264
Journal of the Royal Society of Medicine Volume 84 May 1991
Treatment of colonic anastomotic strictures with 'through the scope'-balloon dilators
M D Dinneen MB FRcsi R W Motson MS FRCS Hospital, Turner Road, Colchester, Essex C04 5JL
Department of Surgery, Colchester General
Keywords: colonic anastomotic stricture; balloon dilation
Summary Stricture occurs in 1.2-4.2% of colonic anastomoses. Symptomatic strictures have previously been treated by resection and re-anastomosis and more recently by radiographically guided dilatation by a modified Seldinger technique. This paper describes the endoscopic balloon dilatation offive symptomatic cases and three asymptomatic cases. Eight patients underwent balloon dilatation of colonic anastomotic strictures. Four patients had no symptoms post dilatation and the strictures remained patient on follow-up endoscopy. All the remaining patients required re-dilatation at approximately 2 months. One of these patients underwent dilatation but remained symptomatic, the dilatation was repeated and a colonic perforation occurred at this time. Of the other three, two continue to be followed up, and are well and one patient died of disseminated malignancy. Balloon dilatation with 'through the scope' dilators is a simpler technique than radiologically guided dilatation. These early results suggest that endoscopic dilatation may avoid further surgery in some patients with anastomotic stricture. Introduction Anastomotic strictures occur in 1.2-4.2% of all patients undergoing colonic resection'. They are reported to be more common with two layer than with single layer or stapled anastomoses2. Symptomatology correlates poorly with stricture diameter and some strictures 1 cm in diameter may be completely
asymptomatic3. Benign colonic anastomotic strictures may result from ischaemia, haemorrhage or leakage at the suture line or recurrent Crohn's disease. Inflammation and
fibrosis develop as a consequence. There may be a Based on paper prolonged active fibrotic process and it may be that presented to early endoscopic intervention could break this cycle. Section of Although some early anastomotic strictures seem Coloproctology to resolve spontaneously, of those that remain Anglo-Swiss Meeting, symptomatic and where conservative measures fail April 1990 re-section or some other abdominal procedure may have to be considered. Balloon dilatation offers a less radical solution. The first description ofthe clinically successful use of balloon dilatation catheters appeared in the German literature in 1974, when Gruntzig described balloon dilatation of atheromatous narrowings of the iliac, femoral and popliteal vessels4. The technique was first applied to the gastrointestinal tract in 1980 when London treated oesophageal strictures in this manner5. In 1983, Ball dilated ischaemic strictures of infant colons with balloon catheters, using a Seldinger technique under fluoroscopic control6. Brower and Freeman in 1984 described balloon dilatation of a large bowel stricture in an adult7.
Materials and methods The technique employed utilizes Microvasive Rigiflex"' 'through the scope' balloon dilatation catheters. Following standard colonoscopic preparation the stricture is visualized and the balloon catheter is passed through it. Colonic balloon dilatation catheters are available in six sizes, 30, 36, 45, 54, 60 and 75 French gauge (Fr.) (the latter two are referred to as rectosigmoid dilators). The balloon length is 8 cm and the shaft length is -180 cm. The pressure required to inflate the balloon decreases as the diameter increases, the 30 Fr. catheter requires 55 psi (pounds per square inch) whereas the 54 Fr. requires 35 psi. Once in position across the stricture the balloon is
Table 1. Patients, primary pathology, anastonotic site and mode of diagnosis Patient No.
Age
Sex
1 2 3
59 71 29
F F
4 5 6 7 8
39 80 77 73 49
M
M M F F
M
Primary pathology
Anastomosis* Site
Diverticular disease Adenocarcinoma Crohn's disease
Vicryl Stapled Dexon
Adenocarcinoma Adenocarcinoma Diverticular disease Adenocarcinoma Adenocarcinoma
Vicryl Vicryl Dexon Vicryl Vicryl
*All handsewn anastomoses fashioned in one layer **Refers to the distance of the anastomosis from the anal verge
Diagnosis
10 cm** Ileocolic trans.
