Pouch Inlet Research Articles

Unraveling Twisted Pouch Syndrome: A Narrative Review of Classification, Diagnosis, Treatment, and Prevention.

We recently described a cluster of symptoms known as twisted pouch syndrome that rarely affects patients with ileoanal pouches. Herein, we present a narrative review in which we describe the diagnosis, treatment, and preventionof twisted pouch syndrome, with a focus on a simple classification schema. Diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies are presented. Patients with twisted pouch syndrome suffer from a triad of obstructive symptoms, erratic bowel habits, and pain which may besevere, debilitating visceral pain, all in the setting of a mechanical pouch abnormality. Diagnostic modalities include imaging, careful pouchoscopy, functional testing, diagnostic laparoscopy or laparotomy, and recently 3-dimensional pouchography. Classification of twisted pouch syndrome is based on the location and degree of rotation of the pouch and its mesentery. Outlet twists mayresult when the distal pouch rotates >90° to 360° clockwiseinadvertently during anastomosis; when only the distal most pouch is twisted, it results in an iris-like deformity of the pouch outlet, or when the distal half of the pouch is twisted, a mid-pouch stenosis and an hourglass-shaped pouchmayresult. Inlet twists are either a full 360° (mesentery posterior), unintentional 180° (mesentery anterior), or90° counterclockwise twists. Both inlet and outlet twists are fixed deformities and may only be reduced by disconnecting the entire pouch from the anus. If they result in twisted pouch syndrome, a redo pouch procedure or pouch excision is required to reduce the twist;90° counterclockwise twists may undergo pouch inlet transposition. Adhesive twists result when the pouch becomes fixed in the pelvis in an abnormal configuration, such as when the efferent limb becomes twisted underneath the afferent limb secondary to an occult tip of the J leak, and may be reduced by pelvic adhesiolysis with or without pouch revision. Pouches may rarely be inadvertently twisted during construction or twisted owing to adhesive disease or leaks. A high index of suspicion is needed to establish the diagnosis. We present a simple classification of twisted pouch syndrome that may aid in the prevention and recognition of these often difficult to diagnose postoperative complications.

Endoscopic therapy of stoma closure site strictures in ileal pouches is safe and effective.

Strictures are a common complication after ileal pouch surgery with the most common locations being at the anastomosis, pouch inlet, and stoma closure site. No previous literature has described endoscopic therapy of stoma site stricture. This study aimed to assess the safety and efficacy of endoscopic therapy in the treatment of stoma closure site strictures. Patients diagnosed with stoma closure site strictures following ileal pouch surgery who underwent endoscopic treatment at the Center for Colorectal Diseases, Inflammatory Bowel Disease (IBD), and Ileal Pouch between 2018 and 2022 were analysed. Primary outcomes (technical success and surgery-free survival) were compared between endoscopic balloon dilation (EBD) and stricturotomy and/or strictureplasty. A total of 30 consecutive eligible patients were analysed. Most patients were female (66.7%) and most patients were diagnosed with IBD (93.3%). Twenty patients (66.7%) had end-to-end anastomosis. A total of 52 procedures were performed, with EBD in 16 (30.8%) and stricturotomy and/or strictureplasty in 36 (69.2%). The mean stricture length was 1.7 ± 1.0 cm. Immediate technical success was achieved in 47 of 52 interventions (90.4%). During a mean follow-up of 12.7 ± 9.9 months, none of the patients underwent surgical intervention for the stricture. Fourteen (46.7%) required endoscopic re-intervention for their strictures with an interval between index and re-interventional pouchoscopy of 8.8 ± 6.3 months. Post-procedural complications were reported in 2 (6.7%) with bleeding and none with perforation. Upon follow-up, 20 (66.7%) patients reported improvement in their symptoms. EBD and endoscopic stricturotomy and/or strictureplasty are safe and effective in treating stoma closure site strictures in patients with ileal pouches, providing symptomatic relief in most patients as well as avoiding surgery.

Structured versus non-structured reporting of pelvic MRI for ileal pouch evaluation: clarity and effectiveness.

