Refractory Anastomotic Rectal Stricture After Lower Anterior Resection and Radiation Exposure

Abstract

We present a patient with history of neoadjuvant radiation and chemotherapy, with lower anterior resection, complicated with rectal anastomotic stricture refractory to endoscopic intervention. In the past, colorectal surgery had been the preferred method of treatment of rectal strictures, but endoscopic techniques, such as balloon dilation, have become the preferred modality. However, there is a high stricture recurrence rate of up to 18-20%, with increased risk of perforation due to uncontrolled stretching reported after balloon dilatation. A 68 year old female who migrated from West Africa with medical history of hypertension, Stage IIIB rectal cancer with low anterior resection and neoadjuvant chemo-radiation one year ago, presented to our gastrointestinal clinic for colon cancer surveillance. She denied melena, hematochezia, abdominal pain, diarrhea, nausea and vomiting, however noted a decrease in frequency of bowel movements. Colonoscopy performed revealed a very tight fibrotic stricture ˜8 cm from anal verge. With the use of a Through the scope (TTS ) balloon (6-7-8mm) dilation was performed. Minimal self limited mucosal oozing was noted. A subsequent flexible sigmoidoscopy was performed 2 weeks later with TTS using a larger sized balloon (8-9-10mm), which was inserted and dilation repeated. During a repeat colonoscopy performed 3 weeks later a very tight stricture was observed again in the rectum. Given recurrent stricturing / fibrosis - dilation was not attempted and was referred to colorectal surgery for surgical correction of stricture. Anastomotic stricture is a relatively common complication of low anterior resection especially in patients who had preoperative radiation. Endoscopic balloon dilatation is the most effective method to correct strictures, although repeated dilation over time is often required. There is some evidence in literature that dilating for the third or subsequent times may be futile. Even though balloon dilatation is a safe treatment, additional treatment modalities described in literature include; the use of neodymium: yttrium-aluminum-garnet laser treatment, electro-incision, electrocautery, and use of sphincterotomes. Colorectal Surgery should be considered in patients with recurrent strictures refractory to endoscopic therapy.2940 Figure 1. A very tight stricture ˜8 cm from anal verge seen. A TTS CRE ballon was inserted (6-7-8 cm) and dilation was performed. Minimal self limited oozing noted.