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Surgical Stricturoplasty in the Treatment of Ileal Pouch Strictures

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Objective

The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures.

Method

Consecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses.

Results

A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (p = 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (p < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups.

Conclusion

Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.

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Abbreviations

CD:

Crohn’s disease

CI:

Confidence interval

EIM:

Extra-intestinal manifestations

EPACT:

European Panel on the Appropriateness of Crohn’s Disease Therapy

FAP:

Familial adenomatous polyposis

HR:

Hazard ratio

IBD:

Inflammatory bowel disease

IC:

Indeterminate colitis

IPAA:

Ileal pouch anal anastomosis

IQR:

Interquartile range

IRB:

Institutional Review Board

NSAID:

Non-steroidal anti-inflammatory drugs

PDAI:

Pouchitis Disease Activity Index

PSC:

Primary sclerosing cholangitis

UC:

Ulcerative colitis

Reference

  1. Bouguen G, Peyrin-Biroulet L. Surgery for adult Crohn's disease: what is the actual risk? Gut 2011;60:1178–1181

    Article  PubMed  Google Scholar 

  2. Shen B. Diagnosis and management of postoperative ileal pouch disorders. Clin Colon Rectal Surg 2010; 23:259–268

    Article  PubMed  Google Scholar 

  3. Marcello PW, Roberts PL, Schoetz DJ, Jr., Coller JA, Murray JJ, Veidenheimer MC. Long-term results of the ileoanal pouch procedure. Arch Surg 1993;128:500–503; discussion 503–504

    Article  PubMed  CAS  Google Scholar 

  4. Fazio VW, Ziv Y, Church JM, Oakley JR, Lavery IC, Milsom JW, Schroeder TK. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222:120–127

    Article  PubMed  CAS  Google Scholar 

  5. Lewis WG, Kuzu A, Sagar PM, Holdsworth PJ, Johnston D. Stricture at the pouch-anal anastomosis after restorative proctocolectomy. Dis Colon Rectum 1994;37:120–125

    Article  PubMed  CAS  Google Scholar 

  6. Senapati A, Tibbs CJ, Ritchie JK, Nicholls RJ, Hawley PR. Stenosis of the pouch anal anastomosis following restorative proctocolectomy. Int J Colorectal Dis 1996;11:57–59

    Article  PubMed  CAS  Google Scholar 

  7. Prudhomme M, Dozois RR, Godlewski G, Mathison S, Fabbro-Peray P. Anal canal strictures after ileal pouch-anal anastomosis. Dis Colon Rectum 2003; 46:20–23

    Article  PubMed  CAS  Google Scholar 

  8. Shen B, Fazio VW, Remzi FH, Delaney CP, Achkar JP, Bennett A, Khandwala F, Brzezinski A, Doumit J, Liu W, Lashner BA. Endoscopic balloon dilation of ileal pouch strictures. Am J Gastroenterol 2004; 99:2340–2347

    Article  PubMed  Google Scholar 

  9. Shen B, Lian L, Kiran RP, Queener E, Lavery IC, Fazio VW, Remzi FH. Efficacy and safety of endoscopic treatment of ileal pouch strictures. Inflamm Bowel Dis 2011; 17:2527–2535

    Article  PubMed  Google Scholar 

  10. Matzke GM, Kang AS, Dozois EJ, Sandborn WJ. Mid pouch strictureplasty for Crohn's disease after ileal pouch-anal anastomosis: an alternative to pouch excision. Dis Colon Rectum 2004;47:782–786

    Article  PubMed  Google Scholar 

  11. Shen B, Achkar JP, Connor JT, Ormsby AH, Remzi FH, Bevins CL, Brzezinski A, Bambrick ML, Fazio VW, Lashner BA. Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. Dis Colon Rectum 2003; 46:748–753

