Successful Treatment of Colorectal Anastomotic Stricture by Using Sphincterotomes

[Crohn2357]



Front Surg. 2014 Jun 20;1:22. doi: 10.3389/fsurg.2014.00022
Successful Treatment of Colorectal Anastomotic Stricture by Using Sphincterotomes
Tzu-An Chen 1,*, Wei-Lun Hsu 2

PMCID: PMC4286977 PMID: 25593946

…

Endoscopic incision for the treatment of anastomotic stenosis in the upper gastrointestinal tract is well accepted (14), but its application for colorectal anastomotic strictures is limited. The sphincterotome is a bow-like device, which has an electrosurgical cutting wire at the distal end of the catheter. A monopolar power source is connected to the catheter at an electrode connector on the handle. During a sphincterotomy activation of the power source causes electrical current to pass along an insulated portion of the wire within the catheter to the exposed cutting wire. A retractable plunger on the control handle permits flexing of the catheter tip upward by pulling on the cutting wire. This flexing assists with aligning the cutting wire and maintaining contact of the wire with the scarred anastomosis while the catheter is pulled back, incising the circular scar of anastomosis by electrocauterization. Because of the bilateral plastic limbs of the sphincterotome, the depth of electrocauterization was limited and perforation of bowel wall could be avoided (Figure 3). We made three or four incisions at different directions to release the stricture. The purpose of the incision was breakdown of the membranous circular scar, and we preferred multiple shallow incisions but not one deep incision with curative intent. We believe that if the strength of stricture was released by multiple incisions, the lumen would be dilated by the following stool passage. One curative deep incision was not necessary so the risk of bowel injury could be diminished.

Some authors also reported small case series about using endoscopic incisions plus balloon dilation for the anastomotic stricture (15, 16). Based on our result, additional balloon dilation might not be necessary if the multiple incisions were completed and the membranous scar was demolished. Recently, some authors tried to treat benign colorectal strictures by stenting (17). Although the use of self-expanding metal stents to treat obstruction colorectal tumors has been commonly described in the literature, the application of stenting to benign stricture is uncommon. The long-term reliability of stenting is questioned; migration, erosion, pressure necrosis, and bleeding all have been reported (18). In our opinion, endoscopic self-expanding metal stent placement as a bridge to surgery is an option for acute malignant colonic obstruction. For the long-term usage in benign anastomotic stricture, colonic stenting is not encouraged.

Chen TA, Hsu WL. Successful treatment of colorectal anastomotic stricture by using sphincterotomes. Front Surg. 2014 Jun 20;1:22. doi: 10.3389/fsurg.2014.00022. PMID: 25593946; PMCID: PMC4286977.

https://pmc.ncbi.nlm.nih.gov/articles/PMC4286977/

 

[Crohn2357]

Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group - PubMed



Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn's disease - PubMed



Endoscopic therapy of stoma closure site strictures in ileal pouches is safe and effective - PubMed

 

[Crohn2357]

Endoscopic Needle Knife Stricturotomy (NKSt) vs balloon dilation for Crohn's disease stricture treatment in distal ileum...any advice??

 

[Crohn2357]

EDITORIAL
Endosc Int Open
. 2018 Mar 7;6(3):E340–E341. doi: 10.1055/s-0043-122495

Stricture at colorectal anastomosis: to dilate or to incise​

Wiriyaporn Ridtitid 1, Aroon Siripun 2, Rungsun Rerknimitr 1,✉

PMCID: PMC5844386 PMID: 29532005

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Benign colonic anastomotic stricture is one the main complications developed after colectomy, it occurred in up to 22 % of patients undergoing colorectal resection 1 . In practice, management of postoperative anastomotic strictures includes endoscopic balloon dilation (EBD), insertion of self-expandable metal stent, repeat surgery, and colostomy. Due to its effectiveness, simplicity, and safety, EBD is always the first choice 2 3 . Nevertheless, multiple sessions of EBD may be required to achieve long-term patency. Moreover, approximately one-fifth of patients initially managed by EBD required additional treatment, including stent insertion and/or revisional surgery 3 . The failure of EBD may be explained by traumatic injury to the deeper muscle layer from repeated EBD, resulting in formation of cicatrized and contracted new scar tissues 4 .

