Transanal minimally invasive surgery as a treatment option for a completely occluded anastomosis after low anterior resection: A new approach to severe anastomotic stenosis

Endoscopic management of complete colorectal anastomotic occlusion: Where do we stand?

We recently read with interest the article by Chi et al published in the World Journal of Gastroenterology. In this article, the authors reported a novel technique for re-establishing luminal continuity in a completely occluded colorectal anastomosis involving two endoscopes, one for radial electrical incision and the other serving as a guide light. However, this technique can be applied only in selected cases. Given the absence of a standardized guideline-based algorithm for the management of complete anastomotic obstruction, by reviewing the available literature, we provide a brief overview of relevant endoscopic techniques while underlining their importance in the management of this postoperative complication to provide clinicians with the necessary knowledge to improve their daily practice.

Transanal Minimally Invasive Surgery for Rectal Anastomotic Stenosis After Colorectal Cancer Surgery

BACKGROUND

Anastomotic stenosis is a common complication of colorectal cancer surgery with anastomosis. Transanal minimally invasive surgery is a novel approach to the treatment of anastomotic stenosis.

OBJECTIVE

This study aimed to evaluate the efficacy and safety of transanal minimally invasive surgery for anastomotic stenosis treatment.

DESIGN

This was a retrospective study.

SETTINGS

This study was conducted at a comprehensive cancer center.

PATIENTS

This study included patients with rectal anastomotic stenosis who after undergoing colorectal surgery were admitted to the Sir Run Run Shaw Hospital between September 2017 and June 2019.

MAIN OUTCOME MEASURES

The primary outcome was the operative success rate. The secondary outcomes were intraoperative variables, postoperative complications, stoma closure conditions, and stenosis recurrence risks.

RESULTS

Nine patients, aged 52 to 80 years, with a history of colorectal cancer with end-to-end anastomosis underwent transanal minimally invasive surgery for anastomotic stenosis. The distance between the stenosis and the anal verge ranged from 5 to 12 cm. The mean stenosis diameter was 0.3 cm. Four patients had completely obstructed rectal lumens. Eight of 9 patients successfully underwent transanal minimally invasive surgery radial incision and cutting. The average operation time was 50 minutes. After the procedure, 1 patient had symptomatic procedure-associated perforations but recovered with conservative treatment. No perioperative mortality occurred. One patient underwent transverse colostomy 1 month after transanal minimally invasive surgery because of proximal colon ischemia induced by primary rectal surgery. Eight patients underwent protective loop ileostomy. After transanal minimally invasive surgery, stoma closure was performed in 88% of patients with no stenosis recurrence or obstruction at follow-up (21-42 mo).

LIMITATIONS

This study was limited by its small sample size and single-center design.

CONCLUSIONS

Transanal minimally invasive surgery provides an excellent operative field, good maneuverability, and versatile instrumentation and is a safe and effective treatment for rectal anastomotic stenosis, especially for severe fibrotic stenosis or complete obstruction. See Dynamic Article Video at http://links.lww.com/DCR/B965 .

Generalized Cross-Correlation Strain Demodulation Method Based on Local Similar Spectral Scanning

Optical fiber measurement technology is widely used in the strength testing of buildings, the health testing of industrial equipment, and the minimally invasive surgery of modern medical treatment due to its characteristics of free calibration, high precision, and small size. This paper presents an algorithm that can improve the range and stability of strain measurements in order to solve the problems of the small range and measurement failure of optical fiber strain sensors based on optical frequency-domain reflectometry (OFDR). Firstly, a Rayleigh scattering model based on the refractive index perturbation of an optical fiber is proposed to study the characteristics of Rayleigh scattering and to guide the strain demodulation algorithm based on the spectral shift. Secondly, a local similar scanning method that can maintain a high similarity by monitoring local Rayleigh scattering signals (LSs) before and after strain is proposed. Thirdly, a generalized cross-correlation algorithm is proposed to detect spectral offset, solving the problem of demodulation failure in the case of a Rayleigh scattering signal with a low signal-to-noise ratio. Experiments show that the proposed method still has high stability when the spatial resolution is 3 mm. The measurement precision is 6.2 με, which proves that the multi-peaks or pseudo-peaks of the traditional algorithm in the case of a large strain, the high spatial resolution, and the poor signal-to-noise ratio are solved, and the stability of the strain measurement process is improved.

