Computed tomography-guided endoscopic sinusotomy for an ileal pouch presacral sinus

Endoscopic sinusotomy for ileal pouch sinus, a detrimental complication caused by chronic anastomotic leak, is an effective and safe treatment option [1]. Endoscopic sinusotomy requires access to the sinus from the pouch lumen and has been considered infeasible in patients with a sealed sinus. We describe herein the first endoscopic sinusotomy for a sealed sinus using computed tomography (CT)-guided wire placement.

The patient was a 28-year-old man diagnosed with ulcerative colitis in 2002, who underwent restorative proctocolectomy with an ileal pouch–anal anastomosis (IPAA). He was later diagnosed with Crohn’s disease based on the presence of inflammation in the pouch body and afferent limb and was started on adalimumab. He was referred for the management of a 2.7 × 1.6-cm presacral sinus that had been found on magnetic resonance imaging (MRI) in 2017 ([Fig. 1 a]). He had symptoms of failure to thrive, tailbone pain, and night sweats.

Fig. 1 The endoscopic sinusotomy procedure. a Contrast-enhanced T1 weighted axial magnetic resonance image through the lower pelvis showing a peripherally enhancing presacral collection without an identified communicating sinus to the adjacent ileal pouch. b Sagittal reconstruction computed tomography image partially showing the guidewire placed into the presacral collection. c Retroflexed endoscopic view showing the guidewire locating the presacral sinus. d Endoscopic view following the successful needle-knife sinusotomy.

Pouchoscopy was performed which failed to detect a sinus opening. We then decided to use CT-guided wire placement to gain access to the sinus through the side of the pouch. An experienced radiologist advanced a 17-Fr trocar needle cutaneously, through the collection and into the pouch, and this was followed by wire placement ([Fig. 1 b]). The patient was subsequently brought to the endoscopy suite, where he received conscious sedation. After the area had been tattooed, partial endoscopic sinusotomy was performed along the path of the wire using an IT needle-knife ([Fig. 1 c, d]), and this was followed by placement of five endoclips to maintain the patency of the orifice ([Video 1]).

Video 1 Video demonstrating computed tomography-guided needle-knife sinusotomy.

Complete endoscopic sinusotomy was performed 1 month later, followed by placement of endoclips to maintain patency. The patient tolerated the procedures well, with resolution of his symptoms.

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• Reference

• 1 Wu XR, Wong RC, Shen B. Endoscopic needle-knife therapy for ileal pouch sinus: a novel approach for the surgical adverse event (with video). Gastrointest Endosc 2013; 78: 875-885