A 47-year-old man presented to our Interventional IBD Unit with dyschezia, bloating,
fecal incontinence, fecal urgency, and frequent bowel movements. He had been diagnosed
with stage IV rectosigmoid cancer (T4aN0MX) in 2014. He underwent palliative low anterior
resection of the rectum and sigmoid with end colostomy, resection of colostomy, Hartmann
reversal operation with colorectal anastomosis. He had been receiving capecitabine
since 2017.
Colonoscopy 6 months prior to presentation showed a stricture at the colorectal anastomosis,
5 cm proximal to the anus. Repeat colonoscopy again identified a severe stricture,
2 cm in length, at the colorectal anastomosis, which the gastroscope could not traverse
([Fig. 1 a]). The stricture was successfully treated with endoscopic needle-knife stricturotomy
during endoscopic retrograde cholangiopancreatography (Monopolar receptacle, mode:
ENDO CUT 1, Effect 2, Upmax 550Vp, cut duration 2, cut interval 3, Coag mode off;
Erbe Elektromedizin GmbH, Tübingen, Germany) ([Fig. 1 b], [Video 1]).
Fig. 1 Endoscopic treatment of concurrent colorectal anastomotic stricture and prolapse.
a A severe stricture was seen at the colorectal anastomosis, 2 cm in length and 5 cm
from the anus, which the gastroscope could not traverse. b The stricture was successfully treated with needle-knife stricturotomy. c A mucosal prolapse blocked the anastomosis. d The mucosal prolapse was treated with banding ligation (× 2).
Video 1 Endoscopic treatment of concurrent colorectal anastomotic stricture and prolapse.
After orienting the strictured area to front view, needle-knife stricturotomy was
performed in a radial fashion, targeting the size of the patent anastomosis to 2 cm
in diameter. The depth of the cut was largely empiric. In the past, we have attempted
to use endoscopic ultrasound guidance. However, ischemic stricture typically does
not have a normal 5-layer structure of bowel wall. The efficacy and risk (perforation)
of needle-knife stricturotomy has to be carefully balanced. The key concept is to
avoid perforation by performing a shallow stricturotomy. A cut, 2 cm deep, may be
sufficient, and the procedure often needs to be repeated. The alternative is balloon
dilation, which is not as effective as needle-knife stricturotomy [1], or surgery, which is more invasive than endoscopic therapy and carries are risk
of stricture recurrence.
Following needle-knife stricturotomy, the scope was passed without resistance. However,
we then found a mucosal prolapse from prestenotic bowel blocking the anastomosis ([Fig. 1 c]). The mucosal prolapse was treated with banding ligation (× 2) ([Fig. 1 d]).
The patient tolerated the procedure well without any complications. The procedure
took about 25 minutes to complete. He was discharged home after observation for 30
minutes. He was followed up 4 weeks postprocedure, and reported resolution of symptoms
and much improved quality of life.
Endoscopic treatment of concurrent colorectal anastomosis stricture and prolapse can
be challenging. Reported treatments for colorectal anastomosis strictures include
radiographically guided dilation by a modified Seldinger technique and endoscopic
balloon dilation [2]. Up to 28 % of patients require a surgical correction resulting into permanent colostomy
[3].
This case report illustrates a unique endoscopic technique in which the colorectal
anastomosis stricture was successfully treated with needle-knife stricturotomy and
the prolapse was subsequently banded. This is the first case report in the literature
to describe the endoscopic procedure to treat colorectal anastomosis stricture and
prolapse simultaneously.
Endoscopy_UCTN_Code_TTT_1AQ_2AF
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
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