Abstract 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. Ileoanal pouch, strictures, dilatation 1. Introduction Restorative proctocolectomy [RPC] with ileal pouch-anal anastomosis [IPAA] removes the diseased tissue in ulcerative colitis [UC], but also allows gastrointestinal continuity and stoma-free living for many patients. It can be considered an option for patients with medically refractory UC and UC with dysplasia, and some patients with familial adenomatous polyposis.1 The complications of proctocolectomy and pouch surgery are well described. Complications specifically related to the pouch can be categorized into septic, inflammatory, functional and mechanical. Early complications include breakdown of the ileo-anal anastomosis with consequent pelvic sepsis. This occurs in 5–10% and is associated with a five-fold risk of long-term failure.1–3 Late complications include fistulation,4 delayed pelvic sepsis,3 pouchitis5 and poor function, which itself can be due to mechanical, inflammatory, septic and functional causes.5 Pouch strictures are a complication with a reported incidence of 5–38%.1,6,7 The discrepancy in this data probably reflects differences in definitions, with some authors describing a ‘stricture’ at reversal of ileostomy after pouch construction that can be treated once with finger dilatation8 but, less commonly, IPAA strictures will reoccur requiring repeated examination under anaesthesia [EUA] and dilatation with the use of Hegar dilators at home to maintain patency. Pouch inlet and mid-pouch strictures are less common and less well described. Causes include recurrent inflammation of the pouch,9 pre-pouch ileitis, medications such as non-steroidal anti-inflammatory drugs10 and ‘kinking’ of the pre-pouch ileum. There is much less known about mid-pouch strictures in terms of incidence, management and outcomes but inflammation and kinking of the pouch are suggested aetiologies. Crohn’s disease should also be considered as an underlying cause for pouch strictures.11 Pouch strictures can cause severe problems when left untreated including bowel obstruction, evacuation problems, pouch dilatation and bacterial overgrowth.8 The management of pouch strictures ranges from simple EUA and dilatation, endoscopic balloon dilatation and medical therapy to reparative or ablative surgery such as stricturoplasty, proximal diversion and stricture resection with redo pouch formation12–14 or excision of the pouch. IPAA strictures are common and relatively easy to manage with repeat EUA and dilatation and dilatation at home as required. More uncertainty surrounds the management of mid-pouch and pouch inlet strictures and we aim to describe and interpret the current literature. This systematic review will explore all studies that report outcome variables following treatment of pouch-anal, mid-pouch and pre-pouch ileal strictures. 2. Methods 2.1. Objectives Our aim was 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. 2.2. Types of studies Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded. 2.3. Search methods for identification of studies A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was undertaken by four independent researchers [JS, GW, KS and SA]. See Supplementary Data for MeSH search terms (Figure 1). Figure 1. View largeDownload slide Prisma diagram. Figure 1. View largeDownload slide Prisma diagram. 2.4. Data collection and analysis Using Covidence Systematic Review Software (Veritas Health Innovation, Melbourne, Australia; available at www.covidence.org), four independent reviewers [JS, KS, GW, SA] used pre-defined selection criteria to screen the studies. Studies were originally screened in abstract format before full text review. Conflicts were resolved by consensus agreement (Figure 2). Figure 2. View largeDownload slide Pouch stricture locations. Figure 2. View largeDownload slide Pouch stricture locations. 3. Results 3.1. Management of pouch-anal anastomotic strictures (Figure 3) 3.1.1. Bougie Fazio et al.1 published a case series reporting on 141 patients with pouch-anal anastomotic strictures. Strictures were dilated using a bougie either in the theatre or in outpatient clinics. Three patients went on to revision of their pouch. Follow-up data on the other patients were not reported. There were no other complications reported. Figure 3. View largeDownload slide Pouchogram showing a pouch-anal anastomotic stricture [arrow]. Figure 3. View largeDownload slide Pouchogram showing a pouch-anal anastomotic stricture [arrow]. 3.1.2. Balloon dilatation (Figure 4) Balloon dilatation for pouch-anal anastomotic strictures has been described in two case reports15,16 and one case series.17 Pescatori and Parks15 reported that following balloon dilatation the patient still had faecal incontinence and pain. Larson et al.16 reported that balloon dilatation allowed ileostomy closure at 6 months’ follow-up. Hultén17 reported the largest case series with nine out of 13 patients having successful balloon dilatation for their pouch-anal anastomotic stricture, the other four patients needing surgical revision. No complications were reported in any of these studies. Figure 4. View largeDownload slide Pouch-anal anastomotic stricture on endoscopy. Figure 4. View largeDownload slide Pouch-anal anastomotic stricture on endoscopy. 