Abdominal Eduard

E. de Lange,

MD

#{149} Hubert

Rectal Strictures: Fluoroscopically

The authors performed 25 fluoroscopically guided balloon dilation procedures in nine patients with rectal strictures. In all cases, the stricture developed after rectal surgery. Four patients underwent ileoanal anastomosis after total colectomy for various conditions; five patients underwent rectosigmoid end-to-end anastomosis after resection of a tumor or as treatment for diverticulitis. Maximal stricture dilatation was attained in 20 instances with a single 15-30-mm balloon. In five procedures, two balloons (20 or 15 mm) were inflated simultaneously (“kissing balloons” technique) to dilate the strictures. In five patients, only one dilation procedure was required for effective treatment of the strictures, with no clinical evidence of strictures after follow-up of 1.556 months (mean, 29.5 months). In the other four patients, multiple procedures were performed: nine in one patient, five in one patient, and three in two patients. In these patients, no recurrent symptoms developed during follow-up of 1.25-18 months (mean, 8.1 months) after the last dilation. Complicating leaks, infection, or hemorrhage did not occur after any of the procedures. Fluoroscopically guided balloon dilation is a safe and effective procedure for the treatment of rectal strictures. Index

terms:

757.1299

757.458

Catheters and catheterization, abnormalities, 757.297, #{149} Rectum, surgery, 757.1299 #{149} Rectum,

Radiology

1

170,

From

1991;

the

178:475-479

Department

University

of Virginia

of Radiology, Health

Center, Jefferson Park Aye, Charlottesville, 22908. Received June 25, 1990; revision ed August 8; revision received September accepted September 26. Address reprint quests to E.E.d.L. RSNA,

1991

Box

Sciences

VA request21; re-

and

A. Shaffer,

Gastrointestinal

Radiology

Jr, MD

Treatment with Guided Balloon Dilation’

S

of the

TRICTURES

tively

rectum

common

following

rectal

surgery,

therapy, on inflammatory 5). In most cases, the solve spontaneously after the insult (1,5), and become obstructive,

radiation

disease (1strictures nein the first year but some persist causing in-

convenience

to the

torns become use of dilatoms

too incapacitating, or surgery may

essany. loon and

patient.

Fluoroscopically dilation effective

ment

patient

are rela-

complications

the be nec-

guided

has proved procedure

of a variety

If symp-

of the

gut. Most reports have concerned strictures of the upper gastnointestinal tract (6,7). We present our expemience with this technique in patients

with

rectal

strictures.

MATERIALS Since 321

AND

January

1984,

fluonoscopically

guided

tion procedures niety of strictures tract.

Twenty-five

were

performed

rectal

strictures

patients

had

METHODS

we have

dila-

for the treatment of a vaof the gastrointestinal of these

in nine (Table clinical

procedures

patients

to treat

1). Seven

of these

symptoms

the

of partial

a stricture

of bowel

radiation

(patient

that

dilation of the

ously described strictures of the (6).

under ication ative, left

was

included

for dilating anastomotic upper gastrointestinal

Dilation

was

always

performed

fluonoscopic control. After with a systemic analgesic the patient was positioned

lateral

tients,

decubitus

position.

a shortened

10-14-F

ten was introduced into lute barium suspension

In

the

stricture.

Under

fluonoscopic

guidance, the catheter was positioned in the region of the stricture. If the stricture was high in the rectum, a steerable catheter (Biliary Stone Removal; Medi-tech, Watertown, Mass) was used to negotiate the

postenoanterior

angulation

on as far as was

from

0.7

to 83 years

(mean,

46.i

of the

proximal rectum. After the catheter was positioned at the stricture orifice or across the stricture, a J-shaped guide wire was introduced through the catheter and ad-

at least 20 cm proximal

age

pa-

cathe-

contrast agent (diatnizoate meglumine and diatrizoate sodium; Renografin-60, Squibb Diagnostics, New Brunswick, NJ) was injected through the catheter to out-

rowing

in

most

the rectum. A dior a water-soluble

vanced

ranging

premedand sedin the

feeding

were

patients,

in

technique used method we pnevi-

obstruction; in two patients (patients 1 and 8), dilation was performed for a stnictune identified with endoscopy. There

five male and four female

6) under-

field.

