Management Of Anastomotic Strictures Research Articles

1522 Management of Benign Anastomotic Strictures Post-Rectal Resection: A Systematic Review

Abstract Aim Approximately a third of all colorectal cancers diagnosed in the UK each year are rectal in origin and will undergo surgical resection with formation of an anastomosis. Focus is placed on techniques to ensure anastomotic integrity however an anastomotic leak, pelvic sepsis, distance to the anal verge and stapler choice are all established risk factors for the formation of a benign anastomotic stricture. This review aimed to assess the use of endoscopic salvage techniques in an attempt to avoid surgical re-intervention. Method A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases. Additional papers were detected by scanning the references of relevant papers. Results A total of 40 papers were included focusing upon balloon dilation, stent insertion, electroincision, stapler stricturoplasty and corticosteroid use. Endoscopic balloon dilatation remains the most commonly used technique in the management of anastomotic strictures, with a low complication rate despite the frequent requirement for repeated dilatations. Although established in the role for malignant obstruction, stent insertion is yet to gain an established role in the benign setting. Conclusions Benign anastomotic strictures can be a significant problem post-rectal resection, impacting upon quality of life and requiring repeated intervention. Endoscopic management should be utilised in the primary setting to avoid surgical re-intervention. Standardisation of these methods is imperative in establishing the best modality of treatment. For refractory strictures a low threshold of suspicion for malignant recurrence should be maintained.

Stricture Following Esophageal Reconstruction.

Owing to varying clinical definitions of anastomotic stricture following esophageal reconstruction, its reported incidence rate varies from 10% to 56%. Strictures adversely impact patients’ quality of life. Risk factors, such as the anastomosis method, leakage, ischemia, neoadjuvant chemoradiotherapy, and underlying disease have been mentioned, but conflicting information has been reported. Balloon dilation is regarded as a safe and effective treatment method for patients with benign anastomotic strictures. Reoperations are seldom required. The etiology and management of anastomotic strictures are reviewed in this article.

Application of Fully Covered Self-Expandable Metallic Stents with and without Antimigration Waist Versus Repeated Plastic Biliary Stent Placement in Management of Anastomotic Biliary Strictures After Orthotopic Liver Transplantation.

BakgroundStandard methods for endoscopic retrograde cholangiopancreatography (ERCP) management of anastomotic strictures (AS) after OLT includes repeated balloon dilation of the stricture with subsequent insertion of a plastic biliary stent (PBS). In post-OLT patients not responding to standard endoscopic treatment, the placement of fully covered self-expanding metal stents (FCSEMS) is a valid alternative to surgical treatment. The aim of this study was to compare the results of new FCSEMS implantation with the standard ERCP stricture management protocol and with conventional FCSEMS insertion.Material/MethodsThis retrospective study involved 39 post-OLT patients with confirmed diagnosis of biliary AS. Enrolled subjects were divided into 2 groups: the FCSEMS group (study group) and the PBS group (control group). The study group was divided into 2 subgroups: the conventional FCSEMS group and the new-type FCSEMS group.ResultsStricture recurrence after PBS placement was observed in 36.36% of controls and in only 9.52% of study group members (P=0.170). Recurrence rates in patients after conventional FCSEMS and new type FCSEMS implantation was similar (10% vs. 9.09%; P=0.501). The applied treatment was successful in 82.61% of study group members and only 43.75% of controls (P=0.029). Success rates of conventional FCSEMS and new-type SEMS insertion did not differ significantly (81.82% vs. 83.33%, P=0.649). There was no statistically significant difference in complication rates between groups (P=0.879).ConclusionsImplantation of FCSEMS is more effective than repeated balloon dilatation of AS with subsequent PBS placement and is they have similar complication rates. Application of new-type FCSEMS gives results comparable to conventional FCSEMS.

Airway complications in the lung transplant recipient

Airway complications are a common source of morbidity and mortality following lung transplantation. Ischemia, infection, or technical issues may all contribute. We discuss surgical techniques to avoid airway complications, management of anastomotic strictures, and treatment options for post-anastomotic bronchial stenosis. Additional potential complications discussed include dehiscence and malacia, as well as management options for each.

Endoscopic Stricturotomy and Stent Placement for Refractory Gastrojejunal Anastomotic Stricture in a Patient With Roux-en-Y Gastric Bypass Surgery: A Case Report