Radiological Endoscopic Radiological
colon Sigmoid
Radiological
8 cm**
Clinical
Ileorectal Sigmoid
Endoscopic Endoscopic Endoscopic
Sigmoid
12 cm**
0141-0768/91/
050264-03/$02.00/0 © 1991 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 84 May 1991
inflated with water for a period of one minute. We generally use the 54 French gauge balloon dilatation catheter.
Results A brief description of the first eight patients, in whom we have performed this technique, follows (see Table 1). Patient 1 A 59-year-old man presented with an acute abdomen. At laparotomy he was found to have peritonitis, secondary to a perforated paracolic abscess. He underwent a Hartmann's procedure. Four months later this was reversed, the anastomosis was fashioned with Vicryl in one layer. One month after this operation he presented with the symptoms and signs of subacute obstruction. Barium enema demonstrated an anastomotic stricture. He underwent 'through the scope' (TS) balloon dilatation and this resulted in a complete resolution of his symptoms. Further endoscopy at 6 and 18 months was normal and the patient was discharged. Patient 2 A 71-year-old woman presented acutely with a large bowel obstruction. An extensive rectal carcinoma was discovered. She underwent an anterior resection with on-the-table lavage and primary stapled anastomosis. She remained asymptomatic for 15 months and then presented again with large bowel obstruction. At endoscopy she was found to have an anastomotic stricture at 10 cm; TTS balloon dilatation was performed immediately and her symptoms resolved. Two months later she again developed large bowel obstruction as the stricture had recurred. Repeat TTS dilatation was performed and again her symptoms resolved completely. She remained asymptomatic until her death 14 months later from liver secondaries. Patient 3 The third patient was a 29-year-old woman who underwent a limited ileo-caecal resection and transverse colectomy for Crohn's disease. Both anastomoses were fashioned in one layer with Dexon. Two months postoperatively her symptoms recurred and barium studies demonstrated a tight colonic stricture and a less tight ileocolic stricture. TTS balloon dilatation was carried out on the distal stricture, after this however it was not possible to advance the colonoscope through the stricture. There was only a minimal improvement in the patient's symptoms. Six months later repeat ¶11S dilatation was performed, this time on both strictures the larger 75 French gauge balloon dilatator was used. Shortly after the procedure the patient developed abdominal pain. On examination she was found to have peritonism and at laparotomy was discovered to have a perforation at the site of the colonic stricture. A strictureplasty was performed and she is now asymptomatic 6 months later.
Patient 4 A 39-year-old man with a Dukes C carconoma ofthe sigmoid colon had had a sigmoid colectomy from which he had made an uneventful recovery. His anastomosis was fashioned in one layer with Vicryl. At routine colonoscopy, performed 10 months later, it was noted that, although the patient was asymptomatic, it was not possible to pass the scope through the anastomosis. Multiple biopsies taken at this time were found to be benign. A barium enema demonstrated a tight anastomotic stricture. TTS dilatation was performed successfully and a full colonosoopy was normal. Two months later he was re-endoscoped, there was a partial recurrence of the stricture and further TTS dilatation was carried out. The patient remains asymptomatic 12 months later. Patient 5 An 80-year-old man who presented with blood and mucous per rectum underwent a low anterior resection of rectum for a Dukes A carcinoma, once again the anastomosis was
fashioned in one layer with Vicryl. At routine follow-up 13 months later it was noted that the anastomosis only just admitted a fingertip. At this time the patient was asymptomatic and biopsies taken from around the anastomotic site were benign. Four months later, he presented acutely with colicky lower abdominal pain. Now the anastomosis no longer admitted a fingertip. Once again biopsies were benign and the patient underwent 1TS dilatation with the 75 French gauge balloon dilatation catheter. The patient was asymptomatic at outpatient follow-up 6 weeks later.
