62 yrs old, no h/o HTN , DM underwent EMR for rectal polypoid lesion about 2 yrs ago, HPE was high grade dysplasia following which he underwent Anterior resection. 6-8 months later he developed difficulty in defecation predominantly frequency .
O/E there is an anastomotic stricture about 7-8 cm from the anal verge. serial endoscopic balloon dilatations were done , improvement f/b narrowing .
presently the stricture diameter is about 5-6 mm.
previous colonoscopy showed only benign looking stricture and scope could not be passed beyond.
Dear Dr Kumar Reddy
First you should rule out cancer recurrence, so new pathology is necessary .
After rule out cancer recurrence , the best way is re anastomosis with annular stapler.
that is, put anvil of stapler from incision above the stricture via colon and hand piece from anus (below stricture) to fix with anvil . After fixing anvil and hand piece above and below stricture make fire and new anastomosis will happened.
Dear Dr Reddy
I recommend to study this paper
Endoscopy. 2015;47 Suppl 1 UCTN:E413-4. doi: 10.1055/s-0034-1392676. Epub 2015 Sep 23.
Treatment of a benign, anastomotic refractory rectal stricture with an AXIOS stent.
Martínez Alcalá F1, Martínez-Alcalá García FR1, Sánchez-Yague A2, Martínez-Alcalá García A1, Ciria Avila JA1, Perez Pozo JM1.
I am on the side of endoscopic balloon dilation as the first step treatment modality. I keep some of the invasive approaches if interval endoscopic dilation fails.
Try RIC (radial incision and cutting) procedure, using an IT knife...
In my opinion it could be very difficult to treat this case. Every dilation would lead to another cicatrisation process. If the local relapse is excluded you would better assess the possibility of a new operation and anastomosis. In poor condition of the patient placement of a stent could help having the adequate lumen and function...
Repeated dilatation's of stricture at 7 to 8 cm from anal verge is not easy and self dilatation by the patient is not possible. Surgical intervention whether transanal(less successful) or transabdominal revision is the only durable option.
After learning that plastic surgeon use fat transposition to treat scar tissues, in two patients with rectal anastomotic stricture, after unsuccessful repeated dilatations, I transferred abdominal subcutaneous fat with 30% platelet rich plasma to the scar tissue of the anastomotic site. I was very surprised to see that it worked in both of these patients and no dilatations were needed after this treatment.
I agree with the fact that if patient has underwent balloon dilatations in the past more than 3 times in last 6 months possibility of recurrence at local site should be ruled out and it should be surgically corrected as it has already a failed balloon dilatation due to extensive luminal fibrosis. But the anastomosis should be a fresh one with CDH 31 OR 33 ..Can be done laparoscopically.
The level of the stricture is unusual, especially if this is also the site of anastomosis, presuming that it is a narrow stricture. After ruling out recurrence, I would establish the length of the structure radiologically I.e is only part of the stricture being dilated each time? If dilatation is successful, then it is likely the anastomosis is being over-stretched during the dilatations, with resultant excessive fibrosis. If so, in the first instance correction using TEMS is an easy option. Postoperatively, it is essential to ensure the bowel movements are bulked-up and not loose, to maintain the dilated width naturally. Osmotic laxatives like Lactulose would be contraindicated in this case. If these measures fail, there is enough length from the anal verge to perform a redo resection- anastomosis, as always, ensuring there is no proximal ietiology, specifically significant diverticulosis; that the splenic flexure is completely mobilised; a TME is performed and the bowel supplied by the inferior mesenteric is removed. Given it was a benign lesion and the site of anastomosis, it is likely that too much mesorectum was removed but some of the corresponding rectal musculomucosal tube was left in situ during the original procedure I.e. The recurrences are due to chronic ischaemia. I would excise more rather than less both proximally and distally, ensuring a good rhoos test. Good luck!
After exclusion of relapse, it is better to do repeated ballon dilatation with or without stenting and if failed do surgery
Dr. Pesanna, although you didn't specify his clinical state of mal-nutition as suspected, but I'll prefer no more surgery but restrict to clinical conservative treatment by compatible meals by pasty ou liquid diet follow-up and wait for improvement.
you need to assess the stricture site by EUS probably through miniprobe so that you can plan better for the next step whether stenting or surgery.
If dilatation fails, I am afraid, the patient is better served with surgical treatment (re-do).
A novel way of treating a short stricture at this level is to excise it with a CDH 33 stapler. The head of the stapler is placed in the proximal aspect of the stricture via colotomy well proximal to the stricture. The body of the stapler is placed per anus. The spike is deployed through the lumen of the stricture and the head is connected. The stapler is then closed and fired. This will only work if the stricture is less than 1 cm in length.
How long is the stricture?
If the stricture is not too long, you can try the covered stent, which is easy to remove.
If it is not easy to insert the stent or the stricture is long, surgery should be considered.
The fatty tissue injection mentioned by Dr. Matti to treat scar tissue is a very interesting technique. Maybe it will be a promising method.
Thanks to all of you,I preformed STARR Stricture using 31EEA stapler.On table result was very satisfactory.Pt was discharged the following day.Shortly vedio will be published in Medtube and Youtube.I would request if you can please let me know any ref publication on Stapled Trans Anal Rectal Resection of Benign Ant Resection stricture.
Might I suggest a minimum of a year's follow up both anatomically and functionally prior to publication? STARR, TEMS, Cecil approach, dilatations are all local options; it is the tissue you start with and what you end off with after treatment that is relevant. The recent introduction of flourescein imaging of vascularity sounds like a useful adjuvant technique in cases such as this one.
Apologies in advance- but mere demonstration of the feasibility of a technique does not make it the appropriate choice in a particular patient. As has been discussed from the start, given the local resources and expertise available, there are a number of ways to skin a cat. The question still remains - is skinning the cat our intention, or is the intention to find out what the pathophysiology behind the condition due to which we think the solution is a-skinning? To do my duty to any patient I still believe the latter is more important. Thus, being a trained, qualified and experienced colorectal surgeon I choose not to watch the link. Thanks but no thanks!
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