Posterior transsacral approach: an alternative for the resection and reconstruction of severe ileoanal anastomotic strictures1

Ileoanal pouch anastomosis is widely regarded as the operation of choice in the surgical management of ulcerative colitis and familial adenomatous polyposis, but this procedure still carries high rates of longterm complications. Among them, the occurrence of an ileoanal anastomotic stricture is a common problem that usually can be solved with two or three dilation sessions. Some patients present with severe strictures for which repeated dilatations have failed and report persistent pouch outlet obstruction, which mandates more sophisticated therapeutic methods. Little has been reported about such cases and their surgical correction. Possibilities are often limited by the anatomic features of the stenosis: thickness, length, and distance from the dentate line, which make endoscopic and transanal approaches difficult or worthless. On the other hand, complete abdominoanal revision may appear to be a very aggressive procedure in this context, providing no guarantee of improved function and requiring a temporary loop ileostomy. We describe a technique of ileoanal anastomosis partial reconstruction, using a posterior sacral approach, that may be regarded as the next therapeutic step for severe strictures when simple transanal procedures have failed. METHODS