The balloon was a variation

line

performed

balloon

segment

tract

bal-

to be a safe for the treat-

of strictures

with

went radiation therapy to the pelvis before resection of a rectal carcinoma and creation of the anastomosis. In this patient, the stricture did not develop in the anastomosis itself but in a more proximal

tam

a good

purchase

to the nan-

necessary

for

to ob-

catheter

ex-

years). In all cases, the stricture ocafter rectal surgery. In four patients, an ileoanal anastomosis was created within a rectal muscular sleeve after

change. The catheter was removed, and a balloon catheter was passed over the guide wire to a position astride the strictune. The balloon was inflated with dilut-

total

ed water-soluble minutes until

curred

colectomy

for

various

conditions

(ul-

cenative colitis [n = 2], Gardner syndrome [n 1], and Hirschsprung disease [n 1]). Four patients underwent nectosigmoid end-to-end anastomosis after resection of a tumor (carcinoma [n 2], leiomyosarcoma [n 1], and villous adenoma [n 1]). In one patient, nectosigmoid end-to-end anastomosis was performed after partial sigmoid colectomy for diverticulitis. In two patients who underwent nectosigmoid anastomosis (patients 5 and 9), an anastomotic leak developed after surgery and was complicated by the formation of a perirectal abscess. Another

the

contrast medium for “hourglass” deformity

3-5

created by the stricture disappeared from the balloon contour or until the rated tolerance of the balloon was reached. Inflation was usually repeated two or three times at maximal balloon distention, with intervening 1-minute intervals of balloon deflation. In no case did the balloon pressure exceed 3.5 atm (51 psi), as measured by

an

in-line

pressure

gauge.

In

one

pa-

tient with a proximal rectal stricture (patient 9), the guide wire was positioned across the anastomotic stricture with use of a flexible sigmoidoscope, after which 475

b.

C.

Figure 1. Dilation of rectosigmoid anastomotic stricture with a single balloon (patient 5). The stricture occurred after creation of an end-toend anastomosis complicated by postoperative anastomotic leak and the formation of an abscess. (a) A steerable catheter is positioned across the stricture (between large straight arrows). Note the surgical staples at the anastomosis (small straight arrow). A guide wire (open arrow) is advanced through the catheter to a position proximal to the stricture. Note drainage catheter (curved arrow) in the abscess. (b) The catheter is exchanged

for

stricture

a 20-mm

(between

18 mm.

Note

balloon

arrows).

the

small,

(C)

residual

catheter,

After

and

several

waistlike

with

loon followed 20-mm balloon,

were

by placement and the two

inflated

balloons”

a single

simultaneously

technique

[8])

20-mm

stricture

at the

end

Radiology

#{149}

across

inflation

balloon

(arrow)

2). In

of the

dilation

stricture.

Initial

by 1-minute

at the

and

site

of the

of the

outlines

is maximally

the

dilated

to

Strictures Interval Surgery

and First Patient

Age (y)/ Sex

Cause

Type of Surgery of Stricture

Formation

and

Dilation (wk)

Indication

1

31/M

Ileoanal

anastomosis

2

46/F

Ileoanal

anastomosis

3

0.7/M

Ileoanal

anastomosis

4

19/F

Ileoanal

anastomosis

5

22/F

Rectosigmoid anastomotic leak with abscess

Total colectomy for ulcerative colitis Rectosigmoid resection for leiomyosancoma

Total colectomy for ulcerative colitis Total colectomy for Gardner syndrome Total colectomy for Hirschsprung

6

74/M

Radiation therapy with radiation proctitis

Resection of rectal carcinoma

44

7

83/F

Rectosigmoid

anastomosis

Local

21

8

81/M

Rectosigmoid

anastomosis

9

58/M

Rectosigmoidanastomoticleak with abscess

4

40 8

disease

of bowel

one

was

balloon

the stricture

stricture.

of Rectal

Causes

inflation

deflation,

between

(“kissing (Fig

the

followed

Table 1 Patient Distribution

of a second balloons

calculated from the maximal diameter of the inflated balloon on spot radiographs. In the instances in which two balloons were used simultaneously, their largest combined diameter was used to determine the final stricture diameter. Barium

