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Balloon catheter dilation of a rectal stricture
pyloric stenosis the narrowest point, which is often immediately postpyloric, is less than 10 mm and is often less than 5 mm in diameter. 2• 5- 8 It follows from these data that symptoms of pyloric stenosis are unusual when the pylorus is greater than 10 mm, that dilation to 15 to 20 mm is sufficient to relieve obstruction, and 15 mm is associated with less risk of perforation. Our desire to dilate to 15 mm is based on this limited information, but the amount of dilation required is likely to vary from patient to patient. In summary, we have demonstrated the utility of balloon dilation of the pylorus in a small group of patients. The technique appears to work at least for limited periods of time (up to 15 months) with the major drawback being the technical difficulty with the larger catheter sizes (10 and 15 mm). Future utility of this procedure might be enhanced by more appropriately designed catheters. If the procedure proves successful for extended periods, it is possible that in the future pyloric stenosis could be approached much like esophageal stricture.
2. Dworken HJ, Roth HP. Pyloric obstruction associated with peptic ulcer. JAMA 1962;180:85-8. 3. Goldstein H, Janin M, Schapiro M, Boyle JD. Gastric retention associated with gastroduodenal disease. A study of 217 cases. Am J Dig Dis 1966;11:887-97. 4. Benjamin SB, Cattau EL, Glass RL. Balloon dilation of the pylorus: therapy for gastric outlet obstruction. Gastrointest Endosc 1982;28:253-4. 5. Johnston D, Lyndon PJ, Smith RB, Humphrey CS. Highly selective vagotomy without drainage procedure in the treatment of haemorrhage, perforation, and pyloric stenosis due to peptic ulcer. Br J Surg 1973;60:790-7. 6. Kirk RM. The size of the pyloroduodenal canal: its relation to the cause and treatment of peptic ulcer. Proc Roy Soc Moo 1970;63:46-8. 7. McMahon MJ, Greenall MJ, Johnston I, Goligher JC. Highly selective vagotomy plus dilation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration. Gut 1976;17:471-6. 8. Delaney P. Preoperative grading of pyloric stenosis: a long term clinical and radiologic follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilation of the stricture. Br J Surg 1978;65:157-60. 9. Pollock TW, Ring EJ, Oleaga JA, et al. Percutaneous decompression of benign and malignant biliary obstruction. Arch Surg 1979;114:148-51. 10. London RL, Trotman BW, DiMarino AJ, et al. Dilation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5.
REFERENCES 1. Moody FG, Beal JM. Pyloric obstruction complicating peptic ulcer. Arch Surg 1962;84:100-4.
Balloon catheter dilation of a rectal stricture R. A. Brower, MD L. D. Freeman, MD
The balloon catheter was originally designed for dilation of vascular stenoses. In addition to its vascular applications, l the balloon catheter has recently received attention for its nonvascular uses. Descriptions of successful dilation of esophageal strictures/· 3 pyloric outlet obstruction,4 and bile duct stenoses5 have been reported. We report yet another use of the balloon catheter in the therapy of a symptomatic high rectal stricture. CASE REPORT
A 31-year-old white woman was referred to the Gastroenterology Clinic at the Naval Hospital, San Diego, California, for evaluation of a postoperative rectal stricture. From the Department of Interrwl Medicine, Division of Gastroenterology, and the Clinical Investigation Department, Naval Hospital, San Diego, California. Reprint reqlU!sts: LCDR R. A. Brower, MC, USNR, Clinical Investigation Department, Naval Hospital, San Diego, California 92134. The opinions or assertions expressed herein are tlwse of the authors and are not to be constrlU!d as official or as necessarily reflecting the views of the Department of the Navy or the naval service at large. VOLUME 30, NO.2, 1984
Ten months previously, the patient had presented with lower abdominal cramping, altered bowel habits, and hematochezia. Evaluation revealed a mass at the rectosigmoid junction which proved to be a Dukes' C adenocarcinoma. Following a low anterior resection, the patient's postoperative course was complicated by a pelvic abscess near the anastomotic site. This was successfully managed with transrectal drainage and irrigation. Following recovery, she underwent external pelvic irradiation, receiving a total of 5950 rads. Over the next several months, the patient developed increasing problems with abdominal bloating, cramping, and constipation. Proctoscopic examination revealed a tight stricture at 8 cm from the