3.1.3. Surgical dilatation Two small case series18,19 report the outcome of surgical dilatation for pouch-anal strictures. Metcalf et al.18 reported on 22 patients who were treated with surgical dilatation at the time of ileostomy closure. Nine of the 22 patients required repeated dilatations. It is our experience that many patients will have a soft, easy-to-dilate ‘stricture’ at ileostomy closure which never recurs and is probably due to simple disuse. This is likely to represent a different group from the nine patients in this study who required further treatment and more robust classification [such as diagnosis after ileostomy reversal rather than at it] might increase the power of a study examining outlet strictures. Zhang19 reported on four patients, three of whom required finger dilatation for full resolution with the other patient requiring transanal endoscopic microsurgery dilatation [TEMS]. Neither study reported any complications. 3.1.4. Multiple techniques There were two case reports20,21 and two case series13,22 that reported on multiple techniques for the management of pouch-anal anastomotic strictures. Mahgerefteh et al.20 reported a hybrid approach in one patient, combining image-guided sharp recanalization of the occluded anastomosis with positioning of a large-diameter Foley balloon catheter across the recanalized segment, followed by immediate surgical revision of the J pouch. Ileostomy closure was performed 1 month later. Ryoo et al.21 reported on two strictures, one managed by stricturoplasty and one via balloon dilatation. Both reported good pouch function following treatment. Rossi et al.23 reported on 29 patients, 19 of whom had a digital dilatation with 10 of these needing an operation. Senapati et al.22 reported outcomes in 50 patients who were treated with either surgical dilatation under anaesthesia, digital dilatation or conservative management [no active treatment]. The selection for each treatment was not defined; 26 patients underwent dilatations under anaesthetic, 12 patients underwent digital and endoscopic dilatation, and three had no treatment. All of these procedures needed repeated attempts with 37 of the total patients ‘resolved’. We were unable to extract success by each method of treatment from the data presented. Prudhomme et al.13 reported the largest case series on 200 strictures, 100 classified as fibrotic and 100 as non-fibrotic [inflammatory]. Dilatations were either with a bougie or with surgery. Surgical procedures included excision of the strictured segment and advancement of ileal mucosa over the excised area [n = 5], pouch excision [n = 9], disconnection, segmental excision of the fibrotic segment and reconnection of the pouch [n = 3], with a further eight patients having dilatation with surgical drainage of abscesses [n = 3], division of obstructing bridge [n = 2] and debridement [n = 3]. Ninety-five of the 100 non-fibrotic strictures responded to bougie dilatation with 45/100 fibrotic structures responding to bougie dilatation. Following bougie failure, 55 fibrotic strictures required surgical intervention whilst 5% non-fibrotic strictures required surgical intervention. Failure, defined as permanent ileostomy, occurred in 0.5% overall but also in 15% of the patients undergoing surgical dilatation after a median follow-up of 6.5 years [range 2–15 years]. No complications were reported in any of these studies. Kraenzler et al.25 reported the management of pouch anal-anastomotic strictures in 16 patients. They treated anal-anastomotic strictures with a step-up strategy. Their algorithm started with one or two attempts at instrumental dilatation followed, in cases of failure, by circular stapler resection or a stricturoplasty. The stapler resection was performed by introducing the stapler through the anastomosis and positioned until the stenosis is caught between the anvil and the rod of the stapler, when the stapler was fired. Transabdominal redo-anastomosis was often reserved for patients with recurrent anastomotic strictures. All procedures were performed under anaesthetic. Success was defined as absence of stenotic symptoms or additional surgical procedure for the stricture within 12 months of intervention. They reported success rates of 1/4 for finger dilatation, 5/18 with instrumental dilatation, 1/5 with circular stapler, 4/4 with stricturoplasty and 5/8 with redo-anastomosis. 3.1.5. Other techniques Philpott et al.24 published a case report in which endocap-guided needle knife stricturotomy was described. The patient’s symptoms resolved following this procedure. There were no procedural complications reported. The data suggest that pouch-anal anastomotic strictures respond to bougie dilatation and Hegar dilators. Pouch-anal anastomotic strictures are likely to require repeat dilatations and decision to escalate to other techniques should be based on each patient’s symptoms and preference. In the event of failure of simple dilatation, the next option should be surgical, i.e. to include stricturoplasty, circular stapler resection and pouch revision. There are insufficient data to suggest balloon dilatation or other techniques for pouch anal anastomotic strictures. 