Multistep endoscopic approach for recalcitrant colorectal anastomosis

We present the case of a 69-year-old man with a history of sigmoid colon adenocarcinoma pN1c treated by laparoscopic sigmoidectomy who required a Hartmann’s intervention for anastomotic dehiscence. The patient subsequently underwent reconstruction of the colon by terminolateral anastomosis. However, he then developed a symptomatic stenosis in the region of the colorectal anastomosis, which resulted in recurrent subocclusive episodes.

The first approach taken to treat the stenosis was endoscopic balloon dilation. Unfortunately, during the second dilation session (18 mm), an iatrogenic perforation occurred. This perforation was treated with hemoclips, without further complication ([Video 1]).

Multistep endoscopic approach for recalcitrant colorectal anastomosis.Video 1

In the follow-up period after balloon dilation, the patient was admitted to the emergency room with a subocclusive episode. As salvage therapy to avoid Hartmann’s intervention, we decided to insert a luminal apposition stent (16 × 20 mm), as described in the literature [1] [2]. The stent was removed 8 weeks later without any secondary events ([Video 1]).

At 8 weeks after removal of the prosthesis, the patient presented with mild symptoms of abdominal pain, increased constipation, and increased need for laxative treatment. A new rectoscopy revealed a millimetric re-stenosis of the anastomosis with keloid appearance ([Fig. 1] a). A new approach was therefore adopted, involving endoscopic stricturoplasty using an ITknife nano (Olympus, Tokyo, Japan), with injection of triamcinolone in four quadrants ([Fig. 1] b). This technique has been previously described for esophagogastric stricture [3]. The patient underwent two more sessions of triamcinolone injection to reduce the keloid component.

Fig. 1 Endoscopic view. a The stenosis with keloid component before stricturoplasty. b The stenosis after completion of stricturoplasty.

During the subsequent follow-up period, the patient remained asymptomatic without recurrent stenosis.

This case demonstrates a complex postoperative colorectal stricture for which multiple step-up endoscopic treatments were mandatory to achieve luminal patency. An important take-home message of this case is that the failure of a given technique should not discourage further attempts at techniques aimed at restoring luminal patency, including endoscopic resection of the fibrotic ring.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Jain D, Patel U, Ali S. et al. Efficacy and safety of lumen-apposing metal stent for benign gastrointestinal stricture. Ann Gastroenterol 2018; 31: 425-438
• 2 Manta R, Magno L, Conigliaro R. et al. Endoscopic repair of post-surgical gastrointestinal complications. Dig Liver Dis 2013; 45: 879-885
• 3 Muto M, Ezoe Y, Yano T. et al. Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video). Gastrointest Endosc 2012; 75: 965-972

Publication History

Article published online:
07 February 2024