Int J Colorectal Dis DOI 10.1007/s00384-015-2385-5
LETTER TO THE EDITOR
Endoscopic incision and selective cutting for the treatment of refractory colorectal anastomotic strictures Yuyong Tan 1 & Liang Lv 1 & Tianying Duan 1 & Junfeng Zhou 1 & Deliang Liu 1
Accepted: 16 September 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Anastomotic benign stricture develops in 3–30 % of patients after surgery for rectal carcinoma. Although most of the strictures can be successfully managed with dilation, refractory stricture that does not respond to repeated dilations is difficult to be managed. Affected patients often suffer from constipation, abdominal pain, bloating, and dyschezia, which severely impair their quality of life. Endoscopic incision and cutting (RIC) is a novel technique for treating refractory esophageal strictures and has shown feasibility and efficacy for refractory colorectal anastomotic stricture in a recent case series. However, RIC leads to a wound surface like circumferential endoscopic submucosal dissection (ESD), which facilitates the formation of postoperative stricture. We modified the procedure by endoscopic incision and selective cutting (EISC) and reported our preliminary experience of EISC for the treatment of refractory colorectal anastomotic stricture. Between July 2011 and March 2015, eight consecutive patients were diagnosed of refractory colorectal anastomotic stricture and received EISC. Refractory stricture was considered because the stricture could not be improved to a diameter of 10 mm or symptom of obstruction was not relieved after three or more sessions of endoscopic treatment. And, malignant stricture was excluded by histological examination. This retrospective study was approved by the ethics committee of the Second Xiangya Hospital of Central South University. Informed consent was obtained from all their patients before
* Deliang Liu [email protected] 1
Department of Gastroenterology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Changsha, Hunan 410011, China
the procedure was performed. All the patients were informed of possible adverse events and other possible treatment options. EISC was performed under conscious sedation with diazepam (10 mg). Radial incisions were performed with an IT-knife (KD611L, IT2, Olympus, Tokyo, Japan) along the virtual line that connects the bowel lumen on the anal side and the lumen on the oral side of the stricture. Two incisions were performed at each cutting site and the scar tissue between the two incisions was removed; however, the tissue located between the adjacent sites was retained. Sufficient incision depth was defined as involvement of the muscularis propria layer or the bottom of incision was in the virtual line. After the procedure, the wound surface of stricture site was closely observed for any occurrence of hemorrhage and perforation. Patients were kept nil per os (NPO) for 1 day, a liquid diet for 5 days, and returned gradually to a soft diet within 2 weeks. Hemostatic drugs and prophylactic antibiotics were used for 3 days. Patients were scheduled for a follow-up visit at 3, 6, and 12 months after EISC and then annually for colonoscopy to observe the healing of the wound and check for any sign of recurrence. Of the eight patients, five were male and three female, aging from 42 to 76 years old. The median distance of the stricture from the anal verge was 5.5 cm (range, 3– 8 cm). All the patients underwent the procedure successfully with the median operation time of 9.5 min (range, 7–20 min), and the median hospital stay was 4 days (range, 2–6 days). All symptoms were remitted after a single treatment during a median follow-up of 20 months (range, 3–45 months). The median anastomotic diameter enlarged obviously from 0.55 cm (range, 0.1–0.8 cm) to 1.9 cm (range, 1.8–2.5 cm) and colonoscopy was completed without difficulty in intubating the anastomotic stoma. Current treatment modalities for refractory colorectal stricture mainly include surgical resection and endoscopic therapy. Surgical resection is indicated in cases of established refractory stricture; however, extensive injury and
Int J Colorectal Dis
postoperative restenosis often ensue. Endoscopic stent insertion is an alternative method, and available stents include selfexpandable metal/plastic stents, biodegradable stents, etc. Although several studies have demonstrated the feasibility of stenting for refractory anastomotic colorectal stricture, the rate of migration is high and the long-term efficacy remains unsatisfactory. What’s more, it is technically difficult for stent insertion for stricture that was located in the distal rectum (up to 4 cm from the anal verge). RIC has been reported as another alternative treatment for anastomotic colorectal stricture. In this method, the stricture area was incised radially with an IT-knife and scar tissue between adjacent incisions was sliced off. However, this method may lead to a wound surface like surface after circumferential ESD, which facilitates formation of fibrosis and results in treatment failure and stricture recurrence. Osera et al. [1] treated seven cases with RIC method and a total of 16 RIC sessions were performed, two of them failed with a follow-up of 18–55 months. Different from Osera [1], we modified the procedure: two incisions were performed at each cutting site and the scar tissue between the two incisions was removed; however, the tissue located between the adjacent sites was retained, that is EISC. This modification could avoid the formation of circumferential surface, prevent the reformulation of stenotic ring, and reduce the risk of recurrence. In the present case series, all the eight cases were benign anastomotic strictures after rectal surgery and
responded badly to repeated balloon dilations. We successfully treated them by EISC, and anastomotic patency was retained after a single treatment and no restenosis has been observed during periodical follow-up. Our study demonstrated that EISC is feasible, safe, and effective and could serve as an alternative method for the treatment of refractory colorectal anastomotic stricture. Large comparative studies are warranted to further confirm our findings. Compliance with ethical standards
Conflict of interest The authors declare that they have no competing interests. Ethics approval and consent to participate This retrospective study was approved by the ethics committee of the Second Xiangya Hospital of Central South University. Informed consent was obtained from all their patients before the procedure was performed. All the patients were informed of possible adverse events and other possible treatment options
Reference 1.
