Self-expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer

A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis

BACKGROUND

Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection.

METHODS

A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort.

RESULTS

72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer.

CONCLUSION

We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.

Editorial article to: Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer

In this editorial we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2023; 15 (11): 634-680. Gastric cancer (GC) remains the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide. The overall prevalence of GC has declined, although that of proximal GC has increased over time. Thus, a significant proportion of GC cases and deaths can be avoided if preventive interventions are taken. Early GC (EGC) is defined as GC confined to the mucosa or submucosa. Endoscopic resection is considered the most appropriate treatment for precancerous gastrointestinal lesions improving patient quality of life, with reduced rates of complications, shorter hospitalization period, and lower costs when compared to surgical resection. Endoscopic mucosal resection (EMR) and endoscopic sub-mucosal dissection (ESD) are representative endoscopic treatments for EGC and precancerous gastric lesions. Standard EMR implies injection of a saline solution into the sub-mucosal space, followed by excision of the lesion using a snare. Complete resection rates vary depending on the size and severity of the lesion. When using conventional EMR methods for lesions less than 1 cm in size, the complete resection rate is approximately 60%, whereas for lesions larger than 2 cm, the complete resection rate is low (20%-30%). ESD can be used to remove tumors exceeding 2 cm in diameter and lesions associated with ulcers or submucosal fibrosis. Compared with EMR, ESD has higher en bloc resection rates (90.2% vs 51.7%), higher complete resection rates (82.1 vs 42.2%), and lower recurrence rates (0.65% vs 6.05%). Thus, innovative techniques have been introduced.

Treatment of benign rectal stricture caused by repeated anal insertion by endoscopy and balloon dilation: A case report

BACKGROUND

Benign rectal strictures can be categorized as primary (disease-related) and secondary (surgical anastomosis-related). Secondary strictures arise from surgical complications, whereas primary strictures have diverse etiologies, including various inflammatory conditions. Benign strictures are usually managed by surgery and endoscopy. We present an unusual etiology of benign rectal stricture caused by the repeated insertion of foreign objects into the rectum for sexual purposes, resulting in rectal injury and subsequent chronic inflammation.

CASE SUMMARY

A 53-year-old man presented to the outpatient clinic of the Colorectal Surgery Department with symptoms of chronic constipation and bloody stools. The patient previously experienced rectal injury due to foreign object insertion for sexual purposes. Colonoscopy revealed benign circumferential narrowing of the rectum. He underwent treatment by endoscopic argon plasma coagulation and balloon dilation and follow-up as an outpatient for 4 months. A colonoscopy at the end of the follow-up period revealed no evidence of rectal stricture relapse.

CONCLUSION

A history of rectal injury, followed by chronic inflammation, should be considered in patients with benign rectal strictures. Management with endoscopic argon plasma coagulation and balloon dilation can prevent the need for surgical resection of benign rectal strictures.

Y-Z deformable magnetic ring for the treatment of rectal stricture: A case report and review of literature

BACKGROUND

Treatment of postoperative anastomotic stenosis for colorectal cancer is often challenging, especially for patients who do not respond well to endoscopy. In cases where patients have undergone an enterostomy, the stenosis can be easily resolved through magnetic compression. However, common magnetic compression techniques cannot be performed on those without enterostomy. We designed a novel Y-Z deformable magnetic ring (Y-Z DMR) and successfully applied it to a patient with a stenosis rectal anastomosis and without enterostomy after rectal cancer surgery.

CASE SUMMARY

We here report the case of a 57-year-old woman who had undergone a laparoscopic radical rectum resection (Dixon) for rectal cancer. However, she started facing difficulty in defecation 6 months after surgery. Her colonoscopy indicated stenosis of the rectal anastomosis. Endoscopic balloon dilation was performed six times on her. However, the stenosis still showed a trend of gradual aggravation. Because the patient did not undergo an enterostomy, the conventional endoscopic magnetic compression technique could not be performed. Hence, we implemented a Y-Z DMR implemented through the anus under single channel. The magnetic ring fell off nine days after the operation and the rectal stenosis was relieved. The patient was followed up for six months and reported good defecation.

CONCLUSION

The Y-Z DMR deformable magnetic ring is an excellent treatment strategy for patients with rectal stenosis and without enterostomy.

Risk factors for anastomotic stenosis after radical resection of rectal cancer: A systematic review and meta-analysis

Radical resection of rectal cancer is a safe and effective treatment, but there remain several complications related to anastomosis. We aimed to assess the risk factors and incidence of rectal anastomotic stenosis (AS) after rectal cancer resection. We conducted a systematic review and meta-analysis after searching PubMed, Embase, Web of Science, and Medline databases from inception until May 2023. Data are reported as the combined odds ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. Six hundred and fifty-nine studies were retrieved, nine (3031 patients) of which were included in the meta-analysis. Young age (WMD = -3.09, P = 0.0002), male sex (OR = 1.53, P = 0.0002), smoking (OR = 1.54, P = 0.009), radiotherapy (OR = 2.34, P = 0.0002), protective stoma (OR = 2.88, P = 0.007), intersphincteric resection surgery (OR = 6.28, P = 0.05), anastomotic fistula (OR = 3.72, P = 0.003), and anastomotic distance (WMD = -3.11, P = 0.0006) were identified as factors that increased the risk of AS, while staple (OR = 0.39, P < 0.001) was a protective factor. The incidence of AS after rectal cancer resection was approximately 17% (95% CI: 13%-21%). We identified eight risk factors and one protective factor associated with AS after rectal cancer resection. These factors may be combined in future studies to develop a more comprehensive and accurate prediction model related to AS after rectal cancer resection.

