ENDOSCOPIC ULTRASONOGRAPHY GUIDED RECANALIZATION OF A COMPLETE POSTOPERATIVE RECTOSIGMOID ANASTOMOTIC OBSTRUCTION WITH A LUMEN-APPOSING METAL STENT

Aims:

To demonstrate that recanalization of a complete postoperative rectosigmoid anastomotic obstruction guided by endoscopic ultrasonography, with a lumen-apposing metal stent (LAMS) is possible.

Methods:

A 58-year-old male who underwent rectal surgery from adenocarcinoma in 2015, with a dehiscence of the colorectal anastomosis in the postoperative period, requiring a colostomy. Subsequently, reconstruction is performed maintaining a diverting ileostomy. 4 months later a rectoscopy showed complete obstruction of the colorectal anastomosis. It is referred to attempt endoscopic approach of the anastomosis. An endoscopic ultrasonography (EUS) guided recanalization of the obstruction was planned.

Results:

Attempt to access by ileostomy without reaching cecum with a colonoscope unable to introduce fluid into sigma to provide acoustic interface. In the rectum, a stump with surgical sutures is observed, without being identified with a linear echoendoscope sigmoid colon. Water and contrast are instilled in the ileum to progress to the distal colon and retry. 24 hours later the liquid administered previously wasn't identified in sigma with EUS or fluoroscopically. With a colonoscope advancing form ileostomy, air is introduce to dilate sigma prior the stenosis, identifying itself with a linear echoendoscope through the rectum. Puncture with a 19G needle is performed, introducing contrast in the sigma, a guidewire is advanced through sigma and cautery-enhanced LAMS 20 × 10 mm under fluoroscopic, endoscopic and EUS control. 24 hours later with colonoscope the stent is dilated up to 20 mm. The stent is maintained, with subsequent closure of the ileostomy and removal of the stent at 12 weeks with good results.

Conclusions:

The recanalization of the complete colorectal obstruction guided by EUS, using LAMS is an effective alternative, and it is feasible even when there is no previous window with liquid.