Pouch Strictures Research Articles

Three-dimensional Pouchography: A Proof-of-concept Study of a Breakthrough Technique for Visualising Ileoanal Pouch Anatomy and Morphology in Normal and Mechanical Pouch Complication Patients.

Herein, we present a proof-of-concept study of three-dimensional [3D] pouchography using virtual and printed 3D models of ileal pouch-anal anastomosis [IPAA] in patients with normal pouches and in cases of mechanical pouch complications. We performed a retrospective, descriptive case series of a convenience sample of 10 pouch patients with or without pouch dysfunction, who had CT scans appropriate for segmentation who were identified from our pouch registry. The steps involved in clinician-driven automated 3D reconstruction are presented. We included three normal patients who underwent CT imaging and were found to have no primary pouch pathology, and seven patients with known pouch pathology identifiable with 3D reconstruction [including pouch strictures, megapouch, pouch volvulus, and twisted pouches], underwent 3D virtual modelling; one normal and one twisted pouch were 3D-printed. We discovered that 3D pouchography reliably identified staple lines [pouch body, anorectal circular and transverse, and tip of J], the relationship between staple lines, and variations in pouch morphology and pouch pathology. Three-dimensional reconstruction of IPAA morphology is highly feasible using readily available technology. In our practice, we have found 3D pouchography to be an extremely useful adjunct to diagnose various mechanical pouch complications and improve planning for pouch salvage strategies. Given its ease of use and helpfulness in understanding the pouch structure and function, we have started to routinely integrate 3D pouchography into our clinical pouch referral practice. Further study is needed to formally assess the value of this technique to aid in the diagnosis of pouch pathology.

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.

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.

S2251 Liver Abscess Associated With Diverted Ileal Pouch

INTRODUCTION: Pyogenic liver abscess (PLA) is a rare disease with an incidence of 3.6 cases per 100,000 in the United States. There is no existing literature about PLA developing in a patient with UC who had undergone long-term bowel diversion. We present the first case of a patient with chronic pouchitis and recurrent stricture formation, presenting with a PLA. CASE DESCRIPTION/METHODS: 46-year-old female with UC status post-total proctocolectomy with ileal pouch-anal anastomosis (IPAA) at age 22 and loop ileostomy at age 43 presented to an outside hospital with a three-week history of intermittent right upper quadrant abdominal pain and increased non-bloody ileostomy output. Her UC had been complicated by a history of anal fistula, chronic pouchitis and recurrent strictures treated with needle knife stricturotomy (NKSt) every six months. The last NKSt session was four months prior to admission. On presentation, the patient was hypotensive and tachycardia. Labs revealed WBC count of 13,600/mm 3 , hemoglobin 8.8 g/dL, AST/ALT 157/170 IU/L, ALP 95 IU, and total bilirubin 0.9 mg/dL. The patient was started on IV fluids and empiric meropenem. Abdominal ultrasound revealed a liver mass, and abdominal CT showed a 10 cm heterogeneous liver mass concerning for malignancy.The next day she was transferred to our institution for further evaluation. A repeat abdominal CT scan showed a 12.7 cm hepatic abscess with a mass effect on the main portal vein. Liver abscess was drained and fluid cultures were positive for streptococcus anginosus. Patient was discharged on IV meropenem for an additional 3 weeks before being switched to oral amoxicillin-clavulanate for an additional 2 weeks. Three months later the patient underwent surgical excision of the diverted pouch and creation of end ileostomy, to prevent future risk of PLA. DISCUSSION: This report highlights the first case of pyogenic liver abscess in a patient with a long-standing history of diversion pouchitis and recurrent pouch strictures. Previously, twelve cases of PLA associated with UC have been reported. The associated pathogens were usually normal gut flora, such as the Streptococcus anginosus family. In animal models the mucosa in a diverted colon becomes a breeding ground for bacteria, increasing the probability of bacterial penetration through the mucosal barrier. Pouch excision and permanent diversion is necessary if there is pouch failure due to pelvic sepsis, chronic pouchitis or recurrent stricture/fistula formation in the pouch.Figure 1

Endoscopic treatment of early leaks and strictures after laparoscopic one anastomosis gastric bypass

