Closure of leak at the tip of the “J” after ileal pouch-anal anastomosis using a novel over-the-scope clipping system

Successful Closure of the Tip of the "J" Fistula of the Ileal Pouch With Double Over-the-Scope Clips

Ileal pouch-anal anastomosis is the surgical procedure of choice for patients who require colectomy for complicated ulcerative colitis with or without associated dysplasia and familial adenomatous polyposis. Leaks from the suture lines or anastomosis can lead to pouch failure. Treatment options have been radiographic drainage and surgical intervention. Endoscopic therapy has emerged a viable nonsurgical treatment option for some of the complications associated with J-pouch surgery. Here, we present a case of endoscopic management of a leak from the tip of the J-pouch with sequential application of 2 over-the-scope clips.

Modern management of perianal fistulas in Crohn's disease: future directions

Perianal fistulae in patients with Crohn's disease (CD) can be associated with significant morbidity resulting in negative impact on quality of life. The last two decades have seen significant advancements in the management of perianal fistulas in CD, which has evolved into a multidisciplinary approach that includes gastroenterologists, colorectal surgeons, endoscopists and radiologists. Despite the introduction of new medical therapies such as antitumour necrosis factor and novel models of care delivery, the best fistula healing rates reported with combined medical and surgical approaches are approximately 50%. More recently, newer biologics, cell-based therapies as well as novel endoscopic and surgical techniques have been introduced raising new hopes that outcomes can be improved upon. In this review, we describe the modern management and the most recent advances in the management of complex perianal fistulising CD, which will likely impact clinical practice. We will explore optimal use of both older and newer biological agents, as well as new data on cell-based therapies. In addition, new techniques in endoscopic and surgical approaches will be discussed.

Interventional IBD: The Role of Endoscopist in the Multidisciplinary Team Management of IBD

Inflammatory bowel disease (IBD) has been traditionally managed by IBD medical doctors or IBDologists and colorectal surgeons. Complications related to IBD and IBD surgery, such as stricture, fistula, and abscess, are common. For the past decade, endoscopic therapy has emerged as a valid treatment option for those complications. Endoscopic therapy provides more effective therapy for those structural complications than medical treatment, while being a less invasive approach than surgery. Endoscopic therapy plays a growing role in bridging medical and surgical therapies and is becoming an important component in the multidisciplinary approach to complex IBD. In fact, endoscopic therapy has become the treatment of choice for anastomotic stricture and anastomotic sinus. The role of endoscopic resection of colitis-associated neoplasia is currently being explored. Interventional IBD is intellectually and technically challenging. We are calling for proper teaching and training of our next generation of IBD interventionists.

Problems after restorative proctocolectomy: assessment and therapy

PURPOSE OF REVIEW

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the surgical procedure significantly improves the patients' quality of life, complications are common. Mechanical or structural complications related to surgical techniques as well as chronic pouchitis are common after the procedure.

RECENT FINDINGS

Recent literature has suggested some of those mechanical complications, along with chronic pouchitis, may share similar risk factors, particularly between anastomotic leak or sinus and chronic pouchitis. Those factors include male gender, obesity, weight gain, and Clostridium difficile infection.

SUMMARY

Mounting clinical evidence suggests that ischemia or excessive fat deposition plays an important role in the development of the surgical procedure-associated mechanical complication as well as chronic antibiotic-refractory pouchitis. Those findings along with the theory of ischemia/fat deposition will shed some light on the pathogenesis of the complex pouch disorders, providing the guidance for the risk stratification, prevention, diagnosis, and management.

Endoscopic Therapy in Crohn's Disease: Principle, Preparation, and Technique

Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.