Endoscopic Polypectomy

Polypectomy is one of the most performed endoscopic procedures in the management of colorectal disease. Polyps are often an intermediate stage in the natural progression from normal mucosa to malignancy. By interrupting this so-called adenoma-carcinoma sequence, endoscopic polypectomy can prevent colorectal carcinoma (CRC) and has been shown to reduce its associated mortality.

Various techniques exist for removing polyps from the colon. The optimal polypectomy technique achieves complete polyp resection in an efficient manner and with minimal risk ( Fig. 2.1 ). Recent evidence favors the use of snares over forceps, due to higher rates of complete resections and lower risk of perforations from thermal injury. For diminutive and small polyps (<10 mm), cold snare is currently the recommended technique. ^, Cold snares increase the likelihood of complete resection and decrease the risk of delayed bleeding and coagulation injury compared to hot snares. For nonpedunculated polyps between 10 and 20 mm, both cold and hot snare techniques can be used. Emerging evidence seems, however, to increasingly favor cold snaring for these lesions as well. ^, For pedunculated polyps larger than ≥10 mm, hot snares are recommended. Finally, for large nonpedunculated lesions (≥20 mm) more advanced techniques, such as endoscopic mucosal resection (EMR) ( Fig. 2.2 ) and submucosal dissection (ESD), are needed to achieve complete and safe resection.

Endoscopic polypectomy. (A) Semipedunculated polyp on the fold of the transverse colon. (B) The polyp was removed with a hot snare.

Endoscopic mucosal resection or mucosal striping of a large colon polyp. (A) A 2.5-cm semi-pedunculated polyp lifted with a submucosal injection. (B) Hot snare for electro-excision. (C) Muscularis mucosa and submucosal plane were exposed after the resection. (D) Placement of endoclips to prevent late-onset bleeding and perforation.

The basic technique for cold snaring is to first position the polyp at the 5 or 6 o’clock position to align with the biopsy channel of the scope ( Fig. 2.1 ). Subsequently, the snare sheet should be advanced and the snare opened and positioned around the base of the polyp. Now, the tip of the snare sheet should be positioned 1 to 2 mm from the base of the polyp and pressed down gently into the healthy mucosa. Subsequently, the snare should be closed gradually taking care of including a small margin of 1 to 2 mm of healthy mucosa in the sample. A slight suction of air at this moment can help the bowel wall retract to facilitate this step. Now the dissection of the polyp can be performed by closing the snare further. Once the lesion is free, it can be retrieved using suction or a wire basket. Inspection of the postresection mucosa with irrigation if needed should always be performed to ensure optimal assessment in terms of completeness of resection and risk of perforation and bleeding. Tissue protrusions from submucosal fibers tissue are commonly seen after cold snaring and are best left untouched, since they do not represent any residual tissue ( Fig. 2.2 ). If there is a large mucosal defect or the risk of perforation is deemed high, closure with clips should be attempted.

In hot snaring, the initial approach and encircling of the polyp are similar to cold snaring. However, cutting is done using electrocoagulation instead of mechanical force ( Fig. 2.1 ). Therefore, it is advised that after grasping the lesion, the snare is elevated from the bowel wall (tenting) to prevent diathermic injury before cutting. Subsequently, an electric current is applied while further closing the snare to transect the lesion. Retrieval and postresection inspection are then performed. Several settings for endoscopic electrocoagulation exist. Current recommendations encourage the use of modern devices with internal processors that can automatically achieve a blend of cutting and coagulation, providing optimal results in terms of balance between hemostasis and thermal injury. After hot snaring for larger pedunculated polyps (head ≥20 mm or stalk ≥5 mm), applying clips or loops for prophylactic hemostasis is recommended. Finally, it should be noted that both cold and hot snaring and the use of dedicated polypectomy snares (compared to traditional snares) have been shown to make resection safer and easier, and increase the likelihood of complete resection.

