Endoscopic strictureplasty for severe colonic anastomotic stricture

Benign anastomotic stricture after colonic resection usually requires surgical or endoscopic dilation. The radial incision and cutting (RIC) method was recently developed to treat resistant strictures and the recurrence rate is 28.5–44.2 % [1] [2]. In this report, we developed endoscopic strictureplasty (ESP) for refractory anastomotic stricture after colorectal surgery not resolved by two RICs.

A 70-year-old man with colorectal cancer at the sigmoid colon underwent surgery with end-to-end anastomosis using a circular stapling device. A colonoscopy for constipation revealed an anastomotic stricture ([Fig. 1 a]). RIC was performed twice, however, both times the stricture recurred ([Fig. 1 b, c]). Therefore, ESP was performed ([Fig. 2 a], [Video 1]).

Fig. 1 Endoscopic images. a Anastomotic stricture at the sigmoid colon after surgery. b Satisfactory patency immediately after radial incision and cutting (RIC). c Resistant anastomotic stricture after 2 RICs.

Fig. 2 Endoscopic images. a Endoscopic strictureplasty performed for resistant anastomotic stricture. b No recurrence 6 months after endoscopic strictureplasty.

Video 1 Endoscopic strictureplasty was performed for resistant anastomotic stricture.

ESP was adapted from the Heineke-Mikulicz (HM) strictureplasty, a conventional method of strictureplasty [3]. The HM strictureplasty involves resection of the tract from the serosal side, although this method uses an endoscope to resect the muscle layer from the mucosal side without full-thickness resection. First, the blade of the ITknife2 (Olympus, Tokyo, Japan) was inserted and three longitudinal incisions were made into the stricture, and the inner circular and outer longitudinal muscle layers were dissected until the subserosal layer was visualized. The incision was resutured transversely; a 30-mm endoloop (HX-400U-30; Olympus) was anchored to the proximal and distal edge of the defect with a SureClip (Micro-Tech, Nanjing, China), and closed bringing both edges together. Finally, clips were applied to close the remaining defect ([Fig. 3]).

Fig. 3 Endoscopic strictureplasty procedure.

The recurrence after two RICs is considered to be due to the distortion of the muscular layer. In such cases, a direct approach to the muscle layer is more effective than RIC. Closing the defect transversely allows the lumen to dilate. There was no recurrence 6 months after the procedure ([Fig. 2 b]).

Endoscopic strictureplasty is an effective endoscopic surgery for resistant anastomotic stricture.

Endoscopy_UCTN_Code_CCL_1AD_2AJ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Moroi R, Shiga H, Nochioka K. et al. Endoscopic radial incision and cutting for benign stenosis of the lower gastrointestinal tract: An investigation of novel endoscopic treatment in multicenter trial. J Gastroenterol Hepatol 2022; 37: 1554-1560
• 2 Osera S, Ikematsu H, Odagaki T. et al. Efficacy and safety of endoscopic radial incision and cutting for benign severe anastomotic stricture after surgery for lower rectal cancer (with video). Gastrointest Endosc 2015; 81: 770-773
• 3 Lee EC, Papaioannou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 1982; 64: 229-233

Publication History

Article published online:
13 December 2022