    Article  PubMed  Google Scholar 

  12. Shen B, Fazio VW, Remzi FH, Bennett AE, Brzezinski A, Lopez R, Oikonomou I, Sherman KK, Lashner B. Risk factors for clinical phenotypes of Crohn's disease of the ileal pouch. Am J Gastroenterol 2006; 101:2760–2768

    Article  PubMed  Google Scholar 

  13. Shen B, Fazio VW, Remzi FH, Bennett AE, Lavery IC, Lopez R, Brezinski A, Sherman KK, Bambrick ML, Lashner BA. Clinical features and quality of life in patients with different phenotypes of Crohn's disease of the ileal pouch. Dis Colon Rectum 2007; 50:1450–1459

    Article  PubMed  Google Scholar 

  14. Shen B, Remzi FH, Brzezinski A, Lopez R, Bennett AE, Lavery IC, Queener E, Fazio VW. Risk factors for pouch failure in patients with different phenotypes of Crohn's disease of the pouch. Inflamm Bowel Dis 2008; 14:942–948

    Article  PubMed  Google Scholar 

  15. Shen B, Remzi FH, Lavery IC, Lopez R, Queener E, Shen L, Goldblum J, Fazio VW. Administration of adalimumab in the treatment of Crohn's disease of the ileal pouch. Aliment Pharmacol Ther 2009; 29:519–526

    Article  PubMed  CAS  Google Scholar 

  16. Shen B. Crohn's disease of the ileal pouch: reality, diagnosis, and management. Inflamm Bowel Dis 2009; 15:284–294

    Article  PubMed  Google Scholar 

  17. Uchino M, Ikeuchi H, Matsuoka H, Matsumoto T, Takesue Y, Tomita N. Long-term efficacy of strictureplasty for Crohn's disease. Surg Today 2010; 40:949–953

    Article  PubMed  Google Scholar 

  18. Wibmer AG, Kroesen AJ, Grone J, Buhr HJ, Ritz JP. Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease–review of the literature. Int J Colorectal Dis 2010; 25:1149–1157

    Article  PubMed  Google Scholar 

  19. Fleshman JW, Cohen Z, McLeod RS, Stern H, Blair J. The ileal reservoir and ileoanal anastomosis procedure. Factors affecting technical and functional outcome. Dis Colon Rectum 1988; 31:10–16

    Article  PubMed  CAS  Google Scholar 

  20. Roy P, Kumar D. Strictureplasty. Br J Surg 2004; 91:1428–1437

    Article  PubMed  CAS  Google Scholar 

  21. Jobanputra S, Weiss EG. Strictureplasty. Clin Colon Rectal Surg 2007, 20:294–302

    Article  PubMed  Google Scholar 

  22. Roy P, Kumar D. Strictureplasty for active Crohn's disease. Int J Colorectal Dis 2006; 21:427–432

    Article  PubMed  Google Scholar 

  23. Tonelli F, Fedi M, Paroli GM, Fazi M. Indications and results of side-to-side isoperistaltic strictureplasty in Crohn's disease. Dis Colon Rectum 2004; 47:494–501

    Article  PubMed  Google Scholar 

  24. Lee EC, Papaioannou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn's disease. Ann R Coll Surg Engl 1982; 64:229–233

    PubMed  CAS  Google Scholar 

  25. Ambe R, Campbell L, Cagir B. A comprehensive review of strictureplasty techniques in Crohn's disease: types, indications, comparisons, and safety. J Gastrointest Surg 2012; 16:209–217

    Article  PubMed  Google Scholar 

  26. Dietz DW, Laureti S, Strong SA, Hull TL, Church J, Remzi FH, Lavery IC, Fazio VW. Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease. J Am Coll Surg 2001; 192:330–337; discussion 337–338

    Article  PubMed  CAS  Google Scholar 

  27. Yamamoto T, Fazio VW, Tekkis PP. Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis. Ds Colon Rectum 2007; 50:1968–1986