anal verge which was confirmed by subsequent barium enema (Fig. 1A). Because the stricture was symptomatic, we elected to attempt dilation therapy. Following a standard colonoscopy preparation and light sedation, the patient was placed in the Sims position and a small caliber endoscope (ACMI FX-7) was inserted into the rectum. A blind pouch adjacent to the end to end anastomosis and the strictured lumen were visualized. With considerable difficulty, the endoscope was advanced through the stricture. A soft-tipped guide wire was passed through the biopsy channel of the endoscope and left in place while the endoscope was withdrawn from the body. The endoscope was reintroduced into the rectum alongside the guide wire. A l()O-cm balloon catheter with a 36 F balloon (MediTech, Watertown, Mass.) was then advanced over the guide wire and into the stricture under direct vision. The 95
Figure 1. A, Barium enema prior to dilation with arrows demonstrating small caliber rectal stricture. B, Gastrograffin study after stricture dilation; arrows reveal increase in stricture diameter.
balloon was fully inflated by using a hand-held syringe filled with a mixture of saline and methylene blue (Fig. 2). Maximum inflation was maintained for 10 to 15 sec, then repeated once. The patient experienced only mild discomfort during the procedure and no complications were noted. A repeat dilation was performed several weeks later with 45 F and 60 F balloon catheters. These catheters were again advanced over a guide wire which had been positioned endoscopically. The guide wire permitted a quick exchange of the 60 F balloon catheter for the 45 F balloon catheter. Following this second dilation, an Olympus CF-LB3W colonoscope was easily passed through the strictured area and total colonoscopy was performed. A Gastrograffin enema obtained after this procedure documented a significant increase in the lumen diameter (Fig. IB). The patient has been symptom-free on an unrestricted diet 15 months following dilation. DISCUSSION
It is not uncommon for benign rectal strictures to develop after colorectal operations. Most often, these lesions form in association with some breakdown of the original surgical anastomosis. While the majority of strictures spontaneously disappear over a period of 6 months to a year,6 some do persist and cause obstructive symptoms. Various measures have been used in the management of symptomatic rectal strictures. Conservative treatment has included the use of stool softeners, bulkforming laxatives, and, occasionally, enemas. 7Dilation of rectal strictures has been accomplished by several different methods. Digital dilation has been employed for low-lying rectal strictures,7 while a number of different instruments have been used for more proximal lesions. Sigmoidoscopes, Hegar metal dilators,6 96
Figure 2. Endoscopic view revealing inflated balloon catheter dilating rectal stricture.
rubber bougies,7 specially designed stricturescopes,8 Foley catheter balloons,9 and Eder-Puestow esophageal dilators lO have all appeared in anecdotal reports. In the management of colorectal strictures, balloon catheter dilation may offer a greater margin of safety than some of the previously described techniques. Balloons for gastrointestinal use are available in graduated sizes ranging from 12 to 60 French when fully inflated. Each balloon is size limited so that excessive pressures cannot cause overexpansion. When recommended operating pressures are exceeded, the balloon simply bursts. In addition, as opposed to the longitudinal and shearing forces generated by traditional bougienage, with balloon catheter dilation, only radially directed forces are applied. This may lessen the likelihood for viscus perforation. A further advantage of this technique is that direct visual observation of the procedure is allowed. With many of the previously described methods of rectal stricture dilation, visual control is not possible. GASTROINTESTINAL ENDOSCOPY
Our experience with one patient suggests that rectal stricture dilation with the balloon catheter is easily accomplished with excellent patient acceptance. We feel that it offers significant advantages over previously reported techniques. REFERENCES 1. Freiman DB, Ring J, Oleaga JA, et al. Transluminal angio~lasty of the iliac, femoral, and popliteal arteries. Radiology 1979;132:285-8. 2. London RL, Trotman BW, DiMarino AJ, et al. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5. 3. Merrel N, McCray RS. Balloon catheter dilation of a severe esophageal stricture. Gastrointest Endosc 1982;28:254-55.
