Perspectives of Corrective Endoscopy

When considering patient characteristics for endoscopic treatment, some patients may require more discretion. Patients with malnutrition, comorbidities, or the use of systemic corticosteroids, are at higher risk of endoscopic complications and may benefit from postponing urgent endoscopy. High-risk patients must undergo proper preprocedural cardiovascular and pulmonary evaluation with an anesthesiologist team. During this evaluation, the provider, endoscopist, anesthesiologist, and colorectal surgeon should consider proper preprocedural management or discontinuation of medications including systemic corticosteroids, or antiplatelet agents. In addition, the patient should be advised and instructed on proper bowel preparation, preferably with polyethylene glycol, as good bowel preparation increases the visibility and safety of the endoscopic procedure.

Therapeutic endoscopy is associated with a higher risk of complications than diagnostic procedures. Many of the complications can be avoided or minimized with careful planning and preparation. Endoscopic procedure-associated complications (PACs) include bleeding, bowel perforation, and less often iatrogenic trauma to the adjacent organs (such as the bladder and vagina), sedation/anesthesia-associated adverse events, and postprocedural ileus. The endoscopist should be aware of which procedures involve higher bleeding risk, that is, endoscopic needle knife (NK) stricturotomy is associated with a higher risk of bleeding than EBD, while the latter carries a higher risk for perforation than the former. In EBD, excessive bleeding is uncommon and self-limited. ESt-associated bleeding is often late-onset, resulting from cauterization-associated ulceration. Patients with IBD may have the extraintestinal manifestation (EIM) of primary sclerosing cholangitis (PSC), which is associated with portal hypertension, thrombocytopenia, and coagulopathy and thus may lead to an increased risk of bleeding. The endoscopist, in collaboration with the preprocedural evaluating clinicians, should consider discontinuing antithrombotic agents or anticoagulants and minimizing the use of systemic steroids, based on individualized patient risk.

Endoscopic balloon dilation is more often associated with perforation than ESt, and older females are in general at increased risk for colonoscopy-associated perforation. Risk factors of EBD-associated perforation have been reported to include concurrent active mucosal inflammation, ^, the use of corticosteroids, ^, ileosigmoid (ISA) or ileorectal anastomotic (IRA) strictures, and primary strictures (vs. anastomotic strictures). Severe disease activity in IBD on endoscopy and concurrent use of corticosteroids was associated with 3.8 times greater and 7.7 times greater risk of colonoscopy-associated perforation respectively.

Perspectives of Corrective Surgery

Anastomotic complications are common in colorectal surgery for benign or malignant disorders. Anastomotic bleeding, strictures, and leaks largely result from colonic ischemia. The common locations for anastomotic complications are at the right colon, splenic flexure, rectosigmoid junction, and distal rectum. Contributing factors include malnutrition, anemia, comorbidities, transmural disease process, and external radiation. Preoperative optimization, intraoperative use of indocyanine green fluorescence, the construction of protective proximal diverting ostomy, and improvement in anastomotic techniques have helped reduce the risk of anastomotic complications. If anastomotic complications do occur, the colorectal surgeon should consult a therapeutic endoscopist and explore the opportunity of corrective endoscopy before reoperation. A surgeon often has concerns about the risk of further disruption of the integrity of anastomosis when urgent corrective endoscopy is performed within 2 to 4 weeks of the surgery. From the endoscopy perspective, the earlier the endoscopic intervention is performed, the better the outcome (such as endoscopic closure of acute anastomotic leaks [AL]). A careful endoscopic intervention may be performed by an experienced endoscopist, especially in patients with diverting ostomy. The senior author of this chapter has performed endoscopic bleeding control and endoscopic closure of anastomotic defects in the surgical intensive care unit and operating room with the colorectal surgery team on guard. Of note, acute ALs with abscesses should first be treated with interventional radiology drainage.