Direct postprocedural complications after polypectomy mainly include bleeding and perforations. Bleeding can either be immediate or delayed ( Fig. 2.3 ). The risk of immediate bleeding is generally low (<1%), although it can be as high as 5% in patients on anticoagulants. ^{, ,} Delayed bleeding is also uncommon (<1%), but this risk can increase significantly (up to 15%) in patients on anticoagulants treated with hot snaring. Finally, perforations are rare but the risk increases with the size of the resected lesion. Resection of smaller polyps has a perforation rate well below 0.1%, ^, but it can increase substantially in EMR and ESD procedures. Finally, incomplete resection is unfortunately a common occurrence, with studies showing an average risk of about 10%, although the risk depends on several factors such as the experience of the endoscopist, the size of the lesion, and sessile morphology. ^,

Postpolypectomy bleeding and control. (A) Immediate bleeding after cold-snare polypectomy. (B) Placement of endoclips for bleeding control.

Endoscopic Mucosal Resection

Removal of larger nonpolypoid lesions can also be performed endoscopically. When these lesions are limited to the mucosa, EMR is the treatment of choice. This minimally invasive technique can substitute the need for surgery while comparing equivalently in terms of oncological control and R0 status. EMR was initially developed for the resection of superficial gastric lesions. Still, with time the technique and equipment have evolved, and it is now widely used for a variety of lesions. EMR is a collection of techniques building up on the standard snare polypectomy to radically resect superficial lesions that are otherwise not resectable. Both en bloc and piecemeal resection are possible, with general curative intent. If submucosal involvement is suspected, EMR should generally not be attempted. EMR can be considered for lesions between 10 and 19 mm when complete resection using conventional polypectomy is deemed challenging. This can be the case with nonpolypoid or serrated lesions. With larger flat lesions (i.e., ≥20 mm) EMR is the treatment of choice ( Fig. 2.2 ).

The conventional EMR, also known as injection-assisted EMR, involves the injection of fluid into the submucosa, allowing the mucosa to be lifted ( Fig. 2.2 ). Subsequently, a snare is used to encircle and capture the tissue. At this stage insufflation of the lumen and careful lifting of the snare, while being slightly loosened, can be used to release deeper tissue layers (e.g., muscularis propria) if needed. When depth is deemed appropriate, the lesion can be transected by closing the snare and applying electrocautery. If the lesion cannot be transected in one bite (i.e., en bloc), the process should be repeated until all visible tissue is removed.

Cap-assisted EMR is a variation of this technique first described in 1990 for patients with esophageal lesions. This technique uses a specially designed cap that is placed on the tip of the endoscope. After submucosal injection for lifting, suction is applied to retract the lesion inside the cap. Subsequently, a snare is placed around its base and the lesion is transected using electrocautery. Some use an intermediate step in which a rubber band is placed on the base of the lesion after suction to form a new polyp-like structure. This facilitates subsequent placement of a snare and removal.

An alternative technique, called underwater EMR, utilizes water immersion to facilitate resection without the need for submucosal injections. Authors of this technique noticed that filling the colon with water resulted in the muscularis propria acquiring a circular shape, while more superficial layers such as mucosa and the submucosa remained involuted. Furthermore, the affected mucosa and submucosa seemed to float away from the deeper layers of the colon because of the buoyancy effect of the water. These characteristics allowed for the safe performance of EMR techniques without the need for submucosal injection for lifting. Underwater EMR is safe and efficacious and has a short learning curve. ^, In experienced hands, it might yield results that are superior in terms of complete resection and coloscopic recurrence rates. It should be noted that combining underwater EMR with submucosal lifting is also possible and has been reported in up to 30% of cases in some series, especially when large lesions (≥30 mm) have to be resected.

Similarly to polypectomy, the main postoperative complications after EMR are bleeding and perforations. In a large meta-analysis, the average incidence of these complications was about 6.5% and 1.5%, respectively. Surgery due to direct postoperative complications after EMR was seen in 1% of cases. Surgery due to noncurative resections (e.g., invasive cancer at histology or nonradical resections) was seen in 8% of cases. Mortality related to EMR was only seen in 0.08% of cases.

Endoscopic Submucosal Dissection

The goal of ESD is en bloc removal of advanced colonic lesions that are not (easily) amenable to EMR. Larger lesions with potential submucosal involvement could be suitable candidates for ESD. Examples include (smaller) T1 tumors, large depressed-type lesions (Paris classification 0-IIc), lateral spreading tumors of nongranular type, lesions with submucosal fibrosis (e.g., ulcerative colitis [UC]), and early recurrence or residual lesions after endoscopic resection. Endoscopic ultrasound evaluation might be useful prior to ESD for the assessment of the depth and extent of such lesions.