Endoscopic electrosurgical treatment for strictures of the gastrointestinal tract Rama P. Venu, MD Joseph E. Geenen, MD Walter J. Hogan, MD James Kruidenier, MD Edward T. Stewart, MD Konrad H. Soergel, MD
Electrosurgical incision is effectively utilized to remove polyps with a wire loop and to perform sphincterotomy with the papillotome, chiefly for removal of common bile duct stones. I. 2 The obvious advantage of electrosurgery is thermocoagulation at the time of tissue incision. I We report the successful endoscopic management of two strictures, one involving the esophagus and the other involving the descending duodenum, by using cutting and coagulation current applied through a straight needle. In case 1, a 31-year-old white woman was admitted with a history of dysphagia. Systemic lupus erythematosus (SLE) had been diagnosed 20 years ago when she presented with fever, seizures, malar flush, polyarthritis, hepatosplenomegaly, pancytopenia, and albuminuria. Corticosteroids induced a remission; this was maintained by low dose treatment for 19 years. Two months after the onset of SLE, she noticed dysphagia for solid food; food boluses seem to be arrested at the sternal notch and passed only with external massage applied posterior to the trachea. This symptom remained unchanged for 18 years and she was able to prevent weight loss by spending 2 to 3 hours daily eating. Two years ago, an esophagogram revealed a "stricture" in the proximal esophagus. AtFrom the Department of Medicine and Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin. Reprints requests: Joseph E. Geenen, MD, 1333 College Avenue, Racine, Wisconsin 53403. VOLUME 30, NO.2, 1984
4. Benjamin SB, Cattau FC, Glass RL. Balloon dilation ~f the pylorus: therapy for gastric outlet obstruction. Gastromtest Endosc 1982;28:253-4. 5. Pollock TW, Ring EJ, Oleaga JA, et al. Percuta~eous decompression of benign and malignant, biliary obstruction. Arch ' Surg 1979;114:148-51. 6. Goligher JC. Surgery of the anus, rectum and colon, 4th ed. '.. London: Bailliere Tindall, 1980:606. 7. Goldberg SM, Gordon PH, Nivatvongs S, eds.,Essentials of anorectal surgery. Philadelphia: LB Lippincott, 1980:337. 8. Dencker H, Johansson JI, Norryd C, Tranberg KG. Dilator for treatment of strictures in the upper part of the rectum and the sigmoid. Dis Colon Rectum 1973;16:550-2. . 9. Mazier WP. A technique for the management of low colome anastomotic stricture. Dis Colon Rectum 1973;16:113-6. 10. Hunt RH, Waye JD, eds. Colonoscopy. London: Chapman and Hall,1981:371-2.
tempts at dilating the stricture with mercury-filled dilators (Maloney size 30 F) resulted in esophageal perforation. This was managed conservatively with parenteral antibiotics and nasogastric suction. Further dilation attempts were unsuccessful. A thoracotomy was performed because of progressive dysphagia and weight loss. Two vertical incisions were made at the stricture site; an esophagoplasty and intraoperative dilation were carried out. Moderate improvement lasted only 3 months. The patient was then referred to the Medical College of Wisconsin for evaluation. Physical examination was unremarkable except for malar rash and minimal hepatosplenomegaly. Laboratory studies revealed an elevated sedimentation of 47 mm/hour and a normochromic, normocytic anemia with a hemoglobin of 10 g/dl. Esophagogram (Fig. lA) showed a stricture involving the upper esophagus which measured 4 mm in diameter and 4 to 5 mm in length. No gastroesophageal reflux of barium sulfate was demonstrated. Esophageal peristalsis was normally propagated to the distal esophagus; this was confirmed by a normal esophageal manometric study. Esophagoscopy using Olympus pediatric 'scope (diameter, 8 mm) revealed an asymmetric stricture 23 cm from the incisor teeth. The endoscope could not be passed through the strictured segment. There was no endoscopic or histologic evidence of esophagitis. The esophageal mucosa surrounding the strictured segment appeared somewhat pale. Triamcinolone acetonide suspension, 40 mg, was injected into the four quadrants of the stricture in four divided doses on seven occasions at weekly intervals. This resulted in only slight symptomatic improvement. The size of a metal olive that would pass the narrowed area increased from 22F to 32F. Endoscopic four quadrant incisions were then performed twice, 3 weeks apart, using a short needle electrode. 97
