Endoscopic Management of Postoperative Floppy Bowel

ABBREVIATIONS

ALS

afferent limb syndrome

ATZ

anal transitional zone

BMI

body mass index

CD

Crohn’s disease

ELS

efferent limb syndrome

FAP

familial adenomatous polyposis

FPC

floppy pouch complex

GGE

gastrografin enema

IBD

inflammatory bowel disease

IPAA

ileal pouch–anal anastomosis

IQR

interquartile range

PRA

pouch-rectal anastomosis

RPC

restorative proctocolectomy

UC

ulcerative colitis

INTRODUCTION

The term floppy bowel is coined from floppy pouch complex (FPC). The term FPC was used to describe a cluster of disorders with narrowed bowel lumen from extrinsic compression or angulation in patients with restorative proctocolectomy (RPC) and ileal pouch–anal anastomosis (IPAA). Common indications for RPC and IPAA are medically refractory ulcerative colitis (UC), colitis-associated neoplasia, or familial adenomatous polyposis (FAP). Obstructive structural complications along with acute and chronic anastomotic leaks and inflammatory pouch complications are common in patients with RPC and IPAA. Structural pouch outlet obstruction from prolapse, twist, and angulation, along with anastomotic stricture, may contribute to the development of fecal stasis-associated, antibiotic-dependent pouchitis.

Common phenotypes of FPC are pouch prolapse, pouchocele, afferent limb syndrome (ALS), efferent limb syndrome (ELS), pouch volvulus, and horizontal pouch folding. Patients with FPC often present with dyschezia, excessive straining, pelvic pain, bloating, and perianal excoriation. Phenotypes of FPC are diagnosed with a combined clinical, radiographic, and endoscopic evaluation. ^,

Pouch prolapse (e.g., transanal repair, abdominal pouch pexy, mucosal excision, and transabdominal revision or removal), ALS (e.g., pouch pexy, ileopexy, and Heineke-Mikulicz strictureplasty), and ELS (e.g., surgical shortening) have been treated with surgery. However, postoperative recurrence of FPC is common, at least being commonly seen in our Center for Ileal Pouch Disorders at Columbia University Irving Medical Center/New York Presbyterian Hospital. Most patients and their colorectal surgeons have been reluctant to be operated on or have permanent diversion or pouch excision. This has led to the development and application of various endoscopic approaches. These endoscopic therapeutic modalities were initially applied to those who failed surgical therapy. Since those endoscopic therapies do not burn the bridge for future surgical treatment, if needed, they have evolved into a first-line treatment before surgical intervention in our Pouch Center.

In addition to FPC in patients with UC or FAP who had RPC and IPAA, we also noticed the “floppy bowel” phenomenon in patients with CD who had a bowel resection and anastomosis. and in those with bowel resection and anastomosis for other benign (e.g., sigmoid volvulus) or malignant (e.g., colon cancer) colorectal disorders. A classic example is mucosal prolapse at the anastomosis with or without distal anastomotic strictures. Rectal prolapse and rectocele are routinely treated with surgery such as rectopexy, repair, and sigmoidectomy. Postoperative current prolapse, rectocele, or volvulus can recur. Endoscopic therapy has been applied to these conditions in a preoperative or postoperative setting.

AFFERENT LIMB SYNDROME IN THE POUCH

Afferent limb syndrome is usually caused by a sharp angulation between the prepouch ileum and pouch body without intrinsic stricture. It can occur in patients with J- or S-pouches. Patients with ALS often suffer from symptoms of partial small bowel obstruction and/or pouch outlet obstruction. In a study of 18 ALS patients with a mean age of 35.6 ± 14.3 years, 15 were found to have angulation of the pouch inlet and difficulty in intubating the prepouch ileum with pouchoscopy.

