Application of Endoscopic Double Illumination Technique for Management of Anastomotic Site Membranes

Abstract

Purpose: To describe the use of endoscopic double illumination technique for treatment of colorectal anastomotic site membranes. Case: An 87 year old female was referred for screening colonoscopy by her primary care physician. Colonoscopy showed a friable, erythematous recto-sigmoid mass approximately 18 cm from the anal verge, engulfing one half to two thirds of the circumference and extending for about 5 cm. Multiple random cold biopsies were obtained that were reported by the pathologist as carcinoma in situ. She underwent laparoscopic coloproctectomy with colorectal anastomosis and diverting loop ileostomy. Surgical pathology tissue examination showed a 3.5 cm tubulovillous adenoma with adenocarcinoma in situ with invasion into lamina propria. All margins and 28 lymph nodes were negative for carcinoma. The patient was lost to follow up for about 3 years duration. Repeat colonoscopy showed complete closure of the anastomosis site by a membrane. Two GIF H-180 EGD scopes were simultaneously passed from the anus (lower scope) and the colostomy site (upper scope) under fluoroscopic guidance and advanced to the rectum pouch and distal end of the colon respectively. Light source from both the scopes was easily seen on both sides. The mucosal wall at the area of the previous colorectal anastomosis was cannulated using an endoknife under direct proximal and distal visualization via the lower scope. Then, by using the lower scope again, a TTS (through-the-scope) balloon was passed over the guide wire in the hole created by needle knife and dilation was performed up to the maximum diameter of 8 mm. Post dilation appearance was satisfactory. Serial dilatations were done up to 20 mm. Colostomy was reversed; the patient is doing well and passing stools per rectum. Colostomy was reversed; the patient is doing well and passing stools per rectum. Conclusion: Complete closure of anastomotic site by mucosal membranes is a rare finding and endoscopic double illumination technique offers a safe and convenient procedure. Endoscopic double illumination technique is a novel approach especially in patient's who are already surgically diverted.Figure: Fluoroscopic images of the lower (from anus) and upper (from colostomy site) scopes.