Comparison of the Efficacy of Endoscopic Radial Incision and Cutting Procedure and Endoscopic Balloon Dilation for Benign Anastomotic Stricture After Low Anterior Resection Combined With Preventive Loop Ileostomy in Rectal Cancer

BACKGROUND

Endoscopic radial incision and cutting procedure is a notable technique in the treatment of benign anastomotic strictures after low anterior resection in rectal cancer. However, the efficacy and safety of the endoscopic radial incision and cutting procedure and traditional endoscopic balloon dilation remain unknown.

OBJECTIVE

To compare the efficacy and safety of the endoscopic radial incision and cutting procedure and endoscopic balloon dilation in patients with anastomotic stricture after low anterior resection.

DESIGN

Rectal cancer patients with anastomotic stricture after low anterior resection combined with synchronous preventive loop ileostomy between January 2014 and June 2021 were retrospectively collected. These patients underwent the endoscopic radial incision and cutting procedure or endoscopic balloon dilation as an initial treatment. The clinicopathological baseline data of the patients, endoscopic surgery success rate, complications, and restricture rate were analyzed.

SETTINGS

This study was conducted at Nanfang Hospital in China.

PATIENTS

A total of 30 patients were eligible after reviewing the medical records. Twenty patients underwent endoscopic balloon dilation, and 10 patients underwent endoscopic radial incision and cutting procedure.

MAIN OUTCOME MEASURES

The adverse event rate and stricture recurrence rate.

RESULTS

There were no significant differences in patient demographics or clinical features. No adverse events occurred in either of the 2 groups. The mean operation time was 18.9 ± 3.6 minutes in the endoscopic balloon dilation group and 10.2 ± 3.3 minutes in the endoscopic radial incision and cutting procedure group ( p < 0.001). The stricture recurrence rates between the endoscopic balloon dilation group and the endoscopic radial incision and cutting procedure group were significantly different (44.4% vs 0%; p = 0.025).

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

The endoscopic radial incision and cutting procedure is safe and more efficacious than endoscopic balloon dilation for anastomotic stricture after low anterior resection combined with synchronous preventive loop ileostomy in rectal cancer.

Uso de stent en estenosis colorrectal benigna

Introducción. La estenosis colorrectal benigna hace referencia a una condición anatómica caracterizada por una disminución del diámetro de la luz intestinal distal a la válvula ileocecal, ocasionando una serie de signos y síntomas de tipo obstructivo. Es una entidad poco frecuente, secundaria en la gran mayoría de veces a la realización de anastomosis intestinales al nivel descrito. El objetivo de esta investigación fue determinar la utilidad del stent colónico en estenosis secundaria a patología colorrectal no neoplásica. Métodos. Estudio descriptivo de una cohorte de pacientes que desarrolló estenosis colorrectal de origen benigna confirmada por colonoscopía, en 3 hospitales de alta complejidad de la ciudad de Medellín, Colombia, entre los años 2007 y 2021. Resultados. Se incluyeron 34 pacientes con diagnóstico de estenosis colorrectal de origen benigno, manejados con stents metálicos autoexpandibles. La mediana de seguimiento fue de 19 meses y se obtuvo éxito clínico en el 73,5 % de los casos. La tasa de complicación fue del 41,2 %, dada principalmente por reobstrucción y migración del stent, y en menor medida por perforación secundaria a la colocación del dispositivo. Conclusión. Los stents metálicos autoexpandibles representan una opción terapéutica en pacientes con obstrucción colorrectal, con altas tasas de mejoría clínica en pacientes con patología estenosante no maligna. Cuando la derivación por medio de estoma no es una opción, este tipo de dispositivos están asociados a altas tasas de éxito clínico y mejoría de la calidad de vida de los pacientes.

Self-expandable metallic stents as a bridge to surgery in obstructive right- and left-sided colorectal cancer: a multicenter cohort study

The insertion of a self-expandable metal stent (SEMS) has been proposed as an alternative to emergent surgery (ES) for obstructive colorectal cancer (CRC). We aimed to evaluate the perioperative and oncologic outcomes of SEMS as a bridge to surgery in obstructive CRC, as compared with ES. We retrospectively reviewed the medical records of patients who underwent curative resection of obstructive CRC at four Hallym University-affiliated hospitals between January 2010 and December 2019. All patients were analyzed overall colon, then according to the side of obstruction (overall, right or left). Of 167 patients, 52 patients underwent ES and 115 underwent SEMS insertion and surgery (SEMS group). The postoperative hospital stay and time to soft diet were shorter in the SEMS group than in the ES group for overall and both sided cancer. The SEMS group had lower rates of stoma formation and severe complications for overall and for left-sided cancer. The 5-year overall survival (P = 0.682) and disease-free survival (P = 0.233) rates were similar in both groups. SEMS insertion as a bridge to surgery was associated with faster recovery, a lower rate of stoma formation with similar oncologic outcomes to those of ES.

