Endoscopic Therapy for Pouch Leaks and Strictures: A Systematic Review.

BACKGROUND

Patients with ulcerative colitis refractory to medication or familial adenomatous polyposis may require ileal pouch-anal anastomosis after a colectomy. IPAA is generally well tolerated. However, patients can experience posttreatment complications, including pouch strictures and leaks. Medical therapy has a limited role in mechanical fibrotic strictures, whereas surgery is invasive and costly. In the past few decades, endoscopic therapies have provided a less invasive and less costly intervention for pouch strictures and leaks.

OBJECTIVE

This systematic literature review aimed to describe the status of advancements in endoscopic therapy for pouch leaks and strictures.

DATA SOURCES

The sources used were PubMed and Cochrane databases.

STUDY SELECTION

Studies between January 1990 and January 2022, in any language, were included. Articles regarding surgical management or pouches other than adult ileal pouch-anal anastomosis were excluded.

INTERVENTIONS

Endoscopic management of acute and chronic leaks and strictures ileal pouch-anal anastomosis was included.

MAIN OUTCOME MEASURES

Successful management (including persistent leak or stricture, pouch failure, subsequent endoscopy, or surgery) was measured.

RESULTS

Sixty-one studies were included in this review, including 4 meta-analyses or systematic reviews, 11 reviews, 17 cohort studies, and 18 case series.

LIMITATIONS

The limitations include qualitative review of all study types, with no randomized controlled studies available.

CONCLUSION

Ileal pouch-anal anastomosis leaks are various in configuration, and endoscopic therapies have included clipping leaks at the tip of the "J" as well as endoscopic sinusotomy. Endoscopic therapies for pouch strictures have included endoscopic balloon dilation, endoscopic stricturotomy, and endoscopic stricturoplasty, which are now considered first-line therapies for pouch strictures. Endoscopic balloon dilation has shown safety and efficacy in single, short, and straight strictures and endoscopic stricturotomy for refractory long, fibrotic, anastomotic strictures. Endoscopic therapies can delay or prevent invasive surgeries. Key tenets of successful endoscopic therapy include patient and lesion candidacy, an experienced endoscopist, and adequate rescue surgery plans.