476

is positioned

of the

bal-

patient, a 20- and a 15-mm balloon were used simultaneously. In three procedures, a 30-mm pneumatic balloon catheter (Rigiflex Achalasia Dilator; Microvasive, Watertown, Mass) was used (Fig 3). The decision to use a 30-mm balloon or two balloons simultaneously was made only if dilation of the stricture with a single 20mm balloon had been easily accomplished and the operator believed that further stretching of the stricture could be performed safely. The final caliber of the

balloon

of 3-minute

deformity

the procedure was continued under fluoroscopic control. Most dilation procedures were performed with fixed-diameter polyethylene balloon catheters of the Gruentzig type (Medi-tech). In some cases of severe stenosis, the dilation was initiated with a small-diameter balloon (6-10 mm), followed by one of greater diameter placed during the same procedure. In 16 instances, the largest balloon catheter used had a 20-mm diameter (Fig 1). In an 8month-old child, a balloon with a maximum diameter of iS mm was used for dilation. In four procedures, initial dilation

was performed

the

cycles

suspension

was

men

completion

at the

to verify

that

no

curred.

Antibiotics

or after

the

injected

into

of the

perforation

procedure.

the had

were

not In

rectal

lu-

procedure given

patients

during who

did not undergo a diverting intestinal ostomy, stool softeners and bulk-forming laxatives were prescribed to prevent constipation and allow the stricture to be dilated naturally by the fecal stream. Most

20

wall

resection

of

villous adenoma Resection of rectal carcinoma Sigmoid colectomy for diventiculitis

patients within

were 1 week

tenmine

oc-

36

tion,

the and

interviewed after the

short-term

clinical

20

by telephone procedure to de-

results

additional

information

obtained by telephone the patient’s physician long-term

12

results.

results

of the

procedure

“good” bowel

when the patient movements were

of the

dila-

was

later

from the patient on to determine the The were

short-term considered

indicated that normal at the 1February

1991

b.

d.

C.

Figure 2. Dilation of a strictured ileoanal anastomosis with the kissing balloons technique onstrates severe stricture of the anastomosis (arrow). (b) Stricture is dilated to 20 mm with of the balloon at the site of the stricture (arrows). (c) A second 20-mm balloon is positioned

dilation.

Note

the waistlike patency

of the

deformity

strates

good

Figure severe

3. Dilation of nectosigmoid sigmoid stricture (straight

indicating

anastomosis

and

no

the stricture

(arrow).

complicating

(d) Barium

study

pneumatic anastomosis

balloon (curved

(patient 2). (a) Initial barium one balloon. There is a slight

proctitis caused by previous stricture. There is waistlike good caliber of the bowel

radiation deformity lumen and

leak.

and

the

results

were

considered

(patient

the short-term good (patients

1), in

the

patients

in whom

clinical results were not 2 and 5), and in a patient

in whom the curned several lation (patient

symptoms of obstruction memonths after successful di6). Barium studies or en-

Volume

#{149}

178

Number

2

doscopy

long-term

pneumatic site of the

were

not

results

balloon stricture.

used

(between (c) Barium

to evaluate

of the

(patient 9). (a) Barium enema study demonstrates arrows). Note thickened folds of the bowel due small straight enema study

the

procedure.

RESULTS

“poor”

when the patient indicated that defecation occurred only with significant straining or pain. Redilation was performed in one patient who underwent diverting Ostomy

C.

stricture with 30-mm to the rectosigmoid

therapy. (b) Air-filled (curved arrow) at the no perforation.

week follow-up; the results were considered “fair” when the patient indicated that bowel function was improved but there was some residual straining or pain;

study demdeformity

next to the first balloon and inflated for further performed immediately after the procedure demon-

b.

anastomotic arrow) proximal

enema waistlike

In five

procedure treat the

patients, only was required

rectal

stricture,

one

dilation

to effectively and no com-

plications or clinical signs of stricture recurrence have occurred after follow-up of 1.5-56 months (mean, 29.5 months). In one of these patients (patient 7), a tumor recurred at the anastomosis after 14 months and required

arrows) is positioned after the procedure

to

astride the demonstrates

multiple laser treatments for control; however, no symptoms of obstruction or stenosis developed. In the other four patients, multiple dilation procedures were performed: nine in one patient, five in one patient, and three in two patients. In these patients, no recurrent stricture has

formed

during

follow-up

of 1.25-18

months (mean, 8.1 months) after the last dilation (Table 2). In the patient who underwent nine dilation procedures (patient 1), an ileoanal anastomosis had been con-

Radiology

#{149} 477

Table

2

Number

and

of Dilation

Results

No. of Dilation Procedure

Patient 1

Procedures,

Interval from Previous

Stricture Diameten before

Dilation (wk)

Dilation (mm)

1

. . .