Given that ileal pouch-anal anastomosis (IPAA) surgery is a technically challenging and high-morbidity procedure, there are numerous pertinent imaging findings that need to be clearly and efficiently communicated to the IBD surgeons for essential patient management and surgical planning. Structured reporting has been increasingly used over the past decade throughout various radiology subspecialties to improve reporting clarity and completeness. We compare structured versus non-structured reporting of pelvic MRI for ileal pouch to evaluate for clarity and effectiveness. 164 consecutive pelvic MRI's for ileal pouch evaluation, excluding subsequent exams for the same patient, acquired between 1/1/2019 and 7/31/2021 at one institution were included, before and after implementation (11/15/2020) of a structured reporting template, which was created with institutional IBD surgeons. Reports were assessed for the presence of 18 key features required for complete ileal pouch assessment: anastomosis (IPAA, tip of J, pouch body), cuff (length, cuffitis), pouch body (size, pouchitis, stricture), pouch inlet/pre-pouch ileum (stricture, inflammation, sharp angulation), pouch outlet (stricture), peripouch mesentery (position, mesentery twist), pelvic abscess, peri-anal fistula, pelvic lymph nodes, and skeletal abnormalities. Subgroup analysis was performed based on reader experience and divided into three categories: experienced (n = 2), other intra-institutional (n = 20), or affiliate site (n = 6). 57 (35%) structured and 107 (65%) non-structured pelvic MRI reports were reviewed. Structured reports contained 16.6 [SD:4.0] key features whereas non-structured reports contained 6.3 [SD:2.5] key features (p < .001). The largest improvement following template implementation was for reporting sharp angulation of the pouch inlet (91.2% vs. 0.9%, p < .001), tip of J suture line and pouch body anastomosis (both improved to 91.2% from 3.7%). Structured versus non-structured reports contained mean 17.7 versus 9.1 key features for experienced readers, 17.0 versus 5.9 for other intra-institutional readers, and 8.7 versus 5.3 for affiliate site readers. Structured reporting of pelvic MRI guides a systematic search pattern and comprehensive evaluation of ileal pouches, and therefore facilitates surgical planning and clinical management. This standardized reporting template can serve as baseline at other institutions for adaptation based on specific radiology and surgery preferences, fostering a collaborative environment between radiology and surgery, and ultimately improving patient care.

S55 Pouch Enteroliths Resulting in Stercoral Hemorrhage: An Extremely Rare Complication of a Chronic Rectal Cuff Stricture in an Ileoanal Pouch

Case: Background: Enterolithiasis in the bowel is a rare condition. Less than 30 cases of enterolithiasis in Crohn's disease patients have been reported. Within the medical literature, a single case of pouch enteroliths has been reported. Herein, we described an extremely rare case of a patient with pouch stricture and enteroliths. Case: A 65-year-old male with morbid obesity, coronary artery disease, and a history of pulmonary embolism presented to the outpatient office endorsing 15-18 non-bloody liquid bowel movements daily, abdominal pain and cramping for 2 months. He denied nausea, vomiting, weight loss. He has a history of presumed ulcerative colitis s/p IPAA in 1988 and his diagnosis transitioned to Crohn’s disease for known pouch-anal anastomotic stricture requiring serial dilations for the past twenty years. He was on no biologics. His last pouchoscopy was performed 12 months prior and revealed stricture at the anus and stricture at the pouch inlet without pouchitis. Of note, several months prior to being seen he had a lower GI hemorrhage from the cuff requiring several transfusions. During his office visit, findings were notable for severe stenosis of the anal canal on digital rectal exam. CT enterography demonstrated a stricture at the pouch inlet with active inflammation, mild mucosal hyperenhancement of the lower pouch extending into the anus concerning for pouchitis, and perianal soft tissue stranding without discrete fistula tract identified. He was taken to the operating room for a pouchoscopy which identified a long 5 cm rectal cuff which was strictured and dilated. Upon dilation, a large amount of liquid stool was lavaged endoscopically to decompress the pouch; after further lavage, half a dozen large enteroliths with sharp edges were removed with a Roth net, snare, and ring forceps. Further pouch intubation was performed to the inlet stricture, which was endoscopically passable. Strictures were both biopsied and revealed chronic active enteritis with ulceration and pyloric gland metaplasia, negative for granulomas or dysplasia. In the follow-up, the patient was started a 3-month taper of budesonide with plan to restart biologics in the future if a response was seen on endoscopy. Pouchoscopy was repeated one week after budesonide was started; the procedure revealed worsening inflammation of the afferent limb. No enteroliths were found. Patient is planned for further surgical discussion and staged intervention with diverting ileostomy, leading to possible pouch excision in the future. Discussion: Strictures will form in up to 40% in patients with Crohn’s disease and may lead to obstructive symptoms, but also fecal stasis - the most important factor in the development of enteroliths. Studies have shown that enterolithiasis in Crohn’s disease occurs only in patients with a long history of mainly untreated symptoms of between 7 and 40 years. Thus, it is critical that rectal cuff strictures be managed surgical to avoid complications by experts, for patients to keep up with endoscopic surveillance, as well as referral to a colorectal surgeon for further management of the strictures to avoid the development of this uncommon complication.

