Endoscopy 2022; 54(03): E90-E91
DOI: 10.1055/a-1393-5165
E-Videos

Endoscopic incision and balloon dilation using the rendezvous technique for complete anastomotic obstruction after rectal low-anterior resection

1   Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
,
1   Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
,
Masayoshi Yasui
2   Department of Surgery, Osaka International Cancer Institute, Osaka, Japan
,
1   Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
,
Tomoki Michida
1   Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
,
Ryu Ishihara
1   Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
› Institutsangaben

Anastomotic stenosis, a major complication after low-anterior resection, can usually be treated by endoscopic balloon dilation [1] [2]. However, endoscopic management is challenging in the presence of a complete obstruction because an endoscope and other devices cannot be passed through the obstruction. Combined endoscopic incision and balloon dilation has reportedly been useful for treating complete rectal anastomotic obstruction [3]. If the patient has a stoma with double orifices, a simultaneous antegrade–retrograde approach to the obstructed anastomosis using two endoscopes may be feasible, a method known as the “rendezvous technique”[4].

A woman in her 60 s underwent laparoscopic rectal low-anterior resection and a diverting loop ileostomy after previous endoscopic submucosal dissection (ESD) for early rectal cancer. Stoma closure was scheduled to be performed 7 months post-surgery, but a colonoscopy performed for preoperative evaluation revealed complete obstruction of the rectal anastomosis ([Fig. 1]). Accordingly, endoscopic intervention was attempted for this obstruction.

Zoom Image
Fig. 1 Colonoscopic view before planned surgical stoma closure showing complete anastomotic obstruction after rectal low-anterior resection.

An endoscope (PCF-H290TI; Olympus Co., Tokyo, Japan) with a distal attachment (D-201-11804; Olympus) was passed through the distal loop ileostomy site until it reached the oral side of the obstruction site. Simultaneously, another endoscope (PCF-H290ZI; Olympus) with a distal attachment (D-201-13404; Olympus) was inserted transanally. Although contrast agent sprayed through the trans-stomal endoscope did not flow to the anorectal side ([Fig. 2]), transillumination from the trans-stomal endoscope could be seen across the septum ([Fig. 3]), suggesting the obstruction was membranous. The obstruction site was incised from the anal side using an electrosurgical endoknife (ISSEN; Kaneka Co., Tokyo, Japan) while the incision site was confirmed from the oral side using the rendezvous technique ([Fig. 4]). After a small aperture was created, a controlled radial expansion balloon (Boston Scientific, Marlborough, Massachusetts, USA) was inserted and endoscopic balloon dilation was performed. The obstruction was completely recanalized without adverse events ([Fig. 5]; [Video 1]).

Zoom Image
Fig. 2 Fluoroscopic image showing the use of two endoscopes, one passed through the distal loop ileostomy site and the other inserted transanally, to approach the obstruction site, with no evidence of flow of contrast agent sprayed from the trans-stomal endoscope to the anorectal side.
Zoom Image
Fig. 3 Endoscopic image from the anal side of the obstruction showing evidence of transillumination from the trans-stomal endoscope across the septum, suggesting that the obstruction was membranous.
Zoom Image
Fig. 4 Photograph during the procedure showing the endoscopist on the left making an incision at the obstruction site from the anal side, while the endoscopist on the right confirms the incision site from the oral side.
Zoom Image
Fig. 5 Endoscopic view showing complete recanalization of the obstruction following endoscopic balloon dilation.

Video 1 The rendezvous technique is used to treat a complete anastomotic obstruction after rectal low-anterior resection, with the obstruction site being incised from the anal side, while being observed with a trans-stomal endoscope.


Qualität:

Endoscopy_UCTN_Code_TTT_1AQ_2AF

Endoscopy E-Videos
https://eref.thieme.de/e-videos

Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos



Publikationsverlauf

Artikel online veröffentlicht:
15. März 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Viriglio C, Consentino S, Favara C. et al. Endoscopic treatment of postoperative colonic strictures using an achalasia dilator: short-term and long-term results. Endoscopy 1995; 27: 219-222
  • 2 Di Giorgio P, De Luca L, Rivellini G. et al. Endoscopic dilation of benign colorectal anastomotic stricture after low anterior resection: a prospective comparison study of two balloon types. Gastrointest Endosc 2004; 60: 347-350
  • 3 Yuan X, Liu W, Ye L. et al. Combination of endoscopic incision and balloon dilation for treatment of a completely obstructed anastomotic stenosis following colorectal resection: A case report. Medicine (Baltimore) 2019; 98: e16292
  • 4 Kaushik N, Rubin J, McGrath K. Treatment of benign complete colonic anastomotic obstruction by using an endoscopic rendezvous technique. Gastrointest Endosc 2006; 63: 727-730