Surg Endosc DOI 10.1007/s00464-015-4191-0

and Other Interventional Techniques

Endoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience Ivana Bravi1 • Davide Ravizza1 • Giancarla Fiori1 • Darina Tamayo1 • Cristina Trovato1 • Giuseppe De Roberto1 • Chiara Genco1 • Cristiano Crosta1

Received: 22 December 2014 / Accepted: 24 March 2015  Springer Science+Business Media New York 2015

Abstract Background Benign anastomotic colonic stenosis sometimes occur after surgery and usually require surgical or endoscopic dilation. Endoscopic dilation of anastomotic colonic strictures by using balloon or bougie-type dilators has been demonstrated to be safe and effective in multiple uncontrolled series. However, few data are available on safety and efficacy of endoscopic electrocautery dilation. The aim of our study was to retrospectively investigate safety and efficacy of endoscopic electrocautery dilation of postsurgical benign anastomotic colonic strictures. Methods Sixty patients (37 women; median age 63.6 years, range 22.6–81.7) with benign anastomotic colonic or rectal strictures treated with endoscopic electrocautery dilation between June 2001 and February 2013 were included in the study. Anastomotic stricture was defined as a narrowed anastomosis through which a standard colonoscope could not be passed. Only annular anastomotic strictures were considered suitable for electrocautery dilation which consisted of radial incisions performed with a precut sphincterotome. Treatment was considered successful if the colonic anastomosis could be passed by a standard colonoscope immediately after dilation. Recurrence was defined as anastomotic stricture reappearance during follow-up. Results The time interval between colorectal surgery and the first endoscopic evaluation or symptoms development was 7.3 months (1.3–60.7). Electrocautery dilation was

& Ivana Bravi [email protected] 1

Division of Endoscopy, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy

successful in all the patients. There were no procedurerelated complications. Median follow-up was 35.5 months (2.0–144.0). Anastomotic stricture recurrence was observed in three patients who were successfully treated with electrocautery dilation and Savary dilation. Conclusions Endoscopic electrocautery dilation is a safe and effective treatment for annular benign anastomotic postsurgical colonic strictures. Keywords Anastomotic strictures  Colon  Electrocautery dilation

Benign anastomotic strictures occur in up to 22 % of patients undergoing colonic or rectal resection [1] (Fig. 1). Although there have been extensive studies on the healing of intestinal anastomosis, the pathophysiology and contributing factors are still only partly understood. Tissue ischemia, leakage, suturing techniques (i.e. use of circular staplers) and radiotherapy have been shown to be implicated [2–4]. Initially, surgical intervention was the only treatment available to manage these strictures, even if it was technically demanding and not always possible or advisable in all patients. In the last few decades, surgery has been replaced by endoscopic dilation techniques. Balloon dilation and dilation with Savary– Gilliard bougies have been demonstrated to be safe and effective in multiple uncontrolled series, even if the stricture sometimes fails to improve despite repeated dilations [5–7]. Few data are available on safety and efficacy of endoscopic electrocautery dilation [8], which is a relatively simple technique, inexpensive and easily available in most endoscopy units. Therefore, the aim of our study was to retrospectively investigate safety and efficacy of endoscopic electrocautery dilation of benign anastomotic colonic and rectal strictures in our experience.

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Fig. 1 Anastomotic annular stricture

Fig. 2 Anastomotic stricture immediately after endoscopic electrocautery dilation