3.2. Management of pouch inlet strictures (Figures 5 and 6) 3.2.1. Balloon procedures (Figure 7) There was one case report26 and one case series27 that explored balloon dilatation for pouch inlet strictures. Obusez et al.26 reported a single case in which, following balloon dilatation, the patient reported complete resolution of symptoms. Kirat et al.27 reported on nine patients who were managed using endoscopic balloon dilatation, six of whom were considered as successfully treated based on resolution of obstructive symptoms with balloon dilatation after a mean follow-up of 1 year [range 0.14–2.5 years]. Four out of nine patients required repeat dilatations, with three of the nine patients requiring pouch excisions. No complications were reported in either study. Figure 5. View largeDownload slide Pouchogram showing poor distension of the pouch and a pouch inlet stricture [arrow]. Figure 5. View largeDownload slide Pouchogram showing poor distension of the pouch and a pouch inlet stricture [arrow]. Figure 6. View largeDownload slide Computed tomography image showing pouch inlet stricture with mural thickening of the pouch inlet [arrows]. Figure 6. View largeDownload slide Computed tomography image showing pouch inlet stricture with mural thickening of the pouch inlet [arrows]. Figure 7. View largeDownload slide Pouch inlet stricture on endoscopy. Figure 7. View largeDownload slide Pouch inlet stricture on endoscopy. 3.2.2. Medical management There were two case series that reported on the use of medical therapy in the management of pouch inlet strictures.28,29 Haveran et al.28 reported on six patients, five of whom received a thiopurine and had complete resolution of their symptoms. The sixth developed pancreatitis whilst receiving a thiopurine. This therapy was stopped and the patient was successfully treated with infliximab. Li et al.29 reported on eight patients who received adalimumab for strictures of the pouch inlet. Three out of the eight patients reported a partial or complete response as defined by symptomatic response back to baseline and a reduction in modified Pouchitis Disease Activity Index [mPDAI]. The authors suggested that adalimumab use had maximal benefit when concurrent balloon dilatation was performed. 3.3. Management of mid-pouch strictures (Figures 8 and 9) 3.3.1. Stricturoplasty Matzke et al.30 reported on a case in which a mid-pouch stricture was treated with stricuroplasty. At 1 year of follow up the patient was asymptomatic. No complications were reported. Figure 8. View largeDownload slide Frontal view of the pouchogram showing a contrast agent passing through a tight mid-pouch stricture. Figure 8. View largeDownload slide Frontal view of the pouchogram showing a contrast agent passing through a tight mid-pouch stricture. Figure 9. View largeDownload slide Magnetic resonance image of a mid-pouch stricture with mural thickening. Figure 9. View largeDownload slide Magnetic resonance image of a mid-pouch stricture with mural thickening. 3.4. Management of strictures at multiple sites 3.4.1. Balloon Shen et al.31 reported a series of 19 patients with pouch inlet [n = 14] and outlet strictures [n = 14] dilated using an 8.6-mm balloon. Strictures were quantified by the endoscopist based on the degree of resistance to the passage of the endoscope [0 = no resistance; 1 = mild resistance; 2 = moderate resistance; 3 = severe resistance; and 4 = pinhole and not traversable]. The mean stricture scores immediately after dilatation were significantly improved [p < 0.001]. One patient required revision of their pouch following intervention due to persistent symptoms following balloon dilatation. No other complications were reported. Following this, the same group32 reported on treatment of 150 mixed pouch strictures. There were 96 pouch inlet strictures, 73 pouch outlet strictures, 33 afferent limb strictures [above the pouch inlet] and two pouch body strictures. These were all dilated using an endoscopic balloon. There were some strictures that needed repeat dilatations and in total there were 646 strictures dilated; the technical success measured by the ability to pass the scope through the stricture was 97.8%. The 5-, 10- and 25-year pouch continuity retention rates were 97.0, 90.6 and 85.9%, respectively. Free perforation occurred in two patients who required urgent laparotomy and diverting ileostomy. There were four post-procedure bleeding events requiring hospitalization and blood transfusion. There was no procedural mortality. 