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}