Nomogram for benign anastomotic stricture after surgery for rectal cancer

BACKGROUND

Benign anastomotic stricture remains among the most prevalent complications following surgery for rectal cancer.

OBJECTIVE

This study is aimed at identifying risk factors of anastomotic stricture as well as generating an effective nomogram for the stricture.

METHODS

Design: This is a retrospective study.

SETTING

This study was conducted from January 2015 to December 2019 in a single tertiary center for rectal cancer.

PATIENTS

A total of 117 rectal cancer patients after surgery without recurrence were enrolled in this study, of which 39 with anastomotic stricture and 78 without stricture.

MAIN OUTCOME MEASURES

Their clinical and pathological data were collected. Multiple logistic regression analysis was conducted to identify risk factors for anastomotic stricture and to generate the nomogram prediction model.

RESULTS

Multivariate analysis of the primary cohort led to the identification of LCA (left colic artery) preservation (OR, 0.074; P = 0.0015), protective stoma (OR, 5.353; P = 0.012), anastomotic leakage (OR, 12.027; P = 0.005), and anastomotic distance (OR, 7.578; P = 0.012) as independent risk factors for anastomotic stricture. The following predictive model was derived: Logit (anastomotic stricture) = 0.074∗ LCA + 5.353∗ Protective stoma +12.027∗ Anastomotic leakage + 7.578∗ Anastomotic distance. Assessment of the predictive model revealed that the area under the curve (AUC) was 0.871, while the cutoff value was 15.444 with a sensitivity of 64.1% and a specificity of 94.8%.

LIMITATIONS

The main limitation is the research design of a retrospective and case-controlled study with a small sample size from a single center.

CONCLUSIONS

LCA preservation, protective stoma, anastomotic leakage, and anastomotic distance may affect the occurrence of anastomotic stricture following surgery for rectal cancer. The nomogram model generated in the present study can be valuable in the prediction of anastomotic stricture. This study has been registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/, ChiCTR 2100043775).

Anastomotic occlusion after laparoscopic low anterior rectal resection: a rare case study and literature review

Background

With the development of laparoscopic techniques and the broad clinical application of various anastomotic types, anal-preserving low anterior rectal resection and ultra-low anterior rectal resection have been popularized. Some patients with rectal cancer have retained their anus and improved their quality of life. Nevertheless, the incidence of postoperative anastomotic stenosis remains high, and anastomotic occlusion is even rarer.

Case presentation

We report a case of anastomotic occlusion in a patient with rectal cancer, which occurred after undergoing laparoscopic low anterior rectal resection + prophylactic terminal ileal fistulation at our department. Under endoscopy, we used a small guidewire to break through the occluded anastomosis, thereby finding the lacuna. After endoscopic balloon dilation, digital anal dilatation, and continuous dilator-assisted dilation, the desired efficacy was achieved, ultimately recovering ileal stoma. Postoperative follow-up condition was generally acceptable, without symptoms like abdominal pain, bloating, or difficulty in defecation.

Conclusion

Numerous factors cause postoperative anastomotic stenosis in patients with rectal cancer. Complete occlusion of anastomosis occurs relatively rare in clinical practice, and is challenging to treat. This case was our first attempt to remove the anastomotic occlusion successfully, which avoided re-operation or pain from the permanent fistula.

Endoscopic Stricturotomy for Patients With Postoperative Benign Anastomotic Stricture for Colorectal Cancer

BACKGROUND

Postoperative benign anastomotic stricture is associated with colorectal anastomosis following surgery for colorectal cancer. Endoscopic stricturotomy is a novel technique that has been demonstrated to be safe and effective for the treatment of colorectal anastomotic stricture in several case reports and series.

OBJECTIVE

We designed this study to investigate the efficacy of endoscopic stricturotomy for postoperative benign anastomotic stricture in patients for colorectal cancer. The primary outcomes were stricture-recurrence-free survival and reoperation-free survival.

DESIGN

This is a retrospective study.

SETTING

This study presents a single-center experience.

PATIENTS

This retrospective study included patients with colorectal cancer who underwent surgical resection and developed anastomotic stricture between January 2014 and June 2019 and were treated with endoscopic stricturotomy.

MAIN OUTCOME MEASURES

Immediate technical success of endoscopic stricturotomy and the factors associated with success and recurrence were investigated.

RESULTS

Endoscopic stricturotomy was performed in 57 patients, and immediate technical success was achieved in 84% of the patients. The mean follow-up was 31.3 (15.8) months (range, 9-74 months). Postoperative benign anastomotic stricture recurred in 11 patients after initial successful endoscopic stricturotomy; 10 of the 11 recurrent patients accepted reoperation. Univariate and multivariate analysis indicated that length of stricture ≥1 cm was an independent risk factor for failure of the initial endoscopic stricturotomy (OR, 9.423; 95% CI, 1.729-51.350; p = 0.010) and the recurrence of postoperative benign anastomotic stricture after the initial endoscopic stricturotomy (OR, 13.521; 95% CI, 2.305-79.306; p = 0.004).

LIMITATIONS

The study was limited by its small sample size and retrospective design.

