What is the evidence that early surgical intervention reduces recurrence rates compared with repeated endoscopic dilatations in patients with refractory pouch inlet strictures

What is known

- In a retrospective comparison (151 dilation vs 16 strictureplasty), recurrence occurred in 55% and pouch failure in 13%, with no difference in overall pouch or stricture-free survival between approaches. ^1,2 - Time interval to recurrence or pouch failure was longer after strictureplasty (2.5 vs 0.4 years, p<0.001), but the surgery-free curves merged by 3 years. ^1–3 - Endoscopic dilation achieves pouch retention ~90% at 10 years but usually necessitates multiple repeat dilatations. ^4,5 - For inlet strictures refractory to endoscopic treatment, salvage/revision surgery and resection-reanastomosis series report high pouch retention on medium-term follow-up. ^1,3,4

What is unknown / caveats

- No RCT or prospective comparison; all comparative data are single-institution retrospective cohorts with selection bias - Surgical series for inlet strictures are largely small cohorts and case reports - No study tests 'early' surgery against continued dilatation for recurrence as the endpoint - Whether earlier surgery changes long-term recurrence or pouch survival is untested. The comparative data show only a durability (time-interval) advantage that dissipates by 3 years.

## References

1. Otero-Piñeiro AM, Floruta C, Maspero M, Lipman JM, Holubar SD, Steele SR, Hull TL. Salvage surgery is an effective alternative for J-pouch afferent limb stricture treatment. Surgery. 2023;174:753-757. PMID: 37085381.

2. Wu XR, Mukewar S, Kiran RP, Remzi FH, Shen B. Surgical stricturoplasty in the treatment of ileal pouch strictures. J Gastrointest Surg. 2013;17:1452-61. PMID: 23690206.

3. Aviran E, Zaghiyan K, Fleshner P. The Surgical Management of Ileal Pouch Strictures. Dis Colon Rectum. 2022;65(S1):S105-S112. PMID: 36399770.

4. Sellers MM, Elnekaveh BM, Hahn SJ, Hirten RP, Greenstein AJ. Surgical solutions for refractory J-pouch inlet obstruction. Colorectal Dis. 2019;21:679-683. PMID: 30706608.

5. Chandan S, Shen B, Kochhar GS. Therapeutic Endoscopy in Postoperative Pouch Complications. Clin Colon Rectal Surg. 2022;35:78-88. PMID: 35069034.

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