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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 6-8 Endoscopic clipping of enterocutaneous fistula from ileocolonic
anastomosis leak. A. Skin site. B. Deployment of an over-the-scope clip.
Although endoscopic vacuum system has been used for the treatment of
acute anastomotic leak, endoscopic clips, including through-the-scope
clips (TTSCs) and over-the-scope clips (OTSCs), have also been used.
We have used the technique to treat leaks at the ileocolonic anastomosis,
the tip of the J (in patients with J pouches), and transverse staple line at
side-to-side anastomosis after ileocolonic resection (Fig. 6-9).
FIGURE 6-9 Endoscopic clips of surgical leak. A. Side-to-side anastomosis after
ileocolonic resection for Crohn disease. B. A leak at the transverse staple line. C and D.
Placement of an over-the-scope clip.
Equipment
Adult colonoscope, pediatric colonoscope, or gastroscope utilizing CO
2
Soft-tip TTS guidewires of various sizes
Energy system
Suction, electrocautery, and irrigation devices
Needle knife or isolated-tip knife
Endoclips
Topical hemostatic agents, such as hypertonic glucose (50% glucose)
Endoscopic clips, such as TTSCs and OTSCs
Betadine, methylene blue, hydrogen peroxide, or other injectates
Cytology brush
Argon plasma coagulation
Technique
Endoscopic clipping is also performed in an outpatient setting with patient
under conscious sedation.
The surgical leak can be detected with soft-tip guidewire.
Surgical leak with enterocutaneous fistula can be detected by the
observation of flow of betadine, methylene blue, or hydrogen peroxide
instilled from skin fistula.
Small leaks can be managed with TTSCs, while larger leaks can be treated
with OTSCs.
Mucosa around the orifice of the leak may be debrided with cytology
brush or argon plasma coagulation, to achieve better success rate of
endoscopic closure.
PEARLS AND PITFALLS
A high quality of abdominal imaging is needed to delineate the location,
length, and degree of the leak. Commonly used imaging modalities are
gastrografin enema, computed tomography enterography, or magnetic
resonance enterography.
CD-associated, nonanastomosis, nonsuture line fistulae have a poor
response to endoscopic clipping.
ENDOSCOPIC SINUSOTOMY
Perioperative Considerations
Sinus results from chronic anastomotic leaks, which commonly take place
in the presacral area in patients undergoing restorative proctocolectomy
with ileal pouch-anal anastomosis.
Presacral sinus has been treated with surgical unroofing or septectomy.
Due to the limitation of instrumentation, surgical unroofing may not be
feasible in some patients.
Endoscopic sinusotomy evolves from surgical unroofing. The principle of
endoscopic sinusotomy is the electroincision of the bowel wall between
the bowel lumen and sinus, making the sinus into an epithelialized
diverticulum (Fig. 6-10).
FIGURE 6-10 Endoscopic sinusotomy. A. A presacral sinus at the ileal pouch. B and
C. Sinusotomy with needle knife. D. Placement of endoclips at the incision area.
Various shapes of the sinus have been described.
Equipment
Adult colonoscope, pediatric colonoscope, or gastroscope utilizing CO
2
Soft-tip TTS guidewires of various sizes
Energy system 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 sinusotomy is often performed in an outpatient setting, with
patient under conscious sedation.
The presacral sinus can be detected with a soft-tip guidewire.
Electroincision is performed with needle knife or isolated-tip knife in a
setting of ERCP endocut.
Following the electroincision, the endoscopist should place multiple
endoclips along both incised edges of sinus, to keep patency of the cavity
and to prevent bleeding.
Depending on the length, sinus can be treated with one single session or
staged sessions.
L-shaped sinus appears to have the best response to endoscopic
sinusotomy.
PEARLS AND PITFALLS
Endoscopic sinusotomy should not be performed in fresh sinus (<6
months of duration), as the sinus is not walled off. Sinusotomy may lead
to gas leak and retroperitoneal air. However, endoscopic sinusotomy
may be performed in fresh sinus in patients with diverting ileostomy.
Sinuses can recur after endoscopic therapy. The main risk factors for
recurrent sinus are weight gain and concurrent CD.
Suggested Readings
Lan N, Hull TL, Shen B. Endoscopic sinusotomy versus redo surgery for the treatment of chronic
pouch anastomotic sinus in ulcerative colitis patients. Gastrointest Endosc. 2019;89(1):144-
156.
Shen B, Kochhar G, Navaneethan U, et al. Role of interventional inflammatory bowel disease in the
era of biologic therapy: a position statement from the Global Interventional IBD Group.
