Endoscopic clipping of ascites from the tip of the "J" leak in ileal pouch-anal anastomosis.

A 40-year-old man underwent “J”-configured ileal pouch–anal anastomosis for ulcerative colitis and did well for the first 2 years. He gradually experienced symptoms of postprandial diarrhea, intermittent bleeding, and pain in the suprapubic area. We observed an angulated afferent limb of the pouch with partial small-bowel obstruction, which was later treated with pouch revision surgery. Postoperatively, although the pouch was functional, the patient had abdominal pain and fever to 38.3°C and did not feel well 5 days after surgery. The laboratory values showed a white blood cell count of 19.1 k/μL, hemoglobin of 14.8 g/dL, and platelet count of 282 k/μL. CT 5 days after surgery showed moderate-volume ascites (Fig. 1), suggestive of a surgical leak at the tip of the “J.” Considering the risk of immediate reoperation, such as postoperative morbidities, and that a procedure such as a radiographic tap would not resolve ascites, our experience with endoscopic management of pouch problems led us to perform an inpatient pouchoscopy on the sixth postoperative day. The patient received clear liquids and did not need to have a bowel preparation. The tip of the “J” leak was detected and confirmed (Fig. 1). Suture line leaks are common in the ileal pouch–anal anastomosis, with the tip of the “J” being a vulnerable location; however, the leak usually results in presacral or pelvic abscess, rarely ascites. To close the leak, we performed a standard over-the-scope clipping procedure with an anchor and a 12 T clip (Model 12/6 gc; Ovesco, Cary, NC, USA). Before deployment of the clip, we aspirated 400 mL of clear fluid from the leak (Video 1, available online at www.VideoGIE.org). Because of the clear nature of the ascites and the lack of severe peritoneal signs, we believe that the fluid collection resulted from peritoneal irritation from the leak of the tip of the “J” and was reactive without significant fecal contamination. The patient felt better for 2 weeks but developed anal pain. Repeated CT showed the clip to be dislodged and located in the distal pouch, with resolving ascites (Fig. 2). A follow-up pouchoscopy was then performed in which the dislodged clip was found in the anal canal and removed (Fig. 2). The tip of the “J” leak had become smaller and was barely detectable with the Jagwire (Boston Scientific, Marlborough, Mass, USA). We placed a new 12 T clip with an anchor (Video 1, available online at www.VideoGIE.org). Repeated CT and gastrografin enema showed that the clip was in place, and ascites was completely resolved (Fig. 3). The patient, who was initially receiving intravenous antibiotics, was then treated with 2 weeks of oral antibiotics. One month after the procedure, the patient underwent follow-up CT, which showed complete resolution of the fluid collection, and the patient felt well. The white blood cell count, which had been 16.3, 12.3, and 8.9 k/μL on postprocedure days 1, 2, and 3, respectively, was also normal at 9.3 k/μL at the 1-month follow-up visit (Video 1, available online at www.VideoGIE.org).

Figure 1

The tip of the “J” leak and ascites. A, Common locations of surgical leak in the ileal pouch. The tip of the “J” leak is shown by a red arrow. B, Ascites around the body of the pouch (yellow arrow). C, Endoscopic view showing leak with superficial ulcer (red arrow).

Figure 2

Results of the first treatment. A, Resolving ascites around the body of the pouch (yellow arrow). B, Endoscopic removal of dislodged clip (green arrow). C, CT view showing dislodged clip trapped at the distal pouch (green arrow).

Figure 3

Results of the second treatment. A, Clip in place at the tip of the “J” on gastrografin enema (green arrow). B, CT view showing resolved ascites (yellow arrow) with clip in place (green arrow). C, Placement of over-the-scope clip at the area (green arrow).

Clips have been used to treat GI bleeding, leaks, and fistulas.1, 2 To our knowledge, this is the first reported case of successful endoscopic treatment of ascites associated with a surgical leak from the “J” pouch.

Disclosure

Dr Shen is a consultant for Janssen and a consultant speaker for Abbvie and Takeda. The other author disclosed no financial relationships relevant to this publication.