1524 Using Transillumination to Aid Dilation of a Severe Colorectal Anastomotic Stricture

Abstract

INTRODUCTION: Colorectal anastomotic strictures are common complications of low anterior resection. Strictures in the lower rectum can be treated with direct digital dilation, but if in the upper rectum, endoscopic balloon dilation or electrocautery can be done. However, both procedures depend on the advancement of the wire through the circumferential scar/narrowed lumen. We present a unique case of endoscopic dilation of a severe anastomotic stricture using an innovative method. CASE DESCRIPTION/METHODS: A 44-year-old male with a history of rectal adenocarcinoma s/p low anterior resection with colorectal anastomosis and loop ileostomy formation presented to the GI clinic for constipation. Barium enema study revealed a stricture at the anastomotic site. A flexible sigmoidoscopy confirmed a severe anastomotic stricture, which could not be traversed nor lumen distal to the stricture visualized. And despite multiple attempts the guidewire could not pass through the stricture. Ten weeks after surgery, a pediatric colonoscope was passed through the ileostomy and advanced to the area of the stricture. Position was confirmed with fluoroscopy. At the same time an adult upper endoscope was inserted into the rectum and advanced to the stricture. The pediatric colonoscope was used to transilluminate the stricture and a needle was then used to puncture through the stricture under direct visualization. A guidewire was advanced through the newly created lumen retrograde and the tract was dilated up to 8 mm. A double pigtail plastic stent was inserted across the newly created tract. On repeat colonoscopy three weeks later, the double pigtail stent was removed and the stricture was dilated up to 15 mm. On subsequent colonoscopy, the stricture was dilated to 18 mm and the patients loop ileostomy reversed. The stricture was dilated again to 20 mm via Flexible sigmoidoscopy a month after the reversal after which constipation and bowel habits significantly improved. DISCUSSION: In patients who develop severe colorectal anastomotic strictures after a low anterior resection, endoscopic dilation can be challenging. In such patients ileoscopy and colonoscopy can be done simultaneously and using transillumination, position can be confirmed and a needle can be used to create a lumen through which a guide wire can be passed, allowing for serial dilation. Endoscopic dilation, should be tried and exhausted before considering surgical correction of a stricture, which can be difficult and increase morbidity.