The conventional technique for ESD starts with marking the boundary of the target lesion using electrocautery taking the necessary margin into account (usually 3 to 5 mm). Subsequently, submucosal injections around the lesion are used to lift it. Next, an incision is performed either circumferentially or at the proximal border depending on the preference of the endoscopist. This is performed with a dedicated ESD knife, of which many varieties exist. Subsequently, the dissection of the lesion at the level of the submucosa is carried out ( Fig. 2.4 ). The submucosa under the lesion can be injected repeatedly as needed. Preferably, the endoscopist should aim to stay just above the muscularis propria layer for optimal radical resection. When the dissection is complete, the remaining mucosal border (if any) should be incised. For retrieval, care should be taken to keep the specimen complete, and its orientation should be marked before sending it for pathological examination.

Endoscopic submucosal dissection of a large flat lesion from colitis-associated neoplasia. (A) The flat dysplastic lesion was highlighted by chromoendoscopy. (B) Endoscopic dissection of the submucosal plane with extensive fibrosis from long-standing ulcerative colitis.

Hybrid ESD is a combination technique of ESD and EMR. Usually, the lesion is marked and incised circumferentially using an ESD knife as described above. Subsequently, a snare is inserted into this incision and used to perform an en-bloc resection. This approach has the advantage of being less technically demanding and thus is shorter in duration. Some studies have shown that this hybrid ESD might provide similar oncological outcomes compared to conventional ESD. ^,

Regarding procedural complications, the rate of bleeding after colonic ESD was reported to be low, occurring in only about 2% of cases. The rate of perforations, however, was higher than EMR, occurring in about 4.8% of cases (135 of 2841 cases in a large meta-analysis). Most of these perforations were identified during the procedure and were able to be managed successfully with clip closure.

Endoscopic Balloon Dilation of Strictures

Strictures are common in colorectal clinical practice. For noncomplex benign strictures, endoscopic balloon dilation (EBD) is considered first-line therapy. ^, It offers a minimally invasive treatment that is safe and often effective. EBD is applied in the treatment of strictures due to Crohn’s disease (CD), surgical anastomoses, endoscopic submucosal dissection, diverticular disease, ischemic colitis, and inlet and afferent limb strictures after pouch surgery. Short strictures (<5 cm) preferably without deep ulcers on surface or prestenotic dilatation are good candidates for EBD ( Fig. 2.5 ).

Endoscopic balloon dilation of strictures. (A) Tight mixed inflammatory and fibrotic strictures at the end-to-side ileocolonic anastomosis in Crohn’s disease. (B) Endoscopic balloon dilation in a retroflex view.

EBD can be performed using various approaches. After the stenosis is visualized, the endoscopist can deploy the balloon in an antegrade or retrograde fashion. Antegrade placement is usually used for nontraversable strictures in which the endoscopist pushes the balloon sheath through the stricture, with or without the use of a guide wire. In retrograde placement, the stricture is first transversed with the scope, and the balloon is placed while the scope is being retracted. This approach is preferable when feasible. Care should be taken to place the balloon in a proper position with the middle of the balloon at the center of the stricture. The balloon is then inflated to the desired size while paying attention to keeping it in place, as it might tend to slip upon dilation. Generally, graded dilation is recommended to reduce any risk of bleeding and perforation. This is commonly achieved using controlled radial expansion balloons, which can be inflated to increasing sizes using higher inflation pressures. Usually partial or complete deflation is performed between each size. No clear data exists on the duration of each inflation, with 1 minute being a generally accepted value. For colonic strictures a size of about 18 to 20 mm should ideally be pursued if possible.