Patient 6 A 77-year-old woman, having had a 30 year history of symptomatic diverticular disease, underwent a sub-total colectomy with ileo-rectal anastomosis (Dexon: one layer) in 1986. Her anastomosis was subsequently damaged at the time of abdominal hysterectomy, but this was recognizd and repaired at the time of surgery. Since this procedure she complained of diarrhoea (six to fourteen times per day). She was otherwise well. Flexible sigmoidoscopy revealed an anastomotic stricture. TTS balloon dilatation was performed and her symptoms resolved. Patient 7 A sigmoid colectomy was performed, for a villous adenocarcinoma, on a 73-year-old woman (one layer anastomosis with Vicryl). Postoperatively she made an uncomplicated recovery. At routine follow-up colonoscopy 18 months later it was found impossible to pass the instrument through the anastomosis. Multiple biopsies were taken at this time and TTS dilatation was performed, following which a full colonoscopy was undertaken. Histology failed to reveal any recurrent malignancy. The patient remains well. Patient 8 A 49-year-old man on routine follow-up, 3 years after anterior resection of the rectum (one layer anastomosis with Vicryl) for a Dukes C adenocarcinoma, was noted to have an anastomotic stricture at 12 cm. This was confirmed on barium enema; it was not possible to outline the colon proximal to the stricture with barium. The stricture was dilated as described above and once again histology was benign. While remaining asymptomatic partial recurrence of the stricture required further dilatation at three months. The patient remains under review.
Discussion In a national survey of endoscopists carried out in 1986 Kozarek collected iniformation on 64 balloon dilatations of colonic strictures of varied aetiology. These were exclusively performed by the Seldinger technique predominantly under fluoroscopic control. He noted that when the balloon diameter was less that 40 Fr, less than than 50% of the patients benefited, increasing the balloon diameter to 51 Fr,. or greater lead to over, 90% symptomatic improvement8. In an earlier paper the same author recommended that for an effective hydrostatic force to be generated pressures of the order of 20-60 psi be maintained for periods of 15-60 a9. The advantages of this technique are numerous. It allows the endoscopist direct visualization thereby maximizing his control over the procedure. As the balloon is inflated radial pressures are generated, as opposed to the longitudinal and shearing forces of traditional bouginage. In theory this should decrease the risk of viscous perforation. The balloon itself is made of an inelastic polymer and can only be inflated to its designed maximum diameter. Excess pressure does not cause an increase in balloon diameter as one would occur with a latex balloon. The procedure is minimally invasive and results in a much shorter hospital stay than operative rsection of the stricture.
265
266
Journal of the Royal Society of Medicine Volume 84 May 1991
Most importantly it appears to be an effective and relatively safe procedure though it is not without risk. The complications of the technique are bowel perforation, as seen above. In Kozareks series there were three perforations in 64 dilatations and two of these occurred at anastomotic strictures. Significant haemorrhagic complications were reported in two of the 64 cases8. Colonoscopic complications such as adverse drug reactions, aspiration and cardiorespiratory events must also be mentioned. In conclusion, this is a preliminary report on a new technique. We believe that TTS balloon dilatation of colonic anastomotic strictures is an effective treatment and has a role in the treatment of patients with both symptomatic and asymptomatic strictures that would otherwise require resection. References 1 Thies E, Lange V, Miersch WD. Perianal dilatation of a postsurgical colonic stenosis by means of a flexible endoscope. Endoscopy 1983;15:327-8 2 Langer S. Colon Nachttechnik: Einreihige Nacht. Langenbecks Arch Chi 1978;347:601
Some recent books Biology Information Processing in Medical Imaging, (Progress in Clinical and Biological Research, Volume 363). Douglas A Ortendahl, Jorge Llacer (pp 584, $99.95) ISBN 0471-56064-2, New York: Wiley-Liss 1990 Noninvasive Techniques in Cell Biology, (Modern Cell Biology, Volume 9). J. Kevin Foskett, Sergio Grinstein (pp 423, $79.95) ISBN 0471-56809-0, New York: Wiley-Liss 1990. ENT A Companion to ENT for Medical Students and General Practitioners. Peter Ellis (pp 116, £3.50) Cambridge: Ellis 1990.