Measurement of Disease Activity of Pouchitis.

Pouchitis is the most common inflammatory complication in ulcerative colitis patients undergoing postoperative construction of an IPAA. Pouchitis refers to a spectrum of diseases, and as such, it lacks a universally accepted definition as well as validated instruments to measure disease activity and treatment response. Assessing pouchitis activity is challenging, and methods for diagnosis and classification of severity of pouchitis are not universally agreed upon. Pouchitis is characterized by a constellation of clinical symptoms, including increased stool frequency, urgency, incontinence, bleeding, and rarely constitutional symptoms such as malaise and low-grade fever. However, these symptoms are subjective, and similar symptoms can be caused by noninflammatory conditions including anal sphincter dysfunction, anastomotic strictures, occult leaks, pouch inlet obstruction, and cuffitis. Objective scores that include endoscopic and histologic criteria have been developed for subjects with an IPAA. However, these instruments are not validated for measuring pouchitis disease activity and are associated with a number of challenges. In addition, the clinical components of the scores correlate poorly with endoscopic and histologic findings. There is a need for prospective studies to facilitate the development and validation of novel instruments that are valid, reliable, and responsive to change that would facilitate the development of therapeutic agents for the treatment of pouchitis.

The Surgical Management of Ileal Pouch Strictures.

Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn's disease. Pouch stricture is a common complication after IPAA. This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm. A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed. Randomized controlled trials, cohort studies, observational studies, and case reports were considered. Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included. Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques' including resection and reconnection, strictureplasty, or bypass. Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection' or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience. Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.

S0695 Appropriateness of Medical and Surgical Treatments in Patients With Chronic Inflammation of the Ileal Pouch: A RAND Panel Approach

INTRODUCTION: The optimal treatment of chronic inflammatory pouch disorders remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in patients with these disorders. METHODS: The appropriateness of medical and surgical treatments in patients with pouchitis was considered in 16 clinical scenarios incorporating pouchitis symptoms, antibiotic response, prepouch ileitis (PI) (extending >10 cm proximal to pouch inlet) and Crohn's disease (CD)-like complications. Appropriateness of permanent ileostomy was considered in 8 additional scenarios. Using the RAND/UCLA modified Delphi method, 13 international inflammatory bowel diseases experts rated appropriateness of treatments on a 1–9 scale (1–3 inappropriate, 4–6 uncertain, 7–9 appropriate) via a web-based survey, then met to discuss and re-rate scenarios. Disagreement was assessed using a validated index; scenarios with disagreement were rated as uncertain. RESULTS: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and was otherwise inappropriate (Table 1). Ileal-release budesonide was rated appropriate in 6/16 (38%) scenarios including patients with extensive PI but no CD-like complications. Its use was considered inappropriate (5/8) or uncertain (3/8) in the presence of CD-like complications. Probiotics were considered inappropriate in 14/16 (88%) and uncertain in 2/16 (12%) scenarios. Biologic therapy was considered appropriate in 14/16 (88%) scenarios and uncertain in the absence of extensive PI or CD-like complications (12%). Permanent ileostomy was considered appropriate in 3/16 (19%) scenarios including symptomatic patients with extensive PPI and CD-like complications (Table 2). In patients refractory to all medical treatments, permanent ileostomy was considered appropriate in all scenarios except in asymptomatic patients with no CD-like complications. CONCLUSION: In the presence of extensive PI or CD-like complications, chronic antibiotics and probiotics are inappropriate. Ileal-release budesonide is appropriate in patients who have chronic pouchitis with extensive PI but no CD-like complications. Biologic use is appropriate in patients with chronic pouchitis except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most patients who have failed all medical treatments.Table 1.: Appropriateness of medical and surgical treatments in patients with chronic pouch inflammationTable 2.: Appropriateness of a permanent ileostomy in patients with chronic pouch inflammation who have failed antibiotics, ileal release budesonide, probiotics and biologics

