EUS-guided rendezvous and reversal of complete rectal anastomotic stenosis after Hartmann's reversal

Abstract

Benign postoperative colorectal anastomotic strictures occur in up to 30% of cases. Strictures can be managed with repeated surgery or endoscopic dilatation and metallic stent placement. A 54-year-old man underwent left colectomy, Hartmann's pouch, and colostomy for treatment of ischemic colitis. Reversal of Hartmann's with diverting loop ileostomy was performed 9 months after surgery. During preoperative endoscopic evaluation for loop ileostomy reversal, complete stenosis of the anastomosis was noted. A colonoscope was advanced through the ileostomy to the proximal aspect of the colonic stenosis. An echoendoscope was advanced transanally to the distal aspect of the stenosis. The proximal colon was filled with water, and a 19-G EUS needle was advanced across the stenosis under endosonographic guidance. A guidewire was advanced through the needle and visualized endoscopically in the proximal colon. The rectocolonic fistula was dilated, and a 10-mm × 80-mm fully covered self-expandable metallic stent was deployed across the rectocolonic fistula. Serial balloon dilatations (15 mm, 18 mm, 20 mm) were performed over a 3-week period before successful reversal of the loop ileostomy (Fig. 1; Video 1, available online at www.giejournal.org). The EUS-guided rendezvous technique was successful in managing complete anastomotic stenosis, and invasive surgery was avoided.