Geriatrics Hearing Loss in the Elderly (The Bloomsbury Series in Clinical Science) Sava Soucek and Leslie Michaels (pp 111, £39.50) ISBN 3-540-19631-5, London: Springer-Verlag 1990. Neurology Advances in Neural Regeneration Research (Neurology and Neurobiology, Volume 60). Fredrick J Seil (pp 422, $85.00) ISBN 0471-56849-X, New York: Wiley-Liss 1990.
Orthopaedics Implant Bone Interface. John Older (pp 177) ISBN 3-54019638-2, London: Springer-Verlag 1990. Revision Surgery in Total Hip Arthroplasty. B M Wroblewski (pp 236) ISBN 3-540-19618-8, London: Springer-Verlag 1990.
3 Mazier WP. A technique for the management oflow colonic anastomotic strictures. Dis Colon Rectum 1973;16:113-6 4 Gruntzig AR, Hopff H. Perkutane Rekanalisation chrnescher Arterieller verschlusse mit einem neuen Dilatation-Katheter. Deutsche Medizinische Wochenschrift 1974;99:2502-5 5 London RL, Trotman BW, DiMarino AJ, Olega JA, Freiman DB, Ring EJ, Rosato EF. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1980;80:173-5 6 Ball WS, Seigel RS, Goldthorn JF, Kosloske AM. Colonic strictures in infants following intestinal ischaemia. Radiology 1983;149:469-72 7 Brower RA, Freeman LD. Balloon catheter dilation of a rectal stricture. Gastrointest Endosc 1984;30:95-7 8 Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 1986;32:15-19 9 Kozarek RA. Endoscopic Gruntzig balloon dilation of gastrointestinal stenoses. J Clin Gastroenterol 1984; 6:401-7
(Accepted 3 January 1991. Correspondence to Mr R W Motson)
Paediatrics Advances in Developmental and Behavioural Pediatrics (Volume 9). Mark L Wolraich, Donald K Routh (pp 224, £40.00) ISBN 1-85302-071-0, London: Jessica Kingsley 1990. Annals ofChild Development (Volume 7). Ross Vasta (pp 180, £27.50) ISBN 1-85302-081-8, London: Jessica Kingsley 1990. Genetics of Pattern Formation and Growth Control (48th Symposium of the Society for Developmental Biology). Anthony P Mahowald (pp 243, $89.95) ISBN 0471-56821-X, New York: Wiley-Liss 1990. Hematologic Disorders in Maternal-Fetal Medicine. Murray M Bern and Fredric D Frigoletto Jr (pp 709, $149.95) ISBN 0-471-56213-0, New York: Wiley-Liss 1990. Paediatric Pocket Companion. Michael D Harari (pp 422, £14.50) ISBN 0-7506-1001-8, Guildford: ButterworthHeinemann 1990. The Embryo Normal and Abnormal Development and Growth. Michael Chapman, Gedis Grudzinskas and Tim Chard (pp 263, £60.00) ISBN 3-540-19630-7, London: SpringerVerlag 1990.
Toxicology Handbook of Pesticide Toxicology (General Principles, Volume 1; Classes of Pesticides, Volume 2; Classes of Pesticides, Volume 3). Wayland J Hayes Jr and Edward R Laws Jr (pp 1576, $395.00) ISBN 0-12-334161-2, 0-12-334162, 0-12-334163-9, California: Academic Press 1991.
Veterinary science A Great British Veternarian Forgotten: James BeartSimmonds 1810-1904. Iain Pattison (pp. 168, £16.00) ISBN 0-85131491-0, London: J A Allen 1990.
