Difference between laparoscopic and robotic assisted laparoscopic and my experience with Dr Shen

I cannot speak regarding the surgeons or surgery type choice.  But, I think I can explain your diagnosis. You do not have an inflammatory mucosal problem. You have a structural dysfunction. Some people have both, so I guess you are lucky in that respect.

First of all, your rectal cuff is twice as long as typical (typical is 1-2 cm). Maybe your surgeon had a problem with the reach of your blood supply, or mayber in 1999 the standards were not as clear. But, I had mine done in 1995 and was told that 1-2 cm was the target for the rectal cuff. This increased length can increase the risk of cuffitis (which you do not have), and it can also change the dynamics of emptying the pouch. A too long cuff can cause the pouch to shift and "flop over," causing outlet obstruction. That could be the second prolapse noted in your report. The long rectal cuff problem is similar to the problems they had with the s-pouch and why it was largely abandoned except in special circumstances.

The other item, circumferential cuff prolapse is sort of like the entire ring of rectal cuff squishing down on itself and the overlapping tissue gathering in the center, narrowing the outlet nearly to obstruction. 

The end result is that the more you strain, the more these prolapses block the exit. The only solution is either irrigation to facilitate emptying (if that works), or surgical repair. If the cuff was not so long, perhaps they could do minimal surgery by tacking the pouch up to the posterior abdominal wall. I don't know. Each case should be evaluated individually.

If it were me, I would choose the surgeon with experience in pouch repair/redo for prolapse, and focus less on the technology. I assume you want to avoid a redo if possible. Unfortunately, intraoperative findings often dictate what is possible and you just cannot know for sure until the surgery is underway.

Oh, and why would Dr. Shen so easily find a prolapse where others did not see it? Experience. Dr. Shen at the pouchitis clinic has seen more j-pouches and their complications than pretty much any other GI I can think of. For all I know, that's all he does. Most GIs see all sorts of GI patients, even if they are IBD specialists. Basically, you do not see what you are not looking for. If you have viewed a limited number of j-pouches, you have few to compare with. You would think other doctors would have ordered a dynamic defacogram to image what was going on inside while you empty. That should have shown something. But, when they stick the scope in there and pump you full of air, everything looks normal, because no pressure from above or gravity is in play. I suspect that Dr. Shen looked for a prolapse based on your history and symptoms.

I hope this helps some. Good luck with your decisions.

Jan

Since the two top pouch surgeons left the Clinic, Dr. Ashburn has become the to go to surgeon (she does Kpouches & Jpouches).  I have not have had any interaction with her, but I hear good things. If Bo Shen recommends her, she's probably very good. But it all comes down to your appointment & feeling.  Best of luck. 

And your right Dr. Shen is one of the best GI's. My GI I had when I lived in Ohio recommended him - so he is a bit famous. Glad you saw him, he is a genius! 

I highly recommend Dr Ashburn simply based on my experience with her over the past 2 weeks. She was involved in my needle knife repair of my mucosal prolapse alongside Dr Shen. She took the time to review my entire history and was able to explain the procedure to repair my prolapse in terms I could understand. She carefully went over all potential problems which may arise during surgery and all possible outcomes. She carefully listened to all of my concerns and responded accordinally. I felt much more reassurred I was in good hands after my pre op appointment with her. Her nurse was also well informed and had wonderful communication skills. Fortunately, all went well during my procedure and I feel far better one week out than I ever anticipated.

Remzi redid my pouch and I had scope with Dr Shen a few months ago and he found a very mild distal pouch prolapse. It was not causing me any issues but noted it. Of course I freaked out but was told if not causing issues then not a concern. Dr Remzi also stated its a non issue so go live life.. I just wonder if these can get worse over time or stay as is? And can they be repaired without losing the pouch if needed?