CONCLUSIONS

Endoscopic stricturotomy is a safe and effective technique for postoperative benign anastomotic stricture. However, if the length of the stricture is ≥1 cm, endoscopic stricturotomy may not be effective, and recurrence of postoperative benign anastomotic stricture is also likely. See Video Abstract at http://links.lww.com/DCR/B739.

ESTRICTUROTOMA ENDOSCPICA PARA PACIENTES CON ESTRICCIN ANASTOMTICA BENIGNA POSTOPERATORIA PARA EL CNCER COLORRECTAL

ANTECEDENTES:La estenosis anastomótica benigna postoperatoria se asocia con anastomosis colorrectal después de la cirugía para el cáncer colorrectal. La estricturotomia endoscópica es una técnica novedosa que se ha demostrado que es segura y efectiva para el tratamiento de la estenosis anastomótica colorrectal en varios informes de casos o series.OBJETIVO:Diseñamos este estudio para investigar la eficacia de la estricturotomia endoscópica para la estenosis anastomótica benigna postoperatoria en pacientes con cáncer colorrectal. El resultado primario fue la supervivencia libre de restricción estricta y la supervivencia libre de reoperación.DISEÑO:Este es un estudio retrospectivo.CONFIGURACIÓN:Este estudio presenta una experiencia de un solo centro.PACIENTES:Este estudio retrospectivo incluyó pacientes con cáncer colorrectal que se sometieron a resección quirúrgica y desarrollaron estenosis anastomótica entre enero de 2014 y junio de 2019 y tratados con estricturotomia endoscópica.MEDIDAS PRINCIPALES DE RESULTADO:Éxito técnico inmediato y estenosurotomía endoscópica, los factores asociados con el éxito y la recurrencia.RESULTADOS:Se realizó estricturotomia endoscópica en 57 pacientes, y se logró un éxito técnico inmediato en el 84% de los pacientes. El seguimiento medio fue de 31,3 (15,8) meses (rango, 9 a 74 meses), el POBAS se repitió en 11 pacientes después del éxito inicial de ESt. 10 de los 11 pacientes recurrentes aceptaron la reoperación. El análisis univariado y multivariado indicó que la longitud de la estenosis ≥1 cm era un factor de riesgo independiente para el fracaso de la estricturotomia endoscópica inicial (odds ratio = 9,423; IC del 95% = 1.729-51.350; p = 0.010) y la recurrencia de estenosis anastomótica benigna postoperatoria después de la estricturotomia endoscópica inicial (odds ratio = 13,521; IC del 95% = 2,305-79,306; p = 0.004).LIMITACIONES:El estudio estuvo limitado por su pequeño tamaño de muestra y diseño retrospectivo.CONCLUSIONES:La estricturotomia endoscópica es una técnica segura y efectiva para la estructura anastomótica benigna postoperatoria. Sin embargo, si la longitud de la estenosis es ≥1 cm, la estricturotomia endoscópica puede no ser efectiva y también es probable que se repita la estenosis anastomótica benigna postoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B739.

Management of benign anastomotic strictures following rectal resection: a systematic review

AIM

Benign anastomotic strictures following colorectal surgical resection are a commonly under-reported complication in up to 30% of patients, with a significant impact upon quality of life. In this systematic review, we aim to assess the utility of endoscopic techniques in avoiding the need for surgical reintervention.

METHOD

A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases. Additional papers were found by scanning the references of relevant papers.

RESULTS

A total of 34 papers were included, focusing upon balloon dilatation, endoscopic stenting, electroincision, stapler stricturoplasty and cortiocosteroids alone and in combination, with success rates varying from 20% to 100%. The most challenging strictures were reported as those with a narrow lumen, frequently observed following neoadjuvant chemoradiotherapy or an anastomotic leak. Endoscopic balloon dilatation was the most commonly used first-line method; however, repeated dilatations were often required and this was associated with an increased risk of perforation. Although initial success rates for stents were good, patients often experienced stent migration and local symptoms. Only a small number of patients experienced endoscopic management failure and progressed to surgical intervention.

CONCLUSION

Following identification of an anastomotic stricture and exclusion of underlying malignancy, endoscopic management is both safe and feasible as a first-line option, even if multiple treatment exposures or multimodal management is required. Surgical resection or a defunctioning stoma should be reserved for emergency or failed cases. Further research is required into multimodal and novel therapies to improve quality of life for these patients.

Non-operative Management of Benign Colorectal Anastomotic Stenosis in Patients Undergoing Elective Surgery for Non-Metastatic Primary Rectal Cancer

Introduction: Benign anastomosis stenosis may develop in postoperative or long term period due to many reasons such as anastomosis leakage and anastomosis ischemia after colorectal surgery. While surgical treatment was commonly used in benign anastomosis stenosis in the past, surgery has left its place to more minimally invasive methods such as endoscopic treatments. There is no gold standard treatment method in the management of benign anastomosis strictures in the literature. In this study, we aimed to present our clinical experience in the treatment of benign anastomosis strictures in patients undergoing elective surgery for nonmetastatic primary rectal cancer. Material and Methods: One hundred fifty-six (156) patients who underwent resection and colorectal anastomosis between January 2013 and January 2018 were included in the study. 22 patients developed benign anastomotic stenosis has been determined and etiological factors and treatment modalities applied has been compared retrospectively. Results: In 22 patients, 9 patients were treated with digital or balloon dilatation, at least 2 sessions and up to 5 sessions. Four patients were treated with dilatation followed by stenting. The remaining 9 patients were taken to surgical treatment. Among whole patients with stenosis, it has been determined that 15 of them had neoadjuvant therapy history, 5 had anastomosis leakage and in 16 of them 28 mm circular stapler have been used. Discussion and Conclusion: Neoadjuvant treatment history, the presence of anastomosis leakage and the usage of 28 mm circular stapler have been detected to be the most important etiological factors in development of benign anastomotic stenosis. Endoscopic treatments should be tried primarily to treat benign anastomotic stenosis. High success rates can be achieved with endoscopic methods and patient quality of life can be improved. With this approach, the need for surgery will be reduced and possible postoperative complications can be prevented. Keywords: Rectal Neoplasms, Stenosis, Laparoscopy, Anastomostic stenosis