Technical success is often defined as the ability to pass the stenosis with the scope immediately after dilation. This is achieved in about 90% of cases with EBD. ^, Symptom resolution is often lower with rates of about 50% to 70%. ^, A significant proportion of patients will require repeat EBD to maintain the clinical improvement of symptoms. For patients in whom surgery can be associated with a high risk of morbidity, short bowel syndrome, or permanent ileostomy performing repeated EBD can offer a way to ameliorate symptoms and prevent surgery. It should be noted that the need for endoscopic reintervention and surgery increases with time and that the cumulative surgery rate at 5-year follow-ups can be as high as 75%. Complication rates are relatively low, with bleeding and perforation being the most common. Large meta-analyses show that the total rate of such complications is about 4% to 6%, and most can be managed conservatively. ^{, ,} Although rare, for strictures adjacent to vulnerable structures, EBD can result in damage to these structures (e.g., anal sphincter) or result in fistula formation (e.g., iatrogenic vaginal fistulae).

Endoscopic Stricturotomy and Strictureplasty

For strictures that do not respond to medical treatment or EBD, surgical intervention has been the usual subsequent step. In the last decade, however, endoscopic electroincision techniques have been effective in the treatment of such strictures. ^, While the exact role of these interventions is being investigated, they clearly can offer a bridge and potentially an alternative to surgery in selected patients. Endoscopic electroincision seems to be particularly useful for fibrotic, anastomotic, and anorectal strictures. In the case of anorectal strictures, electroincision offers precise control over the orientation, location, and depth of the incision. Thus, it may reduce the risk of anal sphincter damage or iatrogenic vaginal fistulae.

Endoscopic electroincision techniques can be categorized into stricturotomy and strictureplasty. Both techniques begin with the endoscopic electroincision of the stricture using an appropriate knife, such as an insulated tip or needle knife ( Fig. 2.6 ). Strictures can be incised circumferentially or radially to achieve adequate widening. In strictureplasty, additional clips are placed on the incised edge to serve as spacers ( Fig. 2.7 ).

Endoscopic stricturotomy. (A) Severe rectal stricture in Crohn’s disease with diverting ileostomy. (B) Stricturotomy with an insulated-tip knife. (C) Stricturotomy with a needle knife. (D) Poststricturotomy appearance.

Endoscopic strictureplasty. (A) A pinhole-shaped stricture at the colocolonic anastomosis after partial colectomy for diverticulosis. (B) Endoscopic electroincision of the stricture in a radial fashion. (C) Placement of endoclips in the incised stricture as spacers.

In expert hands, stricturotomy and strictureplasty have been proven to be safe and effective. The need for endoscopic reintervention after 1 year was about 60%, while the need for surgery in the same period was around 15%. Thus they seem to provide greater efficacy than EBD and have a lower perforation rate of around 1%. ^, The rate of delayed bleeding seems to be higher (between 3% and 8%) than EBD due to the risk of vessel damage.

Endoscopic Stent Placement

Endoscopic stenting is a well-established treatment option for various gastrointestinal conditions. In colorectal disease, its main indications are the (temporary) treatment of malignant and benign strictures. For malignant strictures, it can be used as a palliative treatment or to temporarily relieve the obstruction as a bridge to surgery (converting an emergency to an elective procedure). ^, Its use for benign strictures has gradually lost favor due to questionable sustained efficacy and safety concerns such as stent migration and erosion into the bowel wall.

Technically, several types of stents exist, such as plastic stents, self-expandable metallic stents (SEMS), covered stents, and lumen-apposing metal stents ( Fig. 2.8 ). SEMS are most commonly used in colorectal applications. Colonic stents range in diameter from 20 to 35 mm after deployment and 40 to 120 mm in length. Stents tend to possess flaring ends to prevent migration. The most common technique for stent placement is through the scope. If the enteral lumen at the stricture is tight, the use of a flexible guidewire is often necessary to transverse the lesion. Otherwise, the stent itself can be passed gently under vision across the lesion. If fluoroscopy is used, radio-opaque markers on the stent can help determine adequate positioning. Under visual or fluoroscopic monitoring, the stent is deployed slowly. When the stricture is longer than the stent or placement is suboptimal, placement of a second stent overlapping a part of the first stent is possible. Endoscopically passing the stent after deployment should be avoided, since the metal of the stent can damage the scope.

Endoscopic stenting. (A) A stricture at the side-to-side ileocolonic anastomosis in Crohn’s disease. The patient developed bleeding from previous endoscopic balloon dilation and stricturotomy. (B) A lumen-apposing metal stent was placed across the stricture endoscopically.

