What to do with What to do with Anastomotic Anastomotic

StrictureStrictureGustavo Plasencia Gustavo Plasencia

MD, FACS, FASCRSMD, FACS, FASCRS

Anastomotic Stricture Anastomotic Stricture EtiologyEtiology

Factors contributing Factors contributing Obesity Obesity Ischemia Ischemia Radiation TherapyRadiation Therapy DefunctionalizationDefunctionalization Distance from anal vergeDistance from anal verge DehiscenceDehiscence

Anastomotic Stricture Anastomotic Stricture EtiologyEtiology

Factors contributingFactors contributing Insufficient colon preparation Insufficient colon preparation Inadequate blood supply to colonic or rectal Inadequate blood supply to colonic or rectal stumpstump Tension at the anastomosis Tension at the anastomosis Overactive Inflammatory responseOveractive Inflammatory response Separation between the two mucosasSeparation between the two mucosas

Anastomotic StrictureAnastomotic Stricture

Differ Differ

Length Length

Luminal narrowingLuminal narrowing

ThicknessThickness

Time to presentation after the initial Time to presentation after the initial surgerysurgery

Diagnostic and therapeutic inplicationsDiagnostic and therapeutic inplications

Could be irregular, kinked, and fixedCould be irregular, kinked, and fixed

Anastomotic StenosisAnastomotic Stenosis

CategoriesCategories 0 no evidence of stenosis0 no evidence of stenosis 1 endoscopic or radiologic 1 endoscopic or radiologic

stenosis no symp.stenosis no symp. 2 symptoms requiring endoscopic 2 symptoms requiring endoscopic

dilatationdilatation 3 symptoms requiring surgical 3 symptoms requiring surgical

corrections corrections

Anastomotic StenosisAnastomotic Stenosis

SymptomsSymptoms Constipation (bm < 3 times per Constipation (bm < 3 times per

wk)wk) Abdominal pain (> 1 h 3 times a Abdominal pain (> 1 h 3 times a

day)day) Increased defecation (> 4 times a Increased defecation (> 4 times a

day)day) IncontinenceIncontinence

Predictive Factors of Stenosis after Predictive Factors of Stenosis after Stapled Colorectal AnastomosisStapled Colorectal Anastomosis

Prospective analysis of 179 patientsProspective analysis of 179 patients Anastomotic stricture defined as the Anastomotic stricture defined as the

inability to pass a rigid sigmoidoscope inability to pass a rigid sigmoidoscope through the anastomosisthrough the anastomosis

Mean age 59.3 years (20-91) 85females, Mean age 59.3 years (20-91) 85females, 94males94males

Cancer 59% of patients Cancer 59% of patients Stenosis 36 patients (21%) Stenosis 36 patients (21%)

Bannura et al: WJSurg Sept. Bannura et al: WJSurg Sept. 2004 2004

Predictive Factors of Stenosis after Predictive Factors of Stenosis after Stapled Colorectal AnastomosisStapled Colorectal Anastomosis

Prospective analysis of 179 patientsProspective analysis of 179 patients Parameters studyParameters study

Age, Sex,Indications for Surgery,Height of the Age, Sex,Indications for Surgery,Height of the Anastomosis,Size of Circular Anastomosis,Size of Circular Stapler,Type ofStapler,Type of

Circular Stapler,Type of Anastomosis,(single Circular Stapler,Type of Anastomosis,(single vs doble),Proximal Stoma,Technical vs doble),Proximal Stoma,Technical intraoperative defect,Complication with intraoperative defect,Complication with anastomotic fistula anastomotic fistula

Bannura et al: WJSurg Sept. 2004 Bannura et al: WJSurg Sept. 2004

What to do with What to do with Anastomotic Anastomotic

Strictures.Predictive Strictures.Predictive factors of stenosisfactors of stenosis Prospective analysis of 179 patientsProspective analysis of 179 patients

