Snare-tipped endoscopic radical incision and cutting for postoperative colorectal anastomotic stricture

Postoperative colorectal anastomotic strictures are not uncommon and often require endoscopic or surgical intervention [1]. Initial treatment typically involves endoscopic balloon dilation, which may need to be repeated for long-term efficacy [2] [3]. Endoscopic radical incision and cutting has emerged as a novel technique for the treatment of refractory strictures. This technique enables the direct removal of fibrotic scar tissue, reducing the risk of restenosis [2] [4] [5]. Herein, we introduce a safe and cost-effective method of performing radical incision and cutting using a snare tip to treat benign anastomotic strictures.

A 59-year-old man underwent anterior resection and loop colostomy for sigmoid colon diverticulitis with perforation. A follow-up colonoscopy within 3 months revealed the formation of circular scars and stricturing at the anastomotic site ([Fig. 1]). The standard colonoscope (distal end/outer diameter 12.2/13.7 mm; CF-Q260AI; Olympus, Japan) could not be passed through the stricture. The patient was referred to us for endoscopic management before the closure of the temporary colostomy.

Fig. 1 Endoscopic image showing circular scar formation that has resulted in luminal stricture at the anastomotic site.

Instead of endoscopic balloon dilation, we employed an innovative technique called snare-tipped endoscopic radical incision and cutting (STERIC) to address the postoperative anastomotic stricture. We used the tip of the snare (25-mm Snare Master; SD-210U-25; Olympus), sticking out by 2 mm in length, to perform the radical incision and cutting. The snare tip was placed at the edge of the stricture ring at the 6-oʼclock position and then used to make a circumferential incision with the assistance of the electrosurgical unit (VIO 3; Erbe) in Endocut Q mode (effect 2, duration 2, interval 4), employing a step-by-step excision along the arc of the lumen ([Fig. 2]; [Video 1]). Following complete removal of the circular scar, it was possible to pass the standard colonoscope freely through the anastomotic site, achieving clinical success in only one session.

Fig. 2 Endoscopic images showing progressive radical incision and cutting along the circular scar in a circumferential manner using a snare tip.

Snare-tipped endoscopic radical incision and cutting (STERIC) is performed for a postoperative colorectal anastomotic stricture.Video 1

The patient subsequently underwent loop transverse colostomy closure, with no signs of restenosis during follow-up.

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• References

• 1 Sartori A, De Luca M, Fiscon V. et al. Retrospective multicenter study of post-operative stenosis after stapled colorectal anastomosis. Updates Surg 2019; 71: 539-542
• 2 Tan Y, Wang X, Lv L. et al. Comparison of endoscopic incision and endoscopic balloon dilation for the treatment of refractory colorectal anastomotic strictures. Int J Colorectal Dis 2016; 31: 1401-1403
• 3 Araujo SE, Costa AF. Efficacy and safety of endoscopic balloon dilation of benign anastomotic strictures after oncologic anterior rectal resection: report on 24 cases. Surg Laparosc Endosc Percutan Tech 2008; 18: 565-568
• 4 Lee TG, Yoon SM, Lee SJ. Endoscopic radial incision and cutting technique for treatment-naive stricture of colorectal anastomosis: Two case reports. World J Gastrointest Surg 2020; 12: 460-467
• 5 Asayama N, Nagata S, Shigita K. et al. Effectiveness and safety of endoscopic radial incision and cutting for severe benign anastomotic stenosis after surgery for colorectal carcinoma: a three-case series. Endosc Int Open 2018; 6: E335-E339