Introduction: Gastro-jejunal (G-J) anastomotic strictures are a common complication after Roux-en-Y gastric bypass. We present a case of symptomatic refractory post RYGB G-J stricture treated with endoscopic stricturotomy using an ERCP sphincterotome. Case: A 62-year-old female with prior gastroplasty and RYGB conversion developed an intractable stricture. She underwent open revision of her gastrojejunostomy, complicated by an anastomotic leak. She remained well for nearly 5 years and re-presented again with nausea and vomiting. Endoscopy confirmed a tight G-J anastomosis restricting passage of the adult upper endoscope. The stricture underwent serial dilations using hydrostatic balloon every 4 weeks. After 3 CRE balloon dilations to 10mm, the stricture remained stenosed. Following her 3rd visit, hydrostatic dilation with fully covered metal stent placement was discussed with the patient and surgical team. Balloon dilation was performed initially to 14mm, allowing passage of the radial echoendoscope to evaluate thickness of the stricture and muscularis propria. Using a 4.4 Fr sphincterotome, mucosal incisions were made at 3 O'clock and 9 O'clock positions followed by placement of a TTS duodenal stent. The patient's symptoms improved dramatically following the procedure. On repeat endoscopy 4 weeks later, the G-J anastomosis remained patent. Consequently, the stent was removed. The patient remained asymptomatic on follow up. Discussion: Gastro-jejunal (G-J) anastomotic strictures are a common complication after RYGB occurring in 5-10% of post-operative patients. While endoscopic balloon dilations are effective, they are associated with recurrence, restenosis and rarely may need surgical revision of the anastomosis. Our patient had intractable symptoms of nausea and vomiting due to a G-J anastomotic stricture. Prior surgeries with complicated post-operative periods meant that she was not deemed an appropriate surgical candidate. Endoscopic balloon dilation is a safe and effective option in the management of anastomotic stricture following RYGB with a low incidence of perforation rates. However, in our patient, balloon dilation every 4 weeks did not result in any significant improvement in the luminal diameter of her stricture or her symptoms. Eventually, she successfully underwent a stricturotomy with stent placement as described above. Following her stricturotomy, her symptoms improved and she tolerated an oral diet. To our knowledge, this is the first described case of endoscopic stricturotomy using a biliary sphincterotome for refractory G-J anastomotic stricture. Conclusion: In RYGB patients who are not surgical candidates, endoscopic stricturotomy and stent placement may have a role in management of intractable symptomatic G-J strictures.

Management of Anastomotic Stricture After Artificial Urinary Sphincter Placement in Patients Who Underwent Salvage Prostatectomy

To report on a safe endoscopic management technique for the treatment of an anastomotic stricture (AS) in patients with an artificial urinary sphincter (AUS). Five patients with a history of salvage prostatectomy after radiation therapy that developed an AS after AUS placement were treated with a rigid ureteroscope and a Holmium YAG (Ho: YAG) laser to incise the AS. The AUS was opened and deactivated but not decoupled or removed during the procedure. The rigid ureteroscope allowed complete control of the laser fiber to incise the stricture at the 3 and 9 o' clock positions and then circumferentially. There were no intraoperative complications and the mean operative time was 42.6 minutes. Of the 5 patients who underwent holmium laser incision of an AS after AUS placement, none developed AUS malfunction or required device replacement. No patients reported worsening of urinary incontinence after treatment. Two patients required repeat holmium laser incision for AS recurrence. Using a rigid ureteroscope and a holmium laser to incise an AS after AUS placement seems to be a safe management option that does not damage the AUS or result in worsening incontinence. This treatment strategy provides an endoscopic alternative to using open surgical technique to uncouple or remove the AUS while treating the AS.

Mo1358 Endoscopic Management of Anastomotic Strictures After Orthotopic Liver Transplantation: Long Term Follow-Up

Mo1358 Endoscopic Management of Anastomotic Strictures After Orthotopic Liver Transplantation: Long Term Follow-Up

Mo1297 Endoscopic Management of Anastomotic Strictures in Deceased Versus Living Donor Liver Transplantation

Mo1297 Endoscopic Management of Anastomotic Strictures in Deceased Versus Living Donor Liver Transplantation

T1570: The Role of ERCP in the Management of Biliary Anastomotic Strictures in Non-Liver Transplant Patients

Recent reports have documented the importance of ERCP in the management of anastomotic strictures after orthotropic liver transplant. In contrast, the role of ERCP in non-liver transplant biliary anastomotic strictures following elective and emergency biliary-enteric anastomoses has been less studied.

Single Center Comparison of Anastomotic Strictures After Radical Perineal and Radical Retropubic Prostatectomy