Osera S, Ikematsu H, Odagaki T, et al (2015) Efficacy and safety of endoscopic radial incision and cutting for benign severe anastomotic stricture after surgery for lower rectal cancer (with video). Gastrointest Endosc 81(3):770–773
LETTER TO THE EDITOR
Endoscopic incision and selective cutting for the treatment of refractory colorectal anastomotic strictures Yuyong Tan 1 & Liang Lv 1 & Tianying Duan 1 & Junfeng Zhou 1 & Deliang Liu 1
Accepted: 16 September 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Anastomotic benign stricture develops in 3–30 % of patients after surgery for rectal carcinoma. Although most of the strictures can be successfully managed with dilation, refractory stricture that does not respond to repeated dilations is difficult to be managed. Affected patients often suffer from constipation, abdominal pain, bloating, and dyschezia, which severely impair their quality of life. Endoscopic incision and cutting (RIC) is a novel technique for treating refractory esophageal strictures and has shown feasibility and efficacy for refractory colorectal anastomotic stricture in a recent case series. However, RIC leads to a wound surface like circumferential endoscopic submucosal dissection (ESD), which facilitates the formation of postoperative stricture. We modified the procedure by endoscopic incision and selective cutting (EISC) and reported our preliminary experience of EISC for the treatment of refractory colorectal anastomotic stricture. Between July 2011 and March 2015, eight consecutive patients were diagnosed of refractory colorectal anastomotic stricture and received EISC. Refractory stricture was considered because the stricture could not be improved to a diameter of 10 mm or symptom of obstruction was not relieved after three or more sessions of endoscopic treatment. And, malignant stricture was excluded by histological examination. This retrospective study was approved by the ethics committee of the Second Xiangya Hospital of Central South University. Informed consent was obtained from all their patients before
* Deliang Liu [email protected] 1
Department of Gastroenterology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Changsha, Hunan 410011, China
the procedure was performed. All the patients were informed of possible adverse events and other possible treatment options. EISC was performed under conscious sedation with diazepam (10 mg). Radial incisions were performed with an IT-knife (KD611L, IT2, Olympus, Tokyo, Japan) along the virtual line that connects the bowel lumen on the anal side and the lumen on the oral side of the stricture. Two incisions were performed at each cutting site and the scar tissue between the two incisions was removed; however, the tissue located between the adjacent sites was retained. Sufficient incision depth was defined as involvement of the muscularis propria layer or the bottom of incision was in the virtual line. After the procedure, the wound surface of stricture site was closely observed for any occurrence of hemorrhage and perforation. Patients were kept nil per os (NPO) for 1 day, a liquid diet for 5 days, and returned gradually to a soft diet within 2 weeks. Hemostatic drugs and prophylactic antibiotics were used for 3 days. Patients were scheduled for a follow-up visit at 3, 6, and 12 months after EISC and then annually for colonoscopy to observe the healing of the wound and check for any sign of recurrence. Of the eight patients, five were male and three female, aging from 42 to 76 years old. The median distance of the stricture from the anal verge was 5.5 cm (range, 3– 8 cm). All the patients underwent the procedure successfully with the median operation time of 9.5 min (range, 7–20 min), and the median hospital stay was 4 days (range, 2–6 days). All symptoms were remitted after a single treatment during a median follow-up of 20 months (range, 3–45 months). The median anastomotic diameter enlarged obviously from 0.55 cm (range, 0.1–0.8 cm) to 1.9 cm (range, 1.8–2.5 cm) and colonoscopy was completed without difficulty in intubating the anastomotic stoma. Current treatment modalities for refractory colorectal stricture mainly include surgical resection and endoscopic therapy. Surgical resection is indicated in cases of established refractory stricture; however, extensive injury and
Int J Colorectal Dis
postoperative restenosis often ensue. Endoscopic stent insertion is an alternative method, and available stents include selfexpandable metal/plastic stents, biodegradable stents, etc. Although several studies have demonstrated the feasibility of stenting for refractory anastomotic colorectal stricture, the rate of migration is high and the long-term efficacy remains unsatisfactory. What’s more, it is technically difficult for stent insertion for stricture that was located in the distal rectum (up to 4 cm from the anal verge). RIC has been reported as another alternative treatment for anastomotic colorectal stricture. In this method, the stricture area was incised radially with an IT-knife and scar tissue between adjacent incisions was sliced off. However, this method may lead to a wound surface like surface after circumferential ESD, which facilitates formation of fibrosis and results in treatment failure and stricture recurrence. Osera et al. [1] treated seven cases with RIC method and a total of 16 RIC sessions were performed, two of them failed with a follow-up of 18–55 months. Different from Osera [1], we modified the procedure: two incisions were performed at each cutting site and the scar tissue between the two incisions was removed; however, the tissue located between the adjacent sites was retained, that is EISC. This modification could avoid the formation of circumferential surface, prevent the reformulation of stenotic ring, and reduce the risk of recurrence. In the present case series, all the eight cases were benign anastomotic strictures after rectal surgery and
responded badly to repeated balloon dilations. We successfully treated them by EISC, and anastomotic patency was retained after a single treatment and no restenosis has been observed during periodical follow-up. Our study demonstrated that EISC is feasible, safe, and effective and could serve as an alternative method for the treatment of refractory colorectal anastomotic stricture. Large comparative studies are warranted to further confirm our findings. Compliance with ethical standards
Conflict of interest The authors declare that they have no competing interests. Ethics approval and consent to participate This retrospective study was approved by the ethics committee of the Second Xiangya Hospital of Central South University. Informed consent was obtained from all their patients before the procedure was performed. All the patients were informed of possible adverse events and other possible treatment options
Reference 1.
Osera S, Ikematsu H, Odagaki T, et al (2015) Efficacy and safety of endoscopic radial incision and cutting for benign severe anastomotic stricture after surgery for lower rectal cancer (with video). Gastrointest Endosc 81(3):770–773
