Stricture, depending on its definition, is a complication in 0 %–30 % of colorectal
anastomoses [1]. This article describes a novel technique for endoscopic reanastomosis in a completely
strictured colorectal anastomosis with no visible lumen either at endoscopy or at
radiography; to my knowledge this is the first publication of an entirely endoscopic
technique.
In a 72-year-old man with carcinoma in the distal sigmoid, a stapled side-to-end colorectal
anastomosis was performed and defunctioned with a loop ileostomy. Histopathology showed
a moderately differentiated adenocarcinoma T3 N1 M0, which was considered microscopically
radical.
An anastomotic dehiscence was detected at endoscopy 2 weeks postoperatively. Endoscopic
lavage was initiated as an inpatient procedure for 2 weeks, then continued as an outpatient
procedure for the following 3 months, thereafter pelvic computed tomography (CT) showed
no abscess and the dehiscence was healed at endoscopy. At follow-up 6 months later,
transanal water-soluble enema and water-soluble contrast through the efferent limb
of the diverting loop ileostomy revealed no lumen at all in the anastomosis ([Fig. 1]). Endoscopy showed a completely intact mucosa and no lumen whatsoever to the proximal
bowel ([Fig. 2]). Following intravenous analgesia (alfentanil) and sedation (midazolam), a gastroscope
(Olympus GIF XTQ 160, Olympus Optical Co. Ltd., Tokyo, Japan) was used for transrectal
puncture of the descending colon during fluoroscopic guidance with an Echotip-19®
Ultra Endoscopic Ultrasound Needle (Cook Ireland Ltd, Limerick, Ireland) extended
for 20 mm ([Fig. 3]). Water-soluble contrast was injected, thereby verifying the position of the needle
in the descending colon ([Fig. 4]). A 450 cm long 0.035-inch guide wire (Jagwire, Boston Scientific Nordic AB, Helsingborg,
Sweden) was inserted through the needle to reach the transverse colon ([Fig. 5]). A CRE™ Wireguided Balloon Dilator (Boston Scientific Nordic AB, Helsingborg, Sweden)
was used to dilate the puncture hole to 15 mm (3 atm), a procedure lasting 10 minutes
([Fig. 6]), thus establishing an entirely endoscopically created colorectal anastomosis ([Fig. 7]). The GIF XTQ 160 could then pass through the newly created anastomosis without
difficulty. The anastomosis was dilated again using a CRE™ Wireguided Balloon Dilator
at 6, 9, and 20 weeks. Both ileostomy closure and follow-up 12 months later were uneventful.
Fig. 1 Radiograph showing no lumen at all in the anastomosis on transanal water-soluble enema.
Fig. 2 Endoscopic view showing some staples in the anastomotic area, a completely intact
mucosa and no lumen whatsoever to the proximal bowel.
Fig. 3 Endoscopic view showing transrectal puncture of the descending colon using an Echotip-19
® Ultra Endoscopic Ultrasound Needle.
Fig. 4 Radiograph showing the gastroscope, transrectal puncture of the descending colon,
and injection of water-soluble contrast verifying the position of the needle in the
descending colon.
Fig. 5 Radiograph showing the 450 cm long guide reaching the transverse colon. The colon
is outlined with water-soluble contrast injected through transrectal puncture of the
descending colon.
Fig. 6 Endoscopic view showing the Wireguided Balloon Dilator in place.
Fig. 7 Endoscopic view showing the newly created colorectal anastomosis.
Previous publications describe either different endoscopic techniques for cases where
some lumen exists [2]
[3]
[4]
[5]
[6] or, in a case with no lumen, a combined endoscopic–transanal technique [7]. The difficulty with my technique is that the position of the needle tip, in the
colon proximal to the strictured anastomosis, must be confirmed by fluoroscopy with
absolute certainty before insertion of the guide wire and balloon dilation. The time
to loop closure was due to logistic factors not related to the procedure. An earlier
closure had avoided dilations at 9 and 20 weeks.
The technique is a minimally invasive, outpatient procedure, feasible for an experienced
endoscopist, with limited procedure-related risk because the position of the needle
is carefully checked by fluoroscopy before the guide wire is introduced. The whole
procedure is performed over the guide wire, thus minimizing the risk of perforation.
A redo anastomosis implies major surgery, an inpatient procedure, general anesthesia,
laparotomy to remove the anastomosis and refashion a new anastomosis, and altogether
much greater risk.
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