Gastrointest Endosc. 2019;89(2):215-237.
Chapter 7
Office Endoscopy
JAMES CHURCH
Perioperative Considerations
A full armamentarium of endoscopes maximizes the effectiveness of the
office consultation, with each potentially utilized in different situations.
Before you scope: Although endoscopy should always be thorough, the
examination is directed by the provisional diagnosis reached as a result of
history and physical examination.
Patients with an obvious diagnosis on physical examination do not need
endoscopy in the office. Examples include a patient presenting with anal
pain and a lump that is an obvious thrombosed external hemorrhoid, or a
perianal abscess. Treat the thrombosis or abscess. Patients with rectal
bleeding, rectal pain, or dysfunctional defecation are good candidates for
endoscopy.
Judge the mental state of the patient sitting before you. They are usually
expecting some sort of anal examination and are often dreading it. In their
minds, it will be painful, embarrassing, and involve complete loss of their
personal dignity. This dread and anxiety demands a very relaxing and
respectful examination.
Limit the number of people in the room. This is no time to have multiple
observers and students.
Make sure the patient’s anus is covered most of the time.
Tell the patient exactly what is going to happen before it happens.
Be gentle at all times.
Use plenty of lubricant.
Use lidocaine jelly if there is anal excoriation.
Infiltrate the anus with local anesthetic if immediate anoscopy is important
and you suspect an anal ulcer or fissure.
Equipment (See Chapter 2)
Anoscopes (short and long, adult and pediatric) (Fig. 7-1)
FIGURE 7-1 A selection of closed anoscopes for office anoscopy, including adult-
sized scopes of different lengths and a pediatric-sized anoscope.
Proctoscopes (pediatric, adult standard, and adult large) (Fig. 7-2)
FIGURE 7-2 Selection of instruments for rigid anorectal endoscopy.
Flexible sigmoidoscopes (adult and narrow) (pediatric gastroscope =
“ileoscope”)
Cotton-tip applicators
Suction device
Enemas
Gloves and lubrication
Local anesthetic with corresponding betadine, 5- or 10-mm syringe, and a
27-guage needle, when required
Biopsy forceps (open and endoscopic)
Technique
Position
The easiest way to examine the anus is with the patient in knee-chest
position, on a Ritter table, tipped forward to raise the anus and lower the
head.
The examiner and an assistant on the other side of the patient spread the
buttocks.
A left lateral position can also be used and, in fact, is preferred if there is a
question of pelvic floor nonrelaxation.
Inspection
The anus is then inspected for symmetry, scars, the degree of closure, the
state of the surrounding skin of the perineum, tags, masses, or other
abnormalities.
Digital Examination
The skin beside the anus is gently touched with a Q-tip to elicit an anal
“wink,” a contraction of the corrugator cutis ani muscle that is evidence of
intact anal innervation. The “Open Sesame” technique follows.
“Open Sesame”: This technique of anal examination is based on the
tendency of many patients (especially young patients) to have a tight anal
sphincter that resists attempts at examination.
To achieve intubation, the anus has to be encouraged to relax. This
means a gentle approach with a well-lubricated finger circling the anus
and gradually inserting itself. If the anus is surprised by an attempt at
forceful insertion, there will be spasm and pain. A gradual, intermittent
insertion will avoid the spasm.
The key to comfort is asking the patient to bear down during insertion.
This relaxes the internal sphincter and allows full insertion of the
examining digit or scope.
In addition, bearing down will bring the contents of the lower rectum
down on to the finger, allowing detection of masses that might
otherwise be unreachable. This technique is useful for inserting an
anoscope or a sigmoidoscope, either rigid or flexible.
1
If an initial reconnaissance reveals a very tight sphincter muscle, it is
better to examine with a fifth digit and a pediatric anoscope.
If these do not provide enough information because of the limited
vision afforded by the narrow instrument, then an examination with the
patient under a general anesthetic is warranted.
Anoscopy
No preparation is normally given, although, if a procedure (eg, elastic
band ligation of hemorrhoids) is to be done, patients are encouraged to see
if their rectum is empty.
A short beveled anoscope is good for examining the anal canal, the anal
transition zone (ATZ) and hemorrhoidal area, and the low rectum.
It is inserted with the bevel aligned along the longitudinal
(anterior/posterior) axis of the anus.
Once past the sphincters, the scope is rotated to look at the anterior
quadrant of the anus. The obturator is removed and then the scope
gradually pulled back.
With the dentate line in view, the patient is asked to bear down. Anterior
rectal mucosal prolapse and hemorrhoidal prolapse can be seen (Fig. 7-3).
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