3.4.2. Endoscopic balloon dilatation vs stricturoplasty Wu et al.33 published a retrospective study that compared pouch survival in patients undergoing either stricturoplasty or endoscopic balloon dilatation for a pouch stricture. Pouch survival was defined as avoidance of permanent diversion, complete pouch redo or pouch excision in patients undergoing either technique. In total, 151 patients had balloon dilatation and 16 patients had surgical stricturoplasty. The 5-year overall pouch survival rates were 83 and 82% for patients with stricturoplasty and endoscopic dilation, respectively [log-rank test: p = 0.752]. One [6.3%] patient in the stricturoplasty group developed a deep anastomotic leak/sinus requiring a redo pouch procedure. There was no difference between the two procedures in terms of the overall severe complication rate [p = 0.334] although given the small number of surgical patients, this may represent a type 2 error. 4. Discussion There are various techniques described to treat pouch strictures depending on the stricture location. The most commonly studied location is the pouch-anal anastomosis followed by pouch inlet strictures. Unlike previous reviews on this topic,34 we believe strongly that the management of pouch strictures should be based on location, which is ultimately linked to underlying aetiology. Pouch-anal anastomotic strictures are common and in our experience respond well to both digital and instrumental dilatation such as Hegar dilatation, which patients can be taught to perform independently. These are often successfully treated but may require regular repeated dilatations. Some commonly reported complications include pain and rectal bleeding using Hegar dilatations. The data support our view that pouch-anal anastomotic strictures respond well to simple stretching of the anastomosis through dilatations with a 95% pouch retention rate for non-fibrotic strictures.13 It is hard to define what constitutes a true pouch-anal ‘stricture’, with reports highlighting that many of these strictures are just simple webs following disuse.8 It is therefore difficult to assess success in the management of these strictures. Whilst other techniques have been explored for the management of pouch-anal anastomotic strictures, we suggest that the stricture is likely to be a post-surgical anastomotic stricture. It has been suggested that these strictures may be associated with sepsis, tension at the anastomosis or ischaemia, but many occur without an underlying cause.22 It is our view that these strictures are best managed using dilators, and it is likely that repeat dilatations will be required. The data support a stepwise approach and should simple dilatation fail the next option should be a surgical one, to include stricturoplasty, circular stapler resection or pouch revision. There are insufficient data to suggest balloon dilatation or other techniques for pouch anal anastomotic strictures. Mid-pouch strictures remain poorly understood in terms of both aetiology and management. It is likely that they occur due to a different aetiology from other pouch strictures and, whilst this is unknown, it is our opinion that mechanical kinking of the pouch is contributory. Although it is difficult to address a treatment algorithm, these strictures are unlikely to be reached using Hegar dilatators and therefore we suggest endoscopic and surgical approaches. These are likely to provide the greatest benefit, but pouch revision may ultimately be necessary. Further study of mid-pouch strictures is urgently required. Inlet strictures are likely to be inflammatory in nature although they could also be due to mechanical kinking at the inlet. They are likely to respond to balloon dilatation.26,27 Medical therapy has been explored in small studies,28,29 and may represent a good initial treatment option in those patients in whom an inflammatory process is suspected endoscopically and clinically. We also believe that the presence of a pouch inlet stricture should not be considered a criterion for reclassification to Crohn’s disease although investigation for further sites of luminal disease should certainly be performed. We recommend that pouch inlet strictures should be managed according to underlying aetiology, with inflammatory strictures initially treated with medical therapy and fibrotic strictures managed with endoscopic dilatation, stricturoplasty or revision (Table 1). Table 1. Treatment summary. Stricture location Likely aetiology Initial management Pouch-anal Surgical complications, sepsis Dilators including Hegar Mid-pouch Mechanical inflammatory Endoscopic balloon dilatations +/– surgical revision Pouch inlet Inflammatory fibrotic Inflammatory: consider medical therapy. Fibrotic: consider balloon dilatation Stricture location Likely aetiology Initial management Pouch-anal Surgical complications, sepsis Dilators including Hegar Mid-pouch Mechanical inflammatory Endoscopic balloon dilatations +/– surgical revision Pouch inlet Inflammatory fibrotic Inflammatory: consider medical therapy. Fibrotic: consider balloon dilatation View Large The management of pouch strictures is associated with very few adverse events. Those that occurred did so most frequently following