Showing papers on "Pouchoscopy published in 2011"

Mucosectomy with handsewn anastomosis reduces the risk of adenoma formation in the anorectal segment after restorative proctocolectomy for familial adenomatous polyposis.

Abstract: Objective: The study compared the risk of adenoma or carcinoma formation in the anorectal segment after either mucosectomy with manual anastomosis or stapled ileoanal anastomosis (IAA) following restorative proctocolectomy (RPC) for familial adenomatous polyposis (FAP). Background: Few data exist on the risk of adenoma formation after either technique in FAP. Methods: All endoscopy and histology reports for patients having RPC for FAP attending for annual pouchoscopy from 1978 to 2007 were reviewed. The incidence, timing, and histological characteristics of adenoma or carcinoma formation were recorded. Results: Of the 206 patients, 140 attended for endoscopic follow-up for a median of 10.3 years after RPC. Fifty-two patients developed neoplastic transformation in the anorectal segment, with a cumulative risk at 10 years of 22.6% after mucosectomy with manual anastomosis and 51.1% after stapled IAA (P 10 mm) adenoma. One patient (handsewn ileoanal anastomosis) developed adenocarcinoma in the anorectal mucosa at 13 years and required pouch excision. Conclusions: Adenoma formation in the anorectal mucosa after RPC for FAP is common but carcinoma is rare. The risk is lower after mucosectomy with handsewn anastomosis than after stapled IAA. Regular endoscopic surveillance after either technique is mandatory. (Ann Surg 2011;253:314‐317)

Diagnosis and management of afferent limb syndrome in patients with ileal pouch‐anal anastomosis

Abstract: Background: 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 limb syndrome (ALS). The aim of this study is to report our experience in diagnosis and management of ALS in patients with IPAA. Methods: All patients with ALS after IPAA were identified from prospectively maintained databases. Demographic, clinical, endoscopic, and radiographic features together with its management and outcome were studied. Results: Eighteen patients (12 female) were included. The mean age was 35.6 ± 14.3 years. Most patients presented with intermittent obstructive symptoms. Fifteen patients were diagnosed by pouch endoscopy with features of angulation of the pouch inlet and difficulty in intubating the afferent limb; 12 patients had kinking or narrowing of the pouch inlet identified with abdominal imaging. The median follow-up was 1.3 (range, 0.14–16.1) years. Nine patients underwent empiric balloon dilatation of the afferent limb/pouch inlet. Of nine, four needed repeat dilatations. One patient with repeat dilatation ultimately had pouch excision; another has been scheduled for surgery after failed repeat dilatations. Eight patients underwent surgery, resection of angulated bowel (n = 3), pouchopexy (n = 2), pouch mobilization with small bowel fixation (n = 1), and pouch excision (n = 2). One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy. Conclusions: ALS was 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. (Inflamm Bowel Dis 2011;)

Management of leak from the tip of the "J" in ileal pouch-anal anastomosis.

Abstract: Background Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. Objective The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. Design This study is a retrospective review of prospectively gathered data. Settings Data were obtained from a prospectively maintained single-institution pelvic pouch database. Patients Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. Main outcome measures The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. Results There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 ± 1.9 years. Limitations : The study was limited by its retrospective nature. Conclusions Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.

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

Abstract: 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.