2. Dworken HJ, Roth HP. Pyloric obstruction associated with peptic ulcer. JAMA 1962;180:85-8. 3. Goldstein H, Janin M, Schapiro M, Boyle JD. Gastric retention associated with gastroduodenal disease. A study of 217 cases. Am J Dig Dis 1966;11:887-97. 4. Benjamin SB, Cattau EL, Glass RL. Balloon dilation of the pylorus: therapy for gastric outlet obstruction. Gastrointest Endosc 1982;28:253-4. 5. Johnston D, Lyndon PJ, Smith RB, Humphrey CS. Highly selective vagotomy without drainage procedure in the treatment of haemorrhage, perforation, and pyloric stenosis due to peptic ulcer. Br J Surg 1973;60:790-7. 6. Kirk RM. The size of the pyloroduodenal canal: its relation to the cause and treatment of peptic ulcer. Proc Roy Soc Moo 1970;63:46-8. 7. McMahon MJ, Greenall MJ, Johnston I, Goligher JC. Highly selective vagotomy plus dilation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration. Gut 1976;17:471-6. 8. Delaney P. Preoperative grading of pyloric stenosis: a long term clinical and radiologic follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilation of the stricture. Br J Surg 1978;65:157-60. 9. Pollock TW, Ring EJ, Oleaga JA, et al. Percutaneous decompression of benign and malignant biliary obstruction. Arch Surg 1979;114:148-51. 10. London RL, Trotman BW, DiMarino AJ, et al. Dilation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5.
REFERENCES 1. Moody FG, Beal JM. Pyloric obstruction complicating peptic ulcer. Arch Surg 1962;84:100-4.
Balloon catheter dilation of a rectal stricture R. A. Brower, MD L. D. Freeman, MD
The balloon catheter was originally designed for dilation of vascular stenoses. In addition to its vascular applications, l the balloon catheter has recently received attention for its nonvascular uses. Descriptions of successful dilation of esophageal strictures/· 3 pyloric outlet obstruction,4 and bile duct stenoses5 have been reported. We report yet another use of the balloon catheter in the therapy of a symptomatic high rectal stricture. CASE REPORT
A 31-year-old white woman was referred to the Gastroenterology Clinic at the Naval Hospital, San Diego, California, for evaluation of a postoperative rectal stricture. From the Department of Interrwl Medicine, Division of Gastroenterology, and the Clinical Investigation Department, Naval Hospital, San Diego, California. Reprint reqlU!sts: LCDR R. A. Brower, MC, USNR, Clinical Investigation Department, Naval Hospital, San Diego, California 92134. The opinions or assertions expressed herein are tlwse of the authors and are not to be constrlU!d as official or as necessarily reflecting the views of the Department of the Navy or the naval service at large. VOLUME 30, NO.2, 1984
Ten months previously, the patient had presented with lower abdominal cramping, altered bowel habits, and hematochezia. Evaluation revealed a mass at the rectosigmoid junction which proved to be a Dukes' C adenocarcinoma. Following a low anterior resection, the patient's postoperative course was complicated by a pelvic abscess near the anastomotic site. This was successfully managed with transrectal drainage and irrigation. Following recovery, she underwent external pelvic irradiation, receiving a total of 5950 rads. Over the next several months, the patient developed increasing problems with abdominal bloating, cramping, and constipation. Proctoscopic examination revealed a tight stricture at 8 cm from the anal verge which was confirmed by subsequent barium enema (Fig. 1A). Because the stricture was symptomatic, we elected to attempt dilation therapy. Following a standard colonoscopy preparation and light sedation, the patient was placed in the Sims position and a small caliber endoscope (ACMI FX-7) was inserted into the rectum. A blind pouch adjacent to the end to end anastomosis and the strictured lumen were visualized. With considerable difficulty, the endoscope was advanced through the stricture. A soft-tipped guide wire was passed through the biopsy channel of the endoscope and left in place while the endoscope was withdrawn from the body. The endoscope was reintroduced into the rectum alongside the guide wire. A l()O-cm balloon catheter with a 36 F balloon (MediTech, Watertown, Mass.) was then advanced over the guide wire and into the stricture under direct vision. The 95
Figure 1. A, Barium enema prior to dilation with arrows demonstrating small caliber rectal stricture. B, Gastrograffin study after stricture dilation; arrows reveal increase in stricture diameter.