BackgroundLaparoscopic one anastomosis gastric bypass has become a prominent bariatric procedure. Yet, early and late complications, primarily leaks and strictures, are not uncommon. This study summarizes our experience with endoscopic treatment of laparoscopic one anastomosis gastric bypass complications.MethodsThis is a retrospective study of consecutive patients referred to our hospital from 2015 to 2017 with post laparoscopic one anastomosis gastric bypass complications. Therapy was tailored to each case, including fully covered self-expandable metal stents, fibrin glue, septotomy, internal drainage with pigtail stents, through-the-scope and pneumatic dilation. Success was defined as resuming oral nutrition without enteral or parenteral support or further surgical intervention.ResultsNine patients presented with acute or early leaks: 5 (56%) had staple-line leaks, 3 (33%) had anastomotic leaks and 1 (11%) had both. All were treated with stents. Adjunctive endoscopic drainage was applied in 4 patients (44%). Overall 5 patients (56%) with acute/ early leaks recovered completely, including all 3 patients with anastomotic leak and the patient with both leaks but only 1/5 with staple line leak (20%). Complication rate in the leak group reached 22%. Eight patients presented with strictures, 7 at the anastomosis and one due to remnant stomach misalignment. All anastomotic strictures were dilated successfully. However, the patient with the pouch stricture required conversion to Roux-en-Y gastric bypass after 3 failed attempts of dilation.ConclusionEndoscopic treatments of laparoscopic one anastomosis gastric bypass complications are relatively effective and safe. Anastomosis-related complications are more amenable to endoscopic treatment compared to staple line leaks.

Does Age Affect Surgical Outcomes After Ileal Pouch–Anal Anastomosis in Children?

BackgroundYounger children are referred for surgical intervention in the treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Outcome data in this population after a laparoscopic restorative proctocolectomy and Ileal pouch-anal anastomosis (LRS-IPAA) are limited. We reviewed our experience to determine if younger children would have similar functional outcomes. MethodsAfter institutional review board approval, a review of children with FAP and UC undergoing LRS-IPAA at a children's hospital from 2002 to 2017 occurred. The study groups were defined based on age: young group (YG; 5-12 y) and older group (OG; 13-18 y). Data points included demographics, postprocedure course, and outcomes. Statistical analysis was performed. ResultsSixty-five children were identified and grouped by age: YG (n = 22, average age 9 y) and OG (n = 43, average age 15.4 y). Thirteen children in YG had UC, and nine had FAP. Twenty-eight children in OG were diagnosed with UC, and 15 with FAP. After LRS-IPAA, continence, appetite recovery, and use of antidiarrheal medications were not significantly different between groups. The incidence of pouch stricture, diagnosis of pouchitis, and complications were also not significantly different. Two children (YG), aged 11 and 12 y at the time of colectomy, were initially diagnosed with UC and then reassigned as having Crohn's disease because of persistent symptoms. One child, who underwent colectomy at 17 y for FAP, had invasive rectal cancer and died 3 y later from metastatic disease. Time of follow-up for OG is 8-61 mo (average: 37 mo). Period of follow-up for YG is 11-73 mo (average: 43 mo). ConclusionsThere are no significant differences in the functional outcomes between groups after LRS-IPAA. Although numbers are small, these data suggest younger age should not be a deterrent when contemplating LRS-IPAA in the treatment of UC and FAP in the pediatric population. Younger patients with FAP may benefit from early intervention.

Endoscopic Sinusotomy Using Needle Knife Technique for Treatment of H Pouch Sinus

J-shaped pouch is the most common pouch type used in restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) for medically refractory ulcerative colitis (UC). Due to anatomical difficulties, H-shaped pouch is occasionally performed during salvaging surgery for failed J-pouch. Here, we report the first case of an H-pouch complicated with a presacral sinus and successfully treated with needle knife sinusotomy (NKSi). A 62- year-old male with past medical history of UC, status post total colectomy with IPAA referred to our Pouch Center for progressive rectal pain, loose stool, and perianal swelling. Stool studies were negative including Clostridium difficile. A pouch stricture was found on barium enema. Flexible pouchoscopy revealed chronic fistula, abscess, and anastomotic stricture, for which he had exploratory laparotomy, lysis of adhesions, incision and drainage (I&D), extensive takedown of ileostomy, excision of the old J-pouch, excision of anastomotic stricture with creation of H-pouch with mucosectomy, handsewn anastomosis, and diverting loop ileostomy. Routine water-soluble contrast enema and abdominal computed tomography (CT) following surgery showed a pouch anastomotic leak. Pouchoscopy confirmed the deep sinus with thick walls. A wait and watch approach was tried for 2 months without antibiotics. However, repeat pouchoscopy showed a persistent pouch sinus. The decision was made to treat the sinus with endoscopic NKSi, followed by deployment of multiple endoclips along the edges of incised sinus wall. Patient's symptoms improved significantly following the procedure and he remained asymptomatic at 2 months post-procedure. A follow-up water-soluble contrast enema at 2 months showed normal appearing H pouch with no leak. Pouch sinus is a relatively infrequent complication after IPAA but has never been reported in patients with H-pouch IPAA. The ideal management is not well defined yet. In asymptomatic cases, patients are followed with repeat imaging to monitor for sinus healing. In cases where watchful waiting does not work, patients have habitually been treated with surgical interventions. We herein present the first case in the literature of an H-pouch complicated with anastomotic sinus successfully treated with NKSi. We suggest using NKSi as the preferred technique for H-pouch sinuses before performing any invasive surgical procedure.2053 Figure 1. No Caption available.