Materials and methods • Anastomotic strictures were diagnosed by endoscopy and defined as narrowed anastomosis through which a standard colonoscope (diameter 13 mm) could not be passed. Only annular anastomotic strictures, i.e. strictures with a craniocaudal extension not exceeding 3 mm, were considered suitable for electrocautery dilation. Cleaning was carried out using oral laxatives or cleansing enemas or both. The dilation was carried out under slight conscious sedation (Diazepam 5–10 mg i.v. or Midazolam 2.5–5 mg i.v.) in 53 patients and without sedation in the remaining ones because of patients’ will. A standard colonoscope (EC-3885FK/EC-3890Fi, Pentax, Tokyo, Japan) was used for the procedure. The electrocautery dilation consisted of radial incisions performed with a precut sphincterotome (KD-10Q-1, Olympus, Tokyo, Japan) which was positioned in place under direct visualization. Number (not \4), length and dept of the cuts were decided by the endoscopist. Dilations were all performed by two expert endoscopists (G.F. and C.C.) with at least 15 years of experience in diagnostic and therapeutic endoscopy. No other dilation technique (i.e. balloon dilation/Savary dilation) was associated. Following the procedure, patients were observed for several hours on a dayhospital basis and a free diet was allowed the day after. Treatment was considered successful if the colonic or rectal anastomosis could be passed by a standard colonoscope immediately after dilation (Fig. 2). Recurrence was defined as anastomotic stricture reappearance during follow-up. Endoscopic check of the anastomosis after electrocautery dilation was scheduled to be done as follows: • •

immediately before restoration of bowel continuity for patients with ileostomy or colostomy at the time of occlusive/subocclusive symptoms development or in case of stipsis/stool-shape modification

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according to colonic surveillance protocol for asymptomatic patients. In detail, patients with colorectal cancer were scheduled to undergo surveillance colonoscopy 1 year after surgery and then at 3 and 5 years; these time intervals could be shortened if adenomatous lesions were detected.

Results Sixty patients (37 women; median age 63.6 years, range 22.6–81.7) with benign anastomotic colonic or rectal strictures treated with endoscopic electrocautery dilation between June 2001 and February 2013 were included in the study. Endoscopy was carried out either because of complaints concerning defecation (15 patients) or during routine follow-up. Symptomatic patients had subocclusive symptoms (n = 2), stipsis (n = 8) or stool-shape modification (n = 5). Fifty-four out of 60 patients had been treated surgically for colonic or rectal carcinoma, two patients for sigmoid diverticulitis, two had undergone an anterior rectal resection for ovaric carcinoma and the remaining two patients had had a prophylactic proctocolectomy for familial adenomatous poliposis. Forty patients had been operated at our institution: in 38 patients the anastomosis had been performed using a circular stapling device while a suture-hand anastomosis had been made in two patients. Thirty-seven patients had had a colorectal anastomosis (35 end to end and two end to side), 17 a colo-colic anastomosis (12 end to end, two end to side, three side to side), four an ileorectal anastomosis (one end to end and three end to side), one an ileo-colic anastomosis side to side and one a coloanal anastomosis. Four patients had had a colostomy and

Surg Endosc

12 an ileostomy. In only one of the patients surgical intervention had been complicated by anastomotic leakage. One patient had undergone both neoadiuvant chemotherapy and adiuvant radiotherapy, two both neoadiuvant and adiuvant chemotherapy, seven both adiuvant radiotherapy and chemotherapy and 19 adiuvant chemotherapy only. The time interval between colorectal surgery and the first endoscopic evidence of anastomotic stricture or symptoms development was 7.3 months (1.3–60.7). Forty-eight out of 60 (80 %) endoscopic dilation were performed by G.F. and 12 out of 60 (20 %) by C.C.; in particular, G.F. performed herself 36 procedures and supervised less experienced endoscopists in 12 cases. Electrocautery dilation was successful in all the patients, i.e. dilation of the strictures was achieved in all the patients with a single treatment session (Fig. 3). We did not observe any immediate or delayed procedure-related complication (i.e. perforation or bleeding) and none of the patients complained of symptoms. Median follow-up after dilation treatment was 35.5 months (2.0–144.0). Fifty-five out of sixty patients underwent endoscopic surveillance [median number of endoscopic examinations: 2.0 (1.0-8.0)] after dilation, whereas the remaining five patients, all symptomatic and in poor health conditions, were clinically evaluated only. Forty-nine of the 55 patients who underwent endoscopic surveillance and the five patients who did not had a recorded clinical evaluation at our institution [median number of visits: 5.0 (1.0–23.0)]. The remaining six who had endoscopic surveillance at our institution were otherwise followed up in oncology/surgery clinics closed to home for their own will. Symptomatic patients had a good clinical outcome, with normalization of defecation and disappearance of complaints. No symptoms of constipation or bowel obstruction

