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endoscopic repair of rectal stricture
Laparoscopicbhdoscopic
Repair of Rectal Stricture
Robert A Kozol, M D , Mary Ann Koszl; M D
Although uncommon, anastomotic stricture after low anterior resection may requu-e additional repair
beyond ddatahon Two alternate approaches are described wherem laparoscoplc and endoscoplc techmques were utlhzed to avold repeat pelvic surgery m two cases These can be used whether a stapled or hand-sewn approach was used for the mltlal anastomosls Photo documentaaon demonstrates a wdely patent anastomosls after repnr There ISearly return of bowel funcaon by these methods, and long-term results (3 years) are excellent (J GASTROINTEST SURG 1998,2 426-429 )
Anastomouc stricture IS a recognrzed, Infrequent complication of colonic surgery L2 An anastomotic stricture at the level of the rectum IS often amenable to dllatatlon. When repeated dllataaon falls, surgical repair IS mdlcated Surgical repair through an abdominal approach (m a scarred pelvis) can be a forrmdable procedure Several novel methods have been reported to facllltate repalr of stllctures w&out takedown of the anastomosls 3-6 This report describes two addmonal mnovatlve approaches using laparoscoplciendoscoplc methods to repalr a rectal anastomoat stricture that had falled dllatatlon therapy
CASE REPORTS Case 1 A 64-year-old man underwent a stapled low anterior resectlon for a Dukes’ B adenocarcmoma of the rectum The patlent recovered nicely after surgery Follow-up colonoscopy revealed an anastomotic stncture 1 year postoperauvely Biopsy of the stricture showed no evidence of recurrent carcinoma The patlent developed consupatlon and &m-caliber stools 2 years postoperatively Colonoscoplc examination at the time revealed a stricture that would not pernut msemon of a standard colonoscope (Fig 1) The pauent underwent endoscoplc dilatation of tlus stricture on four occasions over a 14-month penod Balloon dilatation was unsuccessful, but the smcture could be dilated urlth the obturator of a rlgd slgmoldoscope under direct qslon via an adjacent flexible scope m the rectum The patient remamed symptomatic and surgcal repair of the stricture was undertaken using a laparoscoplc approach The transverse colon was ldenufied A 4 cm upper abdominal mclslon was made and a loop of transverse colon was delivered through
the abdommal wall A transverse colotomy was performed and the anvd of an end-to-end stapling Instrument was delivered mto the colon A colonoscope was advanced transanally past the smcture mto the transverse colon A sdk suture previously ued to the anvd was grasped with a snare and the anvd was pulled down the colon to the smcture (Fig 2, A) The shaft of the 3 1 mm stapler was then
passed transanally, Joined with the anvd by havmg the surgeon hold the anvil with fingers m the rectum, and the stapler was fired across the stricture (Fig 2, B) The circular stapler had cut out the smcture resultmg m a new enlarged anastomouc lumen The transverse colotomy was closed as was the 4 cm mclslon The patient had a bowel movement on postoperative day 2 He began a liquid diet on postoperauve day 3 and was discharged on postoperative day 5 He IS currently asymptomatlc Repeat colonoscopy at 1 and 3 years revealed no recurrent stricture (Fig 3)
Case 2 A 74-year-old man underwent a low antenor resection for a large (5 cm) tubulovdlous adenoma wth atypla m the rectum The specimen showed a 4 5 cm well-differentiated adenocarcmoma ansmg m the tubulovlllous adenoma and focal mvaslon of the submucosa A double-staphng technique was used urlth a linear stapler and circular stapling device HIS postoperative recovery was unremarkable No radlatlon or chemotherapy was given postoperatively He was seen for follow-up endoscopy at 6 months when a smcture was noted 7 cm proxlmal to the anal verge (Fig 4, A) Blopsles of the stricture revealed focal areas of granulation tissue and mild chrome mflammatlon The patient had symptoms of constipanon 5 to 6 months postoperatively, at which bme a barmm enema showed stricture Under gen-
From the SurFcal Semce, VA Medical Center, and Wayne State Unrverslty School of Medlcme, Detroit, Mlch Presented at the Sixty-First Annual Sclenufic Meetmg of the Amencan College of Gastroenterology, Seattle, Wash , Ott Reprmt requests Robert A Kozol, M D , VAMedlcal Center (112), 4646 John R, Detroit, MI 48201 426
2 l-23,
1996
Vol 2, No 5 1998
be used repeatedly as resmcturmg occurs, although the device may not yet be commercially available These methods are slmllar m concept to previously reported methods of restaphng the anastomouc smctures usmg end-to-end staphng devxes or an EndoGIA stapler 2-5However, our techmque offers an approach for cases where the smcture 1s too tight for passage of an end-to-end stapler In fact, one could argue that a smcture which 1s amenable to dllataaon to stapler size does not need revlslon at all. For those smctures that reqmre revlslon, these laparoscopic/endoscoplc approaches offer good alternatives to repeat pelvic surgery
CONCLUSION Two laparoscoplciendoscoplc methods are described for repax of symptomaac rectal anastomotlc smcture, which offer the advantage of avoiding open pelvic dlssecaon. These urlll offer the surgeon addluonal approaches to the uncommon problem of anastomouc smcture, whether by stapled or hand-sewn techmque.
