List of Abbreviations
Barnett continent intestinal reservoir
Computed tomography enterography
Endoscopic balloon dilation
Familial adenomatous polyposis
Inflammatory bowel diseases
Ileal pouch-anal anastomosis
Magnetic resonance imaging
Magnetic resonance enterography
Dr. Bo Shen is supported by the Ed and Joey Story Endowed Chair.
It is estimated that 20%–25% of patients with ulcerative colitis (UC) eventually require colectomy for medically refractory disease or development of severe medicine-related adverse effects or colitis-associated neoplasia (CAN). In contrast, at least 60% of the patients with Crohn’s disease (CD) undergo surgery with an over 20 years of disease duration. Various forms of surgical interventions are performed in patients with UC or CD. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been standardized and has become the surgical treatment of choice for patients with UC who require colectomy. The main surgical modalities for the treatment of CD are bowel resection with anastomosis and stricturoplasty. Colostomy or ileostomy for temporary or permanent fecal diversion is a common practice in surgery for inflammatory bowel disease (IBD). The changes in bowel anatomy with or without recurrent disease in IBD have posed challenges for endoscopists. The common surgically altered bowel anatomy in IBD is listed in Table 12.1 . The goals for endoscopy in IBD patients after surgery are several folds: (1) diagnosis and differential diagnosis; (2) disease monitoring for recurrence and response to therapy; (3) surveillance for dysplasia; and (4) delivery of endoscopic therapy. In this chapter, this author discusses the principles and techniques of endoscopy in this patient population based on available literature and personal experience.
|Continent ileostomy (Kock, Barnett)|
|Blow hole (loop)|
|Defunctioned bowel||Diverted colon/rectum|
|Diverted ileal pouch|
|Stricturoplasty commonly performed||Small bowel||Heineke-Mikulicz|
|Postsmall bowel transplant||Small bowel||End ileostomy|
|Bowel bypass surgery||Duodenum||Gastrojejunostomy|
Prior to the diagnostic and/or therapeutic procedure, the endoscopist should familiarize him/herself with the surgical history of bowel by reviewing operative report, previous endoscopic and imaging reports. A preprocedural abdominal imaging examination is needed. The interventional IBD team should ensure adequate preparation for the patient, room setting, equipment, and suppliers ( Table 12.2 ). The general information on the preparation of endoscopy in IBD patients is described in a separate chapter ( Chapter 11 ).
|Bowel Anatomy||Bowel Preparation||Sedation||Endoscope||Special Remarks|
|Diagnostic Procedure||Therapeutic Procedure|
|Ileoscopy/jejunostomy via stoma||Clear liquid diet||Clear liquid diet||Conscious sedation||Adult gastroscope||Aspiration risk|
|Colostomy via stoma||Full prep||Full prep||Conscious sedation||Pediatric colonoscope or adult gastroscope|
|Defunctioned bowel||None||None||None||Adult gastroscope||Superficial biopsies|
|Stricturoplasty||Full prep||Full prep||Conscious sedation||Adult gastroscope or pediatric colonoscope||Aspiration risk. Balloon assisted enteroscopy|
|Small bowel transplant||Clear liquid diet||Clear liquid diet||Conscious sedation||Adult gastroscope||Gentle superficial mucosa biopsy to minimize the risk for bleeding|
|Bypass surgery||None||None||Conscious sedation||Adult gastroscope or pediatric colonoscope|
Delineation of Bowel Anatomy
It is important for the endoscopist to roadmap the bowel anatomy in those with prior surgery, before the endoscopic procedure. The endoscopist should carefully review patient’s medical and surgical history, operative reports, abdominal imaging, and previous endoscopic reports. It is prudent to perform some form of abdominal imaging, such as computed tomography (CT), magnetic resonance imaging (MRI), or contrasted bowel X-ray. In addition, the abdominal imaging can also show number, location, degree and length of stricture, hernia, fistula, abscess, and bezoars. If there is doubt, the endoscopist should review the images with radiologist and colorectal surgeon.