Afferent limb syndrome after total proctocolectomy and ileal pouch-anal canal anastomosis

BackgroundSmall bowel obstruction (SBO) is a common postoperative complication of ulcerative colitis (UC). There have been a few recent reports of afferent limb syndrome (ALS) as a rare occurrence in cases of SBO. We present a case of ALS with recurrent SBO that was successfully managed surgically.Case presentationWhen this male patient was 55 years old, he underwent laparoscopy-assisted anus-preserving total proctocolectomy, the creation of a J-type ileal pouch, ileal pouch-anal canal anastomosis (IPAA), and creation of ileostomy for intractable UC. Three months later, ileostomy closure was performed. The first onset of SBO was observed 5 months after ileostomy closure. SBO occurred repeatedly, and the patient was hospitalized nine times in approximately 2 years. Each SBO was improved by non-surgical treatment. A computed tomography (CT) scan revealed that the afferent limb was narrowing and twisted, and gastrografin enema confirmed narrowing at the proximal portion of the pouch inlet. Endoscopy showed a sharp angulation at the pouch inlet. We suspected ALS and decided on a surgical policy and performed pouchopexy and ileopexy to the retroperitoneum by suturing with excision of the remaining blind end of the ileum. Endoscopy 3 days after surgery showed neither twist nor stricture in the fixed ileal pouch or the afferent limb. At the time of writing, the patient remains free of SBO symptoms.ConclusionClinicians should consider ALS when examining a patient with recurrent intermittent SBO after IPAA surgery. When ALS is suspected, the patient is indicated for surgery such as surgical pexy.

P002 Endoscopic Characteristics and Prognosis of Pouchitis Involving the Pouch Inlet in Patients With Inflammatory Bowel Disease

BACKGROUND: In patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or the development of neoplasia, and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for those with colitis. However, pouchitis can develop in up to 80% of patients after the surgery and significantly impairs quality of life. Despite the high prevalence of pouchitis, endoscopic phenotypes have not been clarified. This study assessed the frequency of and risk factors for inflammation involving the pouch inlet. METHODS: This is a retrospective single-center study of IBD patients treated by total proctocolectomy with IPAA and who subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different anatomic areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. This analysis evaluated all available pouchoscopies and included any patient who had inlet inflammation noted at least once. Demographic and clinical data were also assessed. Log-rank test was used for a univariate analysis to assess factors contributing to pouch excision. Cox proportional hazard regression analysis was performed as a multivariate analysis including univariate variables with a p-value < 0.10. RESULTS: We reviewed 1,081 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 188 patients (44%) with pouchitis involving the inlet. Of these patients, 62% were men, 89% were Caucasian, mean age at diagnosis (SD) was 24 ± 11 years, and mean BMI 26 ± 5. The included patients had pre-pouch diagnoses of ulcerative colitis (165; 89%), indeterminate colitis (14; 7.5%), and Crohn’s disease (7; 3.8%) as the diagnosis before surgery. Twenty-five percent (47/188) had inlet stenosis and 33% (62/188) had pouch-anal anastomotic stenosis. Compared with the cuff, the rate of ulcerations was higher in the pre-pouch ileum and inlet (27.1% vs 42% and 66%, respectively). After a mean of 12 years of follow-up, the overall prevalence of pouch excision was 14% (25/188). Multivariate analysis identified that inlet stenosis significantly predicted pouch excision (HR = 2.92; 95% CI = 1.24-6.86; p = 0.014), whereas anastomotic stenosis was not a significant predictor (HR = 1.48; 0.64-3.42; p = 0.36). CONCLUSION(S): Inlet inflammation and stenosis is present in a significant number of IBD patients with pouchitis, and stenosis in particular is associated with pouch excision. There is a pressing need to understand the causes and develop treatments of this complication.