Several meta-analyses exist on the efficacy and safety of SEMS for colonic obstruction. A review of 88 articles performed in 2007 showed an initial technical success rate of 96% (range 66–100%) and a clinical success rate of 92% (range 46–100%). This is in line with data published later on. In the palliation of malignant obstruction endoscopic stenting can offer an effective and safe procedure. It should be noted, however, that late complications such as migration and reobstruction are important limitations in this group, and alternative treatment should also be considered. For the use of stents as a bridge to surgery, controversy still exists due to concerns regarding long-term efficacy and oncological outcomes. Some more recent meta-analyses show favorable results for stenting, with less morbidity and a lower rate of stoma placement as compared to emergency surgery. Other meta-analyses focusing on long-term outcomes showed similar rates of overall and disease-free survival between bridging with stents and emergency surgery. ^, Thus these results suggest that with proper patient selection and adequate technical expertise, colonic stenting can offer short-term advantages to patients without compromising long-term oncological outcomes. Reports of complications of stenting vary considerably and include bleeding (1–6%, perforation (4–14%), stent migration (2–22%), reobstruction (2–17%), and erosion into the bowel wall (rate not well reported). ^{, , ,}

Endoscopic Sinusotomy

Chronic anastomotic leaks after colorectal surgery often present as chronic abscesses, fistulas, or sinuses. Sinuses are a relatively infrequent complication that is defined as a small defect (opening of the sinus) in the lumen of the bowel (usually at an anastomotic site) leading to a blind-ending tract. It is most frequently seen after pouch surgery for IBD with an incidence of about 2% to 8% of patients. If left untreated, it may result in pouch failure.

Endoscopic sinusotomy was first described in 2010 in patients who developed a pouch sinus after pouch surgery ( Fig. 2.9 ). The sinusotomy procedure is performed through the scope using an electrocautery knife. After identifying the opening of the sinus, the knife is used to cut the wall between the pouch lumen and the sinus cavity. Some authors have described the removal of surrounding mucosa with a snare to optimize the unification between the sinus and the pouch. Subsequently, triamcinolone injection or endoclips could be applied to the edges, to help prevent early sinus closure and recurrence. ^,

Endoscopic sinusotomy. (A) A presacral sinus from a chronic leak at the pouch-anal anastomosis with the discharge of pus intermittently. (B) Endoscopic incision of the posterior wall of the distal pouch to incorporate the sinus and pouch lumen. (C) Placement of endoclips to keep the sinus patent and promote epithelialization of the sinus.

Endoscopic sinusotomy is an effective procedure in a significant proportion of patients. An initial cohort including 65 patients with pouch sinuses showed that more than 40% of patients experienced complete response after a median of two interventions, and yet another 40% showed partial response to the treatment. A recent cohort of 141 patients showed complete sinus healing in over 50% of patients, and 16% showed partial healing. Endoscopic sinusotomy is also safe and is associated with a low risk of complications (mainly bleeding). A recent comparative study has shown it to be associated with far fewer adverse events compared to surgical treatment (2.5% vs. 43.5%, P < .0001).

Endoscopic Septectomy

The septal formation is a rare complication of pouch surgery that can result in pouch inlet or outlet obstruction. ^, The septum is thought to form as a result of a full-thickness bowel wall bridge that develops over time. Endoscopic septectomy is performed using electrocautery to dissect the septum ( Fig. 2.10 ). After visualizing the obstruction caused by the septum, a guidewire is inserted to ascertain the position of the septum. Subsequently, the septum is incised and gradually divided using an electrocautery knife, usually an isolated tip knife to prevent damage to deeper structures. The guidewire is left alongside the knife to allow for better determination of the extent of the septum. After dividing the majority of the circumference, the remaining stump of the septum can be resected using a polypectomy snare. Clips can be applied to the incised edges to maintain patency and prevent bleeding and perforation. The frequency of complications is not well known due to the paucity of data regarding this procedure. However, in experienced hands, it seems to be an effective and safe procedure.