Preparation of Patient
The bowel preparation for endoscopy for IBD patients with prior surgery requires a systemic approach. For patients undergoing upper or lower endoscopy with conscious sedation, monitor anesthesia care, or under general anesthesia, overnight fasting is required to avoid aspiration. This is particularly important in IBD patients who have strictures of the bowel, history of bowel resection, or stricturoplasty or have anticipated prolonged procedures (such as endoscopic therapy). For routine diagnostic endoscopy via ileostomy or jejunostomy or endoscopy for diverted bowel, clear liquid diet the day before without additional bowel preparation may be sufficient. For diagnostic colonoscopy via colostomy, therapeutic ileoscopy via ileostomy, endoscopy for J or Kock pouches, and endoscopy in the setting of partial bowel obstruction, polyethylene glycol (PEG)-based oral preparation is recommended ( Table 12.2 ). Due to the risk of aspiration from large-volume intestinal contrast, the same-day sequential endoscopic evaluation after abdominal imaging, such as CT, MRI, and small bowel series, should be avoided.
The type of sedation depends on the patient’s comorbidities, the extent and location of the bowel examined, and anticipated duration of procedure and need for therapeutic intervention. For example, diagnostic endoscopy of the intestine via stoma, diverted bowel, or pelvic pouches, may or may not need sedation, depending on patient’s preference. Patients undergoing diagnostic ileoscopy, jejunostomy or colostomy via a stoma, or endoscopy for a Kock pouch, with anticipated angulated or strictured bowel are suitable for conscious sedation. Most therapeutic endoscopic interventions, such as stricture dilation with through-the-scope (TTS) balloon or endoscopic stricturotomy (ES) can be safely performed when patients are put under conscious sedation. If prolonged procedure time is anticipated, such as performance of balloon-assisted enteroscopy (BAE), monitored anesthesia care, or general anesthesia may be reasonable for patient comfort. Patients with severe perianal disease may need examination under general anesthesia in the operating room.
The availability and accessibility of fluoroscopy are helpful for therapeutic procedures, such as balloon dilation of tight and/or angulated stricture and stent placement. However, it may not be readily available in most outpatient endoscopy suites and its operation may need additional training. Furthermore, excessive radiation exposure to the patient and the endoscopist has been a concern. In our Interventional IBD Unit, we do not routinely use fluoroscopic guidance for diagnostic or therapeutic endoscopy in IBD patients with or without surgery. We were able to perform most diagnostic and therapeutic endoscopic procedures, including TTS balloon dilation, deployment of through-the-scope or over-the-scope clips, and needle-knife stricturotomy, or needle-knife sinusotomy. Nonetheless, the real-time imaging with fluoroscopy is ideal.
Endoscopy via Anastomosis
Bowel resection and anastomosis is a common practice in IBD surgery, with ileocolonic resection (ICR) and ileocolonic (ICA) being most frequently performed. ICA can be fashioned with side-to-side, end-to-end, and end-to-side configurations. The intubation of the neoterminal ileum is required in all ileocolonoscopy for disease monitoring and endoscopic treatment in CD.
The intubation to the neoterminal ileum is occasionally challenging in patients with high end-to-side ICA and in those with side-to-side anastomosis. The end-to-side anastomosis may be hidden behind colon folds, in a tangential view ( Fig. 12.1 ). This author recommend endoscopic tattoo of the area.
The main intention for side-to-side anastomosis is to make ICA more patent with the application of stapled technique. In a metaanalysis of eight studies comparing stapled side-to-side anastomosis (N = 396) and handsewn end-end anastomosis (N = 425) at ICR for CD patients found that the former to have lower overall postoperative complications. However, the intubation through side-to-side ICA can be difficult. Retroflexion with a pediatric colonoscope can be helpful ( Fig. 12.2 ). Once passing through the anastomosis, it is important to identify the transverse staple line of the blind end of ileum, which is a common location of leak. The blind end of side-to-side ICA is typically located at the left-upper quadrant on straight endoscopy view, while the lumen of the neoterminal ileum is often at right-lower quadrant ( Fig. 12.3 ).