657 Ulceration of the Pre-Pouch Ileum in Patients With Ulcerative Colitis Following Proctocolectomy With Ileal Pouch-Anal Anastomosis: An Analysis of Pouchoscopies From 272 Patients

INTRODUCTION: Colectomy is required in up to 30% of patients with ulcerative colitis (UC) due to medically refractory disease or development of dysplasia/cancer. In such cases, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgery of choice. However, pouchitis may occur in up to 80% of patients and significantly impairs quality of life. Pouchitis usually spares the pre-pouch ileum, however, a subset of patients develops discrete ulcerations in the pre-pouch ileum despite a firm preoperative UC diagnosis. The prevalence of such findings and predictive factors have not been adequately studied. We report a large cohort of patients undergoing pouchoscopies and describe the prevalence of pre-pouch ileal ulcerations. METHODS: This is a retrospective single-center study of adult patients with UC who had a total proctocolectomy with IPAA and subsequently underwent pouchoscopy between January 2007 and August 2018. At our institution, pouchoscopies are performed using a standard operating protocol. These reports include detailed descriptions of the mucosa as well as high definition images of the different areas of the pouch, the pre-pouch ileum, the pouch inlet, forward view of the pouch, a retroverted view of the pouch, and the rectal cuff. Based on these images and descriptions, we characterized pouch phenotypes and ulcer locations. Patient demographic and clinical data were also assessed. RESULTS: We reviewed the pouchoscopies of 272 patients who underwent proctocolectomy with IPAA for a pre-operative diagnosis of UC. Characteristics of the patients included median age 39 years (IQR 30.2-50.7), median BMI 25 (IQR 22.5-28.6), 90% Caucasian, 59% men, 23% ex-smokers and 83% extensive colitis prior to colectomy. 18% of our patients had discrete ulcerations in their pre-pouch ileum. In a multivariate analysis including age, sex, BMI, disease extent, race, ex-smoking status, prior treatment with anti TNFs or immunomodulators, history of PSC and previous infection with C. diff, none of these factors were associated with pre-pouch ileal ulcers (Table 1). CONCLUSION: Despite a firm diagnosis of UC prior to colectomy, 18% of patients at our tertiary center were found to have discrete ulcers in their pre-pouch ileum. We did not identify predictive factors in this patient cohort, but the potential impact of these findings suggests that proactive post-operative monitoring may be helpful.

Surgical solutions for refractory J-pouch inlet obstruction.

Many surgeons consider total proctectomy with ileal pouch-anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients. A retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal-pouch anastomosis for J-pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra-operative findings, type of surgical intervention and postoperative outcomes. Surgical interventions were performed on eight patients with J-pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarilyanastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow-up of 36.5months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred. J-pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J-pouches being performed, awareness of novel surgical techniques is important.

Standardising assessment and documentation of pouchoscopy

Background/aimsVariation in quality of reporting on endoscopic procedures is a common clinical problem. Findings are not documented in a standardised manner and there is a tendency towards reporting abnormal findings...

A Systematic Review: The Management and Outcomes of Ileal Pouch Strictures.

Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and stoma-free living. Pouch strictures are a complication with a reported incidence of 5-38%. The three areas where pouch strictures occur are in the pouch inlet, mid-pouch and pouch-anal anastomosis. To undertake a systematic review of the literature and to identify management strategies available for pouch-anal, mid-pouch and pre-pouch ileal strictures and their outcomes. A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was performed. Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded. Twenty-two articles were considered eligible. Pouch-anal strictures have been initially managed using predominately dilators which include bougie and Hegar dilators with various surgical procedures advocated when initial dilatation fails. Mid-pouch strictures are relatively unstudied with both medical, endoscopic and surgical management reported as successful. Pouch inlet strictures can be safely managed using a combined medical and endoscopic approach. The limited evidence available suggests that pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical revision or resection. Management of mid-pouch strictures requires a combination of medical, endoscopic and surgical management. Pouch inlet strictures are best managed using a combined medical and endoscopic approach. Future studies should compare different treatment modalities on separate stricture locations to enable an evidenced-based treatment algorithm.

