Recalcitrant rectal stricture following circumferential endoscopic mucosal resection: novel application of endoscopic stricturotomy

A 69-year-old woman underwent endoscopic mucosal resection (EMR) of a fully circumferential flat, homogeneous, granular lesion, abutting the anal verge and extending proximally for 6 cm ([Fig. 1]). Steroid enemas were prescribed for a 6-week period. Histopathology confirmed a low-grade tubulovillous adenoma. The procedure was complicated by delayed bleeding which was treated by the patient’s local surgical team with extensive thermal coagulation.

Fig. 1 Endoscopic mucosal resection of a fully circumferential large laterally spreading rectal lesion. a,b Retroflexed and forward views. c Submucosal injection commenced at the dentate line. d Resection commenced at the distal end of the lesion, at the anal verge. e,f Complete resection with margin thermal ablation of the margin, demonstrated in forward and retroflexed views.

At 6 weeks post-EMR, the patient reported obstructive symptoms and was found to have a severe stricture, 8 mm in diameter. This was treated with sequential balloon dilatation to 12 mm at 2–4-weekly intervals. After 5 sessions, minimal progress had been made, and the patient remained symptomatic. A scarred web was noted in the 6–12 o’clock position.

Endoscopic stricturotomy was performed by creating radial incisions to the web using a 4.5-mm triangle-tip needle-knife ([Video 1]). Subsequently, balloon dilatation to 18 mm was possible. At 12 weeks after endoscopic stricturotomy the patient remained asymptomatic. There was no recurrent or residual adenoma ([Fig. 2]).

Fig. 2 Polypectomy site 3 months after endoscopic stricturotomy and 9 months after resection, demonstrating the absence of recurrent or residual adenoma and showing a widely patent lumen with no evidence of stricture recurrence.

Successful endoscopic stricturotomy of a severe stricture, refractory to balloon dilatation, that followed circumferential endoscopic resection of a rectal large nonpedunculated colonic polyp.Video 1

Larger lesions which would have until recently required surgical resection, are now removed endoscopically in centers of excellence. Our group has previously shown that the risk of post-resection stricture formation increases with the lateral extent of the resected area [1]. A post-EMR defect involving ≥90% of luminal circumference carried a 74.2% risk of stricture formation. The median number of dilatation sessions required for severe post-endoscopic resection strictures was 3. Extensive thermal therapy to treat bleeding likely played a role in the degree of scar formation in this case.

Endoscopic stricturotomy has been utilized in the management of Crohn’s and anastomotic strictures with success [2] [3]. To our knowledge, there are no published data on the management of strictures following endoscopic resection. Here we demonstrate the first case of endoscopic stricturotomy in the management of a refractory post-EMR stricture, which was safe and effective.

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• References

• 1 Gupta S, Vosko S, Shahidi N. et al. Endoscopic resection-related colorectal strictures: risk factors, management, and long-term outcomes. Endoscopy 2023; 55: 1010-1018
• 2 Lan N, Shen B. Endoscopic stricturotomy with needle knife in the treatment of strictures from inflammatory bowel disease. Inflamm Bowel Dis 2017; 23: 502-513
• 3 Dezheng L, Wei L, Zexian C. et al. Endoscopic stricturotomy for patients with postoperative benign anastomotic stricture for colorectal cancer. Dis Colon Rectum 2022; 65: 590-598