Endoscopy via Stoma
Surgery with fecal diversion is performed in both CD and UC. Ostomy is classified into (1) ileostomy, jejunostomy, and colostomy, based on the location; (2) temporary and permanent, based on the intention of creation and duration; and (3) loop ileostomy or colostomy, loop-end ileostomy, and end ileostomy or colostomy, based on the configuration. There are other variations of ostomy ( Table 12.1 ). An ostomy is constructed for a variety of indications in IBD. A permanent end ileostomy or temporary loop ileostomy, with or without colectomy may be created in CD patients for perianal or medically refractory diseases. A temporary loop ileostomy is normally performed as an interim step of restorative proctocolectomy and IPAA. Kock pouch and Barnett continent intestinal reservoir (BCIR) are two forms of continent ileostomy created for UC patients with colectomy and poor anal sphincter function or as a rescue operation for failed pelvic J or S pouches. Colostomy may occasionally be created in cases of fulminant colitis or severe colitis in pregnant women. Mucous fistula and blow-hole colostomy for severe or fulminant colitis are variants of colostomy.
Postoperative recurrence of CD is common. After surgical resection of the bowel, 70%–80% endoscopic recurrence at 1 year can occur at the ileocolonic anastomosis in untreated patients. In patients with bowel resection and anastomosis, endoscopic recurrence at the anastomotic site may precede clinical recurrence. The Rutgeerts Score has been routinely used to monitor postoperative endoscopic recurrence for CD.
A similar rate of disease recurrence has been reported during retrograde ileoscopy via stoma in patients after CD surgery. In addition, UC patients who have a failed ileal pouch and have permanent ileostomy may also develop CD of the neoterminal ileum. These patients require endoscopic evaluation and stricture therapy. The Rutgeert’s Score has been shown to be useful to monitor the disease progress in patients with ileostomies.
Ileoscopy via stoma should be avoided in early postoperative period (<4 weeks) to allow healing of the stoma site. Before intubating the bowel via stoma, the endoscopist show carefully inspect stoma and surrounding for stoma prolapse, stoma retraction, stricture at the skin or stoma, fistulous tract stoma ulcers, and pyoderma gangrenous. If there is a tight stricture at the skin level which prevents passage of gastroscope, needle-knife therapy to cut the skin may be attempted ( Fig. 12.4 ).
Significant looping of the scope during ileoscopy or colonoscopy via stoma, abdominal pressure around the stoma may be applied by endoscopy assistant to facilitate passage of scope. Special attention should be given to the location of mucosal or luminal abnormalities. During endoscopy, evaluation of the bowel mucosa should be performed for assessing active disease and strictures. Erythema, friability, and ulceration of the small bowel or colonic mucosa just distal to the stoma, which is normally limited to proximately 10 cm or less from stoma site, can be a consequence of ischemic or mechanical effect from surgery, which is not typical feature for active CD. While biopsy is taken, the location with reference to stoma should be clearly labeled. Active CD in patients with end ileostomy should be treated aggressively, as these patients have a high risk for additional bowel resection surgery and for short gut syndrome.
A loop ileostomy it typically created as a temporary measure for fecal diversion. It can be designed in two configurations, either as a double barrel loop ileostomy with two equally sized stoma openings or as a defunctioned efferent limb with a smaller second stoma opening. Both configurations have the afferent and efferent limbs. The afferent limb leads to the proximal bowel cephalically and efferent limb toward distally to the diverted colon ( Fig. 12.5 ). The endoscopist need cautiously identify the two openings. Active CD can occur in the afferent limb of the loop ileostomy and hardly develop in efferent limb ( Fig. 12.6 ).