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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 6-1 A and B. Endoscopic balloon dilation of tight ileocecal valve stricture.
FIGURE 6-2 A and B. Endoscopic balloon dilation of ileocolonic anastomosis
stricture.
FIGURE 6-3 A and B. Endoscopic balloon dilation of stricture at the strictureplasty
site.
Endoscopic balloon dilation (EBD) has evolved into a main treatment
modality of IBD and non–IBD-associated strictures.
EBD can have associated complications, including bowel perforation and
excessive bleeding.
IBD patients on systemic corticosteroids have a higher risk for procedureassociated bowel perforation. EBD procedure should be avoided or
postponed for those patients.
A high-quality bowel preparation is important for safe and successful
EBD.
Preprocedural abdominal imaging should be obtained and carefully
reviewed, which will help provide a road-map for the endoscopic
intervention.
It is important to review any previous operative notes (since a number of
patients have had some form of surgery in the past) and endoscopy notes
prior to the current endoscopy procedure.
Surgical backup should be readily available, if a perforation occurs.
Equipment
Adult colonoscope, pediatric colonoscope, or gastroscope utilizing CO
2
Through-the-scope (TTS) wires and balloons of various sizes (typically
5.5 and 8.0 cm in length)
Energy system to provide for coagulation/fulguration along with
appropriate graspers and biopsy/ball-tip electrodes (Fig. 6-4)
FIGURE 6-4 Endoscopic ball-tip electrode used for hemostasis.
Suction, electrocautery, and irrigation devices
Technique
EBD can be performed in an outpatient setting with or without
fluoroscopic guidance.
EBD can be performed with patients utilizing conscious sedation alone in
most cases.
EBD can be performed via adult colonoscope, pediatric colonoscope, or
gastroscope, depending on the degree and location of stricture.
Patients are placed in the left lateral decubitus position. This provides
access to the perineum and avoids potential respiratory issues with the
prone position.
During the index endoscopy, any strictures should be biopsied to rule out
malignancy.
The endoscopist should make an attempt to traverse encountered stricture,
even when encountering some resistance. Ultrathin endoscopes may be
used to traverse the stricture and observe the bowel segment proximal to
the stricture.
The passage of scope through the stricture will allow for observation of
the bowel anatomy at the proximal side of the stricture and the
characterization of length, nature, and degree of the stricture.
EBD can be performed in a retrograde (ie, passage of scope through
stricture, introduction of the balloon, then pulling scope back, followed by
insufflation of balloon) or an antegrade manner. Retrograde EBD is
preferred to antegrade EBD.
For strictures that are not traversable, antegrade EBD may be performed.
A wire exchange technique is recommended during antegrade EBD to
reduce the risk of bowel perforation.
The wire should be pushed out from the tip of the balloon during
insufflation to reduce barotrauma from the tip of a forward-slipped
balloon.
For the treatment of an IBD-associated stricture, the targeted balloon size
is set from 15 to 20 mm, depending on the location, degree, length, and
shape of the stricture.
There are two commonly used balloons, 5.5 and 8.0 cm, in length. The
short balloon is equipped with a guidewire.
The duration of balloon insufflation is around 5 seconds.
A second look of stricture and bowel segment proximal to the stricture
after EBD is often performed to observe efficacy of the treatment, to
ensure no excessive bleeding or perforation, and/or to perform a rescuing
procedure (such as clipping of bleeding vessel or perforation) as needed.
In addition, passage of the endoscope through dilated stricture has been
used to measure “technical success” of EBD.
The role of intralesional injection of long acting corticosteroids after EBD
in keeping the lumen patent and avoidance of restricturing is controversial.
Patients are observed in the endoscopy recovery suite for at least 30
minutes. An excessive pain, bloating, or unstable vital sign should
immediately trigger further evaluation, such as plain abdominal series to
rule out a perforation.
PEARLS AND PITFALLS
Minimum air insufflation during procedure should be a routine practice.
Insufflation of carbon dioxide, rather than room air, is recommended.
Postprocedural bloating with trapped gas in the bowel is common,
resulting from air or carbon dioxide insufflation, use of sedatives during
procedure, or loss of bowel volume from prior bowel resection. A
nasogastric tube can be placed via anus or stoma to decompress the
bowel.
An ulcerated stricture is not a contraindication for balloon dilation.
The main concern for repeat EBD has been the risk for perforation.
Always keep a backup rescuing plan (such as clipping of bleeding
vessel or perforation) in mind and be ready.
Primary stricture with prestenotic luminal dilation typically responds
poorly to EBD. Early surgical intervention is preferred.
EBD is not recommended for a long stricture (>4 cm), angulated
stricture, multiple strictures, or stricture associated with fistula and
abscess, due to poor response and the high risk for perforation.
ENDOSCOPIC STRICTUROTOMY
Perioperative Considerations
Endoscopic stricturotomy with a needle knife or isolated-tip knife has
emerged as a valid endoscopic treatment option.
Endoscopic stricturotomy is more effective than EBD, particularly for
short (<3 cm) fibrostenotic stricture. The procedure can be performed in
both primary and anastomotic strictures (Figs. 6-5 and 6-6).
FIGURE 6-5 Endoscopic stricturotomy. A. Colonic stricture from Crohn disease. B.