Anastomotic stricture defined as the inability to Anastomotic stricture defined as the inability to pass a rigid sigmoidoscope through the pass a rigid sigmoidoscope through the anastomosisanastomosis

Mean age 59.3 years (20-91) 85females, Mean age 59.3 years (20-91) 85females, 94males94males

Cancer 59% of patients Cancer 59% of patients Stenosis 36 patients (21%) Stenosis 36 patients (21%) Endoscopic dilatation required in 8 pts. (4.5%)Endoscopic dilatation required in 8 pts. (4.5%)

Bannura et al; WJSurg. Sept. Bannura et al; WJSurg. Sept. 20042004

Predictive Factors of Stenosis after Predictive Factors of Stenosis after Stapled Colorectal AnastomosisStapled Colorectal Anastomosis

Prospective analysis of 179 patientsProspective analysis of 179 patients

Stenosis Affects 20% of the pt’s less than 5% Stenosis Affects 20% of the pt’s less than 5% need any treatment need any treatment

Gender male patients Gender male patients

Time interval between surgery and Time interval between surgery and endoscopic evaluationendoscopic evaluation

This complication depends on the process of This complication depends on the process of cicatrization which individual and cicatrization which individual and unpredictable Bannura et al: unpredictable Bannura et al: WJSurg Sept. 2004 WJSurg Sept. 2004

What to do with What to do with Anastomotic Strictures?Anastomotic Strictures?

Prospective study on 68 patients, 22 (32%) Prospective study on 68 patients, 22 (32%) post-operative symptoms of anastomotic post-operative symptoms of anastomotic stenosis.stenosis.

12 (17.6%) needed dilatation12 (17.6%) needed dilatation median diameter of stenosis 7mmmedian diameter of stenosis 7mm 8 patients, one session8 patients, one session 3 patients, two sessions3 patients, two sessions 1 patient, three sessions 1 patient, three sessions

Ambrosetti, et al DC&R, May 2008Ambrosetti, et al DC&R, May 2008

What to do with What to do with Anastomotic StricturesAnastomotic Strictures

Therapeutic OptionsTherapeutic Options

Transanal Dilataion: manual/bougieTransanal Dilataion: manual/bougie

Microwave coagulation therapyMicrowave coagulation therapy

Transanal incision with argon laserTransanal incision with argon laser

Plasma coagulation therapyPlasma coagulation therapy

TransanalTransanal ballon dilatationballon dilatation

Stapled revision of Stapled revision of complete colorectal complete colorectal

anastomotic obstructionanastomotic obstruction General anesthesia in the modified General anesthesia in the modified

lithotomy positionlithotomy position Laparotomy and the stictured Laparotomy and the stictured

anastomosis identifiedanastomosis identified 2cm longitudianal colotomy to place 2cm longitudianal colotomy to place

anvil of a 29 mm circular stapleranvil of a 29 mm circular stapler Base of instrument placed through the Base of instrument placed through the

rectum and spike is advanced under rectum and spike is advanced under direct vision through the strictured direct vision through the strictured areaarea

Stapled revision of Stapled revision of complete colorectal complete colorectal

anastomotic obstructionanastomotic obstruction The anvil is then placed in the proximal The anvil is then placed in the proximal

colon via the colotomy and connected to colon via the colotomy and connected to the spikethe spike

The stapler is fired, excising the The stapler is fired, excising the stricture completelystricture completely

Sigmoidoscopy is conducted to confirm Sigmoidoscopy is conducted to confirm the integrity of the anastomosis and the integrity of the anastomosis and adequate lumen adequate lumen R.McKee; et al. A J of Surgery R.McKee; et al. A J of Surgery 20082008

Transanal Treatment of Strictured Transanal Treatment of Strictured Rectal Rectal Anastomosis with a Circular Anastomosis with a Circular