Most anastomotic strictures from colorectal surgery can be safely and effectively managed with endoscopic therapy. However, long (>4–5 cm) anastomotic strictures often require surgical intervention with resection and reanastomosis or surgical stricturoplasty. Chronic ALs with fistula or sinus formation may also be treated endoscopically first before the patient is considered for reoperation. To minimize the risk of recurrent anastomotic complications, the colorectal surgeon performing corrective surgical procedures should carefully review reports of index surgery and failed corrective endoscopy, evaluate the disease course, identify the etiology of the anastomotic complication, learn lessons from the last surgeon, and contemplate a comprehensive plan.

Crohn’s Disease

In the treatment of pre- and postoperative structural complications of CD, the goals of endoscopic therapy include: (1) to relieve symptoms; (2) to reduce the structural obstruction; (3) to drain abscesses; (3) to delay or prevent the need for surgery; and (4) to serve as adjunct therapy alongside medicine and/or surgery. Most patients with CD strictures, especially primary disease-associated strictures, would eventually need surgery. However, periodic endoscopic therapy, such as EBD for anastomotic strictures may space out the need for multiple surgeries. ESt, which is more effective than EBD, even provides comparable efficacy in the treatment of CD-associated anastomotic strictures to surgical resection. In most patients with CD, surgical resection or strictureplasty is not a cure, and postoperative disease recurrence and postoperative complications are common. Efforts should be made to reduce the total number of surgeries and the risk for the development of short gut syndrome.

Corrective endoscopy usually does not burn the bridge for future corrective surgery, if the former fails or results in a procedure-associated perforation. However, corrective surgery for corrective endoscopy-associated perforation usually requires urgent intervention and sometimes the construction of a diverting ileostomy. Upfront corrective surgery carries a lower risk for postoperative complications than corrective surgery for failed or complicated corrective endoscopy (such as EBD). Therefore, the proper selection of candidates for patients undergoing corrective endoscopy based on the risk stratification and predictor models is key. Some surgeons believe that the construction of ileostomy without definitive treatment of the disease is an easy outlet for the management of downstream refractory anastomotic complications as well as CD or perianal CD. Combined medical, endoscopic, and surgical therapy provides a better outcome than corrective endoscopy or corrective surgery alone.

In all instances of endoscopic therapy, it is crucial to understand the principles, techniques, and precautions associated with endoscopic therapy. In addition to the general principles of gastrointestinal (GI) endoscopy, interventional endoscopy in IBD and CRC management requires an experienced endoscopist with proper training, skilled support staff, correct equipment, and appropriate setting, characterization of lesions, consideration of patient risks as interventional endoscopy is more invasive than screening endoscopy, and backup plans including backup surgery.

Ulcerative Colitis

Restorative proctocolectomy (RPC) and IPAA is the preferred surgical treatment modality in patients with UC or familial adenomatous polyposis (FAP) who require colectomy. While PRC and IPAA improve patients’ health-related quality of life (QOL), structural, inflammatory, functional, neoplastic, or metabolic complications often occur. Common causes of pouch failure, defined as pouch excision or permanent diversion, are CD of the pouch, chronic pouchitis, strictures, twisted pouch, presacral sinus, pouch neoplasia, and pouch vaginal fistula (PVF). Various predictive models have been developed for pouch failure. Most structural and neoplastic complications can be managed endoscopically. Corrective endoscopy has become the main treatment modality for the management of structural and neoplastic complications of the pouch. Anastomotic bleeding, strictures at anastomosis, inlet, or stoma site, and acute or chronic leaks may be treated with endoscopic bleeding control, EBD, ESt, ESi, endoscopic fistulotomy, and endoscopic therapy of floppy pouch complex. In the endoscopic management of IPAA complications such as strictures and leaks, goals are to (1) relieve symptoms and their underlying causes; (2) reduce the number of emergency room visits or hospital admissions; (3) prevent surgery; (4) prevent pouchitis or enteritis from fecal stasis; (5) heal acute or chronic ALs; and (6) prevent fistula formation from concurrent strictures. A patient’s symptoms and objective findings on endoscopy or imaging do not necessarily correlate, and endoscopic therapy may be given based on objective findings of endoscopy.