balloon was fully inflated by using a hand-held syringe filled with a mixture of saline and methylene blue (Fig. 2). Maximum inflation was maintained for 10 to 15 sec, then repeated once. The patient experienced only mild discomfort during the procedure and no complications were noted. A repeat dilation was performed several weeks later with 45 F and 60 F balloon catheters. These catheters were again advanced over a guide wire which had been positioned endoscopically. The guide wire permitted a quick exchange of the 60 F balloon catheter for the 45 F balloon catheter. Following this second dilation, an Olympus CF-LB3W colonoscope was easily passed through the strictured area and total colonoscopy was performed. A Gastrograffin enema obtained after this procedure documented a significant increase in the lumen diameter (Fig. IB). The patient has been symptom-free on an unrestricted diet 15 months following dilation. DISCUSSION
It is not uncommon for benign rectal strictures to develop after colorectal operations. Most often, these lesions form in association with some breakdown of the original surgical anastomosis. While the majority of strictures spontaneously disappear over a period of 6 months to a year,6 some do persist and cause obstructive symptoms. Various measures have been used in the management of symptomatic rectal strictures. Conservative treatment has included the use of stool softeners, bulkforming laxatives, and, occasionally, enemas. 7Dilation of rectal strictures has been accomplished by several different methods. Digital dilation has been employed for low-lying rectal strictures,7 while a number of different instruments have been used for more proximal lesions. Sigmoidoscopes, Hegar metal dilators,6 96
Figure 2. Endoscopic view revealing inflated balloon catheter dilating rectal stricture.
rubber bougies,7 specially designed stricturescopes,8 Foley catheter balloons,9 and Eder-Puestow esophageal dilators lO have all appeared in anecdotal reports. In the management of colorectal strictures, balloon catheter dilation may offer a greater margin of safety than some of the previously described techniques. Balloons for gastrointestinal use are available in graduated sizes ranging from 12 to 60 French when fully inflated. Each balloon is size limited so that excessive pressures cannot cause overexpansion. When recommended operating pressures are exceeded, the balloon simply bursts. In addition, as opposed to the longitudinal and shearing forces generated by traditional bougienage, with balloon catheter dilation, only radially directed forces are applied. This may lessen the likelihood for viscus perforation. A further advantage of this technique is that direct visual observation of the procedure is allowed. With many of the previously described methods of rectal stricture dilation, visual control is not possible. GASTROINTESTINAL ENDOSCOPY
Our experience with one patient suggests that rectal stricture dilation with the balloon catheter is easily accomplished with excellent patient acceptance. We feel that it offers significant advantages over previously reported techniques. REFERENCES 1. Freiman DB, Ring J, Oleaga JA, et al. Transluminal angio~lasty of the iliac, femoral, and popliteal arteries. Radiology 1979;132:285-8. 2. London RL, Trotman BW, DiMarino AJ, et al. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5. 3. Merrel N, McCray RS. Balloon catheter dilation of a severe esophageal stricture. Gastrointest Endosc 1982;28:254-55.