Journal of the Royal Society of Medicine Volume 84 May 1991
Treatment of colonic anastomotic strictures with 'through the scope'-balloon dilators
M D Dinneen MB FRcsi R W Motson MS FRCS Hospital, Turner Road, Colchester, Essex C04 5JL
Department of Surgery, Colchester General
Keywords: colonic anastomotic stricture; balloon dilation
Summary Stricture occurs in 1.2-4.2% of colonic anastomoses. Symptomatic strictures have previously been treated by resection and re-anastomosis and more recently by radiographically guided dilatation by a modified Seldinger technique. This paper describes the endoscopic balloon dilatation offive symptomatic cases and three asymptomatic cases. Eight patients underwent balloon dilatation of colonic anastomotic strictures. Four patients had no symptoms post dilatation and the strictures remained patient on follow-up endoscopy. All the remaining patients required re-dilatation at approximately 2 months. One of these patients underwent dilatation but remained symptomatic, the dilatation was repeated and a colonic perforation occurred at this time. Of the other three, two continue to be followed up, and are well and one patient died of disseminated malignancy. Balloon dilatation with 'through the scope' dilators is a simpler technique than radiologically guided dilatation. These early results suggest that endoscopic dilatation may avoid further surgery in some patients with anastomotic stricture. Introduction Anastomotic strictures occur in 1.2-4.2% of all patients undergoing colonic resection'. They are reported to be more common with two layer than with single layer or stapled anastomoses2. Symptomatology correlates poorly with stricture diameter and some strictures 1 cm in diameter may be completely
asymptomatic3. Benign colonic anastomotic strictures may result from ischaemia, haemorrhage or leakage at the suture line or recurrent Crohn's disease. Inflammation and
fibrosis develop as a consequence. There may be a Based on paper prolonged active fibrotic process and it may be that presented to early endoscopic intervention could break this cycle. Section of Although some early anastomotic strictures seem Coloproctology to resolve spontaneously, of those that remain Anglo-Swiss Meeting, symptomatic and where conservative measures fail April 1990 re-section or some other abdominal procedure may have to be considered. Balloon dilatation offers a less radical solution. The first description ofthe clinically successful use of balloon dilatation catheters appeared in the German literature in 1974, when Gruntzig described balloon dilatation of atheromatous narrowings of the iliac, femoral and popliteal vessels4. The technique was first applied to the gastrointestinal tract in 1980 when London treated oesophageal strictures in this manner5. In 1983, Ball dilated ischaemic strictures of infant colons with balloon catheters, using a Seldinger technique under fluoroscopic control6. Brower and Freeman in 1984 described balloon dilatation of a large bowel stricture in an adult7.
Materials and methods The technique employed utilizes Microvasive Rigiflex"' 'through the scope' balloon dilatation catheters. Following standard colonoscopic preparation the stricture is visualized and the balloon catheter is passed through it. Colonic balloon dilatation catheters are available in six sizes, 30, 36, 45, 54, 60 and 75 French gauge (Fr.) (the latter two are referred to as rectosigmoid dilators). The balloon length is 8 cm and the shaft length is -180 cm. The pressure required to inflate the balloon decreases as the diameter increases, the 30 Fr. catheter requires 55 psi (pounds per square inch) whereas the 54 Fr. requires 35 psi. Once in position across the stricture the balloon is
Table 1. Patients, primary pathology, anastonotic site and mode of diagnosis Patient No.
Age
Sex
1 2 3
59 71 29
F F
4 5 6 7 8
39 80 77 73 49
M
M M F F
M
Primary pathology
Anastomosis* Site
Diverticular disease Adenocarcinoma Crohn's disease
Vicryl Stapled Dexon
Adenocarcinoma Adenocarcinoma Diverticular disease Adenocarcinoma Adenocarcinoma
Vicryl Vicryl Dexon Vicryl Vicryl
*All handsewn anastomoses fashioned in one layer **Refers to the distance of the anastomosis from the anal verge
Diagnosis
10 cm** Ileocolic trans.