Most structural complications of the ileal pouch have traditionally been treated with corrective surgery before the evolution of corrective endoscopy. Failed corrective endoscopy does not compromise the outcome of subsequent corrective surgery, although corrective surgery as an urgent rescue procedure for endoscopy-associated complications commonly requires the construction of a protective diverting ileostomy. Case-controlled studies have shown that the long-term outcomes of EBD and surgical strictureplasty for pouch strictures are comparable and ESi has a numerically higher efficacy in treating pouch sinus than pouch redo. Some surgeons have a low threshold for giving up the pouch by the creation of permanent ileostomy with or without excision of the pouch. Our previous studies showed that the secondary ileostomy from a failed pouch had far more complications than primary ileostomy in those with colectomy and without trying an ileal pouch. In addition, persistent perineal sinus is a common complication after pouch excision. Therefore, the decision to give up IPAA with a permanent ileostomy and the risk of postoperative complications from pouch excision should be carefully evaluated. Corrective endoscopy in the management of structural or neoplastic complications of the pouch has expanded to endoscopic vacuum therapy (EVT), ESt, ESi, endoscopic fistulotomy, endoscopic septectomy, EMR, and ESD.

Diverticular Diseases

Partial, segmental, or subtotal colectomy with colocolonic anastomosis or colorectal anastomosis is performed for complicated diverticular diseases. Anastomotic bleeding and strictures can usually be managed with corrective endoscopy. Acute or chronic ALs can also be treated with endoscopy first, with endoscopic drainage, clipping, and sinusotomy. Corrective surgery is hardly needed.

Colorectal Cancer

Anastomotic complications are common in patients with CRC undergoing colectomy and anastomosis, especially in those with obesity, low anterior resection (LAR), and pelvic radiation. Corrective endoscopies such as bleeding control, clipping, and sinusotomy should be performed first with corrective surgery as a backup, as the latter often involves the construction of diverting ostomy and results in recurrent anastomotic complications. Routine surveillance biopsy should also be performed. Anastomotic complications solely or partially resulting from pelvic radiation have been difficult to treat with either corrective endoscopy or corrective surgery. The patient and clinician should be mentally and physically prepared. Patients with long anastomotic strictures from ischemia or radiation who respond to endoscopic therapy usually require endoscopic reintervention periodically. Our personal experience suggests that ESi appears to be more effective in treating chronic ALs than endoscopic closure. Patients with refractory anastomotic complications may have permanent ostomy with or without completion of pouchectomy.

Bleeding Control

Most acute or chronic bleeding from anastomotic ischemic ulcers can be successfully controlled endoscopically. We normally use mechanical and chemical techniques, such as endoscopic clipping and injection or spray of hypertonic glucose, spray of hemostatic peptide gel, and removal culprit dislodged surgical staples or hemostatic peptide gel ( Figs. 5.4 – 5.7 ). We found that these techniques were safer and more effective than electric cauterization or topical injection of epinephrine.

Endoscopic polypectomy with bleeding. (A) Endoscopic hot snare polypectomy of a large pedunculated inflammatory polyp. (B) Postpolypectomy bleeding is controlled with clipping.

Postprocedural and Postoperative Ileus

Postprocedural ileus and postoperative ileus are common in patients undergoing prolonged endoscopy procedures or colorectal surgery. Contributing factors also include surgically altered bowel anatomy, electrolyte abnormalities, comorbidities, and the use of narcotic analgesics, anticholinergics, or benzodiazepines. Persistent ileus after the endoscopic procedure or some distal bowel surgery despite conservative therapy and the placement of a nasogastric tube may benefit from the placement of a decompression tube via the anus ( Fig. 5.8 ).