Endoscopic electrosurgical treatment for strictures of the gastrointestinal tract Rama P. Venu, MD Joseph E. Geenen, MD Walter J. Hogan, MD James Kruidenier, MD Edward T. Stewart, MD Konrad H. Soergel, MD
Electrosurgical incision is effectively utilized to remove polyps with a wire loop and to perform sphincterotomy with the papillotome, chiefly for removal of common bile duct stones. I. 2 The obvious advantage of electrosurgery is thermocoagulation at the time of tissue incision. I We report the successful endoscopic management of two strictures, one involving the esophagus and the other involving the descending duodenum, by using cutting and coagulation current applied through a straight needle. In case 1, a 31-year-old white woman was admitted with a history of dysphagia. Systemic lupus erythematosus (SLE) had been diagnosed 20 years ago when she presented with fever, seizures, malar flush, polyarthritis, hepatosplenomegaly, pancytopenia, and albuminuria. Corticosteroids induced a remission; this was maintained by low dose treatment for 19 years. Two months after the onset of SLE, she noticed dysphagia for solid food; food boluses seem to be arrested at the sternal notch and passed only with external massage applied posterior to the trachea. This symptom remained unchanged for 18 years and she was able to prevent weight loss by spending 2 to 3 hours daily eating. Two years ago, an esophagogram revealed a "stricture" in the proximal esophagus. AtFrom the Department of Medicine and Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin. Reprints requests: Joseph E. Geenen, MD, 1333 College Avenue, Racine, Wisconsin 53403. VOLUME 30, NO.2, 1984
4. Benjamin SB, Cattau FC, Glass RL. Balloon dilation ~f the pylorus: therapy for gastric outlet obstruction. Gastromtest Endosc 1982;28:253-4. 5. Pollock TW, Ring EJ, Oleaga JA, et al. Percuta~eous decompression of benign and malignant, biliary obstruction. Arch ' Surg 1979;114:148-51. 6. Goligher JC. Surgery of the anus, rectum and colon, 4th ed. '.. London: Bailliere Tindall, 1980:606. 7. Goldberg SM, Gordon PH, Nivatvongs S, eds.,Essentials of anorectal surgery. Philadelphia: LB Lippincott, 1980:337. 8. Dencker H, Johansson JI, Norryd C, Tranberg KG. Dilator for treatment of strictures in the upper part of the rectum and the sigmoid. Dis Colon Rectum 1973;16:550-2. . 9. Mazier WP. A technique for the management of low colome anastomotic stricture. Dis Colon Rectum 1973;16:113-6. 10. Hunt RH, Waye JD, eds. Colonoscopy. London: Chapman and Hall,1981:371-2.
tempts at dilating the stricture with mercury-filled dilators (Maloney size 30 F) resulted in esophageal perforation. This was managed conservatively with parenteral antibiotics and nasogastric suction. Further dilation attempts were unsuccessful. A thoracotomy was performed because of progressive dysphagia and weight loss. Two vertical incisions were made at the stricture site; an esophagoplasty and intraoperative dilation were carried out. Moderate improvement lasted only 3 months. The patient was then referred to the Medical College of Wisconsin for evaluation. Physical examination was unremarkable except for malar rash and minimal hepatosplenomegaly. Laboratory studies revealed an elevated sedimentation of 47 mm/hour and a normochromic, normocytic anemia with a hemoglobin of 10 g/dl. Esophagogram (Fig. lA) showed a stricture involving the upper esophagus which measured 4 mm in diameter and 4 to 5 mm in length. No gastroesophageal reflux of barium sulfate was demonstrated. Esophageal peristalsis was normally propagated to the distal esophagus; this was confirmed by a normal esophageal manometric study. Esophagoscopy using Olympus pediatric 'scope (diameter, 8 mm) revealed an asymmetric stricture 23 cm from the incisor teeth. The endoscope could not be passed through the strictured segment. There was no endoscopic or histologic evidence of esophagitis. The esophageal mucosa surrounding the strictured segment appeared somewhat pale. Triamcinolone acetonide suspension, 40 mg, was injected into the four quadrants of the stricture in four divided doses on seven occasions at weekly intervals. This resulted in only slight symptomatic improvement. The size of a metal olive that would pass the narrowed area increased from 22F to 32F. Endoscopic four quadrant incisions were then performed twice, 3 weeks apart, using a short needle electrode. 97