Radiological Endoscopic Radiological
colon Sigmoid
Radiological
8 cm**
Clinical
Ileorectal Sigmoid
Endoscopic Endoscopic Endoscopic
Sigmoid
12 cm**
0141-0768/91/
050264-03/$02.00/0 © 1991 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 84 May 1991
inflated with water for a period of one minute. We generally use the 54 French gauge balloon dilatation catheter.
Results A brief description of the first eight patients, in whom we have performed this technique, follows (see Table 1). Patient 1 A 59-year-old man presented with an acute abdomen. At laparotomy he was found to have peritonitis, secondary to a perforated paracolic abscess. He underwent a Hartmann's procedure. Four months later this was reversed, the anastomosis was fashioned with Vicryl in one layer. One month after this operation he presented with the symptoms and signs of subacute obstruction. Barium enema demonstrated an anastomotic stricture. He underwent 'through the scope' (TS) balloon dilatation and this resulted in a complete resolution of his symptoms. Further endoscopy at 6 and 18 months was normal and the patient was discharged. Patient 2 A 71-year-old woman presented acutely with a large bowel obstruction. An extensive rectal carcinoma was discovered. She underwent an anterior resection with on-the-table lavage and primary stapled anastomosis. She remained asymptomatic for 15 months and then presented again with large bowel obstruction. At endoscopy she was found to have an anastomotic stricture at 10 cm; TTS balloon dilatation was performed immediately and her symptoms resolved. Two months later she again developed large bowel obstruction as the stricture had recurred. Repeat TTS dilatation was performed and again her symptoms resolved completely. She remained asymptomatic until her death 14 months later from liver secondaries. Patient 3 The third patient was a 29-year-old woman who underwent a limited ileo-caecal resection and transverse colectomy for Crohn's disease. Both anastomoses were fashioned in one layer with Dexon. Two months postoperatively her symptoms recurred and barium studies demonstrated a tight colonic stricture and a less tight ileocolic stricture. TTS balloon dilatation was carried out on the distal stricture, after this however it was not possible to advance the colonoscope through the stricture. There was only a minimal improvement in the patient's symptoms. Six months later repeat ¶11S dilatation was performed, this time on both strictures the larger 75 French gauge balloon dilatator was used. Shortly after the procedure the patient developed abdominal pain. On examination she was found to have peritonism and at laparotomy was discovered to have a perforation at the site of the colonic stricture. A strictureplasty was performed and she is now asymptomatic 6 months later.
Patient 4 A 39-year-old man with a Dukes C carconoma ofthe sigmoid colon had had a sigmoid colectomy from which he had made an uneventful recovery. His anastomosis was fashioned in one layer with Vicryl. At routine colonoscopy, performed 10 months later, it was noted that, although the patient was asymptomatic, it was not possible to pass the scope through the anastomosis. Multiple biopsies taken at this time were found to be benign. A barium enema demonstrated a tight anastomotic stricture. TTS dilatation was performed successfully and a full colonosoopy was normal. Two months later he was re-endoscoped, there was a partial recurrence of the stricture and further TTS dilatation was carried out. The patient remains asymptomatic 12 months later. Patient 5 An 80-year-old man who presented with blood and mucous per rectum underwent a low anterior resection of rectum for a Dukes A carcinoma, once again the anastomosis was
fashioned in one layer with Vicryl. At routine follow-up 13 months later it was noted that the anastomosis only just admitted a fingertip. At this time the patient was asymptomatic and biopsies taken from around the anastomotic site were benign. Four months later, he presented acutely with colicky lower abdominal pain. Now the anastomosis no longer admitted a fingertip. Once again biopsies were benign and the patient underwent 1TS dilatation with the 75 French gauge balloon dilatation catheter. The patient was asymptomatic at outpatient follow-up 6 weeks later.