Endoscopic Balloon Dilation

Short (<4–5 cm) anastomotic strictures can be treated with EBD ( Fig. 5.9 ). Generally, a flexible, single-channel, video upper endoscope is used. The targeted balloon size is generally between 18 and 20 mm, correlating with the degree, length, and location of the stricture. The targeted size of balloon dilation may take several sessions to achieve, and sequential dilations may be needed. The preferred method is retrograde EBD to antegrade blind dilation if the stricture is traversable. However, if the stricture is nontraversable, antegrade wire-guided-exchanged EBD can be used.

Endoscopic Stricturotomy and Endoscopic Strictureplasty

When performing stricturotomy with the triple-lumen needle knife (NK) (Boston Scientific, Marlborough, Massachusetts) or insulated-tip (IT) knife (Olympus, Tokyo, Japan) may be used using ERCP Endocut settings ( Fig. 5.10 ). For ESt or ESTx, settings of electroincision and electrocauterization are appropriate, knowing that electrocauterization may increase the risk of late-onset bleeding. Circumferential or radial incisions may be made, where circumferential is preferred for strictures near the anal sphincter or to avoid iatrogenic PVF. In ESTx, endoclips may be placed after radial cuts to help keep strictures open as well as prevent perforation and bleeding ( Fig. 5.11 ) (Figure 5Xa-b). Certain endoscopic tools may be better equipped depending on the type of stricture. If important adjacent organs such as the bladder and vagina are near strictures, endoscopic NK ESt may be preferable to EBD as the knife can intentionally cut areas away from those sites. For example, NK ESt can cut at the antimesenteric site which is usually on the opposite side of linear ulcers, which are usually on the mesentery. This can help prevent mesenteric perforation resulting in a mesenteric abscess. In the senior author’s experience, the following stricture types are more prone to perforation during endoscopic therapy: spindle-shaped primary strictures, multiple strictures, angulated strictures, asymmetric anastomotic strictures, and strictures with concurrent severe inflammation, fistulae, or abscess. NK stricturotomy or surgery may be preferable over EBD for avoiding perforation, especially for smooth spindle-shaped primary strictures with normal-appearing mucosa. In addition, NK stricturotomy may be more appropriate for asymmetric strictures, since circumferentially or longitudinally asymmetric strictures may have a higher risk for perforation with the blind radial force of EBD. EBD may be appropriate for web-like strictures, inflammatory strictures, and symmetric structures. Ulcerated strictures may be treated with ESt. If there are multiple strictures (<4–5 cm), endoscopic therapy may be used as long as there are straight segments in between the strictures.

Endoscopic Removal of Foreign Bodies

We have noticed that bleeding, strictures, and leaks at the stapled anastomosis are often associated with dislodged or clustered staples, and removal of these staples can improve outcomes of endoscopic therapy. These staples can be removed with biopsy forceps via endoscopy ( Fig. 5.12 ).

Endoscopic Vacuum Therapy

Endoscopic vacuum therapy (EVT) for suspected ALs after colorectal surgery, an open-cell microporous sponge, an evacuation tube fixed to the sponge, and replacement of the sponge is required until the infection clears and the leak is confirmed closed by endoscopy. In EVT for suspected ALs after colorectal surgery, during flexible endoscopy, an open-cell microporous sponge is placed intraluminally in the transanal area at the site of the AL, or through the leak into an extraluminal perianastomotic abscess. Then, an evacuation tube fixed to the sponge applies negative pressure. The sponge is changed every 2 to 4 days until the infection clears and the leak is determined to be closed by endoscopy.

Endoscopic Fistulotomy

Chronic staple-line or suture-line ALs occasionally can lead to the formation of a fistula, especially in patients with IPAA. Pouch-to-pouch fistulas usually result from a leak from the vertical staple line. Endoscopic fistulotomy can be performed with electroincision of the fistular tract and placement of TTSC as spacers ( Fig. 5.13 ).

Endoscopic Sinusotomy

We described the first ESi for the treatment of presacral sinus of IPAA in the literature. ESt involves electroincision of the posterior pouch wall between the lumen and presacral sinus and placement of TTSC, incorporating the sinus into the pouch body ( Fig. 5.14 ).