Endoscopic septectomy. (A) A distal pouch bar from a pouch-pouch fistula results in dyschezia symptoms. (B) Endoscopic septectomy by electroincision of the bar with an insulated-tip knife. (C) Placement of endoclips to keep the lumen patent.

Endoscopic Fistulotomy

A fistula is generally defined as an abnormal connection between two epithelialized surfaces. These can exist between the bowel and other bowel segments (enteroenteric fistula), skin (perianal and enterocutanous fistula), bladder (enterovesical fistula), or vagina (enterovaginal fistula). Intestinal fistulas have various etiologies, most commonly IBD, infection (e.g., diverticulitis), postsurgery, postradiation, and penetrating trauma.

Management of fistulas is often challenging, due to the high recurrence rate and a variety of functional and anatomical challenges depending on the specific location of the fistula. Medical management is often supportive and can be helpful to reduce the flow over a fistula, often with a concomitant reduction of symptoms. Surgical treatment with resection of the fistula tract including parts of the affected organ(s) is often the most effective treatment. However, not all fistulas are amenable to this approach. Other surgical options include seton drain placement, fecal diversion, and certain location-specific procedures such as mucosal advancement flaps for perianal fistulas.

In selected cases, endoscopy can play a role in the management of colorectal fistulas. Intestinal fistulas are often associated with strictures downstream. Endoscopic treatment of these strictures, particularly stricturotomy, can play an important role in the treatment of such fistulas. However, it is advised not to use EBD for strictures if fistulas are nearby.

Endoscopic fistulotomy has also been shown to be an effective procedure in selected patients. It is thought to be suitable for patients with single-tract, shallow fistulas with a depth of <3 cm. These include postsurgical fistulas located at the suture line, primary ileocecal fistulas, perianal fistulas, and pouch-pouch fistulas. The procedure is performed according to the following principles ( Fig. 2.11 ). First, a fistulous opening is identified by visual inspection. Then, the fistula tract is identified using a flexible tip guidewire, thus locating the inlet and exit opening of the fistula. Subsequently, the fistula is divided using an electrocautery knife, such as a needle or insulated-tip knife. When the complete fistula tract has been opened, endoclips are placed along the incised margins as spacers to prevent (delayed) bleeding.

Endoscopic fistulotomy. (A) A ileocecal fistula from a long-standing ileocecal valve stricture in Crohn’s disease. (B) Endoscopic fistulotomy of the fistula tract along with stricturotomy of the ileocecal valve stricture. (C) Placement of endoclips to keep the fistular tract patent.

Endoscopic fistulotomy for colorectal diseases was first described in 2015 in a young patient with a pouch-pouch fistula after surgery for IBD. In 2018 a cohort from the same research group described the outcomes of 29 patients with IBD who were treated with endoscopic fistulotomy. The types of fistulas treated were as follows: (1) pouch-pouch fistulas (48%), (2) fistula between the pouch and proximal intestine (28%), (3) perianal fistulas (20%), and (4) ileocolonic fistulas (4%). Technical success, defined as a complete division of the fistulous tract, was achieved in all patients. Clinical success, defined as long-term complete healing or disappearance of the fistula, was achieved in 89% of patients after a mean of 1.9 endoscopic interventions. One patient (4%) developed significant bleeding, requiring transfusion and endoscopic control of bleeding. No other adverse events were recorded in this cohort. Other potential complications of fistulotomy do include infection (e.g., abscess formation) and damage of adjacent structures such as the bowel, sphincter muscle fibers, and vagina (e.g., iatrogenic development of vaginal fistula).

Endoscopic Clipping

Endoscopic clipping allows for the closure of bowel wall defects, control of bleeding, and strategic placement of spacers to prevent the early closing of incised tissue. Commonly used tools are through-the-scope clips (TTSCs) and over-the-scope clips (OTSCs). TTSCs have been available for decades, are relatively inexpensive, and are easy to use. OTSCs have a larger opening and more grabbing strength than TTSCs. ^, Studies have shown that OTSCs are more suitable for perforation closure and stopping arterial bleeding. The main drawback of OTSCs is the need to withdraw the scope completely to place a new clip.

