ClinicalRadiology (1991), 44, 77-78
Radiologically Controlled Balloon Dilatation of Rectal Strictures D. M. C A M P B E L L , J. G. G E R A G H T Y , K. M c B R I D E * , J. J. M U R P H Y and D. M A C E R L E A N *
Departments of Surgery and *Radiology, St. Vincent's Hospital, Dublin, Ireland Rectal stricture is a well recognized complication following anterior resection. It is traditionally managed with metal dilators or resection. This paper describes the use of balloon dilatation for benign anastomotic rectal strictures. Eight patients were included in the trial. Only one dilatation was necessary in four patients while the remaining four patients required further dilatation for relief of symptoms. The mean diameter of the stricture increased from 7.2 mm to 17.0 mm post-dilatation. There were no complications associated with the procedure. Balloon dilatation is a safe and effective method of treating benign anastomotic rectal strictures. Campbell, D.M., Geraghty, J.G., McBride, K., Murphy, J.J. & MacErlean, D. (1991). Clinical Radiology, 44, 77-78. Radiologically Controlled Balloon Dilatation of Rectal Strictures
Anastomotic stricture following low anterior resection presents a difficult clinical problem which is normally managed by blunt metal dilators. Balloon dilatation of strictures in the upper gastrointestinal tract is now recognized as a safe repeatable alternative to surgery (Stark et al., 1984; McLean et al., 1987). There is now evidence to suggest that this technique may be used to treat low rectal strictures (Brower and Freeman, 1984). This paper reports our experience with eight cases of anastomotic rectal stricture treated by balloon dilatation.
Technique of Dilatation Patients were admitted to a day care unit and the rectum prepared prior to balloon dilatation using a simple rectal washout. Each patient was placed on the Xray table in the left lateral position and given 10 mg of Diazepam intravenously as sedation. Where necessary 25 mg of intravenous Pethidine was administered for pain control. A sigmoidoscope was passed and the lower end of the stricture visualized. The sigmoidoscope was held against the lower end of the stricture and a J-shaped guide
Table - Details of eight patients with rectal strictures
1 2 3 4 5 6 7 8
Carcinomaof recto-sigmoid Diverticulitis Diverticulardisease Carcinoma of rectum Diverticulardisease Carcinoidtumour of rectum Carcinoma of rectum Diverticulitis
Reversalof Hartmann's Reversal of Hartmann's Sigmoid colectomy Anterior resection Reversal of Hartmann's Anterior resection Anterior resection Reversal of Hartmann's
Handsewn Stapled Handsewn Stapled Stapled Stapled Stapled Stapled
Mid Lower Upper Mid Lower Lower Mid Upper
1 4 3 1 I 3 3 1
MATERIALS A N D M E T H O D S Patients
wire (diameter=0.87 m m ) passed through the stricture under fluoroscopic control. A 19 F polyvinyl chloride Lunderquist-Owman oesophageal dilatation balloon (William Cook Europe, Denmark) was then passed over the guide wire. The balloon was gently inflated with contrast (Conray 280: 50% strength) to confirm the site and extent of the stricture fluoroscopically (Fig. la). The sigmoidoscope was then withdrawn from the rectum. The balloon was inflated with contrast to its m a x i m u m diameter (22 ram) or until pain was experienced by the patient. The balloon was left inflated for 10 rain, if tolerated by the patient. A film was taken at the end of this period to measure the final diameter of the stricture (Fig. lb). The patient was returned to the day ward and observed before discharge.
During the period March 1989 to M a y 1990, a total of eight patients, seven females and one male, presented with radiologically proven rectal strictures. The mean age of the patients was 63 years. The original diagnosis, the type of surgery performed, method of anastomosis, the level of stricture and the number of balloon dilatations are outlined in the Table. Patients presented with typical symptoms of rectal stricture including constipation, narrow stools, diarrhoea and crampy lower abdominal pain. The interval between surgery and presentation with rectal stricture ranged from 1 m o n t h to 16 months. Three patients had dilatation or attempted dilatation with rigid dilators performed prior to referral.
Correspondence to: J. G. Geraghty, Department of Surgery, Meath HoSpital, Heytesbury Street, Dublin 8, Ireland.
