Endoscopic needle-knife treatment of refractory ileo–ascending anastomotic stricture

A 45-year-old man with Crohn’s disease diagnosed in 1988 who had undergone an ileocecal resection with an end-to-side anastomosis in 1995 presented with pain in the right lower abdomen. A colonoscopy was performed using an Olympus colonoscope (Tokyo, Japan), during which a noninflamed fibrotic stricture of the anastomosis that could not be passed by the endoscope was found ([Fig. 1]). Because the patient refused surgery, six balloon dilations of the stricture were performed at 3-monthly intervals. Unfortunately these resulted in limited improvement in both the degree of stenosis and the patient’s symptoms.

Fig. 1 Appearances during colonoscopies performed in a patient with Crohn’s disease showing the ileo–ascending anastomotic stricture: a before balloon dilation; b during balloon dilation; c 3 months after balloon dilation.

In order to overcome the stricture, it was decided to incise the fibrotic bridge with a needle-knife papillotome (Zimmon needle-knife papillotome; Cook Medical Europe, Limerick, Ireland; [Fig. 2]). It was possible to make this incision safely because of a perfect view of the tissue bridge, the enteral loop, and the colonic loop in a parallel position. After the incision had been made, the endoscope was able to be passed beyond the anastomosis. Normal ileal mucosa was seen immediately beyond the anastomosis. At follow-up colonoscopy 3 months later, it was still possible to pass the endoscope beyond the anastomosis. During 7 months of follow-up, the patient has remained symptom free.

Fig. 2 Colonoscopic appearance showing the ileo–ascending anastomotic stricture: a before needle-knife incision; b during needle-knife incision; c after needle-knife incision.

Fibrotic strictures of the ileo–ascending anastomosis are common complications of Crohn’s disease after ileocecal resection [1]. Drug treatment is ineffective in the absence of active inflammation. To minimize the need for multiple resections, bowel-conserving strategies that include surgical stricturoplasty and endoscopic balloon dilation have been developed. The long-term success rate of endoscopic dilations is high (80 %) [2].

Only a few case series of endoscopic needle-knife incision have been published. These include needle-knife incision of upper gastrointestinal anastomotic strictures [3], anastomotic sinuses [4], and rectal anastomotic strictures [5]. To our knowledge, we present the first case of a successful needle-knife incision of an ileo–ascending anastomotic stricture in a patient with Crohn’s disease. Balloon dilation can sometimes be ineffective, especially in very rigid fibrotic strictures, and in these cases needle-knife incision might provide an alternative treatment to balloon dilation.

Endoscopy_UCTN_Code_TTT_1AQ_2AF

• References

• 1 Rutgeerts P, Geboes K, Vantrappen G et al. Predictability of the postoperative course of Crohn’s disease. Gastroenterology 1990; 99: 956-963
• 2 van Assche G, Thienpont C, D’Hoore A et al. Long-term outcome of endoscopic dilatation in patients with Crohn’s disease is not affected by disease activity or medical therapy. Gut 2010; 59: 320-324
• 3 Hordijk ML, Siersema PD, Tilanus HW et al. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 2006; 63: 157-163
• 4 Lian L, Geisler D, Shen B. Endoscopic needle knife treatment of chronic presacral sinus at the anastomosis at an ileal pouch–anal anastomosis. Endoscopy 2010; 42: 14
• 5 Truong S, Willis S, Schumpelick V. Endoscopic therapy of benign anastomotic strictures of the colorectum by electroincision and balloon dilatation. Endoscopy 1997; 29: 845-849