During the last 3 years I have experienced 3 occurences of the stenosis in the colo-rectal end-to-end anastomisis following laparoscopic sigmoid or TME resections for sigmoid/upper rectal cancer. In two cases the stricture occluded the bowel completely. These two patients underwent stenting first. It failled due to the overgrow of the fibrotic tissue in the next 2-4 months leading to the complete obstruction. Thus why, they required emergency laparotomy with excision of the stenosed portion of the bowel with end colostomy. Then, we recreated the continuity of the bowel with protective ileostomy (to make sure they do not go into obstruction). Around a half a year later we closed the ileostomy.
Now I diagnosed the stenosis in the third patient (the lumen of stenosis of 8 mm) and just wonder what other options are, as I do not want to go the same route again.
In this setting, I confirm that the stenting is not ideal. The risk of perforation is important and the surgical morbidity after stenting is important. The old method to perform multiple endoscopic dilatation is in the most of cases effective and not dangereous. You have to dilat at less 3 times with a dilatataion every 4-6 weeks.
The stenosis is due to little colonic ischemia. I prefer the lateral-end anastomosis. The risk of ischemia seems less important.
In spite of endoscopic baloon dilation I also recommend manual manoeuvre with the finger as a dilator introduced through the anus once a day for 3 - 4 consecutive days. However, many patients are doing well even with the 8mm strictured anastomosis, and in these patients dilation is not always required.
It (stenosis of the anastomosis) has been happenned in 4 patients underwent colorectal cancer surgery with anastomosis located up to 7 cm from anal verge last 7 year. (we acctually did 40-45 colorectal surgery for cancer in the division of our Clinic.) we did not do stenting in such a patient with rectal anostomosis narrowed. the stenting at that level is not easy what ıt has been told or recomended. (however a patient facing battlefield explosive injury on the anorectal and inguinal region-mine explosion- additionally losing both legs and had an injury with the great loss of tissue, had taken to the operating room to make sequential surgeries with use of stenting for replacing the rectum large part of which was destroyed . only did the stenting make good job in such poor soldier, at last five year practice) I agree with the authors writing on the panel here before me that is bloon dilation is the first step what we can use clinically. if it does not work then we try to chose how we can advance the anostomosis if it is possible.
By the way, the stenting bridging to surgery has employed more than that was used in other condition in our practice. that gives an easy way to make whole bowel cleaned.
two first line depending on how high the stenosis is from the anal verge. Dilatation using Hegar's followed by Anal dilators used by patient. if not in reach my first line is baloon dialtation. Have found in the small numbers of cases (
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