Transanal Endoscopic Pouch Revision, Transsection of Obstructive Pouch Hemidiaphragm. We have the following disclosures. Rarely, ilioanal pouch patients may suffer from obstructive defecation secondary to anatomic anomalies such as pouch septums. After a thorough workup, a reedy pouch patient with severe obstructive defecation was diagnosed with a pouch hemidiaphragm which was flap valving and obstructing the proximal pouch. These endoscopic screenshots demonstrate the pouch hemidiaphragm which was flap valving and obstructing her defecation. Other testing included fluoroscopic and cross-sectional imaging with the blue arrows denoting the diaphragm. We also performed 3D pouchography using the CT scan with rectal contrast and here we see what appears to be a full thickness obstructing defect in the lower pouch. Diagnostic pouchoscopy had previously been performed revealing a healthy pouch without evidence of enteritis or Crohn's-like disease of the pouch and a retroflex view revealing a partially obstructing hemidiaphragm. In the setting of an examination or under anesthesia with a pudendal block, a pouchoscopy was performed and the septum margin staying centrally and away from the wall of the pouch was marked with a needle knife. A septotomy was then performed using both the needle knife and an electro-surgical instrument and approximately 12 clips were used for hemostasis to re-approximate the bowel wall. The first step was using endoscopic clips to mark the margins of our planned septotomy. This was done at either end of the planned resection and here we see a clip being placed on the opposite corner of the diaphragm. Next, an insulated needle knife was used to mark the resection margins again staying centrally and away from the pouch wall laterally. Here we are marking the septum in the retroflexed manner and you can see the pouch septum hemidiaphragm pushing against the scope in a retroflexed manner simulating the obstructive defecation. Here we see a screenshot of the clips at the corners. We next use the uninsulated needle knife to mark the extent of the resection from below. As you'll see throughout the video, we use a combination of approaching the septum from both above and below. After the planned resection is marked from below, the full thickness needle knife resection of the pouch hemidiaphragm then ensues. As expected, the field is somewhat bloody is somewhat bloody and one of the things we learned from this case is that in the future we will probably use some epinephrine at the beginning. Here we see an electrosurgical instrument inserted transanally to begin to resect more of the pouch septum and this also helps with hemostasis. Here we see a portion of the pouch septum actually being resected. We continue with the electrosurgical resection marching along the pre-marked area to avoid straying too lateral to the pouch wall on the side. We double check everything using retroflex to assure that we're staying within our planned resection margin. Next we use a needle knife to continue to start the resection from above and then again transition to an electrosurgical instrument to continue the resection full thickness. A retroflex view shows that we've made quite a lot of progress and we continue with the initiating the resection using the needle knife and then completing it using the electrosurgical device. Again significant bleeding is observed which is controlled by using both the needle knife as well as the electrosurgical device and ultimately clips. We next insert the electrosurgical device back transanally and now observe the resection from above in the retroflex view. This is really helpful to make sure that we're staying central on the diaphragm and not straying too laterally out onto the side of the bowel wall. After the resection is complete we use some electrocordery to obtain hemostasis as well as having already placed some clips and we then inspect the area looking for defects in the bowel wall and additional clips are placed for both hemostasis and to re-approximate the bowel edges. We can see that the resection has resulted in a widening of the lumen by resecting the obstructing hemidiaphragm. Here we see we have good hemostasis and re-approximation of the bowel with additional clips. The case took about an hour and a half and over half the diaphragm was resected with a blood loss of about 100 cc's. The patient was discharged the next day without complications and reported complete resolution of her symptoms by the next morning with four to seven bowel movements with no urgency or sensation of incomplete evacuation. Pathology revealed changes consistent with prolapse. Transanal endoscopic pouch revision is a minimally invasive option for obstructing pouch septums and hemidiaphragms. Patients and surgeons should be prepared to divert the patient at the time of the revision should concerns for intraoperative perforation arise.

transanal endoscopic pouch revision

obstructive ilioanal pouch

pouch septum

minimally invasive surgery

post-procedural recovery