    Article  Google Scholar 

  28. Felley C, Vader JP, Juillerat P, Pittet V, O'Morain C, Panis Y, Vucelic B, Gonvers JJ, Mottet C, Froehlich F, Michetti P. Appropriate therapy for fistulizing and fibrostenotic Crohn's disease: Results of a multidisciplinary expert panel - EPACT II. J Crohns Colitis 2009; 3:250–256

    Article  PubMed  Google Scholar 

  29. Dietz DW. Mid pouch strictureplasty for Crohn's disease after ileal-pouch anal anastomosis: an alternative to pouch excision. Tech Coloproctol 2005; 9:179; discussion 179

    Article  PubMed  CAS  Google Scholar 

  30. Thomas-Gibson S, Brooker JC, Hayward CM, Shah SG, Williams CB, Saunders BP. Colonoscopic balloon dilation of Crohn's strictures: a review of long-term outcomes. Eur J Gastroenterol Hepatol 2003; 15:485–488

    PubMed  Google Scholar 

  31. Ferlitsch A, Reinisch W, Puspok A, Dejaco C, Schillinger M, Schofl R, Potzi R, Gangl A, Vogelsang H. Safety and efficacy of endoscopic balloon dilation for treatment of Crohn's disease strictures. Endoscopy 2006; 38:483–487

    Article  PubMed  CAS  Google Scholar 

  32. Foster EN, Quiros JA, Prindiville TP. Long-term follow-up of the endoscopic treatment of strictures in pediatric and adult patients with inflammatory bowel disease. J Clin Gastroenterol 2008; 42:880–885

    Article  PubMed  Google Scholar 

  33. Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, Taggi F, Winn S, Morini S. Systematic review: Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther 2007; 26:1457–1464

    Article  PubMed  CAS  Google Scholar 

  34. Greenstein AJ, Zhang LP, Miller AT, Yung E, Branco BC, Sachar DB. Relationship of the number of Crohn's strictures and strictureplasties to postoperative recurrence. J Am Coll Surg 2009; 208:1065–1070

    Article  PubMed  Google Scholar 

  35. Thienpont C, D'Hoore A, Vermeire S, Demedts I, Bisschops R, Coremans G, Rutgeerts P, Van Assche G. Long-term outcome of endoscopic dilatation in patients with Crohn's disease is not affected by disease activity or medical therapy. Gut 2010; 59:320–324

    Article  PubMed  CAS  Google Scholar 

  36. Reese GE, Purkayastha S, Tilney HS, von Roon A, Yamamoto T, Tekkis PP. Strictureplasty vs resection in small bowel Crohn's disease: an evaluation of short-term outcomes and recurrence. Colorectal Dis 2007; 9:686–694

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors thank Mr. Jeffrey P. Hammel for statistical support. The study was supported by research grants from Broad Foundation and the Crohn’s and Colitis Foundation of America (to B.S.). Dr. Xianrui Wu is a research fellow from the Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, and he is supported by the China National Oversea Scholarship.

Disclosure

The authors declare no conflicts of interest.

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Authors and Affiliations

  1. Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA

    Xian-rui Wu, Ravi P. Kiran & Feza H. Remzi

  2. Department of Gastroenterology/Hepatology—Desk A31, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA

    Saurabh Mukewar & Bo Shen

Authors
  1. Xian-rui Wu
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  2. Saurabh Mukewar
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  3. Ravi P. Kiran
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  5. Bo Shen
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Corresponding author

Correspondence to Bo Shen.

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Meeting Presentation

The abstract was presented as a poster at the Digestive Disease Week (SSAT) 2013, Orlando, FL.

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Wu, Xr., Mukewar, S., Kiran, R.P. et al. Surgical Stricturoplasty in the Treatment of Ileal Pouch Strictures. J Gastrointest Surg 17, 1452–1461 (2013). https://doi.org/10.1007/s11605-013-2216-3

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  • DOI: https://doi.org/10.1007/s11605-013-2216-3

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