Risk factors and endoscopic treatment for anastomotic stricture after resection in patients with colorectal cancer

INTRODUCTION

Benign strictures are frequent complications following colorectal surgery, with an incidence of up to 20%. Endoscopic treatment is safe and effective but there is not enough evidence for establishing stricture management at that anatomic level.

AIM

To determine the risk factors associated with the development of stricture in patients with colorectal cancer and describe endoscopic treatment in those patients.

MATERIALS AND METHODS

A retrospective study was conducted on patients with colorectal cancer that underwent surgery and anastomosis, evaluated through colonoscopy, within the time frame of 2014 to 2019.

RESULTS

Of the 213 patients included in the study, 18.3% presented with stricture that was associated with the type of surgery. Intersphincteric resection was a risk factor (OR = 18.81, 95% CI: 3.31-189.40, p < .001). A total of 69.2% patients with stricture had a stoma, identifying it as a risk factor for stricture (OR = 7.07, 95% CI: 3.10-16.57, p < .001). Mechanical anastomotic stapling was performed in 87.4% of the patients that did not present with stricture, identifying it as a protective factor (OR = 0.41, 95% CI: 0.16-1.1, p = .04). Endoscopic treatment was required in 69.2% of the patients and provided favorable results in 83.3%. Only 2.6% of the patients had recurrence. No complications were reported.

CONCLUSION

Intersphincteric resection and the presence of a stoma were independent risk factors for stricture, and mechanical anastomosis was a protective factor against stricture development. Endoscopic treatment was safe and effective.

Endoscopic treatment of pouch inlet and afferent limb strictures: stricturotomy vs. balloon dilation

BACKGROUND

Strictures are common complications after ileal pouch surgery. The aim of this study is to evaluate the efficacy and safety of endoscopic stricturotomy vs. endoscopic balloon dilation (EBD) in the treatment of pouch inlet strictures.

METHODS

All consecutive ulcerative colitis patients with the diagnosis of pouch inlet or afferent limb strictures treated in our Interventional Inflammatory Bowel Disease Unit (i-IBD) from 2008 to 2017 were extracted. The primary outcomes were surgery-free survival and post-procedural complications.

RESULTS

A total of 200 eligible patients were included in this study, with 40 (20.0%) patients treated with endoscopic stricturotomy and 160 (80.0%) patients treated with EBD. Symptom improvement was recorded in 11 (42.3%) patients treated with endoscopic stricturotomy and 16 (13.2%) treated with EBD. Subsequent surgery rate was comparable between the two groups (9 [22.5%] vs. 33 [20.6%], P = 0.80) during a median follow-up of 0.6 years (interquartile range [IQR] 0.4-0.8) vs. 3.6 years (IQR 1.1-6.2) in patients receiving endoscopic stricturotomy and EBD, respectively. The overall surgery-free survival seems to be comparable as well (P = 0.12). None of the patients in the stricturotomy group developed pouch failure, while 9 patients (5.6%) had pouch failure in the balloon dilation group (P = 0.17). Procedural bleeding was seen in three occasions (4.7% per procedure) in patients receiving endoscopic stricturotomy and perforation was seen in three occasions (0.8% per procedure) in patients receiving EBD (P = 0.02). In multivariable analysis, an increased length of the stricture (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0-1.8) and concurrent pouchitis (HR 2.5, 95% CI 1.0-5.7) were found to be risk factors for the requirement of surgery.

CONCLUSION

Endoscopic stricturotomy and EBD were both effective in treating patients with pouch inlet or afferent limb strictures, EBD had a higher perforation risk while endoscopic stricturotomy had a higher bleeding risk.

Quality of Life for Patients With Incurable Stage IV Colorectal Cancer: Randomized Controlled Trial Comparing Resection Versus Endoscopic Stenting

BACKGROUND/AIM

A prospective randomized open label parallel trial, comparing the quality of life (QoL) after endoscopic placement of a self-expandable metal stent or primary tumor resection, in patients with stage IV colorectal cancer was performed.

PATIENTS AND METHODS

Thirty-three patients affected with stage IV colorectal cancer and unresectable metastases were randomly assigned into two groups: Group 1 (16 patients), that underwent self-expandable metal stent positioning and Group 2 (17 patients), in which primary tumor resection was performed. Karnofsky performance scale and QoL assessment using the EQ-5D-5L™ questionnaire was administered before treatment and thereafter at 1, 3 and 6 months.

