Gel immersion echoendoscope-guided puncture before radial incision and cutting for complete rectal anastomotic obstruction

Benign anastomotic complete obstruction rarely occurs after lower rectal cancer surgery [1]. The radial incision and cutting (RIC) method has been reported for complete rectal anastomotic obstruction [2]; however, it is important to penetrate the distal and proximal sides of the intestinal tract safely and accurately before RIC. A forward-viewing echoendoscope is useful for recanalizing postoperative biliary anastomotic atresia in endosonography-guided biliary drainage because it allows a more vertical approach and shortens the puncture distance [3] [4]. Furthermore, gel-immersion techniques have been reported for endoscopic procedures [5].

A 59-year-old man underwent intersphincteric resection and temporary ileostomy for lower rectal cancer. Ileostomy closure was scheduled for 12 months after the surgery. Endoscopic imaging revealed complete rectal anastomotic obstruction 2 cm from the anal verge ([Fig. 1]). We attempted an endoscopic intervention to avoid a surgical procedure.

Fig. 1 The site of the lower rectal anastomosis at 2 cm from the anal verge.

A forward-viewing convex echoendoscope (TGF-UCT260J; Olympus Medical Systems, Tokyo, Japan) and immersed gel (VISCOCLEAR; Otsuka Pharmaceutical Factory, Tokushima, Japan) was inserted through the anus. Gel immersion provided a clear endoscopic ultrasound view and helped identify the puncture line ([Fig. 2]). We inserted a 19-gauge needle (EZ Shot 3 plus; Olympus Medical Systems) toward the proximal intestinal tract ([Video 1]). We confirmed patency of the proximal lumen using contrast enhancement and placed a 0.025-inch guidewire (VisiGlide 2; Olympus Medical Systems). Dilation was performed using a 4-mm biliary dilation balloon catheter (REN; Kaneka Medix Corp., Osaka, Japan) until the notch disappeared ([Fig. 3]), and performed RIC using an ITknife nano (KD-611L; Olympus Medical Systems) ([Fig. 4]). After the procedure, an endoscope with a 9.9 mm diameter could penetrate the anastomotic site ([Fig. 5]).

Fig. 2 Gel immersion endoscopic ultrasound view clearly showed the proximal intestinal tract.

Video 1 Gel immersion forward-viewing echoendoscope-guided puncture before radial incision and cutting with endoscopic balloon dilation for complete rectal anastomotic obstruction.

Fig. 3 Fluoroscopic view of endoscopic dilation using a 4-mm biliary dilation balloon catheter until the notch disappeared.

Fig. 4 The radial incision and cutting method using an ITknife nano (KD-611L; Olympus Medical Systems, Tokyo, Japan).

Fig. 5 After the radial incision and cutting procedure, an endoscope with a 9.9 mm diameter could pass through the anastomotic site.

Forward-viewing echoendoscope-guided puncture using gel immersion before RIC with endoscopic balloon dilation is a safe and effective procedure for resolving anastomotic obstructions after lower rectal surgery.

Endoscopy_UCTN_Code_TTT_1AS_2AZ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Lefevre JH, Bretagnol F, Maggiori L. et al. Redo surgery for failed colorectal or coloanal anastomosis: a valuable surgical challenge. Surgery 2011; 149: 65-71
• 2 Osera S, Akiyama G, Tomori A. et al. Successful radial incision and cutting for complete anastomotic obstruction after intersphincteric resection – a video vignette. Colorectal Dis 2023; 25: 339
• 3 Shimizu T, Sato K, Abe T. et al. Forward-viewing echoendoscope is useful for recanalization of postoperative biliary anastomotic atresia in endosonography-guided biliary drainage. Endoscopy 2020; 52: E437-E438
• 4 Hara K, Yamao K, Hijioka S. et al. Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forward-viewing echoendoscope. Endoscopy 2013; 45: 392-396
• 5 Ishii T, Hayashi T, Takahashi K. et al. Forward-viewing echoendoscope plus gel immersion technique in a patient with Billroth II reconstruction. Endoscopy 2022; 54: E867-E868

Publication History

Article published online:
27 June 2023