Indications for endoscopic clipping include acute (iatrogenic) perforations, leaks, management of bleeding, prophylactic closure of defects after endoscopic resection (e.g., EMR and ESD), and to a lesser extent, closure of fistulas. For TTSCs, the application is relatively straightforward. After insertion of the clip through the working channel of the scope, the target of clipping is identified. The clip is then opened, advanced to the desired location, and closed. If the clip position is satisfactory, it can be deployed ( Fig. 2.12 ). For OTSCs, the preparations include placement of the clip applicator through the working channel as well as placement of a specialized cap and clip on the tip of the scope. After the insertion of the scope, the target for clipping is visualized. Depending on the preference of the endoscopist and the system used, an anchor can be used to engage the target and pull it slightly toward the scope to cause the tenting of the target tissue. Alternatively, this tenting effect can be achieved by pressing the cap on the target and applying gentle suction. Subsequently, the clip is applied.

Endoscopic bleeding control. (A) Low-grade bleeding at the side-to-side ileocolonic anastomosis in Crohn’s disease. (B) Endoscopic placement of hemoclips of bleeding ulcers along the anastomosis.

The efficacy of clipping depends highly on the type of clip used, indication, and patient selection. In a large international cohort, outcomes were presented for patients treated with OTSCs for a variety of gastrointestinal diseases. Out of the 188 patients included 108 presented with fistulas, while 48 and 32 were treated with perforations and leaks, respectively. Long-term clinical success was seen in 90% of patients treated for perforations, 73% for leaks, and 43% for fistulas. Success was also significantly higher in patients treated primarily by clipping compared to rescue therapy (69% vs. 47%). A special case is Crohn’s fistulas. While CD surgery-associated acute anastomotic leaks can benefit from endoscopic clipping, CD-related fistulas have not responded well to such treatment. Despite a case report of success, there are insufficient data to support this practice. Moreover, experts have consistently indicated that long-term outcomes have been unfavorable in this group of patients. ^,

Endoscopic Suturing

In recent years, various suturing devices have been developed for endoscopic closure, including EndoCinch Suturing Device (C.R. Bard, Inc., Boston, Massachusetts), SefeStitch (SafeStitch Medical Inc, Miami, Florida), Apollo Overstitch System, and X-Tack (Apollo Endosurgery, Austin, Texas) ( Fig. 2.13 ), and Medical Power System (Power Medical Interventions, Langhorne, Pennsylvania). The use of these devices varies per manufacturer and can be technically challenging. Indications in colorectal disease are similar to those for endoscopic clipping. For other parts of the gastrointestinal tract, endoscopic suturing has other well-established indications, such as narrowing of a dilated gastrojejunostomy after a Roux-en-Y procedure and esophageal stent fixation. ^, There are limited data on the outcome of endoscopic suturing specifically for colorectal disease. Results will likely be in line with those achieved after clipping. The current use of endoscopic suturing is probably in a subset of patients with defects that might be too large to be enclosed by clips, but that are still amenable for endoscopic closure.

Endoscopic suturing with X-Tack. (A) A leak at the tip of the “J” in a patient with ileal pouch–anal anastomosis previously treated with the placement of over-the-scope clips. (B & C) Suture was placed with X-Tack device.

Surgical Drainage

The ancient dogma “ubi pus, ibi evacua” (“where there is pus, there is evacuation”) still holds to a great extent in the modern era. Although the development of antibiotics has allowed the medical treatment of certain small abscesses, drainage is still a main pillar in the treatment of most. For anorectal abscesses, surgical drainage is the treatment of choice. For intra-abdominal abscesses, percutaneous drainage has replaced the need for surgical intervention except in the narrowest of indications such as diverticulitis or CD with abscesses that are not amenable to percutaneous drainage and that do not respond sufficiently to antibiotic treatment.