RESULTS

At 1 month, index values showed a statistically significant deterioration of the QoL in patients of Group 2 when compared to those of Group 1 (p=0.001; 95%CI=0.065-0.211) whereas, at 6 months, index values showed a statistically significant deterioration of the QoL in patients of Group 1 (p<0.025; 95%CI=0.017-0.238).

CONCLUSION

QoL in patients affected with stage IV colorectal cancer has a bimodal fluctuation pattern: at 1-month it was better in patients that received stent, but at 6-months it was significantly better in patients submitted to surgical resection.

Endoscopic stricturotomy in the treatment of anastomotic strictures in inflammatory bowel disease (IBD) and non-IBD patients

Backgrounds

Endoscopic stricturotomy (ESt) has been shown to be effective in treating inflammatory bowel disease (IBD)-associated anastomotic strictures. However, the outcome of ESt in benign, non-IBD conditions has not been described. The aim of this study was to evaluate the outcome of ESt in the management of IBD and non-IBD-associated strictures.

Methods

Data of all consecutive IBD and non-IBD patients with benign anastomotic strictures treated with ESt from 2009 to 2016 were extracted. The primary outcomes were surgery-free survival and procedure-related complications.

Results

A total of 49 IBD and 15 non-IBD patients were included in this study. The IBD group included 25 patients with Crohn’s disease and 24 with ulcerative colitis and ileal pouches. Underlying diseases in the non-IBD group included colorectal cancer (n = 7), diverticulitis (n = 5), large bowel prolapse (n = 2), and constipation (n = 1). Immediate technical success was achieved in all patients in both groups. Bleeding complications occurred on five occasions (4.7% per procedure) in the IBD group, while no complication occurred in the non-IBD group (P = 0.20). Stricture improvement on follow-up endoscopy was found in 10 (20.4%) and 5 (33.3%) patients in the IBD and non-IBD groups, respectively (P = 0.32). Six (12.2%) patients in the IBD group and four (26.7%) patients in the non-IBD group eventually required stricture-related surgery (P = 0.23). IBD patients appeared to have a higher tendency for maintaining surgery-free after the procedure than non-IBD patients (P = 0.08).

Conclusions

Endoscopic stricturotomy was shown to have comparable outcomes, though non-IBD patients seem to have a higher need for subsequent surgery but a lower complication rate than IBD patients.

Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn's disease

BACKGROUND AND AIMS

Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn's disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR).

METHODS

This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events.

RESULTS

Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P < .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0).

CONCLUSIONS

With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.

A Pediatric Nasogastroscope Facilitates Colorectal Endoscopic Stenting

PURPOSE

Endoscopic placement of self-expandable metal stents (SEMSs) to relieve malignant colorectal obstruction has been widely accepted in clinical practice. Despite increasing experience, early and late complications occur with an incidence ranging from 4% to 20%.

MATERIALS AND METHODS

We have adopted a modification in the technique. A pediatric nasogastroscope (4.8 mm in diameter) has been used to pass the obstruction. It is possible to have a direct vision of the anatomy and pathology, and to pass the guidewire above the obstruction, through the nasogastroscope, under direct vision. Fluoroscopy was also used to follow the course of the guidewire and deployment of the stent.

RESULTS

Early and late complications have been reduced with the new technique.

CONCLUSIONS

In the most recent experience of 64 patients, early and late complications have been reduced significantly. This new technique reduces radiation exposure by 70% for the patients and for the operators.

Endoscopic Stenting for Colorectal Cancer: Lessons Learned From a 15-Year Experience

GOAL

The aim of our prospective study was to analyze the results of endoscopic stenting to treat obstruction due to colorectal cancer and complications after colorectal resection for cancer.

BACKGROUND

Endoscopic stenting for obstructing colorectal cancer has become a common place in clinical practice. However, there is a 2% to 5% risk of bowel perforation, and a percentage of technical failure of 2% to 10%.

MATERIALS AND METHODS

In a 15-year period (August, 1999 to December, 2013), 153 patients with colorectal cancer had endoscopic placement of a self-expandable metal stent for treatment of an obstructing colorectal cancer (133 patients) or for treatment of complications after colorectal resection for cancer (20 patients). They were prospectively evaluated in a database and they form the basis of this report.

RESULTS

There was no case of mortality or major morbidity. Overall technical success was 94.8%. After introducing the use of a pediatric nasogastroscope to pass the obstruction (71 patients), technical success was 100%. Complications in patients in whom the stent was left in place during the follow-up were frequent, requiring a close observation. We had 20 patients with fecal obstruction, 4 cases of stent dislodgment, and 8 cases of obstruction from ingrowth of the tumor. All patients were treated successfully endoscopically.

CONCLUSIONS

Placement of self-expandable metal stents represents a valid technique. A proper training is required.

Endoscopic Stricturotomy Versus Balloon Dilation in the Treatment of Anastomotic Strictures in Crohn's Disease

BACKGROUND

Current treatment modalities for anastomotic stricture in Crohn's disease (CD) include endoscopic balloon dilation (EBD) and surgery. We recently published a case series of inflammatory bowel disease patients treated with the novel endoscopic stricturotomy (ES). The aim of this case-control study was to compare the efficacy and safety of ES versus conventional EBD in the treatment of anastomotic strictures in CD patients.