Afferent Loop Syndrome

Introduction: Distal small bowel obstruction following ileal pouch anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent loop syndrome (ALS). It is characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive. Case Presentation: A 33-year-old female with original diagnosis of ulcerative colitis (UC) underwent a 3 stage total proctocolectomy (TPC) and IPAA in 2014 for medically refractory UC. She had chronic complaints of abdominal bloating, intermittent nausea, vomiting and diarrhea starting one year after closure of stoma. She was treated with nasogastric tube placement and antibiotics intermittently without significant relief of symptoms. In the current encounter, patient presented to the hospital with nausea, vomiting, abdominal pain and cramping. A pouchoscopy was performed, which showed a normal pouch body and cuff. However there was a sharp luminal angulation 20 cm above pouch inlet, where attempted passage of flexible sigmoidscope failed, for which an afferent loop syndrome (ALS) was considered. Defecography showed a 180-degree kink in the afferent limb of the pouch approximately 18 cm above the anal verge correlating with the findings of pouchoscopy. Exploratory laparotomy was performed with extensive lysis of adhesions and plication of afferent loop of the small intestine to the anterior abdominal wall to prevent rotation into the pelvis. Patient experienced a significant improvement in her symptoms after the surgical correction of ALS. Discussion: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with UC who require surgery. Small bowel obstruction is one of the common complications after IPAA. When a patient presents with recurrent intermittent obstructive symptoms after IPAA, then we recommend considering ALS and conducting both endoscopy and abdominal imaging for the diagnosis. Bypass of the obstructed segment from the distal ileum to the pouch has been attempted. Due to risk of recurrent afferent limb angulation, pouchopexy may also be considered.

Single-Center Experience on the Use of Vedolizumab for the Treatment of Inflammatory Conditions of the Ileal Pouch: 2016 ACG Presidential Poster Award

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is the surgical treatment of choice in patients with ulcerative colitis. Pouchitis is the most common complication after IPAA and its treatment has not been standardized. Vedolizumab has been used in the treatment of ulcerative colitis but its use in inflammatory conditions of the pouch has not been evaluated. Retrospective chart review was performed on patients with IPAA and pouchitis in our institution who had been exposed to vedolizumab. Pouchitis was confirmed by evaluation of clinical, endoscopic, and laboratory parameters. We identified 4 patients with ulcerative colitis who underwent restorative proctocolectomy with IPAA and were exposed to vedolizumab after IPAA. A Caucasian male with IPAA and pouch repair/reconstruction and a history of chronic untreated pouchitis developed moderate pouchitis mainly affecting the proximal pouch, refractory to antibiotics, adalimumab and infliximab. He achieved complete mucosal healing one month after four vedolizumab infusions (See Figures). A Caucasian male with recurrent pouchitis refractory to steroids, antibiotics, adalimumab and certolizumab pegol developed prepouch ileitis and pouch inflammation suggestive of Crohn's disease (CD) that responded to three vedolizumab infusions along with antibiotics with mucosal healing after one month. A Caucasian female intolerant to infliximab and adalimumab developed CD of the pouch requiring diverting loop ileostomy due to anal pain. Seven months later she developed pouchitis that responded to three vedolizumab infusions and steroids with repeat pouchoscopy after two weeks revealing scant/rare pouch ulcerations and anal-IPAA stricture. A Hispanic female developed proximal pouch and pouch inlet inflammation and cuffitis refractory to antibiotics and adalimumab. She received five vedolizumab infusions, and methotrexate was initiated four weeks after the first vedolizumab infusion. She did not respond to vedolizumab and repeat pouchoscopy one week after the last infusion revealed deep pouch ulcerations and cuffitis. ESR and CRP decreased after treatment in 3 out of 4 patients (See Table). Vedolizumab was successful in the treatment of inflammatory conditions of the pouch in three out of four IPAA patients. Inflammatory markers improved in three out of four patients. Further studies are needed to examine its potential role for treating refractory pouchitis.Table 1: Endoscopic and inflammatory marker response to vedolizumab treatment. Repeat endoscopic findings and laboratory values obtained 3-6 months after medication induction phase.Figure 1Figure 2

Outcomes with Anti-Tumour Necrosis Factor-Alpha Therapy and Serology in Patients with Denovo Crohn's Disease After Ileal Pouch Anal Anastomosis.

