Successful treatment of colorectal anastomotic stricture by using sphincterotomes

Postoperative complications of colorectal cancer

Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.

Endoscopic ultrasound-guided colo-colostomy in a case of acute large bowel obstruction

Bowel obstruction is one of the most common surgical emergencies and a major cause of morbidity and mortality. Standard supportive measures must be instituted as soon as the diagnosis is confirmed. Anastomotic strictures are a benign etiology of intestinal obstruction, occurring in up to 22 % of patients following colorectal resection. Traditionally, endoscopic balloon dilation (EBD) has been the intervention of choice in such cases; however, it may not be feasible in all settings. We report a novel application of the AXIOS stent and electrocautery-enhanced delivery system (Boston Scientific, Marlborough, Massachusetts, United States) to create a colo-colostomy to bypass a sigmoid colon stricture in a 51-year-old woman who presented with acute intestinal obstruction. Despite stent dislodgment during the procedure, the preexisting tract allowed us to improvise our technique with a second LAMS placement. The patient was discharged well 48 hours after the procedure. However, 4 months later, she required a session of EBD following a presentation for fecal impaction. She is currently asymptomatic and being followed up regularly as an outpatient.

Fluoroscopy and endoscopy-guided transanastomotic rendezvous: a novel technique for recanalization of a completely obstructed colorectal anastomosis

BACKGROUND

Colorectal anastomotic stricture is a frequent complication that may affect up to 30% of patients. However, a complete obstruction is rare. Endoscopic balloon dilation is the first-line therapy, but it invariably requires being able to cross the stricture with the dilation device. When this is not possible, surgical revision is the alternative, but it is associated with higher morbidity.

CASE PRESENTATION

A 76-year-old male patient underwent an urgent high anterior resection with transverse loop colostomy for an occlusive high rectal tumor. On postoperative day 8, he presented with anastomotic leakage and abscess formation, requiring percutaneous drainage. Ten months after surgery, a colonoscopy revealed a complete stricture of the anastomosis, refractory to negotiation of a guide wire, thus precluding balloon dilation. Hence, a modified rendezvous technique was planned. Simultaneously, a flexible endoscope and a rigid rectoscope were progressed through the distal loop colostomy, and the anus, respectively. A needle device was introduced through the rectoscope and used to pierce the colonic stump. A guide wire was progressed, and the stricture was dilated with a controlled radial expansion balloon catheter. Finally, a 12-Fr Foley catheter was left through the anastomosis. A total of three endoscopic balloon dilation sessions were completed, and successful colostomy reversal was carried out 10 days after the last session.

CONCLUSION

Fluoroscopy-endoscopy-guided recanalization is an effective and safe treatment option for complete colorectal anastomotic stricture.

A Novel Approach to Dilation of Complete Colorectal Anastomotic Stricture Using Transillumination

Colorectal anastomotic strictures are a well-known complication of low anterior resection. Depending on their location, strictures are amendable to different forms of endoscopic intervention. However, all endoscopic interventions are contingent on passing a guidewire across the anastomotic stricture. We present the case of a patient with a complete anastomotic stricture that could not be traversed by conventional endoscopy and the unique method by which a lumen was created in the anastomotic strictures that allowed for a guidewire to be passed across.

Endoscopic Management of Benign Colonic Obstruction and Pseudo-Obstruction

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

Inverted "upside-down" esophageal fully-covered self-expanding metal stent is effective for temporary treatment of colorectal strictures: a pilot case series

Background and study aims  Placement of a fully-covered self-expanding metal stent (FC-SEMS) is a valid alternative for benign and malignant colorectal strictures treatment. Despite the reportedly high technical success rate, stenting is still challenging, due to high rates of adverse events. Migration still represents the main issue, although several anti-migration systems have been proposed. Patients and methods  Before insertion, esophageal Beta Niti-S FC-SEMSs were inverted and reloaded on the deployment device to invert the proximal and distal parts of the stent, with the largest end placed above the stricture to contrast peristaltic activity. The inverted "upside-down" Beta Niti-S FC-SEMS was placed in five consecutive patients: four pts with benign anastomotic stricture unresponsive to repeated balloon dilation and persisting for at least 10 weeks, and one with malignant rectal neoplasia. In five patients, six inverted FC-SEMSs were placed. Results  The modified FC-SEMS did not migrate in 5/6 cases (83 %). Stent migration occurred in the neoplastic case, induced by neoadjuvant chemotherapy. The "upside-down" esophageal Beta Niti-S FC-SEMS stayed in place for an average of 6 weeks, achieving resolution of stricture in all patients but one, who required an additional stent placement, due to incomplete stricture resolution after 6 weeks. Conclusion  The inverted esophageal Beta Niti-S FC-SEMSs proved to be effective in treating colorectal stricture in all cases, with no spontaneous migration or significant side effects, and achieved resolution of strictures where a traditional approach, recommended by guidelines, failed.

Transanal minimally invasive surgery as a treatment option for a completely occluded anastomosis after low anterior resection: A new approach to severe anastomotic stenosis

New techniques have been developed to treat severe anastomotic strictures after rectal surgery. This report describes a new approach using transanal minimally invasive surgery for the treatment of complete anastomotic occlusion. A 49-year-old man presented with a completely occluded anastomosis after low anterior resection with temporary ileostomy for rectal cancer. The lumen was completely obstructed with a blind wall. A transanal surgical approach was used to treat the obstruction. Water-soluble radiopaque contrast medium was injected intraoperatively to identify the proximal lumen, and an incision was made by electrocautery until the luminal diameter was sufficient. There was no sign of bleeding or perforation after surgery. The patient underwent ileostomy takedown after all the chemotherapy sessions were completed. This report shows that transanal minimally invasive surgery is safe and feasible for the treatment of complete anastomotic occlusions requiring invasive interventions.

Biodegradable Stents: An Evolution in Management of Benign Intestinal Strictures

Benign intestine strictures secondary to postoperative narrowing or inflammatory bowel disease can be managed surgically or conservatively. Some patients may not be suitable surgical candidates and some patients may choose not to have repeat surgery. Biodegradable (BD) stents offer a prolonged dilatory effect before gradual degradation and obviates the need of a second procedure for stent removal. BD stents have high technical success rates (mean, 94.4%; median, 100%; range, 86% to 100%) but widely variable clinical success rates (range, 45% to 100%). Stent migration is the most commonly reported complication (mean, 22.2%; range, 0% to 36%). In the future, with better understanding of the factors contributing to stent migration, improvement in present stent design and better anchoring techniques, the stent migration rate is expected to decrease and improve clinical outcome. The role of prophylactic BD stent placement to prevent stricture development postintestine surgery is an intriguing idea and needs to be explored. As of now, the use of BD stents is a reasonable option for patients with dilatation resistant intestinal strictures who are unfit for surgery or refuse to have surgical treatment.

Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: outcome in 29 patients

BACKGROUND

Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases.

METHODS

From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula.

RESULTS

Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6-65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus.

CONCLUSION

FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient.