http://www.gastroenterologyandhepatology.net/files/2013/10/gh0913_makkarshen1.pdf

Colonoscopic perforation in inflammatory bowel disease.

Background 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. Aim 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. Methods 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. Results 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. Conclusion 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.

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

https://www.gastro.theclinics.com/article/S0889-8553(12)00014-3/pdf

Evaluating pouch problems.

Patients with inflammatory bowel diseases often undergo surgical procedures for medically refractory disease or colitis associated dysplasia. Endoscopic evaluation of the surgically altered bowel is often needed to assess for disease recurrence, its severity, and for therapy. It is important to obtain and review the operative report and abdominal imaging before performing the endoscopy. Diagnostic and therapeutic endoscopy can be safely performed in most patients with inflammatory bowel disease with altered bowel anatomy under conscious sedation without fluoroscopy. Carefully planned stricture therapy with balloon dilation or needle knife stricturotomy can be performed for simple, short, and fibrotic strictures. A multidisciplinary approach involving a team of endoscopist, endoscopy nurse, colorectal surgeon, gastrointestinal pathologist, and gastrointestinal radiologist is important for a safe and effective endoscopy. We attempt to review the aspects that need consideration before the endoscopy, the technique of endoscopy, and briefly the therapies that can be performed during endoscopy of the bowel through an ileostomy, a colostomy, in the diverted large bowel or ileal pouch, and small bowel after stricturoplasty and bowel bypass surgery in patients with inflammatory bowel diseases.

Endoscopic evaluation of surgically altered bowel in patients with inflammatory bowel diseases.

Crohn’s disease stricture evaluation and management

Ileal pouch strictures that are visually inaccessible by an endoscope may be balloon-dilated by exchange guide wire across the stricture with the aid of fluoroscopy. We present a technique of wire-guided balloon dilation without fluoroscopy to navigate strictures in the ileal pouch. A 50-year-old Caucasian female presented with a 24-year history of ulcerative colitis (UC) with restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) for 7 years. She developed Crohn’s disease (CD) of the pouch with multiple strictures at the afferent limb of 	the pouch and a pouch-vaginal fistula. On pouchoscopy, the patient had two strictures at the distal neoterminal ileum, at 10 cm and 15 cm proximal to the pouch inlet. In retrospect, the distal stricture was angulated and 1 cm in length, and the proximal one was ulcerated and pinhole in size, which prevented the passage of an endoscope (9.8-mm single-channel, GIF-H180; Olympus Optical, Tokyo, Japan). The stricture number and locations were confirmed by retrograde water-soluble contrast X-ray. There was great difficulty in negotiating the strictures with balloon dilation and hence concern that blind passage of the balloon into the strictures might induce mucosal trauma or perforation. A controlled radial expansion (CRE) wire-guided balloon dilation catheter (CRE TM Single-Use Wire Guided Balloon Dilator; Boston Scientific Microvasive, Natick, MA) was introduced through the scope. Wire exchange technique was applied with help of our endoscopy nurse (A.O.). The guide wire was passed through the strictures without any resistance under endoscopy view. Subsequently, the balloon was introduced across the strictures, and both were successfully dilated to 16 mm (Videos 1 and 2). The procedure and postprocedure course were uneventful, and patient reported great symptomatic relief. Endoscopic guide-wire balloon dilation without fluoroscopic guidance appears to be feasible for CD-related strictures in experienced hands.

https://link.springer.com/content/pdf/10.1007%2Fs00464-010-1339-9.pdf

Abigail Oberc

Papers

Successful endoscopic wire-guided balloon dilatation of angulated and tight ileal pouch strictures without fluoroscopy