It's my pleasure to introduce Dr. Bo Shen. He doesn't really need an introduction. He has made the pouch famous and endoscopic techniques famous. I had the privilege of working with Bo at Cleveland Clinic for a few years when I started and he's moved on to Columbia and is doing incredible work on endoscopy and IBD. And Bo's going to give the talk on endoscopy in the postoperative IBD patients. So Bo, go ahead and take it away. Thank you. Thank you, Miguel. And thank you, Monique. Really, when you do the endoscopy in the post-surgical anatomy, you don't want to get lost. Like myself, I got lost in my luggage and I'm still waiting for my luggage to come. Sorry. Thanks for United. So here's my disclosure. And I'm really grateful to my mentor, Dr. Fazio, who designed all the art and slides, and Mr. Pengrace from Cleveland Clinic. So this is an anatomy of the IBD. Depends on the surgery for coronary disease, ulcerative colitis. The common performed surgery is resection with anastomosis, ostomy, ileal pouch, diverted pouch, strictureplasty, and bowel bypass. So our group is a global interventional IBD group, proposed endoscopy evaluation consensus guideline to guide how to perform the endoscopy in patients with a surgically altered anatomy. So the goal of the endoscopic therapy in surgically altered bowel is mainly disease monitoring, postoperative recurrence, check the response medical therapy or endoscopic therapy, and the possible treatment including stricture, anastomotic leak, acute or chronic leaks, and postoperative bleeding, anastomotic bleeding. We need to be prepared mentally and physically and logistically to prepare the endoscopy in postoperative anatomy in IBD patients. We need to review the operating reports, pre-procedure imaging is very important, especially cross-sectional imaging, CTE, MIE, and apply endoscopy report. And it should be colored. And in the bowel prep, we use PEG-based solution, and CO2 insufflation is important, and possible delivered therapy including bone dilatation. So look at this imaging. You can get a fold by the endoscopy alone. Endoscopy inflammation actually is a minimum, but pre-procedure imaging already showed that it's a significant disease, fistula, and a stricture there. The same thing, then endoscopy, the pre-procedure imaging can give you some clue. You can see the ileo-sigmoidal fistula on the CT scan, and then you can see the hole at the ileo side and then sigmoidal side, and endoscopically. Now to cover the topic, we've got tools, how far should we go, normal and abnormal, and the therapy you can do. Here's some tools. So when we do the ileo-resection patients, pediatric colonoscope, if the patient had a diverted bowel or patient had ileo pouch, we recommend you use EGD scope. And if the patient had a tiny, tiny hole, a luminal opening, such as this with a diverted bowel, you can use ultrathin scope, and you also use a guide wire. Make sure the jagged wires are available. And how far should you go? So these are all guidelines pointed out. So now, looking for that, this is the common performed surgery for Crohn's disease that include ileo-clonic resection, ileostomy, and a diverted bowel, and a strictoplasty, the common surgical procedure for Crohn's disease. Now next one is a surgery for ulcerative colitis. In the left side is J pouch, and then middle is S pouch. S pouch has two limbs, and the effluent limb is here, and the J pouch, the effluent is in here. And there, on the right side is a coca pouch, the pouch underneath abdominal wall. So this is the important slides published 20 some years ago. You can see that actually the disease recurrence, and after surgery, it's parallel to the disease length of the preoperative period. So there's a linear correlation. So you don't need to go far. For the people that postoperative recurrence, the last segment of the 5 to 10 centimeter is the key. So we recommend a depth intubation. When you have a ileo-clonic resection, you intubate 10 centimeters. When you have the ileostomy, you need to intubate 10 centimeters beyond the facial level. Facial level typically is around 5 to 7 centimeters thick. And when you do the pouch, you will do that 25 centimeters above the pouch inlet, which is you're beyond that stoma closure site. So this depth intubation is important. Now what are the normal and abnormals? So here is a ileo-clonic anastomosis, two kind, side to side anastomosis, and end to side anastomosis. You can see the hole here. You can see the hole here is under retroflex. So here is a unit described, is a configuration, is a side to side, end to side, ulceration, structure, and possible leaks. Now here is actually, when you do the side to side anastomosis, on the top of the 12 o'clock, it is transverse staple line. And here below, it is actually the