For the next 2 months, the patient was monitored off of any antibiotics. However, repeat pouchoscopy revealed a persistent pouch sinus. The decision was made to treat the sinus with endoscopic NKSi followed by deployment of multiple endoclips along the edges of the incised sinus wall (Figure 3). The procedure was performed in an outpatient setting, with the patient under conscious sedation. Carbon dioxide insufflation was used during the procedure. A microvasive needle-knife (Boston Scientific, Marlborough, MA) was used to cut the posterior wall between the distal pouch body and the sinus, in a setting of endoscopic retrograde cholangiopancreatography endocut. Subsequently, both edges of the incised pouch wall were separated with an endoclip (Cook Medical, Bloomington, IN) to prevent bleeding and reformation of the sinus.
After the procedure, the patient was observed in the endoscopy recovery unit for 30 minutes and discharged home. The patient's symptoms improved significantly after the procedure, and he remained asymptomatic at 2 months after the procedure. A follow-up water-soluble contrast enema at 2 months showed an H-pouch with a normal appearance and no leak (Figure 4).
Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with severe UC refractory to medical treatment. J, S, and W are the most common pouch configurations used for IPAA. On the other hand, the H-pouch configuration is rare and predominantly used for salvaging a failed IPAA (Figure 5).1 In 2017, a case series of 5 patients by Aydinli, demonstrated that H-pouch configuration is a good and rare alternative for a failed IPAA.2 Pouch sinus is a relatively infrequent complication of IPAA and is defined as a blind-ended tract resulting from a chronic anastomotic leak. It occurs only in 2.8%–8% of patients undergoing IPAA, but if left untreated, it can lead to pouch failure.3–7
Patients with a pouch sinus may present with symptoms, such as pelvic discomfort, urgency, and dyschezia; others may be asymptomatic.8,9 It is commonly found incidentally during routine surveillance before or after ileostomy closure. Pouchoscopy with a thorough examination usually can detect the opening of sinuses. However, contrast radiographic examination or magnetic resonance imaging is often needed to characterize the sinuses and differentiate them from fistulae. The treatment is challenging, and the ideal management of pouch sinuses are not well defined yet. A conservative watch-and-wait strategy is commonly practiced in asymptomatic cases in which patients are followed up with repeated imaging at regular intervals to monitor for sinus healing.3,5
In cases where watchful waiting does not work, patients have habitually been treated with fecal diversion by an ileostomy, I&D, surgical unroofing, and pouch revision.10 Endoscopic needle-knife therapy provides a viable and effective alternative when spontaneous healing of the pouch sinus does not occur.11 In 2010, our group reported the first case of curative endoscopic NKSi therapy for a pouch sinus, and since then, this technique has gained favor in treating pouch sinuses, sparing most patients from the invasiveness of surgical approaches.8 The purpose of the procedure is to cut the wall between the lumen of the pouch body and that of the presacral sinus, essentially making them into a single space. We report for the first time a case of an H-pouch complicated by an anastomotic sinus successfully treated with NKSi. We suggest using NKSi as the preferred technique for H-pouch sinuses before performing any invasive surgical procedure.
Author contributions: G. Khoudari wrote the manuscript. A. Singh edited the manuscript. B. Shen performed the NKSi, supervised, edited the manuscript, and is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
1. Fonkalsrud EW. Endorectal ileal pullthrough with lateral ileal reservoir for benign colorectal disease. Ann Surg. 1981;194(6):761–6.
2. Aydinli HH, Peirce C, Aytac E, et al. The usefulness of the H-pouch configuration in salvage surgery for failed ileal pouches. Color Dis. 2017;19(8):e312–5.
3. Akbari RP, Madoff RD, Parker SC, et al. Anastomotic sinuses after ileoanal pouch construction: Incidence, management, and outcome. Dis Colon Rectum. 2009;52(3):452–5.
4. Whitlow CB, Opelka FG, Gathright JB, et al. Treatment of colorectal and ileoanal anastomotic sinuses. Dis Colon Rectum. 1997;40(7):760–3.
5. Nyam DC, Wolff BG, Dozois RR, et al. Does the presence of a pre-ileostomy closure asymptomatic pouch-anastomotic sinus tract affect the success of ileal pouch-anal anastomosis? J Gastrointest Surg. 1997;1(3):274–7.
6. Ali UA, Shen B, Remzi FH, et al. The management of anastomotic pouch sinus after IPAA. Dis Colon Rectum. 2012;55(5):541–8.
7. Korsgen S, Nikiteas N, Ogunbiyi OA, et al. Results from pouch salvage. Br J Surg. 1996;83(3):372–4.
8. Lian L, Geisler D, Shen B. Endoscopic needle knife treatment of chronic presacral sinus at the anastomosis at an ileal pouch-anal anastomosis. Endoscopy. 2010;42(Suppl 2):E14.
9. Li Y, Shen B. Successful endoscopic needle knife therapy combined with topical doxycycline injection of chronic sinus at ileal pouch-anal anastomosis. Color Dis. 2012;14(4):197–9.
10. Zhuo C, Trencheva K, Maggiori L, et al. Experience of a specialist centre in the management of anastomotic sinus following leaks after low rectal or ileal pouch-anal anastomosis with diverting stoma. Color Dis. 2013;15(11):1429–35.
© 2019 by Lippincott Williams & Wilkins, Inc.
11. Lan N, Shen B. Endoscopic treatment of ileal pouch sinus. Inflamm Bowel Dis. 2018;24(7):1510–9.