To analyze the incidence and management of anastomotic strictures (ASs) after radical perineal prostatectomy (RPP) and retropubic prostatectomy (RRP) and to identify possible predisposing factors. Between 1997 and 2007, we performed 866 RPP and 2052 RRP for localized prostate cancer. Median follow-up was 52 months (12-136). We analyzed preoperative serum prostate-specific antigen, prostate size, clinical and pathologic tumor stage, neoadjuvant hormone deprivation, previous transurethral resection of the prostate, transfusion requirement, anastomotic insufficiency, and acute urinary retention (AUR) and its subsequent management to identify possible predisposing factors for AS formation. The rate of AS after RPP and RRP was 3.8% (33/863) and 5.5% (113/2048), respectively (P = .067). In multivariate analysis, RRP was a statistically significant risk factor for AS (P = .0002). On survival analysis, the incidence of AS was lower for RPP as compared with RRP at median follow-up (P = .0229). Primary response to endoscopic AS incision or resection was 94% (31/33) and 72.6% (82/113) after RPP and RRP, respectively. On multivariate logistic regression analysis biopsy Gleason score, previous transurethral resection of the prostate, prostate volume, pathologic tumor stage and grade, transfusion requirement, AUR, and surgical technique were independent risk factors for the development of AS. An AS developed in 45.4% (20/44) and 10.9% (5/46) of the postoperative AUR cases treated with a suprapubic cystostomy tube and a transurethral Foley catheter, respectively (P <.05). ASs occur more frequently after RRP in comparison with RPP. Primary endoscopic AS incision or resection are both highly successful. Treating postoperative AUR with a suprapubic cystostomy poses a high risk for AS formation and should be avoided.

Management of persistent gastroesophageal anastomotic strictures with removable self-expandable polyester silicon-covered (Polyflex) stents: an alternative to serial dilation

A benign gastroesophageal anastomotic stricture occurs in up to 42% of patients after transhiatal esophagectomy for esophageal cancer. Management of anastomotic strictures may require extended periods of serial endoscopic dilation, with significant risk, cost, and inconvenience for the patient. To determine if placement of removable self-expandable polyester silicon-covered (Polyflex) stents (SEPSs) prolonged the interval between endoscopic interventions in the management of persistent anastomotic stricture. Retrospective cohort study. National Cancer Institute designated comprehensive cancer center. Eight patients after a transhiatal esophagectomy referred for management of benign persistent anastomotic strictures. Serial balloon and bougie dilations and SEPS placement. The interval between endoscopic interventions and the number of endoscopic interventions before and after SEPS placement. Over a 365-day period, 13 SEPS were placed in 8 patients with benign persistent anastomotic strictures after a transhiatal esophagectomy. A SEPS placement delayed the interval between endoscopic interventions from a mean of 7 days before stent insertion to 62 days after insertion (P < .008). The median number of preinsertion interventions was 4 and was reduced to 1 after insertion (P < .005). The small number of patients. A SEPS placement did not result in stricture resolution or stabilization after SEPS removal. The SEPS migration rate was much higher in our patients with postesophagectomy anastomotic strictures than previously reported for other types of strictures. However, a SEPS placement did significantly delay the interval between endoscopic interventions in patients with persistent gastroesophageal anastomotic strictures after transhiatal esophagectomy. SEPS placement should be considered as an alternative to continued serial dilation in patients with persistent anastomotic strictures after transhiatal esophagectomy.

A single center experience in management of anastomotic strictures after roux-en-y gastric bypass (RGB)

A single center experience in management of anastomotic strictures after roux-en-y gastric bypass (RGB)

Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass

Anastomotic stricture is a frequent complication after Roux-en-Y gastric bypass (GBP). We evaluated the frequency of anastomotic stricture following laparoscopic GBP using a 21 mm. vs. a 25 mm circular stapler for construction of the gastrojejunostomy and the safety and efficacy of endoscopic balloon dilation in the management of anastomotic stricture. We reviewed data on 29 patients in whom anastomotic strictures developed after laparoscopic GBP. All strictures were managed with endoscopic balloon dilation using an 18 mm balloon catheter under fluoroscopic guidance. Main outcome measures were the number of anastomotic strictures in patients in whom the 21 mm (vs. 25 mm) circular stapler was used to create the gastrojejunostomy, time interval between the primary operation and symptoms, complications of endoscopic balloon dilation, the number of patients with resolution of obstructive symptoms, and body weight loss. There were 28 females with a mean age of 39 years and a mean body mass index of 48 kg/ m2. Anastomotic stricture occurred significantly more frequently with the use of the 21 mm compared to the 25 mm circular stapler (26.8% vs. 8.8%, respectively; P<0.01). The median time interval between the primary operation and presentation of stricture was 46 days. After the initial dilation, recurrent stricture developed in 5 (17.2%) of 29 patients. These five patients underwent a second endoscopic dilation, and only one of these five patients required a third endoscopic dilation. None of the 29 patients required more than three endoscopic dilations. The mean percentage of excess body weight loss at 1 year for patients in whom the 21 mm circular stapler was used for creation of the gastrojejunostomy was similar to that for patients in whom the 25 mm circular stapler was used (68.2% vs. 70.2%, P = 0.8). In this series the rate of anastomotic stricture significantly decreased with the use of the 2 5 mm circular stapler for construction of the gastrojejunostomy without compromising weight loss. Endoscopic balloon dilation is a safe and effective option in the management of anastomotic stricture following laparoscopic GBP.

Role of ERCP in the evaluation and management of anastomotic strictures following liver transplantation a single center experience

Role of ERCP in the evaluation and management of anastomotic strictures following liver transplantation a single center experience