The Surgical Management of Ileal Pouch Strictures

BACKGROUND: Radiographic imaging of abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including computed tomography, magnetic resonance imaging, contrasted pouchography, and defecography. OBJECTIVES: A systematic review of the literature was performed and applications of cross-sectional imaging, pouchography, defecography, and ultrasonography are described. DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on endoscopy in ileal pouches published between Jan 2003 and June 2023 in English were included based on PRISMA guidelines. INTERVENTION: Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included. MAIN OUTCOME MEASURES: Accuracy in characterization of the ileal pouch disorders. RESULTS: Computed tomography is the test of the choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). Magnetic resonance imaging of the pelvis is suitable for the evaluation of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn’s disease of the pouch. Computed tomography enterography and magnetic resonance enterography are useful in the assessment of intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for the evaluation of acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers. LIMITATIONS: This is a qualitative, not quantitative review of mainly case series and case reports. CONCLUSIONS: Abdominopelvic imaging along with clinical and endoscopic evaluation is imperative for the accurate assessment of structural, inflammatory, functional, and neoplastic disorders. See video from symposium.

Section: S73mentioning

confidence: 99%

Section: Ct and Ctementioning

confidence: 99%

Section: Mri and Mrementioning

confidence: 99%

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Radiographic Evaluation of Ileal Pouch Disorders: A Systematic Review

Shen,

Bruining,

2024

“…Alternatively, structural problems, such as strictures, anastomotic stenosis, or pouch twist, can cause outlet-related dysfunction or secondary effects on the pouch, leading to functional problems with bloating, incomplete emptying, and frequent small volume of liquid stools. 18 In most cases, the pouch can be salvaged by endoscopic or surgical interventions. 19 However, a subgroup of patients might not respond favorably or may not be amenable to these interventions, resulting in pouch failure.…”

Section: Indications and Contraindication For Conversionmentioning

confidence: 99%

Conversion of Failed J Pouch to Kock Pouch: Indications, Contraindications and Outcomes

Ahmed Ali,

Kiran

2024

BACKGROUND: The ileal pouch-anal anastomosis has been successful in restoring intestinal continuity and preserving continence in the majority of patients requiring a proctocolectomy. However, a subset of individuals experience significant complications that might result in pouch failure. The conversion of the J pouch to a continent ileostomy pouch represents a significant surgical procedure. In this article, we discuss the indications and contraindications, present the technical principles applied for the conversion, and describe the outcomes of such conversion in the literature. OBJECTIVE: The main objective during the conversion of the J pouch to a continent ileostomy is the creation of a sufficiently sized reservoir with a high-quality valve mechanism while preserving as much small bowel as possible. CONCLUSIONS: The conversion of the J pouch to a continent ileostomy represents a significant surgical procedure. When performed in centers of expertise, it can be a good option for patients who otherwise will require an end ileostomy. Indications for conversion include most cases of J pouch failure, with few important exceptions. See Video.

“…Anastomotic strictures are usually treated with endoscopic dilation or stricturotomy, and refractory cases require surgical intervention. 30,68…”

Section: Ileal Pouch-anal Anastomosismentioning

confidence: 99%

Endoscopic Evaluation of the Ileal Pouch

Shen

2024

BACKGROUND: Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and ileal pouch-anal anastomosis. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE: A systemic review of the literature was performed and principles and techniques of pouchoscopy were described. DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on endoscopy in ileal pouches published between Jan 2000 and May 2023 were including based on PRISMA guidelines. INTERVENTION: Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES: Accurate characterization of the ileal pouch at the healthy or diseased states. RESULTS: The main anatomic structures of a J or S pouch are the stoma closure site, prepouch ileum, inlet, tip of the “J,” pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the “J” and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS: This is a qualitative, not quantitative review of mainly case series. CONCLUSIONS: Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch, and recognize common abnormalities. See video from symposium. See Video.