A combined abdominal and transanal minimally invasive (TAMIS) approach in redo anastomoses for severe refractory rectal strictures

AIM

Anastomotic stricture following anterior resection is an uncommon but challenging problem. Endoscopic dilatation and transanal endoscopic surgery (TES) are proven methods of treatment. However, a small proportion of patients repeatedly fail transanal local therapy for underlying reasons of tension, insufficient blood supply or irradiated tissue, eventually necessitating a complete anastomotic excision. We aimed to combine transanal minimally invasive surgery (TAMIS) with an abdominal approach in redo anastomoses for severe refractory anastomotic strictures.

METHOD

For the TAMIS phase, we use a Lonestar® retractor with a GelPOINT® Path transanal access platform. A circumferential full thickness rectotomy is performed and the dissection is continued proximally in the mesorectal fascial plane past the strictured segment to meet the abdominal dissection or until the peritoneal cavity is entered, facilitating mobilization of the rectum. The abdominal phase is performed as usual with sufficient mobilization of the left colon to enable tension-free redo anastomosis. An accompanying video demonstrates this technique.

RESULTS

Two patients with refractory anastomotic strictures following a previous low anterior resection underwent the procedure. One patient had laparoscopy followed by TAMIS and the other had TAMIS followed by laparotomy. Both cases were performed by surgeons experienced in laparoscopy and TES. One patient had postoperative ileus which resolved conservatively. Both anastomoses were widely patent on follow-up.

CONCLUSION

TAMIS combined with a conventional abdominal approach offers significant technical advantages over a totally abdominal approach for the definitive management of patients with severe anastomotic strictures refractory to first-line methods of therapy. The operator should already be proficient with TES.

Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review

BACKGROUND

Anastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations.

CASE PRESENTATION

In this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3-4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.

CONCLUSIONS

We reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.

Fluoroscopy and endoscopy-guided transanastomotic rendezvous: a novel technique for recanalization of a completely obstructed colorectal anastomosis

BACKGROUND

Colorectal anastomotic stricture is a frequent complication that may affect up to 30% of patients. However, a complete obstruction is rare. Endoscopic balloon dilation is the first-line therapy, but it invariably requires being able to cross the stricture with the dilation device. When this is not possible, surgical revision is the alternative, but it is associated with higher morbidity.

CASE PRESENTATION

A 76-year-old male patient underwent an urgent high anterior resection with transverse loop colostomy for an occlusive high rectal tumor. On postoperative day 8, he presented with anastomotic leakage and abscess formation, requiring percutaneous drainage. Ten months after surgery, a colonoscopy revealed a complete stricture of the anastomosis, refractory to negotiation of a guide wire, thus precluding balloon dilation. Hence, a modified rendezvous technique was planned. Simultaneously, a flexible endoscope and a rigid rectoscope were progressed through the distal loop colostomy, and the anus, respectively. A needle device was introduced through the rectoscope and used to pierce the colonic stump. A guide wire was progressed, and the stricture was dilated with a controlled radial expansion balloon catheter. Finally, a 12-Fr Foley catheter was left through the anastomosis. A total of three endoscopic balloon dilation sessions were completed, and successful colostomy reversal was carried out 10 days after the last session.

CONCLUSION

Fluoroscopy-endoscopy-guided recanalization is an effective and safe treatment option for complete colorectal anastomotic stricture.

Transanal and transabdominal combined endoscopic resection of rectal stenosis and anal reconstruction based on transanal endoscopic technique

OBJECTIVE

To propose a method for the resection of the rectal anastomotic stenosis and anal reconstruction based on the transanal endoscopic technique through a transanal and transabdominal combined endoscopic resection, and to verify its clinical effectiveness.

METHODS

Thirty-eight patients with anastomotic stenosis were admitted to the Sixth Affiliated Hospital, Sun Yat-sen University, China, from January 2016 to September 2019. Patients were divided into an experimental group (17 patients) and a control group (21 patients) subjected to the removal of the intestinal stenosis followed by anal reconstruction, they underwent transanal and transabdominal endoscopic surgery and traditional transabdominal surgery, respectively. Data on intraoperative blood loss, operation time, postoperative recovery, and prognosis were collected.

RESULTS

(1) The median intraoperative blood loss was approximately 100 ml, without conversion to laparotomy during the surgery and intraoperative complications. The safety of the surgical operation was improved. (2) The operation time was shortened compared to previous reports, and the median operative time was 193 min. The average time of transanal endoscopic dissociation to the retroperitoneal fold was 76 min. (3) Laparoscopic assistance was carried out on 14 of the17 patients, and the incision was reduced. (4) The short-term curative effect was quite satisfactory, without permanent stoma. The average time to recover food intake after the surgery was 1.5 days. The average ambulation time was 3 days. Within 30 days after the surgery, one case suffered anastomotic leakage and then underwent refunctioning stoma through a second surgery. One patient suffered from intestinal obstruction, and the condition was improved through a conservative treatment. One case experienced delayed abdominal wound healing.