Laparoendoscoplc Rectal Smcture Repalr
429
REFERENCES Moran BJ Staphng mstruments for mtestmal anastomosls m colorectal surgery Br J Surg 1996,83 902-909 Vignah A, Fazlo VW, Lavery IC, Wlsonm, Church JM, Hull TL, Strong SA, Oakley JR Factors associated mth the occurrence of leaks m stapled rectal anastomoses A review of 1,014 paaents Ann Surg 1997,185 105-113 Hmton CP A new techmque for exaslon of recurrent anastomotic smctures of the rectum Ann R Co11 Surg Engl1986,68 260-261 Lausten SB, Saks0 P Treatment of a stenotlc colorectal anastomosls by transanal use of an endoscoplc stapler Br J Surg 1994,81 144 Pagm S, McLaughlm CM Simple techmque for the treatment of structured colorectal anastomosls Dls Colon Rectum 1994,38 433-434 Shlmada S, Matsuda M, Uno K, Matsuzalu H, Murakaml S, Ogawa M A new device for the treatment of coloproctostomlc stllcture after double stapling anastomoses Ann Surg 1996, 224 603-608 Fmgerhut A, Elhadad A, Hay J-M, Lacame F, Flamant Y Infrapentoneal colorectal anastomosls Hand-sewn versus clrcular staples A controlled chnlcal ma1 Surgery 1994,116 484490 Detry RJ, Kartheuser A, Delnvlere L, Saba J, Kestens PJ Use of the circular stapler in 1000 consecuuve colorectal anastomoses Expenence of one surgcal team Surgery 1994,117 140145
Repair of Rectal Stricture
Robert A Kozol, M D , Mary Ann Koszl; M D
Although uncommon, anastomotic stricture after low anterior resection may requu-e additional repair
beyond ddatahon Two alternate approaches are described wherem laparoscoplc and endoscoplc techmques were utlhzed to avold repeat pelvic surgery m two cases These can be used whether a stapled or hand-sewn approach was used for the mltlal anastomosls Photo documentaaon demonstrates a wdely patent anastomosls after repnr There ISearly return of bowel funcaon by these methods, and long-term results (3 years) are excellent (J GASTROINTEST SURG 1998,2 426-429 )
Anastomouc stricture IS a recognrzed, Infrequent complication of colonic surgery L2 An anastomotic stricture at the level of the rectum IS often amenable to dllatatlon. When repeated dllataaon falls, surgical repair IS mdlcated Surgical repair through an abdominal approach (m a scarred pelvis) can be a forrmdable procedure Several novel methods have been reported to facllltate repalr of stllctures w&out takedown of the anastomosls 3-6 This report describes two addmonal mnovatlve approaches using laparoscoplciendoscoplc methods to repalr a rectal anastomoat stricture that had falled dllatatlon therapy
CASE REPORTS Case 1 A 64-year-old man underwent a stapled low anterior resectlon for a Dukes’ B adenocarcmoma of the rectum The patlent recovered nicely after surgery Follow-up colonoscopy revealed an anastomotic stncture 1 year postoperauvely Biopsy of the stricture showed no evidence of recurrent carcinoma The patlent developed consupatlon and &m-caliber stools 2 years postoperatively Colonoscoplc examination at the time revealed a stricture that would not pernut msemon of a standard colonoscope (Fig 1) The pauent underwent endoscoplc dilatation of tlus stricture on four occasions over a 14-month penod Balloon dilatation was unsuccessful, but the smcture could be dilated urlth the obturator of a rlgd slgmoldoscope under direct qslon via an adjacent flexible scope m the rectum The patient remamed symptomatic and surgcal repair of the stricture was undertaken using a laparoscoplc approach The transverse colon was ldenufied A 4 cm upper abdominal mclslon was made and a loop of transverse colon was delivered through
the abdommal wall A transverse colotomy was performed and the anvd of an end-to-end stapling Instrument was delivered mto the colon A colonoscope was advanced transanally past the smcture mto the transverse colon A sdk suture previously ued to the anvd was grasped with a snare and the anvd was pulled down the colon to the smcture (Fig 2, A) The shaft of the 3 1 mm stapler was then
