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Video

Session: Ongoing Videos

VM49 - Pouch Inlet Heineke-Mikulicz Strictureplasty

ONGOING VIDEOS
Location: ASCRS Connect Lounge, Hall B1/B2, Ground Level

    Video Presentation(s)

  • Jeongyoon Moon, MD

    Colorectal Fellow
    Cleveland Clinic
    Cleveland, OH, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    • Author(s)

  • OL

    Olga Lavryk, MD, PhD

    Staff, IBD Surgery Section
    Cleveland Clinic
    Cleveland, Ohio, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • TQ

    Taha Qazi, MD

    Clinical Assistant Professor
    Cleveland Clinic
    Cleveland, Ohio, United States

    Disclosure information not submitted.

    • Senior Author(s)

  • Stefan D. Holubar, MD, MS, FACS, FASCRS

    Director of Research
    Cleveland Clinic
    Cleveland, Ohio, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no relevant relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.
Jeongyoon Moon, MD: This individual has no financial relationships with ineligible companies.
Olga Lavryk, MD, PhD: This individual has no financial relationships with ineligible companies.
Stefan D. Holubar, MD, MS, FACS, FASCRS: This individual has no relevant relationships with ineligible companies.
Image or Table (Do Not add text here):

Purpose/Background: Crohn’s-like diseases of the pouch (CLDP) may result in afferent limb or pouch inlet strictures with obstructive symptoms. Fibrostenotic strictures refractory to advanced therapies and endoscopic balloon dilation may require surgical management including resection and reimplantation of the afferent limb, or pouch excision. However, isolated short-segment pouch inlet strictures may be amenable to Heineke-Mikulicz strictureplasty (Video).

Methods/Interventions: Preoperative workup includes CT/MR enterography, pouchoscopy, and examination of anesthesia to determine the nature (i.e., inflammatory vs. fibrotic) and length of stricture(s) and assess for pouch body inflammation and anal stenosis. Functional workup includes anorectal manometry and defecating pouchogram assesses for comorbid pelvic floor dysfunction. Prior to surgical intervention, patients should be under the care of a multidisciplinary IBD team to optimize advanced medical therapy and nutritional status.

Results/Outcomes: Diagnostic laparoscopy and adhesiolysis may be performed to run the entire small bowel. Intraoperative pouchoscopy assesses the distal extent of the stricture, which is marked. A Pfannenstiel or laparotomy incision is made. The stricture is opened longitudinally using electrocautery, and the small bowel may be examined using calibration spheres to confirm the absence of additional proximal strictures. The enterotomy is closed transversely using 2-layers of interrupted or running 3-0 slowly absorbable sutures; Turnbull stitches (horizontal mattress sutures) may also be used. At the conclusion of the case, a completion pouchoscopy air leak test is performed and strictureplasty patency confirmed. Patients are selectively diverted based on the risk factors for anastomotic leak. A pouchogram is performed at 3 months prior to diverting loop ileostomy closure, and the patient continued on advanced medical therapy for CLDP.

Conclusion/Discussion: Heineke-Mikulicz strictureplasty is an effective treatment for short segment strictures of the pouch inlet secondary to CLDP. Patients should be optimized preoperatively, selectively diverted, and continued on advanced medical therapies postoperatively to decrease the risk of recurrent strictures.