Efficacy and Safety of Endoscopic Balloon Dilatation of Ileoanal Pouch Strictures.

Colectomy with ileoanal pouch is the standard of care for most patients with ulcerative colitis (UC) who require surgery. However, 5%-38% of patients with ileoanal pouch develop pouch strictures that can severely impact the functional results. We retrospectively evaluated the efficacy and safety of endoscopic balloon dilation of ileoanal pouch strictures in patients with inflammatory bowel disease (IBD). All consecutive patients with IBD that underwent endoscopic balloon dilatation of a pouch stricture at our institution between January 1, 2011, and April 31, 2016, were included. Clinical, endoscopic, and surgical variables were collected retrospectively. Stricture-related pouch failure was defined by the need for surgical management of pouch stricture including pouch excision, diversion ileostomy, or stricturoplasty. Secondary outcomes included technical success, clinical success, and safety. Eighty-eight endoscopic balloon dilatations were identified in 20 patients. Sixty percent of patients were female, with a median age at ileoanal pouch of 28.6 years (interquartile range [IQR], 25.5-37.2). Ileoanal pouch was performed for UC in 95% of cases; 95% of patients underwent J pouch; and 65% had a stapled anastomosis, whereas 35% had a handsewn anastomosis. Strictures were diagnosed at a median of 4.6 years (0.2-10.6) after surgery, and half of patients were symptomatic. The most frequent location of stricture was the anal-pouch anastomosis (87%). Half of patients were found to have associated pouchitis, 4 (20%) had at least 1 fistula, and 5 (25%) had ulcerations of the pouch. At the end of follow-up, 6 patients (30%) underwent a change in diagnosis from UC to Crohn's disease (CD) of the pouch, and in 1 patient (5%) a diagnosis of ischemic stricture was made. A median of 3.5 dilatations per patient (IQR, 2.0-7.0) were performed. Technical efficacy was observed in 87 procedures (98%). Twenty-two procedures were preceded by obstructive symptoms, and a clinical improvement after endoscopic balloon dilatation was observed in 95% of cases. After a median follow-up of 3.0 years (2.1-3.5), only 1 patient had stricture-related pouch failure. After the first dilatation, 4 patients were hospitalized for obstructive symptoms. Conservative management with another endoscopic balloon dilation was clinically effective in all cases. No major complications related to dilation were observed. Endoscopic balloon dilatation of ileoanal pouch strictures is largely effective and safe and can be recommended as the first line strategy to treat ileoanal pouch strictures in patients with IBD.

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.

Preoperative Clostridium difficile Infection Does Not Affect Pouch Outcomes in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-anal Anastomosis.