Patient 6 A 77-year-old woman, having had a 30 year history of symptomatic diverticular disease, underwent a sub-total colectomy with ileo-rectal anastomosis (Dexon: one layer) in 1986. Her anastomosis was subsequently damaged at the time of abdominal hysterectomy, but this was recognizd and repaired at the time of surgery. Since this procedure she complained of diarrhoea (six to fourteen times per day). She was otherwise well. Flexible sigmoidoscopy revealed an anastomotic stricture. TTS balloon dilatation was performed and her symptoms resolved. Patient 7 A sigmoid colectomy was performed, for a villous adenocarcinoma, on a 73-year-old woman (one layer anastomosis with Vicryl). Postoperatively she made an uncomplicated recovery. At routine follow-up colonoscopy 18 months later it was found impossible to pass the instrument through the anastomosis. Multiple biopsies were taken at this time and TTS dilatation was performed, following which a full colonoscopy was undertaken. Histology failed to reveal any recurrent malignancy. The patient remains well. Patient 8 A 49-year-old man on routine follow-up, 3 years after anterior resection of the rectum (one layer anastomosis with Vicryl) for a Dukes C adenocarcinoma, was noted to have an anastomotic stricture at 12 cm. This was confirmed on barium enema; it was not possible to outline the colon proximal to the stricture with barium. The stricture was dilated as described above and once again histology was benign. While remaining asymptomatic partial recurrence of the stricture required further dilatation at three months. The patient remains under review.
Discussion In a national survey of endoscopists carried out in 1986 Kozarek collected iniformation on 64 balloon dilatations of colonic strictures of varied aetiology. These were exclusively performed by the Seldinger technique predominantly under fluoroscopic control. He noted that when the balloon diameter was less that 40 Fr, less than than 50% of the patients benefited, increasing the balloon diameter to 51 Fr,. or greater lead to over, 90% symptomatic improvement8. In an earlier paper the same author recommended that for an effective hydrostatic force to be generated pressures of the order of 20-60 psi be maintained for periods of 15-60 a9. The advantages of this technique are numerous. It allows the endoscopist direct visualization thereby maximizing his control over the procedure. As the balloon is inflated radial pressures are generated, as opposed to the longitudinal and shearing forces of traditional bouginage. In theory this should decrease the risk of viscous perforation. The balloon itself is made of an inelastic polymer and can only be inflated to its designed maximum diameter. Excess pressure does not cause an increase in balloon diameter as one would occur with a latex balloon. The procedure is minimally invasive and results in a much shorter hospital stay than operative rsection of the stricture.
265
266
Journal of the Royal Society of Medicine Volume 84 May 1991
Most importantly it appears to be an effective and relatively safe procedure though it is not without risk. The complications of the technique are bowel perforation, as seen above. In Kozareks series there were three perforations in 64 dilatations and two of these occurred at anastomotic strictures. Significant haemorrhagic complications were reported in two of the 64 cases8. Colonoscopic complications such as adverse drug reactions, aspiration and cardiorespiratory events must also be mentioned. In conclusion, this is a preliminary report on a new technique. We believe that TTS balloon dilatation of colonic anastomotic strictures is an effective treatment and has a role in the treatment of patients with both symptomatic and asymptomatic strictures that would otherwise require resection. References 1 Thies E, Lange V, Miersch WD. Perianal dilatation of a postsurgical colonic stenosis by means of a flexible endoscope. Endoscopy 1983;15:327-8 2 Langer S. Colon Nachttechnik: Einreihige Nacht. Langenbecks Arch Chi 1978;347:601
Some recent books Biology Information Processing in Medical Imaging, (Progress in Clinical and Biological Research, Volume 363). Douglas A Ortendahl, Jorge Llacer (pp 584, $99.95) ISBN 0471-56064-2, New York: Wiley-Liss 1990 Noninvasive Techniques in Cell Biology, (Modern Cell Biology, Volume 9). J. Kevin Foskett, Sergio Grinstein (pp 423, $79.95) ISBN 0471-56809-0, New York: Wiley-Liss 1990. ENT A Companion to ENT for Medical Students and General Practitioners. Peter Ellis (pp 116, £3.50) Cambridge: Ellis 1990.