Recently, an endoscopic electrocautery incision (EEI) technique has been reported as an alternative treatment for anastomotic colorectal strictures 5 6 7 . Radial incisions were performed using either a precut sphincterotome 5 7 or an insulated tip (IT) knife 6 . However, location, depth and length of the incision in each series were different because these were left to the discretion of the endoscopists. Four case series (n = 76) showed good efficacy for EEI in combination with other endoscopic techniques including EBD, adjunctive corticosteroid injection, or Argon plasma coagulation (APC) 8 9 10 11 . Furthermore, three studies (n = 47) demonstrated the advantage of more aggressive EEI by adding a cutting method after finishing radial incision (RIC), which involves removal of the flaps that developed after radial incisions. In other words, RIC is more like “conization of cervical cancer” 12. The only difference is that the scar tissue removed by RIC is more cylindrical shaped than cone shaped. In other words, RIC is the technique that “scoops” the deeper fibrotic scar (  Fig.1a ) that may reform again after EBD ( Fig. 1b ) or EEI ( Fig. 1c ). A recent systematic review of 10 studies by Jain et al summarized experience in 186 patients with benign lower gastrointestinal tract anastomotic strictures undergoing EEI, either alone (n =  63) or in combination with another modality (n =  123) 13 . Of those, 47 patients underwent RIC. During long-term follow up, the initial success rates were 95.2 %, 95.8 %, and 87.8 % for EEI alone, RIC, and EEI with EBD, respectively. Recurrent rates of strictures were 4.8 %, 0 %, and 12.5 % for EEI alone, RIC, and EEI with EBD, respectively. Based on these data, stricture recurrence rates in patients undergoing EEI either alone or in combination with RIC were much lower than that previously reported for EBD alone. More interestingly, no recurrent stricture was seen in those who underwent RIC. The advantage of RIC may be due to the technique that can directly excise the scar tissue which could be the cause of refractory stenosis.

Fig. 1 .​

The cross section of the rectal anastomotic site (SS, serosa; MP, muscularis propria; SM, submucosa; MM, muscularis mucosae; LP, lamina propria): a Radial incision and cutting method (RIC; white lines), b Endoscopic balloon dilation (EBD; blue dashes), cEndoscopic electrocautery incision (EEI; white dashes)

In this issue of Endoscopy International Open, Asayama et al. demonstrated success in 3 patients undergoing RIC at the level of intraperitoneal colonic anastomotic strictures after failed EBD 14 . Of those, 2 patients had improvement following a single session and the other succeeded after 6 sessions. No procedure-related adverse events or recurrent stricture occurred during a median follow-up of 27 (range 8 – 37) months. Although this showed the effectiveness and safety of RIC in patients with benign anastomotic strictures, there are certain key issues that have to be addressed in this setting. First, estimation of the length of incision and the depth of cutting to avoid perforation is subject to the endoscopist’s discretion. Second, the learning curve to reach competency in RIC may be steeper because it appears more difficult than conventional EEI. Perhaps endoscopists who are very experienced in endoscopic submucosal dissection (ESD) would be the preferred operators for RIC. Third, the feasibility of RIC in a case with long stricture may be limited and the procedure may be dangerous. Fourth, this technique can lead to significant risks of bleeding, infection, and perforation, therefore, surgical back up is recommended. Perhaps there may be a role of colonic stenting as the rescue treatment for perforation that develops after RIC.

Although EBD is the current standard for primarily endoscopic management in patients with benign colorectal anastomotic strictures, it requires multiple dilations and results in a significant rate of restenosis. Given these data, conventional EEI is a promising technique for short anastomotic stricture. In our opinion, RIC may be better but more dangerous than conventional EEI ( Table 1 ). Therefore, we recommend that RIC be performed only by expert endoscopists. Randomized controlled trials comparing the outcomes of EBD, conventional EEI, and RIC are warranted to confirm the long-term effectiveness and safety of the three techniques in treating benign colorectal anastomotic strictures.

Table 1. Comparison of efficacy and feasibility among the three techniques.​

	EBD	EEI	RIC
Technical difficulty​	Easy​	Difficult​	More difficult​
Risk of perforation​	+ ​	+ + ​	+ + + ​
Effectiveness 1​	+ ​	+ + ​	+ + + (?) 1​

EBD, endoscopic balloon dilation; EEI, endoscopic electrocautery incision; RIC, radial incision and cutting method
1
Require studies to confirm


Ridtitid W, Siripun A, Rerknimitr R. Stricture at colorectal anastomosis: to dilate or to incise. Endosc Int Open. 2018 Mar;6(3):E340-E341. doi: 10.1055/s-0043-122495. Epub 2018 Mar 7. PMID: 29532005; PMCID: PMC5844386.

https://pubmed.ncbi.nlm.nih.gov/29532005/