Needle knife was used. C. Radial cut. D. Deployment of endoclips.
FIGURE 6-6 Endoscopic stricturotomy. A. Tight ileocolonic anastomosis stricture. B.
Stricturotomy with circumferential cut.
Endoscopic stricturotomy may have a lower risk for perforation, but a
higher risk for late-onset bleeding than EBD.
The main advantage of endoscopic stricturotomy over EBD is that
endoscopist has a full control of the depth and topographical location of
the electroincision utilized. This feature is particularly useful in the
management of strictures that are close to adjacent vital organs, such as
the anal sphincter and vagina.
In contrast to the radial force of EBD, various electroincision manners can
be performed during stricturotomy, including radial, circumferential, and
horizontal cut.
Equipment
Adult colonoscope, pediatric colonoscope, or gastroscope utilizing CO
2
Energy system to provide for electroincision
Suction, electrocautery, and irrigation devices
Needle knife or isolated-tip knife
Endoclips
Topical hemostatic agents, such as hypertonic glucose (50% glucose)
Anal intubation catheter (eg, nasogastric tube), as needed
Technique
Bowel preparation recommendations and endoscopy setting of endoscopic
stricturotomy are the same as EBD.
It is important to the keep the tip of the scope stable and to keep the
targeted stricture at front view.
The setting on the electroincision is endoscopic retrograde
cholangiopancreatography (ERCP) endocut.
Either needle knife or isolated-tip knife is used.
The manner of cutting can be radial (Fig. 6-5), horizontal, or
circumferential (Fig. 6-6), depending on the degree, depth, and location of
the stricture.
The targeted size of cutting is normally set around 15-20 mm, to keep
adequate luminal patency, while minimizing the risk of perforation.
Endoclips are routinely placed in the horizontally or radially incised
tissue, to maintain luminal patency and to prevent bleeding.
A second look is usually feasible.
PEARLS AND PITFALLS
Orientation of scope is critical, which is particularly true in treating
distal bowel or anal strictures. Recognition of the anterior wall (4-5
o’clock position on left lateral decubitus position) versus posterior wall
(10-11 o’clock position) of the rectum or anal canal is important to
avoid iatrogenic trauma to the vagina and prostate.
Endoscopic stricturotomy can result in large ulcerated area, which may
bleed 1-4 days after the procedure. Endoscopist may consider spraying
or injecting hypertonic glucose (50% glucose) to the treated area.
Following stricturotomy, especially radial or horizontal cutting, we
normally place endoclips to keep the lumen patency as well as to
prevent bleeding.
An amount of gas is introduced during the procedure. Therefore,
minimum air insufflation, use of carbon dioxide, and postprocedural
placement of nasogastric tube via anus for suction are recommended.
We recommend that the patient stays admitted to observation or the
hospital for the next 1-2 days, if there is bleeding and endoscopy
reintervention is needed.
ENDOSCOPIC FISTULOTOMY
Perioperative Considerations
The concept and practice of endoscopic fistulotomy derives from surgical
fistulotomy. Application of the latter is limited to perianal fistulae.
Endoscopic fistula can be performed deep in the bowel in selected patients
with IBD, especially in those with a fistula resulting from surgical leaks.
Endoscopic fistulotomy can be performed in patients with superficial (<2
cm in depth), short (<3 cm) fistulae, including ileocolonic fistula (Fig. 6-
7), pouch-to-pouch fistula, and perianal fistula (outside the external anal
sphincter). Enterocutaneous fistulas are typically not candidates for
endoscopic therapy.
FIGURE 6-7 Endoscopic fistulotomy. A. Ileocolonic fistula opening at the ileum side. B
and C. Needle knife fistulotomy. D. Placement of endoclips at the incision site.
Equipment
Adult colonoscope, pediatric colonoscope, or gastroscope utilizing CO
2
Soft-tip TTS wires of various sizes
Energy system to provide for electroincision
Suction, electrocautery, and irrigation devices
Needle knife or isolated-tip knife
Endoclips
Topical hemostatic agents, such as hypertonic glucose (50% glucose)
Technique
Endoscopic fistulotomy is normally performed in an outpatient setting,
with patients under conscious sedation, with or without fluoroscopy
guidance.
The fistula track is detected by a soft-tip guidewire via the working
channel.
The scope is pulled out while the guidewire remains.
The scope is reintroduced to the distal opening of the fistula.
The fistula track is then incised open along the guidewire, with needle
knife or isolated-tip knife in a setting of ERCP endocut.
Multiple endoclips are deployed along both edges of the incised fistula
track, to keep its patency and to prevent bleeding.
The patient is then observed in recovery unit for 30 minutes.
PEARLS AND PITFALLS
Endoscopic fistulotomy can have a high success rate, especially if
candidate patients are carefully selected.
It is important to accurately measure the depth and length of fistula.
In candidate patients, complete fistulotomy can be achieved in a
majority.
ENDOSCOPIC CLOSURE OF SURGICAL LEAK
Perioperative Considerations
Suture line or anastomotic leaks are relatively common after IBD surgery,
leading to abscess, sinus, or abscess. Some of them may lead to
enterocutaneous fistula (Fig. 6-8).
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