2 3 4 5

3 3 2.5 2

*

after

request

Unknown

20

20

Unknown 18

52 56

3

1 week

procedures,

Radiology

9

36

20+20

20

38

20+20

Good Fair Fair Good

. .

.

1 4

15 20

15 20

Good Cood

. .

.

. .

.

2 10 13 3 8 8

16 20 16 16 16 32

20 20 20 20 20 20+15

Poor Poor Fair Good Good Good

15

30

...

19

5

60

10 5 Unknown 10

... . . . . . .

after

colectomy

because

considered tion of the

ul-

it was

would closed,

the

free.

recur. only

was perpatient In an-

2 years recurrence

his

underwent

(patient 5) conof the treatment each

of the

but

after

three

assessment

of the

first

more

less than anastomosis

did

onrhage

not

dilation, non ed at clinical The diameter

Good Good Unknown Good

good, the funcalso im-

occur

during

or after

were infections follow-up. of the strictures

reportbe-

fore dilation was 1-20 mm (mean, 7.2 mm). Balloon dilation produced a new bowel caliber of 15-38 mm (mean, 22.2 mm). In 14 procedures in a single

was

used,

15-,

20-,

on 30-mm

the

stricture

was

bal-

fully

dilated

to

to the rated maximum diameten of the balloon; in the remaining 1 1 procedures, the maximal diameter of the single balloon or two balloons combined could not be achieved be-

cause

of rigid

patient

dune

in which

cliniwas

used tune

simultaneously

improved

dilation

6

Good

30 20+20 20 30

proved to good after two repeat procedunes. In one patient (patient 6) who underwent three dilation pnocedunes, each with good short-term mesuits, symptoms of obstruction recunred 19 and 60 weeks after the first and second procedures, respectively. In this patient, no symptoms have mecunned 5 weeks after the third dilation; however, the long-term followup after this last procedure has been relatively short. The interval between dilation procedures in the patients who underwent multiple procedunes was 1-60 weeks (mean, 8.1 weeks). Complicating leaks or hem-

which

five

after

25 30 20 30

7

1.25 14* 24 1.5

14 months.

for

from fain to good. In another (patient 2) in whom the initial

#{149}

20+20

1 1 2 3

at anastomosis

who

be

478

20

30

loon

patient

effectiveness

20

2

symptom

procedures the results

cal

4

10

20 ...

stricture.

procedures,

Unknown Unknown

18

surgeon

dilation sidemed two

20 20

3

Hartmann pouch performed after dilation showed no

poor

20 20

8

other patient (patient 8), who underwent a diverting colostomy, the functional effect of dilating the stnictured nectosigmoid anastomosis could not be determined because colon continuity was never reestablished due to the relatively poor clinical condition of the patient. However, a barium enema study of the blind rectosigmoid

One

Unknown

13 4

Unknown

that the stricture the ileostomy was

of the

Unknown

20

20

was therefore repeated at regular intervals at the

remained

Unknown

20

20

20

one more dilation procedure formed, and subsequently has

20

20

20

total

of the

feared After

20

1 1

20

cenative colitis and a diverting ileostomy had been created to protect the healing anastomosis. In this patient, the clinical effectiveness of the dilation could not be determined as long as the ileostomy diverted the intestinal stream away from the anastomosis. Dilation empirically

Follow-up after Last Dilation (mo)