The procedure was well tolerated by all patients. The mean follow-up period was 11.5 months (range 6-17 months). Four patients required a single dilatation and
CLINICAL RADIOLOGY 25 2O E
(b) Fig. 1 - (a) Balloon filled with contrast before dilatation demonstrating the rectal stricture. (b) Post-dilatation film showing fully inflated balloon and small residual rectal stricture. the remainder required a mean o f three dilatations for relief o f s y m p t o m s (Table). The m e a n diameter o f the stricture area increased f r o m 7.2 m m pre-dilatation to 17.0 m m after the last dilatation (Fig. 2). There were no complications associated with the procedure. DISCUSSION The incidence o f anastomotic strictures o f the rectum is increasing and this rise has been attributed to the use o f circular stapled anastomoses. A recent survey demonstrated that 52 patients out o f 70 with rectal strictures had their anastomosis performed with the circular stapling gun (Luchtefeld et al., 1989), and there is n o w experimental evidence to show that stapled anastomoses are associated with an increased a m o u n t o f scar tissue (Polglase et al., 1981). The potential rise in the incidence o f rectal strictures will cause a difficult problem in management. This paper describes a simple non-operative m e t h o d o f rectal dilatation which is safe, easy to perform and well tolerated by the patient. The technique was successful in achieving at least a two-fold increase in the diameter o f the stricture in all cases. Balloon dilatation is repeatable and, as in the present study, a schedule o f serial dilatation m a y be necessary for tight rectal strictures before a successful result is achieved. A variety o f different techniques are in use to treat rectal strictures. Surgical resection m a y be necessary, and more recently a transanal technique involving the use o f
Fig. 2 - Diameter of the rectal stricture before and after dilatation in all eight cases. the urological resectoscope has been described (Kelly, 1989). The c o m m o n e s t non-operative m e t h o d involves the use o f metal dilators including Hegar, M a l o n e y and E d e r - P u e s t o w types. These dilators exert an axial as well as a radial force. Balloon dilatation exerts only a radial force (Skreden et aI., 1987) which in theory m a y result in less t r a u m a at the site o f narrowing. A l t h o u g h half the patients required only one dilatation, the present study shows that a subgroup o f patients will require repeated dilatation for symptomatic relief. The other advantage o f balloon dilatation is that the balloon will not expand b e y o n d a fixed diameter, and if overinflated, will rupture because o f the low compliance o f the p o l y m e r material (Webb, 1988). We would recommend, despite this safety factor, that the whole procedure, including insertion o f the guide wire and balloon inflation, be performed under fluoroscopic control. It is also i m p o r t a n t that the sigmoidoscope is used t o ensure accurate positioning o f both guide wire and balloon. Dilatation should n o t be performed for malignant strictures as there is a risk o f perforation (Aston et al., 1989), and if biopsy is indicated, balloon dilatation should be deferred. Balloon dilatation o f the rectum is safe and effective and should be considered as the treatment o f choice for benign anastomotic rectal strictures. REFERENCES
Aston, NO, Owan, NJ & Irving, JD (1989). Endoscopic balloon dilatation of colonic anastomotic strictures. British Journal of Surgery, 76, 780 782. Brower, RA & Freeman, LD (1984). Balloon catheter dilation of a rectal stricture. Gastrointestinal Endoscopy, 30, 95-97. Kelly, MJ (1989). Use of the urological resectoscope in benign and malignant rectal lesions- review of 12 cases. Journal of the Royal Society of Medicine, 82, 588 590. Luchtefeld, M, Milson, JW, Sanagore, A, Surrell, JA & Majier, WP (1989). Colorectal anastomotic stenosis: results of a survey of the ASCRS membership. Diseases of the Colon and Rectum, 32, 733 736. McLean, GK, Cooper, GS, Hartz, WH, Burke, DR & Meranze, SG (1987). Radiologically guided balloon dilation of gastrointestinal strictures. Radiology, 165, 35-40. " Polglase, AL, Hughes, ESR, McDermott, FT & Burke, FR (1981). A comparison of end-to-end staple and suture colorectal anastomosis in the dog. Surgery, Gynecology and Obstetrics, 152, 792-796. Skreden, K, Wiig, JN & Myrvold, HE (1987). Balloon dilation of rectal strictures. Acta Chirurgica Scandinavica, 153, 615 617. Starck, E, Paoluca, V, Herzer, M & Crummy, A (1984). Oesophageal stenosis: treatment with balloon catheters. Radiology, 153, 637-640. Webb, WA (1988). Oesophageal dilation: personal experience with current instruments and techniques. American Journal of Gastroenterology, 83, 471-475.