Division of Gastroenterology, University of California, San Diego, La Jolla, California.
Gastroenterology Unit, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France.
Inflamm Bowel Dis. 2018 May 18;24(6):1316-1320. doi: 10.1093/ibd/izy006.
Colectomy with ileoanal pouch is the standard of care for most patients with ulcerative colitis (UC) who require surgery. However, 5%-38% of patients with ileoanal pouch develop pouch strictures that can severely impact the functional results. We retrospectively evaluated the efficacy and safety of endoscopic balloon dilation of ileoanal pouch strictures in patients with inflammatory bowel disease (IBD).
All consecutive patients with IBD that underwent endoscopic balloon dilatation of a pouch stricture at our institution between January 1, 2011, and April 31, 2016, were included. Clinical, endoscopic, and surgical variables were collected retrospectively. Stricture-related pouch failure was defined by the need for surgical management of pouch stricture including pouch excision, diversion ileostomy, or stricturoplasty. Secondary outcomes included technical success, clinical success, and safety.
Eighty-eight endoscopic balloon dilatations were identified in 20 patients. Sixty percent of patients were female, with a median age at ileoanal pouch of 28.6 years (interquartile range [IQR], 25.5-37.2). Ileoanal pouch was performed for UC in 95% of cases; 95% of patients underwent J pouch; and 65% had a stapled anastomosis, whereas 35% had a handsewn anastomosis. Strictures were diagnosed at a median of 4.6 years (0.2-10.6) after surgery, and half of patients were symptomatic. The most frequent location of stricture was the anal-pouch anastomosis (87%). Half of patients were found to have associated pouchitis, 4 (20%) had at least 1 fistula, and 5 (25%) had ulcerations of the pouch. At the end of follow-up, 6 patients (30%) underwent a change in diagnosis from UC to Crohn's disease (CD) of the pouch, and in 1 patient (5%) a diagnosis of ischemic stricture was made. A median of 3.5 dilatations per patient (IQR, 2.0-7.0) were performed. Technical efficacy was observed in 87 procedures (98%). Twenty-two procedures were preceded by obstructive symptoms, and a clinical improvement after endoscopic balloon dilatation was observed in 95% of cases. After a median follow-up of 3.0 years (2.1-3.5), only 1 patient had stricture-related pouch failure. After the first dilatation, 4 patients were hospitalized for obstructive symptoms. Conservative management with another endoscopic balloon dilation was clinically effective in all cases. No major complications related to dilation were observed.
Endoscopic balloon dilatation of ileoanal pouch strictures is largely effective and safe and can be recommended as the first line strategy to treat ileoanal pouch strictures in patients with IBD.
对于大多数需要手术的溃疡性结肠炎（UC）患者，回肠肛管吻合术是标准治疗方法。然而，5%-38%的回肠肛管吻合术患者会出现吻合口狭窄，严重影响功能结果。我们回顾性评估了内镜球囊扩张术治疗炎症性肠病（IBD）患者回肠肛管吻合口狭窄的疗效和安全性。
本研究纳入了 2011 年 1 月 1 日至 2016 年 4 月 31 日期间在我院接受内镜球囊扩张术治疗的 IBD 患者，所有患者均接受了回肠肛管吻合口狭窄的内镜球囊扩张术。回顾性收集临床、内镜和手术变量。吻合口狭窄相关的吻合口失败定义为需要手术治疗吻合口狭窄，包括吻合口切除、转流性回肠造口术或吻合口成形术。次要结局包括技术成功率、临床成功率和安全性。
本研究共纳入 20 例患者的 88 次内镜球囊扩张术。60%的患者为女性，回肠肛管吻合口的中位年龄为 28.6 岁（四分位距[IQR]，25.5-37.2）。95%的患者因 UC 而行回肠肛管吻合术；95%的患者行 J 袋；65%的患者行吻合器吻合，35%的患者行手工吻合。吻合口狭窄的中位诊断时间为术后 4.6 年（0.2-10.6），且半数患者有症状。狭窄最常见的部位是吻合口肛侧（87%）。一半的患者伴有吻合口炎，4 例（20%）至少有 1 例瘘管，5 例（25%）有吻合口溃疡。随访结束时，6 例（30%）患者从 UC 改为 pouch CD，1 例（5%）患者诊断为缺血性狭窄。每位患者的中位扩张次数为 3.5 次（IQR，2.0-7.0）。87 次操作中观察到技术疗效（98%）。22 次操作前有梗阻症状，95%的病例经内镜球囊扩张后临床症状改善。中位随访 3.0 年（2.1-3.5）后，仅 1 例发生吻合口狭窄相关的吻合口失败。首次扩张后，4 例患者因梗阻症状住院。所有病例均通过再次内镜球囊扩张进行保守治疗，均取得了临床疗效。未观察到与扩张相关的主要并发症。
内镜球囊扩张术治疗回肠肛管吻合口狭窄效果显著且安全，可作为 IBD 患者回肠肛管吻合口狭窄的一线治疗策略。