Dilation after 1 Week

3

of

Length

of

4

1 1 2 3 4 5 1 2 3 1 1 1

structed

Clinical Results

6

4 5

recurrence

Maximum Balloon Size Used (mm)

at End of Dilation (mm)

at Follow-up

Findings

3

1

Tumor

and

2

3

7 8 9

Procedures,

Maximum Stricture Diameter

6

3

6

between

7 9 1 2

2

Intervals

be enlarged

scarring. two

In no proce-

balloons

could to the

were

the

diameter

stnicof

both fully distended balloons, though the maximum diameter tamed was always greaten than of either balloon alone.

alobthat

DISCUSSION Rectal strictures most commonly develop after surgical procedures that include construction of an anastomosis. The most common operation leading to a rectal stricture is low antenon resection with end-to-end anastomosis. A stricture develops when inflammation and scan fonmation occur, most often in association

with

partial

breakdown

of the

anas-

tomosis (1). In patients with an ileoanal pull-through, the entire colon and rectal mucosa are resected, followed by construction of an endorectal ileoanal anastomosis. In these patients, the ileum may narrow when the rectal cuff around it shrinks, creating a stricture. A stricture is more

likely

to occur

is diverted

ostomy.

by

Most

when a proximal

the

fecal

stream

intestinal

anastomotic

strictures

disappear spontaneously months to 1 year (1); may persist and cause

oven however, obstructive

symptoms. can also

of the

Strictures

6 some

rectum

occur as a complication of madiation therapy (2), bowel ischemia (3), or inflammation (4,9). A number of treatments have been

reported

for managing

symptomatic February

1991

rectal strictures. Conservative therapies such as stool softeners, bulkforming laxatives, or enemas have been used to alleviate symptoms (10). In patients with more severe complaints, dilation has been achieved by a variety of methods. Digital dilation has been employed to stretch low rectal strictures within the reach of the finger (10). For more proximal

of the

longitudinal

demonstrated

shearing by

the

force

postdilation

is re-

latons (14), or surgery (9) have been used. Recently, the use of balloon cathetens to dilate rectal strictures has been reported (15,16). In the reported

lapse-free interval, which is about six times longer after balloon dilation than after bougienage of esophageal strictures (18). Another advantage of use of a balloon is that the dilation pressure can be monitored and controlled with an in-line pressure gauge. Also, balloon dilation produces less discomfort for the patient because it usually requires only a single passage of a small catheter with a collapsed balloon, while bougienage requires several exchanges for progressively larger dilatons. In all of our patients, our goal was to dilate the rectal stricture to an optimal diameter in a single session if it was considered safe to do so. In most cases dilation was performed with a

cases,

single

strictures,

instruments

such

as sig-

moidoscopes, rubber bougies (10), Hegar metal dilatons (1), Foley catheten balloons (1 1), specially designed stricture scopes (12), other metal dilatons

(13),

Eden-Puesto

the

esophageal

procedure

was

di-

performed

under endoscopic control. However, in our patients, fluonoscopy was used to guide the balloon dilation. Fluonoscopically guided dilation has advantages oven blindly performed or endoscopically controlled procedures. Fluoroscopy allows visualization of the stricture as well as the gut proximal and distal to the site of narrowing. In contrast to bougienage, which usually

is done

blindly,

fluoroscopy

permits visual control of the entire balloon catheter during its placement and inflation. Even when endoscopy is used balloon,

to guide a dilating the operator can

bougie on only visual-

ize the gut segment between the end of the scope and the entrance to the stricture until the dilator enters the stricture. Thereafter the instrument is passed

forward

without

visual

con-

trol, and the tip of the dilator can perforate the gut. Balloon dilation offers advantages over bougienage. The most impontant is that the balloon remains stationary during inflation and applies only radially directed forces against the gut wall. Forces are maximal at the narrowest point-the stricture itself. In contrast, a bougie must exert considerable longitudinal force on the wall to generate an effective radial force on the stricture. This longitudinal shearing force increases the risk of gut rupture ry, which can lead

the

stenosis

Volume

178

(17).

and mucosal to recurrence

The

Number

#{149}

adverse

2

injuof

effect

20-mm

preceded smaller

balloon,

during balloons

the

occasionally

same

of the

of our

patients.

3.

procedures.

4.

5.

6.

7.

