Endoscopic needle-knife stricturotomy for nipple valve stricture of continent ileostomy (with video)

Abstract

A 65-year-old woman with ulcerative colitis underwent a total proctocolectomy with continent ileostomy in 1981. She developed strictures at the neoterminal ileum, pouch inlet, and nipple valve and required repeated hydrostatic balloon dilatation initially every 3 to 6 months, then every 1 to 2 months, since 2007. From October 2012 to December 2012, she experienced several medical emergencies with “bowel obstruction” while traveling. CT enterography (A) and a gastrograffin enema through the continent ileostomy (B) showed a thick and fibrotic nipple valve stricture (yellow arrow). For the bowel preparation for pouchoscopy, the patient emptied the continent ileostomy with intubation of a drainage catheter. She received intravenous sedation with midazolam and meperidine. Pouchoscopy again showed a tight ulcerated nipple valve stricture, which was not traversable to a GIF scope. The pouch body, which was later intubated after endoscopic treatment, was otherwise normal (C).The nipple valve stricture was treated with an Olympus triple-lumen needle-knife (Olympus Medical Systems, Tokyo, Japan) at a setting of ERCP Endocut on ERBE (USA Incorporated Surgical Systems, Marietta, GA); Doppler US (VTI Vascular Technology, Nashua, NH) was used to guide the needle-knife therapy to identify the area with minimum blood flow. The tight fibrotic stricture was incised longitudinally around the clock (D; Video 1, available at www.giejournal.org). The nipple valve became widely patent after the therapy and was traversable to the GIF scope without resistance. The whole procedure was uneventful. The patient’s bowel obstructive symptoms have been relieved after the procedure. A repeated pouchoscopy was performed 7 months later. The strictured area remained traversable to the GIF scope. This case was enrolled in Institutional Review Board-approved Pouch Registry, and informed consent for the endoscopic procedures was obtained from the patient for each session of endoscopy.