A subset of patients who undergo ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC] will later be diagnosed with denovo Crohn's disease [CD]. These patients have a higher risk of pouch failure. In this study we evaluated inflammatory bowel disease [IBD] serology in patients with denovo CD and examined the success of anti-tumour necrosis factor-alpha [anti-TNFα] therapy in preventing ileostomy in denovo CD patients who failed anti-TNFα therapy before IPAA. A prospectively maintained database of patients undergoing IPAA was reviewed to identify patients who developed denovo CD [defined as small bowel inflammation above the pouch inlet or pouch fistula/perianal disease appearing more than 3 months after stoma closure]. Clinical characteristics and IBD serology were analysed. Treatment failure was defined as pouch failure requiring ileostomy or pouchectomy. Of 350 patients included in the study, 92 [26%] patients developed denovo CD. Significantly more denovo CD patients had anti-I2 positivity postoperatively versus preoperatively [p = 0.007]. Anti-TNFα therapy successfully treated denovo CD in 28 out of 38 [74%] patients. Out of 17 patients with denovo CD who had failed to respond to anti-TNFα agents before surgery and were treated with anti-TNFα therapy after surgery, 12 [71%] patients responded to treatment. I2 serology may possibly help identify patients who have developed or are at risk for developing denovo CD. Anti-TNFα therapy for denovo CD after IPAA can help prevent permanent ileostomy in almost 75% of cases, even in patients who previously failed anti-TNFα treatment before surgery.

Frequency, manifestations and management of bezoars in ileal pouches

Background and AimTo evaluate the frequency, diagnosis and management of ileal pouch bezoars.MethodsPatients diagnosed with ileal pouch bezoars at the Pouch Center at Cleveland Clinic from 2002 to 2013 were included. Demographic, clinical and endoscopic features, management and outcomes were evaluated.ResultsTwelve patients with ileal pouch bezoars were enrolled, including five (0.4%) of 1390 patients with J‐pouch and seven (13.0%) of 54 with continent ileostomy (P &lt; 0.001). Males accounted for 25% (n = 3) of the cohort. Mean age at time of detection was 61.5 ± 10.3 years. Of the 12 patients, six (50.0%) had phytobezoars, four (33.3%) had lithobezoars, one (8.3%) had pharmacobezoar and one (8.3%) had a retained‐Jackson‐Pratt drain. Median number of harvested bezoars was one (range: 1–224), and mean diameter was 4.0 ± 2.4 cm. Bezoars were located at the pouch body in eight (66.7%) patients, pouch inlet in two (16.7%), pouch‐anal anastomosis in one (8.3%) and efferent limb in one (8.3%). Ten patients (83.3%) were symptomatic, including seven (58.3%) with partial bowel obstructive symptoms. Eleven patients (91.7%) were initially managed with endoscopic treatment including basket, RothNet®, mechanical lithotripsy Tripod and snares. After a median of one (1–3) endoscopic therapy, bezoars were successfully removed in seven patients (58.3%). Surgical intervention was required in the remaining five patients (41.7%).ConclusionsIleal pouch bezoars appeared to be more frequently encountered in patients with continent ileostomies than in those with J‐pouches. Endoscopic management seemed to be effective in some patients, whereas surgical intervention was needed in others.

Prophylactic surgery in familial adenomatous polyposis (FAP)--a single surgeon's short- and long-term experience with hand-assisted proctocolectomy and smaller J-pouches.

Prophylactic proctocolectomy with an ileoanal neo-reservoir is the established procedure in non-attenuated familial adenomatous polyposis (FAP). Traditionally, the ileal J-pouch is created by doubling 15cm of the terminal ileum. Pouch inlet problems are not infrequently encountered in longer pouches. On this rationale, this series reports on the functional outcome and quality of life (QoL) following standardized construction of a shorter J-pouch with a limb of 8-9cm length. All patients of a single-surgeon series with FAP who underwent hand-assisted laparoscopic proctocolectomy and small ileal pouch-anal anastomosis as the primary procedure between 10/2005 and 04/2010 and responded to the questionnaire were included and retrospectively analyzed. A total of 46 patients (78%) out of the consecutive series who underwent operation in this period were included in the study. After a mean follow-up of 38months, 40/46 patients (87%) did not report any incontinence and 3 patients (6.5%) complained about occasional nocturnal incontinence (3 failed to answer this question). The mean stool frequency per 24h was 6.25. No significant difference was encountered between the QoL outcome of our patients versus the German normative population. Comparable results were achieved in a study analyzing the long-term results in FAP patients with a 15-cm pouch. Smaller, 8-9cm J-pouches show excellent functional results both in short- and in long-term results. The hand-assisted procedure was safe and no conversions were required. QoL is equal to a normative population, as it is in a series of patients with larger J-pouches.

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

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.

Surgical Stricturoplasty in the Treatment of Ileal Pouch Strictures

ObjectiveThe objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures. MethodConsecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses. ResultsA total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6±13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2±0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (p = 0.019). After a mean follow-up of 4.1±2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (p < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups. ConclusionSurgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.