Forward-viewing echoendoscope-guided recanalization plus radial incision and cutting technique for rectal anastomotic atresia

Rectal anastomotic atresia is rare in clinical practice and is challenging to manage using traditional approaches [1] [2] [3] [4]. Here, we report successful recanalization utilizing a forward-viewing echoendoscope and endoscopic radial incision and cutting (ERIC) technique.

A 61-year-old man who had undergone laparoscopy-assisted radical resection combined with protective ileostomy and post-surgical chemoradiotherapy for rectal carcinoma was admitted to our hospital. Colonoscopy revealed a completely occluded anastomosis 10 cm from the anus, characterized by surgical staples and white scar ([Fig. 1]).

Fig. 1 Complete obstruction of the anastomosis after surgery and chemoradiotherapy for rectal cancer.

To recanalize the lumen, the colonoscope was first inserted through a temporary stoma ([Video 1]). A mixed solution of contrast medium and methylene blue was injected and revealed by X-ray fluoroscopy ([Fig. 2]). Second, a forward-viewing echoendoscope (Olympus, Tokyo, Japan) was advanced to the obstruction site through the anus. The distal intestinal lumen was punctured with a 19-gauge needle (Cook Medical Inc., Bloomington, Indiana, USA) under the guidance of X-ray and endoscopic ultrasound (EUS) ([Fig. 3]), which was confirmed by successfully withdrawing the mixed solution. Then, a 0.035-inch guidewire was inserted and retained, and the puncture needle was retrieved. Unfortunately, dilation using an 8.5-Fr bougie (Cook Medical Inc.) failed due to the staples and severe fibrosis. Alternatively, a 10-Fr cystotome (Cook Medical Inc.) was used to incise the occlusion, and then the ERIC technique was meticulously executed using a Multi-Function Knife (Anrui Medicine Co., Ltd., Hangzhou, China), allowing the passage of the colonoscope. The anastomotic stenosis was sequentially dilated to 15 mm with a balloon (Micro-Tech [Nanjing] Co., Ltd., Nanjing, China) ([Fig. 4]). No severe immediate or delayed complications were observed during the procedure.

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Forward-viewing echoendoscope-guided recanalization plus endoscopic radial incision and cutting technique in a patient with rectal anastomotic atresia.Video 1

Fig. 2 X-ray fluoroscopy showed the mixed solution of contrast medium and methylene blue in the intestinal cavity on the oral side of the obstruction.

Fig. 3 Endoscopic ultrasonogram showed the access of the puncture needle into the intestinal cavity on the oral side of the obstruction.

Fig. 4 Endoscopic image after radial incision and cutting technique, and dilation to a maximum diameter of 15 mm.

Four more balloon dilation procedures were performed, and no progressive stenosis was revealed ([Fig. 5]). Eventually, the ileostomy was successfully reversed.

Fig. 5 No progressive stenosis was revealed by a follow-up colonoscopy.

This case highlights the utility of EUS-guided recanalization plus ERIC technique, providing a safe, effective, and less invasive option than surgery.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Marrache MK, Itani MI, Farha J. et al. Endoscopic gastrointestinal anastomosis: a review of established techniques. Gastrointest Endosc 2021; 93: 34-46
• 2 Inoue T, Shichijo S, Yasui M. et al. Endoscopic incision and balloon dilation using the rendezvous technique for complete anastomotic obstruction after rectal low-anterior resection. Endoscopy 2022; 54: E90-E91
• 3 Ni J, Zhang L, Mao Y. et al. Endoscopic recanalization of complete fibrotic colorectal anastomosis using an endoscopic ultrasound-guided hybrid approach. Endoscopy 2024; 56: E43-E44
• 4 Yang H, Wang S, Ji R. A new endoscopic solution for rectal anastomotic atresia: contrast agent-guided precision dilation. Endoscopy 2024; 56: E171-E172

Publication History

Article published online:
13 November 2024