Presacral sinus is also common in patients with LAR with colorectal or coloanal anastomosis for rectal cancer. ESi can safely and effectively be performed in these patients ( Fig. 5.15 ).

Endoscopic Closure

When treating ALs in IBD-related complications, similar ESt or endoscopic clipping may be used. TTSC or OTSC is used for acute leaks. ^, Complicated chronic leaks with fistula or presacral sinus, PVF, or enterocutaneous fistulas (ECF) usually do not respond to endoscopic clipping. However, OTSC can be attempted for transverse staple-line leaks at the side-to-side anastomosis of ICA ( Fig. 5.16 ), colorectal anastomotic leaks ( Fig. 5.17 ), or chronic leaks at the tip of the “J” or stoma closure site or the author has also used X-Tack suturing device (Apollo Endosurgery, Boston Scientific, Marlborough, Massachusetts) to close acute and chronic ALs.

Endoscopic Ligation

Pouch prolapse with or without pouchocele is a primary clinical phenotype of floppy pouch complex in IPAA. Patients with pouch prolapse or pouchocele commonly complain of dyschezia, the sensation of incomplete evacuation, and bloating. We routinely use endoscopic banding ligation with a cushion of hypertonic glucose to treat pouch prolapse and pouchocele ( Fig. 5.18 ). We also use endoscopic banding to treat rectal prolapse and rectocele.

Endoscopic Septectomy

Twisted pouch is also a phenotype of floppy pouch complex in IPAA. While surgical intervention with an untwist is an option, endoscopic septectomy can be formed to open up the tip of the twist ( Fig. 5.19 ).

Endoscopic Plication

The first endoscopic plication for the treatment of diseased lower GI tract is afferent limb syndrome in IPAA. Afferent limb syndrome, also a form of floppy pouch complex, results from a sharp angulation at the inlet between the afferent limb and pouch body. Endoscopic plication can be performed with the placement of TTSCs at the angulation ( Fig. 5.20 ).

Endoscopic Removal of Neoplastic Lesions of the Large Bowel

Due to concern about the risk of bleeding after endoscopic removal of neoplastic lesions of the large bowel, we recommend avoiding bowel preparation with red solution ( Fig. 5.21 ). Carcinogenesis of sporadic colorectal neoplasia and colitis-associated neoplasia (CAN) appears to be different. Sporadic adenomas typically present with polyps or polypoid lesions that can be readily removed with snare polypectomy or EMR ( Fig. 5.22 ). Colorectal polyps have been traditionally removed by simple methods during endoscopy such as biopsy forceps and cold or hot snares. However, this technique is not effective for more flat polyps and has perforation risk. Various procedures have been developed, including EMR, ESD, and endoscopic full-thickness resection (EFTR). For EMR and ESD, injection needles and fluid are required to lift the lesion for better removal. EMR requires an electrocautery snare, while ESD requires a knife. EFTR requires clips to close the defect before cutting.

As snares are not effective for flatter lesions, EMR was developed, wherein the fluid is injected into the submucosal space to lift the lesion away from the muscle, allowing resection of a flatter polyp via electrocautery snare. Underwater EMR was developed, in which the polyp was immersed in water, such that the polyp could “float” from the muscularis propria, theoretically decreasing the risk of perforation. Underwater EMR has not been widely performed nor studied. Polyps have been seen to recur after EMR, possibly due to resecting in multiple pieces. ESD was developed, in which the lesion is marked with cautery, a lifting agent is injected into the submucosa, and the mucosa is cut with a specialized knife. ^, At the submucosa, partial mucosal incisions are made to dissect the polyp completely. ^, This procedure is challenging; assistive devices have been used to facilitate dissection, including the use of a traction device or the creation of a large submucosal pocket under the lesion using a small-caliber tip transparent hood. ^, EFTR is a procedure that was developed recently and entails the resection of a polyp and closure of the defect using mechanical clips or endoscopic sutures. OTSC can be used as well, closing the defect before releasing the snare to cut the lesion. ^,

