Although anastomotic strictures are a recognized complication of
colorectal surgery, complete colonic anastomotic obstruction from benign
disease is rare and there are few reports of endoscopic management
[1]
[2]
[3]
[4]. Here, we describe a case of successful endoscopic
treatment using a novel combined anterograde-retrograde endoscopic rendezvous
technique facilitated by CT-guided fluoroscopy.
A 73-year-old man presented to us with complete anastomotic
obstruction following deep anterior resection for UICC stage III rectal
carcinoma complicated by an anastomotic leak that had been treated by
endoscopic sponge placement in the pararectal cavity [5].
We attempted to employ a rendezvous method to perforate the stenosis as
described previously [1]
[3]
[4], with a colonoscope passed through the existing loop
ileostomy and an upper endoscope advanced to the stenosis in a retrograde
fashion. The scopes, under fluoroscopy, were seen to be in proximity to each
other, but a “kissing position” could not be attained ([Fig. 1]).
Fig. 1 The first attempt at
endoscopic dilatation failed because it was not certain that the two endoscopes
were facing each other in this rendezvous procedure.
This was because of the J-shaped configuration of the anastomosis
with two dead ends on its lower aspect, neither of which could be positively
identified as the anastomotic stenosis in question ([Fig. 2]).
Fig. 2 Endoscopic view of the
stenotic anastomosis from below.
Administration of barium through both endoscopes, in addition,
revealed a nonlinear alignment of the colon and showed that the oral and aboral
ends were separated only by a fibrous membrane ([Fig. 1]).
To demonstrate the exact position of the endoscopes in a
three-dimensional fashion we repeated the procedure with CT guidance. CT
fluoroscopy confirmed that the tips were facing each other when the lower
endoscope was placed in one of the two dead ends ([Fig. 3]).
Fig. 3 CT-guided fluoroscopy
shows the two endoscopes exactly facing each other.
Under CT-fluoroscopic and transillumination guidance, the fibrous
septum was penetrated using a biopsy forceps passed through the accessory
channel of the retrograde endoscope. After visualization of the forceps by the
anterograde colonoscope, a wire-guided “through-the-scope” balloon
was placed at the site of the stricture and used to dilate it sequentially to
12 mm ([Fig. 4]).
Fig. 4 Balloon dilatation
following successful recanalization of the stenosis.
Within 1 month following this first intervention, the stenosis was
dilated up to 20 mm in a series of five endoscopic sessions. Clinically,
the patient was well with normal defecation. Barium enema confirmed good
passage ([Fig. 5]) and the ileostomy was closed 6
weeks after the CT-guided endoscopic intervention.
Fig. 5 Barium enema before the
planned ileostomy takedown shows a residual stricture with good passage.
We believe that CT fluoroscopy guidance adds a measure of safety by
allowing the endoscopist to visualize the stenosis and the position of the
endoscopes three-dimensionally in complex situations where unambiguous
identification of the stenosis is not possible in conventional fluoroscopy.
Limitations of the technique include the need for either instrument exchange or
a second endoscopy unit and a pre-existing ostomy to perform the rendezvous
procedure.
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