Stapler DeviceStapler Device General anesthesia patient in lithotomy General anesthesia patient in lithotomy

positionposition Anvil introduced proximal to the stricture Anvil introduced proximal to the stricture

with a long clampwith a long clamp The base of the instrument pass through the The base of the instrument pass through the

rectumrectum Introduction placement and tightening of the Introduction placement and tightening of the

stapler perform under fluoroscopic controlstapler perform under fluoroscopic control Final result, check with gastrographin Final result, check with gastrographin

contrastcontrast

Transanal Treatment of Transanal Treatment of Strictured Rectal Strictured Rectal

Anastomosis Anastomosis with a with a Circular Stapler DeviceCircular Stapler Device 3 patients 3 patients

No complicationsNo complications Discharge home, first post-operative dayDischarge home, first post-operative day No recurrence of stricture at 8, 12 and No recurrence of stricture at 8, 12 and

14 months14 months

M. Pabst; et alM. Pabst; et al

Digestive Surgery Digestive Surgery

March 2007 March 2007

Results of Reoperations Results of Reoperations in Colorectal in Colorectal

Anastomotic StricturesAnastomotic Strictures Study of 27 patientsStudy of 27 patients 78% of pt’s had post-operative leak78% of pt’s had post-operative leak Median time between surgery and diagnosis Median time between surgery and diagnosis

7.2 months (1-24 months)7.2 months (1-24 months) Locations at a mean distance 9.5 cm (4-15 Locations at a mean distance 9.5 cm (4-15

cm)cm) Surgery performed 7 colorectal anastomosis Surgery performed 7 colorectal anastomosis

and 20 coloanal anastomosisand 20 coloanal anastomosis Intestinal continuity restored in all casesIntestinal continuity restored in all cases

Schlegel; et al DC&R Oct. 2001Schlegel; et al DC&R Oct. 2001

Efficacy and Safety of Endoscopic Efficacy and Safety of Endoscopic Balloon Dilation of Benign Strictures Balloon Dilation of Benign Strictures

after Oncologic Anterior Rectal after Oncologic Anterior Rectal ResectionResection

24 Patients24 Patients

Dilatation using through the scope balloon Dilatation using through the scope balloon technique technique

No procedure related complicationsNo procedure related complications

The mean number of sessions required was The mean number of sessions required was 2.3 2.3

No relation between sessions and recurrenceNo relation between sessions and recurrence

Dilatation successful in 22 patientsDilatation successful in 22 patients

Araujo and Costa; SLEPT Dec. 2008Araujo and Costa; SLEPT Dec. 2008

Stapled revision of Stapled revision of complete colorectal complete colorectal

anastomotic obstructionanastomotic obstruction General anesthesia in the modified General anesthesia in the modified

lithotomy positionlithotomy position Laparotomy and the stictured Laparotomy and the stictured

anastomosis identifiedanastomosis identified 2cm longitudianal colotomy to place 2cm longitudianal colotomy to place

anvil of a 29 mm circular stapleranvil of a 29 mm circular stapler Base of instrument placed through the Base of instrument placed through the

rectum and spike is advanced under rectum and spike is advanced under direct vision through the strictured areadirect vision through the strictured area

Anastomotic StrictureAnastomotic Stricture

Striture DilatationStriture Dilatation

Reinforced AnastomosisReinforced Anastomosis

Perforated Stricture Perforated Stricture DilatationDilatation

Stented StrictureStented Stricture

Perforated StentPerforated Stent

ConclusionConclusion

Sricture is uncommon ocurrence after Sricture is uncommon ocurrence after colon and rectal anastomosis colon and rectal anastomosis

Treatmeant varies depending of the Treatmeant varies depending of the nature and locationnature and location

Usually ballon dilatation effective, Usually ballon dilatation effective, stents use as other alternativestents use as other alternative

Surgery reserved for failed less Surgery reserved for failed less invasive treatmeant or complications invasive treatmeant or complications of the aboveof the above