Colitis-associated neoplasia usually presents with flat or slightly raised lesions. When resecting flat CAN, hot snare, cold snare, or EMR can be difficult, due to extensive submucosal fibrosis. For these lesions, ESD can be performed, although en bloc resection is challenging. Careful histopathological evaluations of the resected lesion and its resection margin, are the key to managing CAN. The surrounding mucosa should also be biopsied due to the field effect of CAN. The long-term outcomes of endoscopic excision of CAN are not well known. Subsequent surveillance with deep biopsies should be taken in prior polypectomy, EMR, or ESD sites in CAN. In this senior author’s experience, hot snares appear safe in IBD-associated sessile lesions or pedunculated lesions with prolonged noncauterizing tightening of snares. Bleeding, if occurs, can be controlled by the application of hypertonic glucose or TTSC.

Surgical Injection of Fibrin Glue or Plug

Fibrin sealant was approved by the U.S. Food and Drug Administration (FDA) for clinical use for all three uses as a hemostat, sealant, and adhesive in 1998. There has been increasing interest in the clinical application of fibrin glue since then. Fibrin glue or plugs have been studied for anastomotic fistulas; however, the efficacy and safety of fibrin glue or plug remain to be proven. The literature on the efficacy of fibrin glue has been mixed; one randomized controlled trial (RCT) comparing fibrin glue versus conventional treatment (fistulotomy or loose seton insertion with or without subsequent advancement flap) for anal fistulas, and found that fibrin glue healed more complex fistulas than conventional treatment (69% vs. 13%; 95% confidence interval [CI]: 25.9–86.1; P = .003), however, did not heal more simple fistulas. Another RCT compared fibrin glue injections (n = 36) or only observation (n = 41) after removal of setons in CD perianal fistulas and found increased clinical remission in the fibrin group compared with the observation group (38% vs. 16%; odds ratio [OR] = 3.2; 95% CI: 1.1–9.8; P = .04). One study of the long-term effect of fibrin glue injection on Crohn’s anal fistulas found that at the end of an average 23.4-month follow-up period, over half (57%) of patients showed clinical signs of remission, in that leakage had dried up. However, when compared with mucosal flap, fibrin glue did not show improved outcomes. An RCT compared advancement flap repair alone or flap repair combined with fibrin glue obliteration of the fistula tract, and found recurrence rate for fistulas repaired by advancement flap alone was 20%, whereas the recurrence rate for fistulas repaired by advancement flap with fibrin glue was 46.4% ( P < .05). One study compared fibrin glue with a suturable bioprosthetic plug (Surgisis, Cook Surgical, Bloomington, Indiana) to close the primary opening of anorectal fistulas, and found that the plug prevented persistence of the fistula more than the glue (13% vs. 60%, P < .05). Despite mixed evidence on efficacy, fibrin glue has multiple benefits, including its simplicity, relative safety, ability to be repeated, and that use of fibrin glue does not compromise further treatment options moving forward. ^,

Diverting Ostomy

Diverting ileostomy or colostomy with or without a more definitive, corrective surgical procedure is sometimes performed for the cooling or healing of downstream anastomotic complications or the promotion of healing of distal neo-anastomosis. This procedure diverts the fecal stream away from the affected bowel, which can be helpful, as the fecal stream is thought to trigger tissue damage in CD as well as other colorectal diseases. It can be used to mitigate refractory perianal fistulas or abscesses, complications from surgery, or to control the disease downstream. However, the likelihood of restoring bowel continuity after fecal diversion remains low. ^,

Resection and Reanastomosis

Resection of the bowel segment with anastomotic bleeding, strictures, or leaks is followed by reanastomosis, for those who failed conservative therapy or corrective endoscopy ( Figs. 5.23 and 5.24 ). The risk of recurrent anastomotic complications may persist. Careful tissue handling during the surgery is critical. Failure to fully mobilize the splenic flexure was found to be a risk factor for anastomotic stricture. Full mobilization of the splenic flexure, high ligation of the mesenteric vessels, anastomotic stricture resection, and reanastomosis appear to be feasible for the treatment of index colorectal anastomotic strictures. It is also critical to avoid suture-line or staple-line tension when neo-anastomosis is constructed. For patients at risk for anastomotic complications, a proximal diverting ostomy is constructed.