METHODS

All eligible patients with CD anastomotic stricture who were treated with ES or EBD were included. The primary outcomes were surgery-free survival and post-procedural complications.

RESULTS

A total of 185 patients were studied, including 21 treated with ES since 2009, and 164 treated with EBD since 1998. The immediate technical success after therapy was achieved in 100% of patients treated with ES and 89.5% of patients with EBD. Symptomatic and endoscopic improvement rates were higher in those treated with ES than EBD. Subsequent surgery was needed in 2 (9.5%) patients with ES and 55 (33.5%) with EBD (P = 0.03), during a median of 0.8 (interquartile range [IQR]:0.1-1.6) year and 4.0 (IQR: 0.8-6.9) years, respectively. Five procedure-associated perforation (1.1% per procedure) occurred in the EBD group and none in the ES group. In contrast, 4 procedure-associated, transfusion-required bleeding (8.8% per procedure) occurred in the ES group and none in the EBD group.

CONCLUSIONS

ES appears to be more effective in treating CD patients with anastomotic stricture than EBD. Although ES may have a lower risk for perforation, the procedure needs to be perfected to reduce its bleeding risk.

Anastomotic stricture after ultralow anterior resection or intersphincteric resection for very low-lying rectal cancer

BACKGROUND

Anastomotic stricture following colorectal cancer surgery is not a rare complication, but proper management of anastomotic stricture located close to the anal verge is uncertain. This study aimed to investigate risk factors and management strategies for anastomotic stricture after ultralow anterior resection (ULAR).

METHODS

We retrospectively reviewed a database of patients with rectal cancer who underwent surgery between January 2007 and June 2015, and included patients with an anastomosis within 4 cm from the anal verge. Clinical outcomes and risk factors for anastomotic stricture were investigated.

RESULTS

Among the 586 patients included, 46 (7.8%) were diagnosed as having anastomotic stricture. Multivariable logistic regression analysis revealed that intersphincteric resection (ISR) with hand-sewn anastomosis (odds ratio [OR] = 3.070; 95% confidence interval [CI] 1.247-7.557) and postoperative radiotherapy (OR 6.237; 95% CI 1.961-19.841) were independent risk factors of anastomotic stricture. Forty-one (89.1%) underwent anastomotic dilatation with a Hegar dilator; while three patients (6.5%) underwent endoscopic balloon dilatation and two (4.3%) underwent surgery initially. Among the patients with initial nonoperative management (n = 44), 21 (47.7%) were completely cured with nonoperative management alone, 12 (27.3%) experienced complications, such as bowel perforation, anastomotic rupture, and perirectal abscess; and 21 (47.7%) underwent further surgical management. Fifteen patients (32.6%) eventually had permanent stoma.

CONCLUSION

ISR with a hand-sewn coloanal anastomosis, compared to ULAR with double-stapling anastomosis, and postoperative radiotherapy were independent risk factors of anastomotic stricture after surgery for very low-lying rectal cancer. Nonoperative anastomotic dilatation showed poor clinical outcome, with high complication rates, and subsequent surgical management. Therefore, nonoperative management of such patients should be carefully selected.

Endoscopic Stricturotomy with Needle Knife in the Treatment of Strictures from Inflammatory Bowel Disease

BACKGROUND

Fibrotic strictures in patients with inflammatory bowel disease (IBD) are often not amenable to medical therapy. Therapy with endoscopic balloon dilation usually requires frequent repeat treatments. Therefore, we developed the novel needle knife stricturotomy (NKSt) for the treatment of strictures in the patients with IBD. The aim of this study was to evaluate the efficacy and safety of NKSt.

METHODS

Data of patients with strictures treated with NKSt in our Interventional IBD Unit at the Cleveland Clinic were extracted from the registry. The primary and secondary outcomes were surgery-free survival and procedure-related complications.

RESULTS

A total of 85 patients were included in this study. Multiple strictures were noticed in 30 (35.3%) patients at inception, giving a total of 127 strictures treated. The median length of the treated strictures was 1.5 cm (interquartile range: 1.0-2.0) and 52 (41.6%) were endoscopically nontraversable. The immediate success with passage of the scope through the stricture after NKSt therapy was achieved in all patients. During the median follow-up of 0.9 years (interquartile range: 0.3-1.8) and a median of 2.0 treatment (interquartile range: 1.0-3.0), 13 (15.3%) patients required stricture-related surgery. There were 77 (60.6%) patients who required additional NKSt, endoscopic balloon dilation, or both after the inception of NKSt. In a total of 272 NKSt procedures performed, 10 (3.7%) adverse events occurred, including 9 with delayed bleeding and one hospitalization due to perforation.

CONCLUSIONS

Endoscopic NKSt is effective and safe for treating the primary and secondary IBD-related strictures, which may provide an alternative for endoscopic balloon dilation and surgical intervention.

Application of Y-shaped, coated self-expandable metallic stents for anastomotic stenosis after gastrojejunostomy (Billroth II)

BACKGROUND

Anastomotic stenosis is an infrequent but life-threatening complication after gastrojejunostomy (Billroth II). Tubular or single tubular stents have limited efficacy due to the particular anatomy.

PURPOSE

To assess the feasibility of a Y-shaped, fully-coated, self-expandable, metallic stent (SEMS) for anastomotic stenosis after gastrojejunostomy (Billroth II).