The operation of choice for patients with chronic ulcerative colitis (CUC) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis is the most common complication after IPAA. The incidence of Clostridium difficile infection (CDI) is higher in CUC patients than the general population and can lead to significant disease flares and higher rates of colectomy. We sought to determine the risk of pouchitis in patients with precolectomy CDI and 90-day postoperative IPAA complications. A retrospective case-control study was conducted on patients with CUC who underwent an IPAA between January 1, 2000 and January 10, 2015. The study cohort was comprised of patients diagnosed with CDI within 90 days before colectomy; patients with CUC without CDI comprised the control cohort. The primary outcome measure was the frequency of pouchitis after IPAA. Secondary outcomes included time to pouchitis, 90-day postoperative pouch morbidity: surgical site infection, hemorrhage, anastomotic leak, fistula formation, pouchitis treatment and response, and pouch failure requiring end-ileostomy or fecal diversion. Univariate and multivariable analysis was used to determine differences between CDI and non-CDI groups. Forty-eight case patients and 154 control patients were included. Patients with preoperative CDI were younger (P = 0.010), had higher rates of medically refractory disease (P = 0.002), and had greater use of biologic therapy (P = 0.046). The rate of pouchitis was 50.0% (n = 24) and 46.8% (n = 72) (P = 0.694) among patients with and without preoperative CDI, respectively. Patients with preoperative CDI who developed pouchitis post-IPAA were more likely to require medical management with an anti-TNFα (P = 0.042) and surgical management with end/diverting ileostomy (P = 0.042). Preoperative CDI was associated with higher rates of postoperative IPAA anastamotic or pouch strictures (P = 0.018). Multivariable analysis revealed primary sclerosing cholangitis (PSC) as the only variable associated with increased risk for pouchitis (OR 10.59; 95% CI, 3.07-51.08; P < 0.001). Preoperative CDI does not seem to be associated with an increased risk of pouchitis in patients with CUC.

Mo1788 - Efficacy and Safety of Endoscopic Balloon Dilation of Ileoanal Pouch Strictures

Mo1788 - Efficacy and Safety of Endoscopic Balloon Dilation of Ileoanal Pouch Strictures

Early Results of Laparoscopic Sleeve Gastrectomy for Treatment of Morbid Obesity : Experience of Surgery Unit 8b- Ain Shams University, Egypt

Background: Sleeve gastrectomy (SG) is a relatively new bariatric procedure with a number of advantages compared with Roux-en-Y gastric bypass. However, SG also has a number of disadvantages and associated risks. We sought to examine perioperative complications and early outcomes of laparoscopic SG (LSG). Patients and methods: Since July 2013, LSG has been performed at surgery unit8B- department of surgery, Ain Shams University, Cairo, Egypt, and we reviewed the cases of all patients. We conducted a retrospective review in September 2015. Results: Forty patients had LSG, and none was lost to follow-up. Indications for LSG over other bariatric procedures were patient preference 80% (n = 32), severe obesity with a body mass index (BMI) greater than 60 kg/m2 (n =5) and severe upper abdominal adhesions (n = 3). 28 patients out of forty were women, while the other 12 were men; and the average age was 38 (standard deviation [SD] 10) years. Preoperatively, the average BMI was 50.3 (SD 7.7) kg/m2. Preoperative obesity-related comorbidity rates were 25% (n = 10) for type 2 diabetes mellitus (T2DM), 50% (n = 20) for hypertension, 20% (n = 8) for dyslipidemia, 10% (n = 4) for obstructive sleep apnea (OSA), 30% (n = 12) for knee and/or hip pain and 37.5% (n = 15) for depression and/or anxiety. The mean duration of surgery was 78 (SD 21) minutes. There were 2 major perioperative complications: 1 staple line leak and 1 gastric pouch (sleeve) stricture. The median stay in hospital was 3 days. Postoperative upper gastrointestinal imaging studies were conducted in all patients; 1 was positive for staple line leak. Histopathology on the excised gastric segments revealed chronic helicobacter pylori gastritis in 4 patients. The mean postoperative follow-up interval was 10 months. Weight loss averaged 28.4 (SD 9.3) kg. Overall weight loss was 3.7 (SD 1.8) kg/month. Resolution occurred in 60% of patients with T2DM, 40% with hypertension, 25% with dyslipidemia, 75% with OSA, 25% with joint pain and 80% with depression/anxiety. Overall satisfaction was rated as excellent by 60% of patients (n = 24), good by 25% (n = 10) and poor by 15% of patients (n = 6). Conclusion: Preliminary analysis of our experience with LSG indicates that this is an effective and safe procedure for the treatment of obesity.

Endoscopic Needle-knife Stricturotomy in a UC Patient with Diverted Ileal Pouch and Anastomotic Stricture

Endoscopic Needle-knife Stricturotomy in a UC Patient with Diverted Ileal Pouch and Anastomotic Stricture

Sa1430 Endoscopic Balloon Dilation of Kock Pouch Strictures

Sa1430 Endoscopic Balloon Dilation of Kock Pouch Strictures

Advanced therapeutic endoscopist and inflammatory bowel disease: Dawn of a new role