Fig. 3 Anastomosis at 1-year follow-up endoscopy

were reported during follow-up. In patients who had undergone surgery for cancer no recurrence of malignancy was observed during follow-up. Anastomotic stricture recurrence was observed in three (5 %) asymptomatic patients: two of them were then successfully treated with a second electrocautery dilation and one, in whom the anastomotic stricture was judged not to be annular during a second endoscopy, received a Savary– Gilliard bougies dilation. Two patients had a colorectal and one a colo-colic anastomosis; in one of them, the anastomosis had been performed using a circular stapling device (data are missing for the other two patients). None of the patients had had an anastomotic leakage nor have received radiotherapy. Only one of them received adiuvant chemotherapy and had had a colostomy.

Discussion Anastomotic colonic or rectal strictures, which are the result of an inflammatory and fibrotic process, represent a challenging complication after colonic or rectal resection. The incidence of postoperative strictures of the rectum and colon has risen in recent years, probably due to an increase in the number of anastomoses created with staplers [9]. Anastomotic strictures, even if asymptomatic, should be treated for two reasons. First, all the patients with previous colorectal cancer are at risk of developing metachronous lesions over time (1.8–3.4 %) [10]; therefore, anastomosis patency is mandatory to allow complete endoscopic colon surveillance. Second, anastomotic strictures may become narrower during time causing obstructive symptoms development. Surgical dissection and several endoscopic procedures have been used to treat benign anastomotic stenosis. However, surgery does not completely eliminate the possibility of re-stenosis [11] and it is not free of complications. Among endoscopic techniques, balloon dilation is the most frequent intervention described in the literature and it has been demonstrated to be safe and effective [5, 6]. A study from Alonso Araujo et al. on 24 patients with postsurgical colorectal anastomotic strictures showed that through the scope hydrostatic balloon dilation was successful in almost 92 % of patients, there were no procedure-related complications and recurrence was observed in 18 % of the patients. The majority of patients required 2–4 dilation sessions to achieve success [5]. Belvedere et al. treated 31 patients with colorectal strictures with an overthe-wire hydrostatic balloon: good short-term (3 weeks time) results were obtained in 87 % of patients and good long-term (3–4 months time) results in 66 % of them; no complications were observed. Moreover, 17 % of patients initially treated with endoscopic dilation needed an

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extra-treatment (surgery/stenting) [6]. Endoscopic dilation with Savary bougies has been shown to be easy to perform, successful in the majority of cases, inexpensive and well tolerated by the patients. Werre et al. treated 15 patients with benign strictures after low anterior resection by using Savary bougies: in 10 patients success was achieved with one to three dilation sessions, whereas the remaining five patients needed four or more dilation sessions and had only partial improvement; no procedure-related complications were observed. However, no data on recurrence were reported [7]. Moreover, in a case study, Pietropaolo and colleagues found balloon dilation more effective than bougienage with respect to the proportion of patients successfully treated in a single session (76.9 vs 51.8 %) [12]. Few data are available on the use of electrocautery dilation for the treatment of benign stenosis. We observed that electrocautery dilation is a safe and effective treatment for annular benign anastomotic colonic or rectal postsurgical strictures. In fact, we had no immediate or delayed procedure-related complications, dilation of the strictures was achieved in all the patients with a single treatment session and recurrence of the stenosis was observed only in 5 % of the patients during a long-term follow-up. Moreover, this technique does not require a dedicated device, can be performed on a day-hospital basis and is not expensive. Our study confirms data from a study of Brandimarte et al. on 39 patients, showing that electrocautery dilation was successful in all of them with one treatment session without any complications or recurrences [8]. Even if all endoscopic dilation techniques have been demonstrated to be safe and effective in the majority of cases, patients treated with balloon dilation and Savary dilation often needed more than one treatment session to achieve success (more than four in some cases) [7]. Moreover, recurrence was observed in up to 18 % of the patients [5]. In ours and Brandimarte’s experience only one electrocautery dilation session was successful in all the patients and a low number of recurrences occurred (0–5 %). Thus, electrocautery dilation seems to offer better results with few treatment sessions, it has a low percentage of recurrence and does not need a dedicated device which could be expensive. Compared to others, our study includes a bigger number of patients and, even if data had been retrospectively

