IS IT REALLY SMALL BOWEL OBSTRUCTION IN PATIENTS WITH PARADOX AFTER IPAA?
Principal Author: Jorge Silva, MD1
Co-authors: Tracy Hull, MD2, Luca Stocchi, MD2, Emre Gorgun, MD2
1
Reasearch Fellow, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.
2
Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.
Purpose: The etiology of outlet obstruction in patients with ileal J pouch-anal anastomosis (IPAA) is multifactorial
and can depend on structural abnormalities, anal or pelvic floor muscle spasm, or anal strictures. Diagnosing this
problem after IPAA can be challenging. The aim of this study was to assess possible factors associated with outlet
constipation from paradox (Px) after IPAA unrelated to strictures or structural abnormalities.
Methods: All patients with Px after IPAA inclusive of Px pressures on anal physiology were identified from our
prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other anatomic
abnormalities were excluded. A number of demographic, clinical and perioperative factors were tested for possible
association with Px, including prior abdominal operations, history of pouchitis, need for anal intubation, diagnosis of
small bowel obstruction (SBO) and radiological findings at the time of Px diagnosis.
Results: There were 40 patients (17 females) with overall mean age of 39 years (range 17-60), and mean follow-up
of 15 (range 1-28) years since IPAA creation. Pathologic diagnoses at the time of IPAA were ulcerative colitis
(n=27), indeterminate colitis (n=11), Crohn’s disease and familial adenomatous polyposis (1 case each). A total of
15/40 (37%) patients were diagnosed with SBO before their Px diagnosis, 8 of whom underwent surgery, which
revealed diffusely dilated small bowel without intraoperative identification of any transition point. Time from IPAA
creation to Px diagnosis was significantly longer in patients receiving a diagnosis of SBO than in the remaining Px
patients (7.2 vs. 2.6 years, p <0.001). No other factors were significantly associated with Px.
Conclusions: Patients with IPAA can develop Px, which can be mistaken for SBO. Therefore, Px should be
considered in the differential of IPAA patients without classic findings of mechanical SBO.