Geriatrics Hearing Loss in the Elderly (The Bloomsbury Series in Clinical Science) Sava Soucek and Leslie Michaels (pp 111, £39.50) ISBN 3-540-19631-5, London: Springer-Verlag 1990. Neurology Advances in Neural Regeneration Research (Neurology and Neurobiology, Volume 60). Fredrick J Seil (pp 422, $85.00) ISBN 0471-56849-X, New York: Wiley-Liss 1990.
Orthopaedics Implant Bone Interface. John Older (pp 177) ISBN 3-54019638-2, London: Springer-Verlag 1990. Revision Surgery in Total Hip Arthroplasty. B M Wroblewski (pp 236) ISBN 3-540-19618-8, London: Springer-Verlag 1990.
3 Mazier WP. A technique for the management oflow colonic anastomotic strictures. Dis Colon Rectum 1973;16:113-6 4 Gruntzig AR, Hopff H. Perkutane Rekanalisation chrnescher Arterieller verschlusse mit einem neuen Dilatation-Katheter. Deutsche Medizinische Wochenschrift 1974;99:2502-5 5 London RL, Trotman BW, DiMarino AJ, Olega JA, Freiman DB, Ring EJ, Rosato EF. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1980;80:173-5 6 Ball WS, Seigel RS, Goldthorn JF, Kosloske AM. Colonic strictures in infants following intestinal ischaemia. Radiology 1983;149:469-72 7 Brower RA, Freeman LD. Balloon catheter dilation of a rectal stricture. Gastrointest Endosc 1984;30:95-7 8 Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 1986;32:15-19 9 Kozarek RA. Endoscopic Gruntzig balloon dilation of gastrointestinal stenoses. J Clin Gastroenterol 1984; 6:401-7
(Accepted 3 January 1991. Correspondence to Mr R W Motson)
Paediatrics Advances in Developmental and Behavioural Pediatrics (Volume 9). Mark L Wolraich, Donald K Routh (pp 224, £40.00) ISBN 1-85302-071-0, London: Jessica Kingsley 1990. Annals ofChild Development (Volume 7). Ross Vasta (pp 180, £27.50) ISBN 1-85302-081-8, London: Jessica Kingsley 1990. Genetics of Pattern Formation and Growth Control (48th Symposium of the Society for Developmental Biology). Anthony P Mahowald (pp 243, $89.95) ISBN 0471-56821-X, New York: Wiley-Liss 1990. Hematologic Disorders in Maternal-Fetal Medicine. Murray M Bern and Fredric D Frigoletto Jr (pp 709, $149.95) ISBN 0-471-56213-0, New York: Wiley-Liss 1990. Paediatric Pocket Companion. Michael D Harari (pp 422, £14.50) ISBN 0-7506-1001-8, Guildford: ButterworthHeinemann 1990. The Embryo Normal and Abnormal Development and Growth. Michael Chapman, Gedis Grudzinskas and Tim Chard (pp 263, £60.00) ISBN 3-540-19630-7, London: SpringerVerlag 1990.
Toxicology Handbook of Pesticide Toxicology (General Principles, Volume 1; Classes of Pesticides, Volume 2; Classes of Pesticides, Volume 3). Wayland J Hayes Jr and Edward R Laws Jr (pp 1576, $395.00) ISBN 0-12-334161-2, 0-12-334162, 0-12-334163-9, California: Academic Press 1991.
Veterinary science A Great British Veternarian Forgotten: James BeartSimmonds 1810-1904. Iain Pattison (pp. 168, £16.00) ISBN 0-85131491-0, London: J A Allen 1990.