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collected, it shows that electrocautery dilation is a safe and effective procedure and could be considered the first treatment choice for annular benign anastomotic colonic and rectal postsurgical strictures. Disclosures Drs. Ivana Bravi, Davide Ravizza, Giancarla Fiori, Darina Tamayo, Cristina Trovato, Giuseppe De Roberto and Chiara Genco have no conflicts of interest or financial ties to disclose. Dr. Crosta is consultant and teacher of Pentax Education Center in Milan. The European Institute of Oncology receives an unrestricted grant by Pentax Italia to undertake research activities and training programs.

References 1. Luchtefeld AM, Milsom JW, Senagore A, Surrell JA, Mazier WP (1989) Colorectal anastomotic stenosis: results of a survey of the ASCRS membership. Dis Colon Rectum 32:733–736 2. Irvin TT, Goligher JC (1973) Aetiology of disruption of intestinal anastomoses. Br J Surg 60:461–464 3. Morgenstern L (1981) The intestinal anastomosis with the end-toend stapling instrument. Progress and problems, 1980. Arch Surg 166:141–142 4. Waxman BP (1983) Large bowel anastomoses. II. The circular staplers. Br J Surg 70:64–67 5. Araujo SE, Furtado Costa A (2008) Efficacy and safety of endoscopic balloon dilation of benign anastomotic strictures after oncologic anterior rectal resection. Report on 24 cases. Surg Laparosc Endosc Percutaneous Tech 18:565–568 6. Belvedere B, Frattaroli S, Crabone A, Viceconte G (2012) Anastomotic strictures in colorectal surgery: treatment with endoscopic balloon dilation. G Chir 33:243–245 7. Werre A, Mulder C, van Heteren C, Bilgen ES (2000) Dilation of benign strictures following low anterior resection using Savary– Gilliard bougies. Endoscopy 32(5):385–388 8. Brandimarte G, Tursi A, Gasbarrini G (2000) Endoscopic treatment of benign anastomotic colorectal stenosis with electrocautery. Endoscopy 32(6):461–463 9. Polese L, Vecchiato M, Frigo AC, Sarzo G, Cadrobbi R, Rizzato R, Bressan A, Merigliano S (2012) Risk factors for colorectal anastomotic stenoses and their impact on quality of life: what are the lessons to learn? Colorectal Dis 14(3):e124–e128 10. Bouvier AM, Latournerie M, Jooste V, Lepage C, Cottet V, Faivre J (2008) The lifelong risk of metachronous colorectal cancer justifies long-term colonoscopic follow-up. Eur J Cancer 44:522–527 11. Schlegel RD, Dheni N, Parc R, Caplin S, Tiret E (2001) Results of reoperations in colorectal anastomotic strictures. Dis Colon Rectum 44:146–148 12. Pietropaolo V, Masoni L, Ferrara M, Montori A (1990) Endoscopic dilation of colonic postoperative strictures. Surg Endosc 4:26–30

Endoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience.

Benign anastomotic colonic stenosis sometimes occur after surgery and usually require surgical or endoscopic dilation. Endoscopic dilation of anastomo...
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