The Surgical Management of Ileal Pouch Strictures

BACKGROUND: Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn’s disease. Pouch stricture is a common complication after IPAA. OBJECTIVE: This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm. DATA SOURCES: A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed. STUDY SELECTION: Randomized controlled trials, cohort studies, observational studies, and case reports were considered. INTERVENTIONS: Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included. MAIN OUTCOMES: Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques‚ including resection and reconnection, strictureplasty, or bypass. RESULTS: Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection‚ or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience. LIMITATIONS: Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.