balloon dilatation, and in the largest single study of 150 patients, a total of seven [5%] patients experienced adverse events which included two [1%] perforations and two [1%] post-procedural bleeds.32 In the same study, one [6.3%] patient who underwent stricturoplasty developed a deep anastomotic leak/sinus requiring pouch revision. One of five patients treated with azathioprine developed pancreatitis. There are many limitations to this systematic review, not least that there are no randomized controlled trials exploring the efficacy between any two different treatments. Many studies report outcomes in strictures at various locations within the pouch. These strictures are likely to be of different aetiologies so probably need to be managed differently, and certainly reported separately. Furthermore, the studies are often based on small numbers of patients and retrospectively analysed. Future studies should group pouch strictures according to location and compare different treatment modalities in order to assess efficacy and safety. 5. Conclusion There is a paucity of data on the management of pouch strictures; studies are small and heterogeneous in terms of stricture location, aetiology, method of treatment and outcomes reported. Pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical intervention at the stricture or pouch revision. The management and aetiology of mid-pouch strictures are relatively unstudied and we suggest that a combination of medical, endoscopic and surgical management may be beneficial depending on the presence of ongoing inflammation. Pouch inlet strictures can be safely managed using balloon dilatation and we suggest a combined medical and endoscopic approach is best for this type of stricture. Conflict of Interest None of the authors have any relevant disclosures. Acknowledgment We thank Steven Preston for artwork. References 1. Fazio VW, Ziv Y, Church JMet al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222: 120– 7. Google Scholar CrossRef Search ADS PubMed 2. Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR. Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 2007; 94: 333– 40. Google Scholar CrossRef Search ADS PubMed 3. Heuschen UA, Allemeyer EH, Hinz U, Lucas M, Herfarth C, Heuschen G. Outcome after septic complications in J pouch procedures. Br J Surg 2002; 89: 194– 200. Google Scholar CrossRef Search ADS PubMed 4. Lolohea S, Lynch AC, Robertson GB, Frizelle FA. 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Philpott J, Kulkarni H, Shen B. Use of endocap guided needle knife stricturotomy to treat stricture of ileoanal anastomosis. Inflamm Bowel Dis 2014; 20: S20. 25. Kraenzler A, Maggiori L, Pittet O, Alyami MS, Prost à la Denise J, Panis Y. Anastomotic stenosis after coloanal, colorectal and ileoanal anastomosis: what is the best management? Color Dis 2017; 19: O90– 6. Google Scholar CrossRef Search ADS 26. Obusez EC, Lian L, Oberc A, Shen B. Successful endoscopic wire-guided balloon dilatation of angulated and tight ileal pouch strictures without fluoroscopy. Surg Endosc 2011; 25: 1306– 1306. Google Scholar CrossRef Search ADS PubMed 27. Kirat HT, Kiran RP, Remzi FH, Fazio VW, Shen B. Diagnosis and management of afferent limb syndrome in patients with ileal pouch-anal anastomosis. Inflamm Bowel Dis 2011; 17: 1287– 90. Google Scholar CrossRef Search ADS PubMed 28. Haveran LA, Sehgal R, Poritz LS, McKenna KJ, Stewart DB, Koltun WA. Infliximab and/or azathioprine in the treatment of crohnʼs disease-like complications after IPAA. Dis Colon Rectum 2011; 54: 15– 20. Google Scholar CrossRef Search ADS PubMed 29. Li Y, Lopez R, Queener E, Shen B. Adalimumab therapy in Crohnʼs disease of the ileal pouch. Inflamm Bowel Dis 2012; 18: 2232– 9. Google Scholar CrossRef Search ADS PubMed 30. Matzke GM, Kang AS, Dozois EJ, Sandborn WJ. Mid pouch strictureplasty for crohnʼs disease after ileal pouch-anal anastomosis: an alternative to pouch excision. Dis Colon Rectum 2004; 47: 782– 6. Google Scholar CrossRef Search ADS PubMed 31. Shen B, Fazio VW, Remzi FH, Delaney CP, Achkar J-P, Bennett Aet al. Endoscopic balloon dilation of ileal pouch strictures. Am J Gastroenterol 2004; 99: 2340– 7. Google Scholar CrossRef Search ADS PubMed 32. Shen B, Lian L, Kiran RP, Queener E, Lavery IC, Fazio VWet al. Efficacy and safety of endoscopic treatment of ileal pouch strictures. Inflamm Bowel Dis 2011; 17: 2527– 35. Google Scholar CrossRef Search ADS PubMed 33. Wu X, Mukewar S, Kiran RP, Remzi FH, Shen B. Surgical stricturoplasty in the treatment of ileal pouch strictures. J Gastrointest Surg 2013; 17: 1452– 61. Google Scholar CrossRef Search ADS PubMed 34. Bharadwaj S, Shen B. Medical, endoscopic, and surgical management of ileal pouch strictures (with video). Gastrointest Endosc 2017; 86: 59– 73. Google Scholar CrossRef Search ADS PubMed Copyright © 2017 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: firstname.lastname@example.org
Journal of Crohn's and Colitis – Oxford University Press
Published: Mar 1, 2018
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