Endoscopy plays a key role in the diagnosis and treatment of patients with inflammatory bowel disease (IBD). Colonoscopy has been traditionally used in the diagnosis of IBD and helps in determination of an important end point in patient management, "mucosal healing". However, the involvement of an advanced endoscopist has expanded with innovations in therapeutic and newer imaging techniques. Endoscopists are increasingly being involved in the management of anastomotic and small bowel strictures in these patients. The advent of balloon enteroscopy has helped us access areas not deemed possible in the past for dilations. An advanced endoscopist also plays an integral part in managing ileal pouch-anal anastomosis complications including management of pouch strictures and sinuses. The use of rectal endoscopic ultrasound has been expanded for imaging of perianal fistulae in patients with Crohn's disease and appears much more sensitive than magnetic resonance imaging and exam under anesthesia. Advanced endoscopists also play an integral part in detection of dysplasia by employing advanced imaging techniques. In fact the paradigm for neoplasia surveillance in IBD is rapidly evolving with advancements in endoscopic imaging technology with pancolonic chromoendoscopy becoming the main imaging modality for neoplasia surveillance in IBD patients in most institutions. Advanced endoscopists are also called upon to diagnose primary sclerosing cholangitis (PSC) and also offer options for endoscopic management of strictures through endoscopic retrograde cholangiopancreatography (ERCP). In addition, PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime risk. Brush cytology obtained during ERCP and use of fluorescence in situ hybridization which assesses the presence of chromosomal aneuploidy (abnormality in chromosome number) are established initial diagnostic techniques in the investigation of patients with biliary strictures. Thus advanced endoscopists play an integral part in the management of IBD patients and our article aims to summarize the current evidence which supports this role and calls for developing and training a new breed of interventionalists who specialize in the management of IBD patients and complications specific to those patients.

Clinical value of surveillance pouchoscopy in asymptomatic ileal pouch patients with underlying inflammatory bowel disease

There is no consensus on the need for and the interval of surveillance pouchoscopy in asymptomatic ileal pouch patients with underlying ulcerative colitis (UC). The purpose of this study was to evaluate the likelihood of finding dysplasia or incidental ileal pouch disorders in asymptomatic patients undergoing surveillance pouchoscopy. This study included all eligible consecutive asymptomatic UC patients undergoing surveillance pouchoscopy to our subspecialty Pouchitis Clinic from 2002 to 2011. Univariable and multivariable analyses were performed. A total of 138 patients met the inclusion criteria, with 72 (52.2 %) being male. The mean age at pouch construction was 45.4 ± 15.0 years, and the mean interval from ileostomy closure to the inception of first surveillance pouchoscopy was 89.4 ± 78.8 months. One patient was found to have indefinite for dysplasia on pouch body mucosal biopsy (0.7 %), and two patients had non-caseating granulomas, suggesting Crohn's disease (CD) of the pouch. Of the 138 patients, 69 (50 %) had abnormal endoscopic findings, 102 (73.9 %) had acute and/or chronic inflammation on histology, and 62 (44.9 %) had both abnormal endoscopy and histology. The abnormal endoscopic findings included isolated pouch ulcer (n = 29, 21 %), active pouchitis (n = 31, 22.5 %), inflammatory polyps (n = 10, 7.2 %), strictures at the anastomosis (n = 5, 3.6 %), inlet (n = 10, 7.2 %) or outlet (n = 2, 1.4 %). Thirteen patients (13/17, 76.5 %) with pouch strictures underwent endoscopic balloon dilatation therapy and nine had (9/10, 90 %) endoscopic polypectomy. Multivariable analysis showed that patients with a preoperative diagnosis of CD and concomitant extraintestinal manifestations had a higher risk for abnormal pouch endoscopic findings with odds ratios of 2.552 (95 % confidence interval [CI] 1.108-16.545, p = 0.035) and 4.281 (95 % CI 1.204-5.409, p = 0.014), respectively. Dysplasia was rare in asymptomatic patients with restorative proctocolectomy who underwent surveillance pouchoscopy in this cross-sectional study. However, "incidental" abnormal endoscopic and/or histologic findings were common, which often needed endoscopic therapeutic intervention.

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.