The basic technique for abscess drainage depends on the type and the location of the abscess involved. For extrasphincteric anorectal abscesses (i.e., located in the ischioanal or ischiorectal fossae) drainage through the perineal skin is required. The incision is placed at the point of maximal bulging and ideally at the medial most aspect in case it eventually evolves into an anal fistula. It can be radial to the anus for smaller abscesses but might be placed circumferentially especially if the abscess has a horseshoe configuration. It is common practice to widen the incision by excising skin and subcutaneous tissue to prevent edges from closing rapidly. Digital probing of the cavity is applied next to take down nearby smaller compartmentalized abscesses. The goal is for secondary healing to occur from the bottom up. Regular irrigation of the cavity might be sufficient for superficial abscesses. For deeper abscesses, packing of the wound is often needed for adequate healing. The use of a Malechot or mushroom drain can limit the extent of skin incision, which otherwise needs to be wide to prevent premature healing of the skin with a persistent abscess cavity. Placement of Penrose drains can be useful, especially in larger abscesses where multiple incisions are needed (i.e., contraincisions) ( Fig. 2.14 ).

Surgically placed drainage catheter for intraabdominal abscess from complicated diverticulitis.

For intersphincteric abscesses, drainage is often performed transanally. For this, the internal opening of the abscess (if present) is visualized using a proctoscope. If not present, the bulging of the abscess is identified by visual inspection and digital palpation; and a small opening is made sharply. The opening is then enlarged using a hemostat or similar instrument until adequate drainage is achieved. Abscesses limited only to the intersphincteric space are usually small and can be sufficiently treated using this approach. Intersphincteric abscesses with extensive involvement of the extrasphincteric space might require combined transanal and transcutaneous surgical drainage. Note that such procedures are associated with a high risk of persistent anal fistula after drainage.

For supralevator abscesses, management can be more challenging. If the abscess is adjacent to the rectum, it might be amenable to transrectal drainage. If not, then percutaneous drainage might be a viable option, although there might be a higher risk of recurrence. If both approaches are not possible or do not achieve the desired results, transabdominal (laparoscopic or open) drainage might be necessary ( Fig. 2.14 ).

For surgical drainage of anorectal abscesses, the risk of complications is low. Bleeding is occasionally seen, but can usually be well managed. There is a theoretical risk of damage to the sphincter complex, although with proper technique this is seldom seen. The risk of recurrence of abscess is about 10%, while the risk of development of a secondary fistula can be as high as 56%. ^,

Anorectal Procedures

Fecal Diversion

Fecal diversion using colostomy ( Fig. 2.15 ) or ileostomy ( Fig. 2.16 ) has a variety of indications and can be performed in conjunction with several colorectal procedures. In some cases, the fecal diversion itself is the end goal of treatment, such as in the treatment of refractory constipation or incontinence. In these cases, usually, an end ostomy is preferred. This is also the case when the anal canal has to be resected (e.g., abdominoperineal resection (APR) or in high-risk surgical patients when anastomosis cannot be safely attempted. In other cases, it is a temporary step to allow for healing of an anastomosis (e.g., loop ileostomy in selected patients undergoing colorectal resections), subsiding of inflammation or sepsis (e.g., the Hartmann procedure for diverticulitis or loop colostomy for perineal fistulas or abscesses) ( Fig. 2.17 ) or as a bridge to surgery in cases of malignant obstruction. Finally, it might be performed as a contingency measure in case of an anastomotic leak or pouch failure.

Loop colostomy with the afferent and efferent limbs opening on the side.

End ileostomy in a patient with Crohn’s disease.

Diverted rectum or Hartmann pouch in Crohn’s disease. (A) Diverted rectum with sealed stump. (B) Chromoendoscopy for dysplasia surveillance.

Loop Ileostomy

A loop ileostomy is usually performed as a temporary diversion to protect a more distally located anastomosis ( Fig. 2.18 ). The relative ease involved in the construction and takedown of this type of stoma makes it the preferred approach in these cases. Meta-analyses have shown that a diverting loop ileostomy can significantly reduce the risk of clinical anastomotic leaks and reduce the need for reoperations. It should be noted that loop ileostomy is associated with certain drawbacks and complications such as the need for a second operation for a takedown with its associated risks, higher rates of anastomotic strictures, and potentially delayed diagnosis of chronic leaks. Therefore, sound clinical judgment should be used in selecting patients who are to benefit from such diversion and overuse is generally not advised. Sufficient time must be given before the loop ileostomy is closed. According to a recent randomized trial, closing loop ileostomies early (<2 weeks) is associated with a high rate of complications compared to closing them late (>8 weeks).

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