Mariane Camargo, MD1, Thaís Reif De Paula, MD2, Scott R Steele, MD1, Conor P Delaney, MD, PhD1, Hermann Kessler1. 1Cleveland Clinic Foundation, 2Columbia University
Anastomotic leakage (AL) is an important complication after colorectal surgery, leading to high rates of morbidity, prolonged hospitalization, and mortality. It often requires further surgery and stoma formation. The aim of this video is to show an option to operative approach of an anastomotic stricture that was developed after an anastomotic leak.
The patient underwent surgery for rectal cancer with a primary anastomosis and no ostomy. On the 6th postoperative day, there was an AL and he was diverted. He subsequently received both adjuvant radiotherapy and chemotherapy. A CT scan and an MRI revealed a presacral mass and complete obliteration of the anastomosis. Ultrasound-guided biopsies were taken from the presacral mass, which did not show any malignancy, but only scar tissue. A Gastrografin enema revealed the rectal stump to be entirely occluded. The patient also had a background history of pulmonary embolism, which had occurred postoperatively and he had been on treatment for about 9 months at that time and then was taken off anticoagulation. He was now very hesitant to undergo a major abdominal and pelvic surgery for resection of the anastomosis and new restoration of the bowel continuity.
Procedure: Simultaneously using a second colonoscope, the afferent loop of the transverse colostomy was scoped towards the proximal side of the anastomotic stricture. The obliterated oral side of the anastomosis was reached after about 65cm. However, the light of the lower colonoscope was transparent and could be identified through the scar stricture. Using a needle knife and electrosurgery, the scar was now stepwise excised first from proximally then from the distal rectal side until an opening was created, which was big enough to protrude a guidewire from proximally towards distally. With the guidewire placed, further excision of the scar was performed using a needle knife. A lumen of about 2 cm was reached. A guide wire was adapted in position and left in place and sutured towards the skin of the abdomen for further potential dilatations before ostomy closure.
A colonoscopy was performed after 3 weeks and showed a patent anastomosis. The stoma was closed and the patient underwent more dilations in the follow-up. After 5 months, a wide open anastomosis could be seen. The patient reported a relief in symptoms.
This case had success in the nonoperative approach to an anastomotic complication and could reduce the morbidity for this patient. The indication should be considered case by case.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95155
Program Number: V204
Presentation Session: Video Loop Day 1
Presentation Type: VideoLoop