supply consists of terminal branches of the superior mesenteric artery and is therefore limited. The patient presented with pain and on MRI was found to have deep infiltrating endometriosis of the ileoanal anastomosis approximating 3.2 by 1.0 cm, as well as a left endometrioma. Intra-operatively, the deep infiltrating lesion was identified on the efferent limb on the antimesenteric border of the J-pouch ileum and removed using a shave technique. Care is taken to avoid the vascular supply to the J-pouch on the mesenteric aspect, as no collateral supply is available. An omental pedicle flap was created and secured overlying the pouch to reduce the risk of fistula formation. The patient underwent the procedure without complications.

Conclusion

Patients with endometriosis are at increased risk of comorbid inflammatory bowel disease. Knowledge of J-pouch anatomy is crucial to dissection in cases of endometriosis involvement, including delicate blood supply. The use of an omental flap can be helpful to prevent formation of future adhesions. A multidisciplinary approach is key to patient care.