Journal Article

P-002 Use of Endocap Guided Needle Knife Stricturotomy to Treat Stricture of Ileoanal Anastomosis

Jessica, Philpott, Geeta, Kulkarni, Bo, Shen

2014

Overview

Strictures are a common complication of restorative proctocolectomy with IPAA (ileoanal pouch anastomosis). Although basic measures such as balloon dilation are effective, some strictures are not effectively treated by this measure. Use of needle knife has been demonstrated to safely treat refractory strictures and strictures that require a targeted approach. However, the use of this modality at the ileoanal anastomosis is limited by the narrow diameter and in presence of pouch prolapse, which may result in the risk of uncontrolled damage to the opposing wall and adjacent structures from current transferred across the narrow and collapsing lumen.MethodsA 22-year old female patient presented with symptoms of pelvic pain, and diarrhea. She had undergone 3- stage colectomy with IPAA for medically refractory colitis. She had subsequent pouch dysfunction with chronic pelvic pain and urgent stools. She was found to have stenosis at the ileoanal anastomosis. This had been initially treated with balloon dilation without improvement of symptoms. At our institution, initial pouchoscopy revealed a slightly dilated pouch with normal mucosa and a 7 mm stricture. Initial attempt at stricturotomy by needle knife of the posterior wall was limited by prolapse of the anterior wall into the anal canal. A month later, pouchoscopy was repeated. The endocap was inserted within the anal canal and the needle knife probe was applied to posterior wall with good result. The endocap prevented the previously noted prolapse of anterior wall of pouch into the field of treatment.ResultsPatient tolerated procedure well with no complications. She has noted improvement in symptoms of pelvic pain.ConclusionsRestorative colectomy with IPAA is the surgical treatment of choice for medically refractory colitis. While most patients note great clinical improvement after this surgery, post surgical complications including stricture do result in symptoms and occasionally pouch failure. Up to 11% of patients by some studies will suffer from strictures. Use of needle knife is effective for complicated strictures that do not respond to balloon dilation and strictures that are so positioned anatomically that require targeted therapy instead of the uncontrolled effect of balloon dilation. Use of endoscopic therapy is of great interest to avoid additional surgical therapy or pouch failure. This case demonstrates how use of endocap can guide a technically difficult needle knife stricturotomy.

• Publisher: Oxford University Press
• Subject: Anus / Colorectal surgery / Inflammatory bowel disease