MATERIAL AND METHODS

Between January 2008 and August 2014, 14 patients (10 with gastric carcinoma and four with duodenal ulcers) had anastomotic stenoses following Billroth II reconstructions. Eight patients with gastric cancer had tumor recurrence near the anastomosis; two had benign strictures. The four duodenal ulcer patients had benign stenoses. An integrated Y-shaped, fully coated SEMS was designed to accord with the anatomy of residual gastrojejunal anastomotic strictures. Fourteen stents were inserted under fluoroscopic control. Follow-up was at 1, 3, 9, and 12 months, and then annually.

RESULTS

All 14 stents were inserted successfully at the first attempt with a technical success rate of 100%. After stenting, abdominal symptoms resolved in all patients. All patients were followed up for 4-27 months (mean, 13.9 months). One of the eight recurrent cases died of multiple tumor metastases and liver failure after 7 months, without obstruction symptoms. In all six patients with benign anastomotic stenosis, the stents were removed successfully without complication and with no evidence of restenosis based on clinical evaluation and imaging.

CONCLUSION

A Y-shaped, fully-coated SEMS proved to be a feasible and minimally invasive procedure for treating anastomotic stenosis after gastrojejunostomy (Billroth II).

[Late complications and functional disorders after rectal resection : Prevention, detection and therapy]

The prognosis of patients with rectal carcinoma has been improved with the implementation of multimodal therapy and improvement of the surgical technique. Therefore, late complications and functional consequences that determine the quality of life following oncological rectal resection are increasingly being recognized. In general both the surgical trauma and side effects of the multimodal therapy play a critical role in the manifestation of various problems in the long-term course after treatment of rectal carcinoma. In this context the low anterior resection syndrome (LARS) has been described which is influenced by different factors and can be worsened by neoadjuvant radiation. Disorders of the urinary bladder and sexual dysfunction as well as benign anastomotic stenoses are problems independent of LARS. Therapeutic approaches for these late complications and functional disorders have either been insufficiently evaluated or are not available. Treatment of functional disorders can be attempted by pelvic floor training, biofeedback and sacral nerve stimulation. Interventional and surgical procedures are available to treat anastomotic stenosis. It must be emphasized that an adequate surgical technique is indispensable to avoid most of these late complications and functional disorders.

Transanal anorectal stricturoplasty using the Heineke-Mikulicz principle: a novel technique

AIM

Current surgical options for the treatment of rectal stricture are either technically difficult or result in a high rate of recurrence. We describe the results of a simple and potentially effective technique of transanal stricturoplasty using the Heineke-Mikulicz principle.

METHOD

The medical records and a prospectively maintained database of patients with rectal stricture were searched. Those who underwent transanal stricturoplasty for an anorectal stricture from 2007 to 2013 were studied retrospectively. Morbidity, length of hospital stay and the rates of success and recurrence were recorded.

RESULTS

Fifteen patients with a symptomatic rectal stricture who failed dilatation underwent transanal stricturoplasty. The types of stricture included strictures in Crohn's disease (n = 7) and anastomotic stricture after stapled ileoanal anastomosis for ulcerative colitis (n = 4), after stapled hemorrhoidopexy (n = 3) and after low anterior resection for rectal cancer (n =1). The median (range) distance of the stricture from the dentate line was 4 (0-6) cm. Recurrence of symptoms after anal dilatation occurred at a median of 3 (1-4) weeks. The median follow up after transanal stricturoplasty was 21 (6-88) months. Two patients had symptomatic recurrence at 12 months and both underwent a repeat transanal stricturoplasty, resulting in persistent patency of the strictured area at the time of the last follow up, 10 and 26 months, respectively, after repeat transanal stricturoplasty. The remaining 13 had a satisfactory result.

CONCLUSION

Despite the retrospective nature of this report and the small sample size and short follow up, the results strongly suggest that transanal Heineke-Mikulicz-type stricturoplasty is a promising treatment for this important condition. This operation is easy to perform and may result in success.

Outcomes of the use of fully covered esophageal self-expandable stent in the management of colorectal anastomotic strictures and leaks

Introduction. Colorectal anastomotic leak or stricture is a dreaded complication leading to significant morbidity and mortality. The novel use of self-expandable metal stents (SEMS) in the management of postoperative colorectal anastomotic leaks or strictures can avoid surgical reintervention. Methods. Retrospective study with particular attention to the indications, operative or postoperative complications, and clinical outcomes of SEMS placement for patients with either a colorectal anastomotic stricture or leak. Results. Eight patients had SEMS (WallFlex stent) for the management of postoperative colorectal anastomotic leak or stricture. Five had a colorectal anastomotic stricture and 3 had a colorectal anastomotic leak. Complete resolution of the anastomotic stricture or leak was achieved in all patients. Three had recurrence of the anastomotic stricture on 3-month flexible sigmoidoscopy follow-up after the initial stent was removed. Two of these patients had a stricture that was technically too difficult to place another stent. Stent migration was noted in 2 patients, one at day 3 and the other at day 14 after stent placement that required a larger 23 mm stent to be placed. Conclusions. The use of SEMS in the management of colorectal anastomotic leaks or strictures is feasible and is associated with high technical and clinical success rate.