Background

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been widely accepted as the surgical procedure of choice for the majority of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who require colectomy. However, this procedure can cause various postoperative complications. Anastomotic leak resulting in the formation of sinus is one of the most common surgical technique-associated complications.¹,² On the other hand, fecal bezoar can occur in patients with ileal pouches, being often located at the pouch body.²,³ Here we reported on a patient with a large fecalith located at the orifice of anastomotic sinus causing severe symptoms. The fecalith and sinus were successfully treated with a stepwise endoscopic approach.

The patient

A 67-year-old female presented to our Pouch Center with a 4-month history of perianal pain and urgency in April 2012. Her past medical and surgical history was significant for having a two-stage J pouch surgery for medically refractory ulcerative colitis (UC) in 1999. Both surgery and hospitalization were uneventful.

At presentation, the patient was taken to the outpatient endoscopy suite. Informed consent was obtained. On conscious sedation, a pouchoscopy was performed with a GIF-H180 gastroscope (Olympus, Tokyo, Japan). An anastomotic sinus with a depth of 3 cm was found and the orifice was blocked by a large hard fecalith. Initially we planned to retrieve the fecalith first followed by treating the pouch sinus with ultrasound (Vascular Technology Inc. [VTI], Nashua, New Hampshire, USA) guided endoscopic needle knife (Olympus Medical Systems, Tokyo, Japan) sinusotomy at the setting of ERCP endocut (USA Incorporated Surgical Systems, Marietta, Georgia, USA). Multiple attempts using RothNet (US Endoscopy, Mentor, OH), Tripod (Endoscopy Support Service America, Brewster, NY), or endoscopic Basket (Olympus America, Melville, NY) were made to remove the fecalith, however none of them succeeded. Then we decided to use the needle knife to cut the common wall between the sinus and the pouch body to lay open the sinus tract and try to take out the fecalith in the next pouchoscopy. At the pouchoscopy, there was also a tight anastomotic stricture, which was successfully dilated using the guide wire-controlled radial expansion (CRE) balloons (Boston Scientific, Boston, MA). Multiple biopsies were taken, which were not remarkable.

One month later, the patient returned to our Pouch Center. Pouchoscopy was performed following the same protocol as the previous one. The fecalith at the sinus cavity was successfully removed with two endoscopic Baskets and two Rothnets (Fig. 1A). Since there was still mucosal scar at the septum between the sinus and pouch body resulted from the last session of needle-knife therapy, pouch sinus was not treated. Six months after removing the fecalith, the patient came back to our Pouch Center for the further management of the pouch sinus. Then, the pouchoscopy showed a compartalized distal pouch sinus with two cavities. Another session of Doppler ultrasound guided endoscopic needle knife sinusotomy was offered to treat the sinus (Fig. 1B). At the most recent follow-up 6 months after treating the pouch sinus, the pouchoscopy showed a healed sinus (Fig. 1C). The patient tolerated all procedures well in an outpatient setting without any complication. The patient continued to do well after the procedures and reported the resolution of her symptoms.

Fig. 1 Successful endoscopic treatment of fecalith blocking sinus in a patient with an ileal pouch. A, fecalith removed using two baskets and two Roth-Nets; B, compartmentalized sinus treated with needle-knife sinustomy; C, a healed and epithelialized pouch sinus. 

Discussion

Pouch sinus, a less known disease entity in patients with IPAA, is a special form of anastomotic leak defined by a blind-ended track. The reported frequency of pouch sinus in patient undergoing IPAA ranged from 2.8% to 8%.¹,⁴,⁵ The common symptoms of pouch sinus included pelvic discomfort or pain, dyschezia, and urgency. Pouch sinus deserves a close surveillance and timely treatment, as it may have a significant impact on pouch outcomes and patients' QOL. Bezoar in the ileal pouches is an even more rare complication following IPAA, with only case reports published in the literature.²,³,⁶ To the best of our knowledge, our study reported the first case with a symptomatic sinus at the distal pouch which was blocked by a large fecalith. Furthermore, we showed the feasibility of treating fecalith blocking sinus by removing the fecalith and applying the ultrasound guided needle knife sinusotomy accomplished using the endoscopic approach.

The management for bezoar in the ileal pouches is straight-forward. With advanced equipment and techniques, retrieval of the bezoar using the endoscopic approach has become the preferred treatment modality. The challenging part of endoscopic extraction in this patient is the location of the fecalith. In our case, we failed to remove the fecalith in the first pouchoscopy although multiple attempts were made using different tools.

Pouch sinus may be managed by observation, endoscopy, or surgery. Patients with pouch sinuses have been historically managed with an operative approach, including drainage or surgical closing of the sinus, mucosal advanced flaps, redo pouch surgery or pouch excision.⁴ Although surgical treatment for pouch sinus might be effective in experienced hands, the procedures themselves are often technically challenging with the potential risk for procedure-related adverse events. In our study of 65 patients with pouch sinuses from our group,¹ we showed that endoscopic needle-knife therapy was an efficacious and safe procedure for pouch sinuses. With previous vast experience of this treatment modality, we applied ultrasound guided needle knife sinusotomy to treat the pouch sinus in this patient, after two sessions of which the pouch sinus was found to be completed healed in the follow-up pouchoscopy. As shown in our previous study,¹ the needle-knife therapy has its pros and cons. Endoscopic needle-knife sinusotomy holds the benefits of being less invasive, relatively easy to perform. No hospitalization is required, and patients have a quick recovery. However, some of patients need to be treated in multiple sessions. Furthermore, this procedure should be performed in experienced hands.

In conclusion, we successfully applied endoscopic therapy in a symptomatic patient with a large fecalith trapped at the orifice of presacral sinus. We demonstrated that this complex surgical complication might be successfully treated with a carefully planned, stepwise endoscopic approach.