We thank and Kelly Powell for secretarial ol Chowdhry, PhD, for editorial Ursula Bunch for the photography.

intestinal

in

ischemia:

ing

8.

treatment

by

bal-

loon catheter dilation. Radiology 1983; 149:469-472. Rodgers K, Hughes LE. Rectal strictures associated with intra-uterine contraceptive device. Br J Sung 1982; 69:151-152. Tonkin ILD, Bejlland JC, Hunter TB, Capp MP, Firor H, Enmocilla R. Spontaneous resolution of colonic strictures caused by necnotizing enterocolitis: therapeutic implications. AJR 1978; 130:1077-1081. de Lange EE, Shaffer HA. Anastomotic strictures of the upper gastrointestinal tract: results of balloon dilation. Radiology 1988; 167:45-50. McLean GK, Cooper CS, Hartz WH, Burke

5G.

balloon dilation tunes. I. Technique procedural

Radiologically of gastrointestinal and factors

success.

guided stnicinfluenc-

Radiology

1987;

165:35-40. Tegtmeyer

CJ, Kellum CD, Knon IL, RM. Percutaneous transluminal angioplasty in the region of the aortic bifurcation: the two-balloon technique with results and long-term follow-up study. Radiology 1985; 157:661-665. Miles RPM. Benign strictures of the rectum. Ann R CoIl Sung Eng 1972; 50:310311. Goldberg SM, Gordon PH, Nivatvongs 5, eds. Essentials of anorectal surgery. Philadelphia: Lippincott, 1980; 337. Mazier WP. A technique for the management of low colonic anastomotic strictunes. Dis Colon Rectum 1973; 16:113-116. Dencker H, Johansson JI, Norryd C, Tranberg KG. Dilator for treatment of strictures in the upper part of the rectum and the sigmoid. Dis Colon Rectum 1973; 16:550-552. Hood K, Lewis A. Dilator for high rectal strictures. Br J Sung 1986; 73:633. Hunt RH, Waye JD, eds. Colonoscopy. London: Chapman & Hall, 1981; 371-372. Brower RA, Freeman LD. Balloon catheter dilation of a rectal stricture. Gastrointest Endosc 1984; 30:95-97. Skreden K, Wiig JN, Myrvold HE. Salloon dilation of rectal strictures. Acta Chin Scand 1987; 153:615-617. McLean GK, LeVeen RF. Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage. Radiology 1989; 172:983-986. Starck E, Paolucci V. Onneken M, Herzer

Mentzer

9.

10.

11.

12.

Clinical

However,

Goligher JC. Survey of the anus, rectum and colon. 4th ed. London: Bailliere Tindali, 1980; 606. Green N, Goldberg H, Goldman H, Lombardo L, Skaist L. Severe rectal injury following radiation for prostatic cancer. Urol 1984; 131:701-704. Ball WS, Seigel RS, Goldthorn JF, Kosloske AM. Colonic strictures in infants following

of progressively

some cases the follow-up period was relatively short, and the ultimate effect of the dilation procedures has yet to be determined. Also, no objective means of measuring the longterm effect of dilation on the stenoses was used, as follow-up contrast matenial studies of the strictures or endoscopy was not performed in most cases. Nevertheless, our results mdicate that fluoroscopically guided balloon dilation is safe and can be an effective procedure for the treatment of rectal strictures. U Acknowledgments:

2.

by

follow-up surveys after the last dilation revealed that obstructive symptoms indicative of significant strictune recurrence did not develop in any

1.

DR. Meranze

session

larger diameter. In the cases in which we believed further stretching could be safely performed, a 30-mm pneumatic balloon on pained hydrostatic balloons were used to achieve a langen diameter. A problem with the latten technique is that stretching occurs predominantly in one direction, as the two balloons together form an oval shape; however, in our patients, the final shape of the stricture caliber did not appear to have an effect on the clinical results. We encountered no complications as a result

References

13. 14. 15.

16.

17.

18.

M, McDermott

J.

Konsenvativen

lung von oesophagusstenosen katheter. Dtsch Med Wochenschr 110:1025-1030.

behandmit

balloon 1985;

Diana Bowman assistance; Carassistance; and

Radiology

479

#{149}

Rectal strictures: treatment with fluoroscopically guided balloon dilation.

The authors performed 25 fluoroscopically guided balloon dilation procedures in nine patients with rectal strictures. In all cases, the stricture deve...
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