An Endoscopic Approach to a Pouch Stricture After Failed Needle Knife Stricturotomy

CASE REPORT Anastomotic strictures may occur after ileal pouch–anal anastomosis, although strictures between the pouch body and proximal limb are uncommon. Balloon dilation with or without needle-knife stricturotomy is first-line therapy, but dense fibrosis may lead to early restenosis.1–3 We report the use of bipolar radiofrequency (RF) scissors for a refractory pouch anastomotic stricture. A 22-year-old man with ulcerative colitis underwent 3-stage ileal pouch–anal anastomosis and developed a fibrotic stricture between the pouch body and proximal limb, preventing ileostomy reversal (Figure 1). Balloon dilation and needle-knife stricturotomy achieved transient patency, but contrast enema demonstrated rapid restenosis (Figure 2). Bipolar RF scissor stricturotomy was performed using 3 radial incisions (3–4 mm depth) in cut mode (400 kHz, 15–35 W), followed by balloon dilation to 15 mm. Mild bleeding was controlled endoscopically. Follow-up imaging confirmed restoration of luminal continuity without leak (Figure 3). The patient underwent successful ileostomy reversal and remained asymptomatic at 6 months (Video 1).Figure 1.: Flexible pouchoscopy demonstrated that the pouch was obstructed and a central scar formation.Figure 2.: Follow-up pouchogram and gastrograffin study demonstrated severe restricturing with failure of contrast to enter the proximal pouch.Figure 3.: Follow up pouchogram showed mild narrowing of the ileoanal anastomosis and the pouch distending normally with contrast flowing through the pouch and to the stoma without obstruction and without leak. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"A novel endoscopic bipolar radiofrequency cutting tool was used to perform stricturotomy.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_ayatutp5"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Bipolar RF scissors provide a precise salvage option for fibrotic strictures refractory to standard therapy, enabling controlled energy delivery and durable luminal patency.4,5 DISCLOSURES Author contributions: R. Kaul, A. Chatterjee, R. Prado: drafting the article. H. Siddiki: final approval of manuscript. H. Siddiki is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.