Surgical Stricturoplasty

Strictureplasty on a strictured ileocolic anastomosis is occasionally performed ( Fig. 5.25 ). There was a small case series of 215 strictureplasties in 54 patients with CD, in which at 1-year follow-up, all but two patients had relief of obstructive symptoms, with symptomatic recurrence in 14 patients. Surgical strictureplasties can be used for ileal pouch strictures that fail repeat EBD, or are not amenable to EBD. One study by the senior author compared the efficacy and safety of stricturoplasty versus EBD, with 16 patients (9.6%) with surgical stricturoplasty and 151 patients (90.4%) with EBD, finding that patients in both groups had comparable overall pouch survival and stricture-free survival rates, however, the time interval between procedure and stricture recurrence or pouch failure was longer in the stricturoplasty group than in the EBD group ( P < .001). We concluded that while EBD is less invasive and easier to perform, strictureplasty is more durable. The findings may apply to the management of anastomotic strictures in other colorectal diseases.

Mucosal and Muscle Flap

Mucosal and muscle flaps are used for the treatment of vaginal fistula and perianal fistula in patients with colorectal diseases. Studies mentioned above comparing mucosal flaps to fibrin glue for closing perianal fistulas have found the superiority of mucosal flaps. ^, Mucosal and muscular advancement flaps are a popular transanal procedure for simple rectovaginal fistulas, in which they excise and close the rectal part of the fistula, and cover it with a vascularized mucosal flap on the high-pressure side of the fistula. This is a well-tolerated procedure with few complications including fever, urinary tract infection, and spinal headaches. Endorectal advancement flaps close primary openings to preserve the anal sphincter and have been used for CD with varying rates of success, with higher success rates for patients on biologic therapy prior to surgery. A meta-analysis found that there was no significant difference in recurrent fistulas of CD after endorectal mucosal advancement flap and fistulotomy. Complex and refractory perineal fistulas are sometimes repaired with the gracilis muscle flaps due to the ability of the muscle to preserve its vascularization due to its proximal pedicle and vestigial function.

Pouch Revision, Redo, or Conversion

Pouch revisions, redos, or conversions include resection of anastomosis or cuff with pouch advancement, J (“J” pouch)-to-J conversion, or J-to-K (Kock pouch) conversion. ^, Patients with persistent presacral sinus, pouch-vaginal fistula (PVF), or dysplasia of the cuff may be treated with pouch advancement. Patients with floppy pouch complex, such as pouch twist and volvulus, may be treated with revision, untwist, or pexy. Some patients with significant structural complications of the “J” or “S” pouch that are not amenable to pouch revision may benefit from the excision of the existing pouch and reconstruction of a new pouch, typically another “J” pouch. A J-to-J conversion denotes a transabdominal IPAA redo surgery for a failed initial IPAA, and some patients can be offered this complicated surgery as a way to attempt to avoid permanent ileostomy. The operating surgeon can determine whether to excise the old pouch to create a new one or to repair, revise, or reattach the old pouch depending on the viability of the old pouch, the reach of the new pouch, and the reasons for the failure of the previous pouch. An analysis of 502 patients who underwent J-to-J conversion saw zero postoperative mortality, and 53% postoperative morbidity (at least one postoperative complication), with complications including short-term ALs (8%). At a median follow-up time of 7 years postsurgery, 20% of patients had redo IPAA failure. The primary indicator of pouch failure was pelvic sepsis after redo surgery (hazard ratio = 3.7; 95% CI: 2.4–5.7; P < .0001).