lumen. Now this is a slide where I always use a slide to use example. Here the structure is a small bowel. And then our primary care gastroenterologist think that this is a luminal narrowing here. As a matter of fact, it's not a luminal narrowing. Actually it is the transverse staple line leak. So there's a fistula there. So again, show the other slides. So retroflex, you can see the opening here actually is not a structure. It is actually a transverse staple line leak. Now here to show that, so when we do the scope side to side anastomosis, sometimes you have to do retroflex. And you can intubate a small bowel like this, retroflex. I'll skip this slide. Now Dr. Logero already mentioned about this, look at the score, the very important score for postoperative disease monitoring. And it is important, how important to take the biopsy. If you feel like the ulcer is out of the shape of the chronic disease ulcer, such as a circumferential ulcer, you may take some biopsies. This patient actually has ischemia. Now how about anastomosis? Actually when you do the anastomosis, sometimes you have ulcer there, structure there. You do the biopsy. Actually the majority of the people at the anastomotic biopsy, they find it's a chronic disease rather than ischemia. So that's what leave the room for the medical therapy. For example, this anastomotic structure, typically we believed it was ischemia-related. You know what? This patient, we put a biologic agent and opened the structure up. Actually some of the patients, even anastomotic structure, you can still treat it with a biologic agent. We need to do stoma, careful about stoma, around the skin, peristomal ulcer, and then facial level, the level that is easy to develop a structure and a fistula. Now here's a quick ileostomy. This is lupi ileostomy. You can see the stoma completely normal. You go back, and then there's another lumen. You can go there, other side. This is effluent. So the color is a little bit different. So this is related to the fecal diversion, a lot of the mucus there, okay? Next slide. So actually, Ruka's score has been used for today's monitoring in the people with stoma. Looks very good. Actually, the Ruka's score zero versus Ruka's score one to four has had different outcome in terms of readmission, structure dilatation, and need for surgery. Now the pouch, and the anatomy of the pouch, this is the side called effluent, pouch inlet, tip of the J, vertical staple line, cuff, and anal transition zone, and the dental line, all important structure. So when you do the pouch endoscopy, you see the cuff area here. So typically, cuff should be around two centimeters. And then when you push a scope, you can see the straight pouch. So no angulation, no twist. And this is called owl's eye, with a vertical staple line, one pouch inlet, other side is tip of the J. You need to push further, push further, past beyond the stoma closure site. So this is, each patient should go that far, okay? Now this is the important one, the anatomy is cuff and owl's eye here. And then strictureplasty, strictureplasty's anatomy is inlet, lumen, and outlet. So strictureplasty, you go there, a little bit further, fast, let's see, a little bit more. So this is, you will meet the outlet of the stricture, outlet, strictureplasty site. And then when you push inside, you see the lumen. Is it the lumen? Sometimes the lumen is dilated. You can do retroflex, look at the size, and inflammation there, and go a little bit beyond, you can see the inlet of the strictureplasty site, this inlet. So inlet and outlet of the stricture, and sometimes it's diverted about, totally sealed. You may use a little bit of knife to cut. The challenging one, the biopsy can be, the mucosa can be very friable, and the surveillance needed, lots of the biopsy can be very, very bloody. And the bacterial translocation can happen in friable mucosa. So in the therapy you can do, you can do the balloon dilatation, if there's a stricture. You can do the knife therapy to open the stricture, in order to introduce the scope. Here's the retroflex in the stricture, at the strictureplasty site. This is my last slide, and the post-operative dedesal recurrence is common. And anatomy landmarks should be reviewed before the procedure, operative report, endoscopy report, pre-operative imaging. We should know the normal, abnormals, and the definition for desal recurrence varies. Recurrence score is for the neo-terminal alienating people with ilioclonic resection and ileostomy. And the challenge will be how to score the patient with strictureplasty and diverted about. Endoscopy played a key role in the disease monitoring, disease diagnosis, cancer surveillance, and therapy. Thank you.

endoscopy

postoperative

inflammatory bowel disease

Crohn's disease

ulcerative colitis