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Afferent Limb Efferent Limb and the Koch Pouch (for CC)-SD

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So, this is actually a picture I took from when I went on a trip to India. He's looking at me. We call this "Owl eye anatomy." When we go in to do the pouch endoscopy we can see the nice little, " Owl's eye" One eye is leading to the small bowel, and one is leading to the tip of the J in the pouch dome. With sharp demarcations. With a sharp beak. A little bit of ulceration around the beak in the pouch body is normal. In our community we try not to biopsy that because there are staples or a suture line under that. If you biopsy somebody with what is called a fallen body granuloma, it is easy to confuse with a Crohn's disease granuloma. We try not to biopsy the face. Occasionally it can cause trouble because the ulcers can cause bleeding. On the low end is all the disruption of the "Owl's eye anatomy." On a scope you can see asymmetrical eyes. You can see an ulcer there and that patient has a high risk for pouch failure. 3x more than a patient who has a normal looking pouch. Owl's eye anatomy. Now here is called an "S pouch." We will talk about what is called Efferent Limb Syndrome and Afferent Limb Syndrome. For the "S pouch" the inlet is here and the outlet is here. The pouch volume is a little bit bigger than in a "J pouch." Then sometimes when you come in with the endoscopy it can be hard and difficult to intubate and put the scope through. This pouch is angulated which is no problem. But this patient has a problem because in here it is angulated. Being angulated can cause an obstruction. If you use a gastro-graph enema to go upwards and see that there is angulation here and you cannot pass a scope through. Those things typically need surgical corrections. These patients typically have the largest experience of having pouch revision surgery. Now here is called Efferent Limb Syndrome. E means out, A means in. A means in, E means out. Efferent Limb Syndrome now remember we talked about the "S pouch" having a 2cm stump. In Efferent Limb, this is too long. This patient has 7cm which is too long and it's angulated. Liz: "So its supposed to be vertical?" Yes, and shorter. After surgical corrections, it is shorter. This one was done by Dr. Remzi many years ago. This is shorter. So that if they have angulation there the harder you push to have a bowel movement, the harder it is to get the stool out. They struggle and it's counterproductive. So this is called Efferent Limb Syndrome. The pouch surgery is a very delicate surgery. You need really technical expertise for that. I don't want it to be too short and I don't want it to be too long. Either way, what's the fine line? You need that technical experience. Now here is what we call a "Twisted pouch." So now we find out that sometimes if a surgeon discovers that the pouch body is harder to reach the anus on the same plane, then they do this way. They twist in order to reach that area. Now here is a pouch that was corrected by a surgeon and untwisted. This was done in an open procedure…open procedure. Because, actually to untwist the pouch is not simple. Every time you go through the pelvis there is so much scar tissue and adhesions. And now we have the "Kock pouch." This is what the Kock pouch looks like. This is the outside and this is called the nipple valve. This patient doesn't need to have any type of outside appliance. You can put a bandage there and that's okay. It can't leak because of the valve function. Here is my scope and its looking at the back of the valve here. The valve prevents the stool from coming out. So then you put a catheter there to let the stool out. The problem with the Kock pouch sometimes is that the nipple valve gets narrow because of repeated trauma. Some patients after many years of having the surgery and the abdominal wall having scars and if the nipple valve gets angulated it can be hard to intubate and causes trauma. So here we've developed a technique where we do a needle knife endoscopy to cut it open and make the valve bigger. The nipple valve can stricture which we can treat with the endoscopic balloon dilation. For the people with the refractory, hard stricture sometimes we use the needle knife procedure. We take the tip of the knife with electricity and you cut and cauterize at the same time. Cauterize, stop the bleeding, cauterize and stop the bleeding.

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Duration: 6 minutes and 35 seconds
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Language: English
License: Dotsub - Standard License
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Views: 25
Posted by: ibdgirls on Mar 22, 2016

Afferent Limb Efferent Limb and the Koch Pouch (for CC)-SD

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