In J (or S) to K conversion, an existing failed pelvic pouch is converted into a continent ileostomy, either Kock pouch ( Fig. 5.26 ) or Barnett Continent Intestinal Reservoir. Candidate patients include those with an isolated perianal disease, presacral sinus, cuff neoplasia, or PVF but normal pouch body, inlet, the tip of the “J”, and afferent limb. Patients with a “nonsalvageable” pelvic pouch body may require excision of the existing pelvic pouch and construct a Kock pouch from a new loop of the distal small bowel. Decision on the construction of the K-pouch converted from the existing J-pouch or the new loop of the distal bowel is determined by the patient (e.g., obesity, length of the bowel), disease or pouch (e.g., cause of failed J-pouch), and technical (e.g., expertise of colorectal surgeon) factors. For patients with a suspected diagnosis of perianal CD, a staged conversion surgery a temporary diverting ileostomy is recommended. Small bowel CD should be ruled out by periodic ileoscopy via stoma before the construction of the K-pouch converted from a failed J-pouch or fashioned from the new small bowel. A retrospective study of 64 patients undergoing this procedure showed zero postoperative mortality and a 30-day complication rate of 31.3%. At a median follow-up of 5 years, the dysfunction rate was 50%, the complication rate was 60.9%, the revision rate was 45.3%, and the retention rate of continent ileostomy was 95.3%. Overall, the median revision-free interval was 2.8 years, indicating that patients may require multiple future operations to preserve a functioning pouch, however, for patients who desire an alternative to standard ileostomy, a J-to-K conversion may be acceptable. Patients and clinicians should be aware that a failed K-pouch would result in the loss of 50 to 60 cm of the small bowel.

Exit Strategy for Procedure-Associated Complications

Backup plans are essential to ensure a safe therapeutic endoscopy and colorectal surgery. For corrective endoscopy, plan A is the therapeutic endoscopy going as planned—targeting the lesion and delivering the therapy. Plan B includes endoscopic damage control, for example, clipping or spraying 50% dextrose for bleeding. Plan C is a surgical backup. The multidisciplinary endoscopy team should have a high suspicion for PACs, looking for signs such as unusual abdominal pain or distension, changes in vital signs, and increased sedation requirements during or after the procedure. A high index of suspicion as well as prompt evaluation and treatment are essential for better outcomes in the case of PACs. This is exactly the reason that patients will be advised to keep a clear liquid diet for 24 hours after the procedure in the case of complications and subsequent Plan B or C. There is a low threshold for hospital admission and observation when there is a high suspicion of PACs. In the recovery suite, patients should be observed for at least 30 to 60 minutes, monitoring for signs of bleeding and perforation. Patients may be advised to stay near the hospital on the day of the therapeutic procedure. Complex endoscopic procedures, such as endoscopic therapy of multiple strictures, are performed by experienced endoscopists with a backup colorectal surgeon standing by.

Similarly, corrective colorectal surgery is complex. Patients with corrective surgery performed during EUA, such as placement of setons or mushroom catheters, can be observed in the postanesthesia care unit and discharged the same day. Patients undergoing more complex colorectal surgery procedures should be admitted and observed as an inpatient. Intraoperative endoscopy may be performed by an experienced endoscopist for diagnostic and therapeutic purposes.

Bleeding

Various techniques have been used to control bleeding from polypectomy, EMR, and ESD, including injection, clipping, and cauterization ( Figs. 5.4 and 5.5 ). Bleeding from endoscopic therapy at the distal rectum, distal pouch, or anorectal ring can be treated with tamponade with a tampon ( Fig. 5.5D ). In our clinical practice, most intraluminal anastomotic bleeding can be managed endoscopically, and interventional radiology or surgical intervention is hardly required. However, large-amount, postoperative extraluminal or intraabdominal bleeding needs angiographic embolization or surgical reintervention.

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