Endoscopic approaches can be attempted, including balloon dilation (using a 20 mm through-the-scope balloon to disrupt thin extraluminal adhesions) ( Fig. 15.1 ), endoscopic electroincision ( Fig. 15.2 ), endoscopic band ligation ( Fig. 15.3 ), or endoscopic plication ( Fig. 15.4 ). The mechanisms of action of endoscopic electroincision, banding ligation, or plication are to reduce the sharp corner between the prepouch ileal and pouch body. Endoscopic electroincision is performed with the use of a needle knife or insulated-tip knife followed by the placement of endoclips to keep the patency ( Fig. 15.2 ). Endoscopic banding ligation is performed in the angulated part of the pouch inlet preceded by the submucosal injection of hypertonic glucose to promote intramucosal fibrosis ( Fig. 15.3 ). Endoscopic plication can be achieved by the application of long (2 cm), strong through-the-scope clips to straighten the corner between the prepouch ileum and pouch body ( Fig. 15.4 ). These endoscopy procedures can be performed in an outpatient setting. In this author’s experience, at least 50% of patients noticed an improvement in symptoms after the endoscopic therapy. For partial responders or those with recurrent symptoms, repeat endoscopic therapy can be performed.

A combined endoscopic and surgical approach has been described for the treatment of ALS. For example, ALS was treated with endoscopy-assisted transanal repair and ileopexy.

EFFERENT LIMB SYNDROME IN THE POUCH

The classic appearance of ELS is the angulation of an excessively long efferent limb and pouch body of an S-pouch, resulting in dilated pouch body. A “normal” efferent limb is approximately 2 cm long. Patients with ELS complain of excessive straining, the sensation of incomplete evacuation, and bloating. Most cases of ELS require surgical intervention. ^, For symptomatic patients who are not candidates for surgery, endoscopic therapy with EBD (of the angulation between the efferent limb and pouch body) ( Fig. 15.5 ) or banding ligation of the mucosa of the proximal entrance of the efferent limb may be attempted ( Fig. 15.6 ). Most patients require repeat endoscopic therapy.

POUCH PROLAPSE, POUCHOCELE, RECTAL PROLAPSE, AND RECTOCELE

Pouch prolapse, pouchocele, rectal prolapse, and rectocele may share similar disease mechanisms.

Pouch Prolapse and Pouchocele

Pouch prolapse is characterized by excessive bulging of the pouch wall into the lumen of the pouch body or through the anus in severe cases. Pouch prolapse can be mucosal prolapse or full-thickness prolapse. Pouch prolapse is more often observed in the anterior wall of the distal pouch or cuff. Severe cases may present with circumferential prolapse resembling intussusception ( Fig. 15.7 ). Pouch prolapse may be seen in the pouch inlet. Distal anterior pouch prolapse may go hand in hand with a pouchocele. The latter presents with outpouching of the anterior pouch wall. Pouch prolapse is more common in female patients with a low body mass index, and those with a lower peripouch fat, or think pouch wall. The common clinical manifestations include dyschezia, excessive straining, bloating, and hematochezia.

The management of ileal pouch prolapse has been challenging. Symptomatic patients with refractory prolapse require surgical treatment. Reported surgical procedures include pouchopexy, placement of biological mesh, transanal reduction of the prolapsed tissue, redo pouch construction, and pouch excision with permanent diversion. ^, The main issue of the surgical approach for the treatment of pouch prolapse is the long-term efficacy. We have noticed a high frequency of postoperative recurrence. This has led us to explore alternative approaches, including endoscopic therapy.

Endoscopy plays a key role in the diagnosis and management of pouchocele. At our Pouch Center, we routinely performed endoscopic banding ligation of pouch prolapse. The concept is similar to that of abdominoplasty or “tummy tuck.” Banding ligation following submucosal injection of hypertonic glucose ( Fig. 15.8 ) results in fibrosis of the mucosa, submucosa, and superficial muscularis propria. The endoscopic technique has been used for the treatment of both mucosal and full-thickness prolapse with favorable outcomes in our Pouch Center. Our protocol is that the patient undergoes testing therapy with 3 to 4 bands and repeat therapy with 7 to 14 bands if patient responds or partially responds to the testing therapy. After the initial two sessions, endoscopic therapy may be performed in the future as needed. This author also started using endoscopic mucosal resection and clipping ( Fig. 15.9 ) and argon plasma coagulation ( Fig. 15.10 ) in patients with pouch prolapse refractory to endoscopic banding or surgical pexy. The bands typically fall off hours after the procedure. Some patients may experience transient mild bleeding, pelvic discomfort, bloating, and transient difficulty in defecation. Treatment strategies for postprocedural discomfort include oral intake of activated charcoal and self-catheterization.