passed transanally, Joined with the anvd by havmg the surgeon hold the anvil with fingers m the rectum, and the stapler was fired across the stricture (Fig 2, B) The circular stapler had cut out the smcture resultmg m a new enlarged anastomouc lumen The transverse colotomy was closed as was the 4 cm mclslon The patient had a bowel movement on postoperative day 2 He began a liquid diet on postoperauve day 3 and was discharged on postoperative day 5 He IS currently asymptomatlc Repeat colonoscopy at 1 and 3 years revealed no recurrent stricture (Fig 3)
Case 2 A 74-year-old man underwent a low antenor resection for a large (5 cm) tubulovdlous adenoma wth atypla m the rectum The specimen showed a 4 5 cm well-differentiated adenocarcmoma ansmg m the tubulovlllous adenoma and focal mvaslon of the submucosa A double-staphng technique was used urlth a linear stapler and circular stapling device HIS postoperative recovery was unremarkable No radlatlon or chemotherapy was given postoperatively He was seen for follow-up endoscopy at 6 months when a smcture was noted 7 cm proxlmal to the anal verge (Fig 4, A) Blopsles of the stricture revealed focal areas of granulation tissue and mild chrome mflammatlon The patient had symptoms of constipanon 5 to 6 months postoperatively, at which bme a barmm enema showed stricture Under gen-
From the SurFcal Semce, VA Medical Center, and Wayne State Unrverslty School of Medlcme, Detroit, Mlch Presented at the Sixty-First Annual Sclenufic Meetmg of the Amencan College of Gastroenterology, Seattle, Wash , Ott Reprmt requests Robert A Kozol, M D , VAMedlcal Center (112), 4646 John R, Detroit, MI 48201 426
2 l-23,
1996
Vol 2, No 5 1998
be used repeatedly as resmcturmg occurs, although the device may not yet be commercially available These methods are slmllar m concept to previously reported methods of restaphng the anastomouc smctures usmg end-to-end staphng devxes or an EndoGIA stapler 2-5However, our techmque offers an approach for cases where the smcture 1s too tight for passage of an end-to-end stapler In fact, one could argue that a smcture which 1s amenable to dllataaon to stapler size does not need revlslon at all. For those smctures that reqmre revlslon, these laparoscopic/endoscoplc approaches offer good alternatives to repeat pelvic surgery
CONCLUSION Two laparoscoplciendoscoplc methods are described for repax of symptomaac rectal anastomotlc smcture, which offer the advantage of avoiding open pelvic dlssecaon. These urlll offer the surgeon addluonal approaches to the uncommon problem of anastomouc smcture, whether by stapled or hand-sewn techmque.
Laparoendoscoplc Rectal Smcture Repalr
429
REFERENCES Moran BJ Staphng mstruments for mtestmal anastomosls m colorectal surgery Br J Surg 1996,83 902-909 Vignah A, Fazlo VW, Lavery IC, Wlsonm, Church JM, Hull TL, Strong SA, Oakley JR Factors associated mth the occurrence of leaks m stapled rectal anastomoses A review of 1,014 paaents Ann Surg 1997,185 105-113 Hmton CP A new techmque for exaslon of recurrent anastomotic smctures of the rectum Ann R Co11 Surg Engl1986,68 260-261 Lausten SB, Saks0 P Treatment of a stenotlc colorectal anastomosls by transanal use of an endoscoplc stapler Br J Surg 1994,81 144 Pagm S, McLaughlm CM Simple techmque for the treatment of structured colorectal anastomosls Dls Colon Rectum 1994,38 433-434 Shlmada S, Matsuda M, Uno K, Matsuzalu H, Murakaml S, Ogawa M A new device for the treatment of coloproctostomlc stllcture after double stapling anastomoses Ann Surg 1996, 224 603-608 Fmgerhut A, Elhadad A, Hay J-M, Lacame F, Flamant Y Infrapentoneal colorectal anastomosls Hand-sewn versus clrcular staples A controlled chnlcal ma1 Surgery 1994,116 484490 Detry RJ, Kartheuser A, Delnvlere L, Saba J, Kestens PJ Use of the circular stapler in 1000 consecuuve colorectal anastomoses Expenence of one surgcal team Surgery 1994,117 140145