Endoscopic radial incision and cutting technique for treatment-naive stricture of colorectal anastomosis: Two case reports

Abstract

Background: Anastomotic stenosis (AS) after colorectal surgery was treated with balloon dilation, endoscopic procedure or surgery. The endoscopic procedures including dilation, electrocautery incision, or radial incision and cutting (RIC) were preferred because of lower complication rates than surgery and are less invasive. Endoscopic RIC has a greater success rate than dilation methods. Most reports showed that repeated RICs were needed to maintain patency of the anastomosis. We report that single session RIC was applied only to treatment-naive patients with AS.

Case summary: Two female patients presented with AS. One patient had advanced rectal cancer and the other had a refractory stenosis following surgery for endometriosis at sigmoid colon. The endoscopic RIC procedure was performed as follows. A single small incision was carefully made to increase the view of the proximal colon and the incision was expanded until the surgical stapling line. Finally, we made a further circumferential excision with endoscopic knife along the inner border of the surgical staple line. At the end of the procedure, the standard colonoscope was able to pass freely through the widened opening. All patients showed improved AS after a single session of RIC without immediate or delayed procedure-related complications. Follow-up colonoscopy at 7 and 8 mo after endoscopic RIC revealed intact anastomotic sites in both patients. No treatment-related adverse events or recurrence of the stenosis was demonstrated during follow-up periods of 20 and 23 mo.

Conclusion: The endoscopic RIC may play a role as one of treatment options for treatment-naive AS with short stenotic lengths.

Keywords: Anastomosis; Case report; Colorectal surgery; Endoscopy; Radial incision; Stenosis.

Figure 1

The radial incision and cutting technique with a single incision for two patients. A: Anastomotic stenosis (AS) at 4 cm from the anal verge in patient 1; B: A single incision using the electrosurgical ITknife2 in patient 1; C: Circumferential excision with the ITknife2 along the inner margin of the surgical staple line in patient 1; D: The enlarged opening after the radial incision and cutting (RIC) procedure in patient 1; E: AS at 12 cm from the anal verge in patient 2; F: Single incision using the ITknife2 in patient 2; G: Circumferential excision with the ITknife2 along the inner margin of the surgical staple line in patient 2; H: The enlarged opening after the RIC procedure in patient 2.

Figure 2

Follow-up colonoscopy. A: Seven months after the radial incision and cutting (RIC) procedure in patient 1; B: Eight months after the RIC procedure in patient 2.