Endoscopic treatment of completely occluding anastomotic web using incision and ballooning after dye injection

A 73-year-old woman with rectal adenocarcinoma at 10 cm from the anal verge underwent laparoscopy-assisted low anterior resection with a protective loop ileostomy. Postoperatively the patient received adjuvant radiotherapy and chemotherapy for 6 months. After the chemoradiation treatments, a digital rectal examination prior to ileostomy takedown revealed anastomotic obstruction. Under direct visualization using a colonoscope (CF-Q240; Olympus Optical Co, Ltd, Japan), no opening was found in the anastomotic occlusive web (Figure [1]). Fluoroscopy showed a blind end at the level of the anastomosis (Figure [2]). An injector (NM-200U; Olympus) was inserted into the center of the circular staple line at the level of the anastomosis, and diluted dye (Telebrix; Guerbet, France) was injected to identify the proximal lumen under fluoroscopic guidance (Figure [3]). Injection of water through the injector dilated the lumen of the proximal atrophied bowel. The anastomotic occlusive web was incised in a radial fashion using a needle-papillotome (MTW Endoskopie, Germany) (Figure [4]). Under endoscopic observation, a controlled radial expansion balloon dilator (Boston Scientific Cork Ltd, Ireland) was inserted through the web opening and insufflated with water (Figure [5]). The successful destruction of the occlusive web facilitated passage of the colonoscope, allowing evaluation of the entire colon (Figure [6]). The patient tolerated the procedure well without complications.

Figure 1 Appearance of a completely occluding web at the level of the anastomosis, 8 cm from the anal verge.

Figure 2 Fluoroscopy showing a blind end at the level of the anastomosis.

Figure 3 Fluoroscopic identification of the proximal bowel after dye injection at the center of the circular staple line.

Figure 4 Rupture of the anastomotic occlusive web using a needle-knife at the site of injection.

Figure 5 Water insufflation of the ”through the scope” hydrostatic balloon dilation at the level of the anastomosis.

Figure 6 Complete destruction of the occlusive web after balloon dilation and restoration of bowel lumen.

Management of anastomotic strictures is mainly performed endoscopically by balloon dilation [1] [2] [3]. Patients with a completely occluding anastomotic web lack even a small opening through which a guide wire can be inserted, making further major corrective surgery technically demanding. In one patient, a completely obstructed colonic anastomosis was managed using a combined antegrade-retrograde endoscopic rendezvous technique using two colonoscopes [4]. With our endoscopic technique, injection of a dye under fluoroscopic guidance enabled us to identify the proximal lumen and to rupture the occlusive web successfully.

Endoscopy_UCTN_Code_TTT_1AQ_2AF

References

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