Mo1701 Surgical Stricturoplasty in the Treatment of Pouch Strictures

Mo1701 Surgical Stricturoplasty in the Treatment of Pouch Strictures

Preoperative pelvic radiation increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer

Background and aimsTo evaluate the impact of preoperative radiation on pouch outcomes in patients with colitis-associated cancer (CAC). MethodsCAC patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1984 to 2009 were identified from our registry. The impact of preoperative pelvic radiation for CAC or other pelvic cancer on pouch related outcomes was evaluated. ResultsSixty-three pouch patients with confirmed CAC were included (37 male, 58.7%). The mean age at pouch construction was 46.9±10.6years. Seven patients were excluded due to the presence of persistent diverting ileostomy (n=2) or no follow-up (n=5). The remaining 56 patients were analyzed, including 9 who received pelvic radiation prior to IPAA creation for CRC or other cancers. Preoperative pelvic radiation was significantly associated with chronic pouchitis (P=0.024). There was, however, no correlation between pelvic radiation and pouch/anal transitional zone neoplasia, pouch stricture, pelvic abscess and pouch fistula/sinus. Pouch failure occurred in 13 patients after a median follow-up of 66.4 (range: 2.7–322.2) months. Although a simple statistical analysis based on the number of patients with pouch failure did not achieve significance (4/9 vs. 9/47, P=0.19), Kaplan–Meier analysis showed a strong association between preoperative pelvic radiation and the risk for pouch failure (P<0.001). A subgroup analysis of rectal cancer patients revealed that 3/7 patients (42.9%) with radiation and 3/17 (17.6%) without had pouch failure (P=0.31). Again, the association between pelvic radiation and pouch failure was confirmed using Kaplan–Meier analysis (P=0.02). ConclusionsPelvic radiation administered prior to IPAA creation appears to be associated with poor pouch outcomes. Oncological benefits and pouch functional outcomes should be carefully balanced before pelvic radiation is considered prior to restorative proctocolectomy.

Clinical Significance of Surveillance Pouchoscopy in Asymptomatic Ileal Pouch Patients with Underlying Inflammatory Bowel

Purpose: 1) To evaluate the frequency of dysplasia detected in asymptomatic patients undergoing surveillance pouchoscopy; 2) To investigate the frequency and risk factors of various pouch disorders incidentally found on the surveillance pouchoscopy. Methods: This cross-sectional study included all consecutive patients referred for surveillance pouchoscopy in our subspecialty Pouchitis Clinic from 2002-2011. Symptomatic patients undergoing diagnostic pouchoscopy and pouch patients with underlying familial adenomatous polyposis were excluded. Univariable and multivariable analyses. Results: A total of 138 patients met the inclusion criteria and were included, with 72 (52.2%) being male. The mean age at the time of ileal pouch construction was 45.4±15.0 years, with the mean interval from stoma closure to the inception surveillance pouchoscopy of 89.4 ± 78.8 months. We found 1 patient with indefinite dysplasia on pouch mucosal biopsy (0.7%) and 2 patients with non-caseating granulomas, suggesting Crohn's disease (CD) of the pouch. Of all patients, 69 (50.0%) had abnormal endoscopic findings, 102 (73.9%) had abnormal histopathological changes (including acute and chronic inflammation, pyloric gland metaplasia), and 64 (46.4%) had both during the surveillance pouchoscopy. The abnormal endoscopic findings included pouch ulcer (n=29, 21.0 %), pouchitis (n=31, 22.5%), inflammatory polyps (n=10; 7.2%), and pouch strictures at the anastomosis (n=5, 3.6%)), pouch inlet (n=10; 7.2 %), pouch outlet (n=2, 1.4%). Thirteen patients with pouch strictures underwent endoscopic balloon dilatation and nine patients had endoscopic polypectomy. Compared with patients who had normal endoscopic findings, patients with abnormal endoscopy were more likely to have a preoperative diagnosis of CD (p=0.026) and have concomitant extraintestinal manifestations (EIM, p=0.011). However, no significant difference was identified between the two groups in other 21 demographic and clinical variables. Multivariable analysis showed that patients with a preoperative diagnosis of CD and concomitant EIM had a high risk for have abnormal pouch endoscopic findings with odds ratios of 2.552 (95% confidence interval [CI]: 1.108˜16.545, p=0.035) and 4.281 (CI: 1.204˜5.409, p=0.014) respectively. Conclusion: Dysplasia or cancer appeared to be rare in asymptomatic patients with IPAA who underwent the one-time pouchoscopy. However, approximately ½ of the patients had “incidental” abnormal findings on pouchoscopy and some of them had clinically-indicated endoscopic therapeutic intervention. Therefore, the surveillance pouchoscopy may deliver the benefits of diagnostic and therapeutic maneuvers in other pouch disorders, particularly for those with a preoperative diagnosis of CD or EIM.Table: Multivariate analysis of risk factors associated with abnormal endoscopic findings in asymptomatic patients with ileal pouches