CONCLUSION

The transanal and transabdominal endoscopic resection of the rectal anastomotic stenosis and anal reconstruction reduced the difficulty of the surgery, improved its safety, shortened the operation time, decreased the operative complications, and enabled patients to recover well after surgery.

An endoscopic dilation method using the rendezvous approach for the treatment of severe anastomotic stenosis after rectal cancer surgery: a case report

Background

Postoperative anastomotic stenosis is a common complication in colorectal cancer patients (3–30%). Complete anastomotic stenosis is rare; however, when it occurs, almost all cases require surgical treatment. We herein report a case in which endoscopic dilation was effective for treating complete anastomotic stenosis after high anterior resection in a rectal cancer patient.

Case presentation

The patient was a 67-year-old man who underwent laparoscopic high anterior resection for rectal cancer (RS, T4a, N0, M0, Stage IIB (TNM Classification of Malignant Tumors)) in May 2018. The postoperative course was good and the patient was discharged on the 12th postoperative day. Subsequently adjuvant chemotherapy was initiated with oral uracil and tegafur plus leucovorin (UFT/LV); however, he complained of frequent defecation and melena after completion of the first course of chemotherapy. Thus, colonoscopy was performed, which revealed anastomotic stenosis. Endoscopic dilation was initially attempted, but failed. Thus, low anterior resection was performed with diverting colostomy. Four additional courses of chemotherapy were administered for 1 month after surgery. At 6 months after the second surgery, colonoscopy was performed, and complete anastomotic stenosis was pointed out again. The patient was successfully treated by endoscopic dilation using the rendezvous method. After this treatment, the lumen of the anastomotic site was observed to have narrowed again and endoscopic dilatation to treat anastomotic stenosis was repeated. In addition, he received local injection of steroids in anastomotic stenosis site. The lumen of anastomotic stenosis remained after the local injection of steroids and closure of colostomy was performed 9 months after the second operation.

Conclusions

Endoscopic dilation using the rendezvous method was effective for treating anastomotic stenosis after colorectal surgery.

Endoscopic diagnosis and treatment of complete anastomosis stenosis after colorectal resection without protective ileostomy: report of two cases and literature review

This case report describes a novel procedure for opening the lumen of a completely obstructed anastomosis when open surgery is not an option. Two patients underwent ileocecal or colorectal resection and one-stage anastomosis reconstruction without diverging ileostomy. The patients developed post-surgical abdominal distension and nausea. Emergency imaging indicated complete anastomotic obstruction and distal intestinal anastomosis emptiness. Colonoscopy revealed an anastomosis that was completely discontinued by a membranous structure. Considering that open surgery was not a viable treatment option, a minimally invasive endoscopic approach was adopted to repair the obstruction. A needle knife was used to puncture the linear white scar and contrast agent was injected under endoscopy and fluoroscopic guidance. Fluoroscopically, the proximal bowel was identified and a dual knife-mediated membrane puncture was performed. A guidewire was then passed through the incision into the proximal bowel and progressive pneumatic dilatation was performed successively with a controlled radial expansion balloon dilator until a 1.8 cm diameter dilation was achieved. After conventional balloon dilatation, the endoscope easily passed through the anastomosis without any patient discomfort. There were no postoperative signs of immediate or delayed complications. Overall, endoscopic incision and dilatation was a safe and effective treatment for acute anastomotic obstruction after colorectal surgery.

Combination of endoscopic incision and balloon dilation for treatment of a completely obstructed anastomotic stenosis following colorectal resection: A case report

RATIONALE

The management of complete obstruction of anastomosis following colorectal surgery is challenging. Some modified minimally invasive methods have been reported to be successfully implemented in some cases. In this case report, we present a case to share our experience.

PATIENT CONCERNS

A 64-year-old man underwent low anterior resection and single barrel ileostomy for rectal cancer 5 months ago. Completely obstructed anastomotic stenosis was found during colonoscopy.

DIAGNOSIS

Colonoscopy showed the anastomosis at 8 cm from the anal verge was completely obstructed.

INTERVENTIONS

A small incision was made by a needle knife, and then the stenosis was sequentially dilated by using a wire-guided balloon dilator.

OUTCOMES

The luminal continuity was reestablished. The patient underwent successful ileostomy closure 2 months later. At 18-months follow-up, no restenosis of the anastomosis was observed during colonoscopy.

LESSONS

Endoscopic small incision with a needle knife along with balloon dilation could be an alternative method for patients with complete obstruction of anastomosis after colorectal resection. But this procedure should be performed with great caution in selected patients and performed only by highly experienced endoscopists.