Endoscopic management of complete colonic obstruction

Abstract

A patient with metastatic rectal cancer underwent a diverting transverse loop colostomy due to rectal obstruction. 16 months later, he underwent a low anterior resection to resect his rectal cancer along with reversal of his transverse colostomy, and creation of a temporary loop ileostomy. Six months later, he was brought to the operating room for closure of his ileostomy. Post-operatively, the patient developed nausea, vomiting, and abdominal distention and imaging revealed a large bowel obstruction, confirmed by colonoscopy. The patient refused surgical diversion and a cecostomy tube was placed for decompression. After maturation of the cecostomy fistula, a rendezvous colonoscopy was performed, retrograde through the rectum and antegrade through the cecostomy fistula. The obstructing mucosa was traversed and the site of obstruction was balloon dilated, relieving the obstruction endoscopically.

Introduction

Benign anastomotic strictures are a rare complication after colonic resection. Endoscopic therapy with balloon dilation and temporary stents offers a minimally invasive alternative to surgical revision in these patients. In this report, we describe a case in which a complete colonic obstruction secondary to a benign post-operative anastomotic stricture was successfully treated by a novel approach with colonoscopic rendezvous.

Case report

A 50 year old man with metastatic rectal cancer to the liver underwent a diverting transverse loop colostomy due to rectal obstruction. He underwent chemotherapy with 5-florouracil, irinotecan, and bevacizumab. Eight months later, he developed prolapse of his colostomy and underwent surgical repair with the creation of an end colostomy and a mucous fistula. The patient requested palliative resection of his primary rectal tumor and colostomy takedown due to difficulty managing his ostomy because of congenital blindness. Eight months later, he underwent a low anterior resection, reversal of his transverse colostomy and mucous fistula, and creation of a temporary loop ileostomy. Six months later, a barium enema showed a patent rectal anastomosis. The patient was brought to the operating room for closure of his ileostomy. On post-operative day four, the patient developed nausea, vomiting, and abdominal distention. An abdominal radiograph showed a large bowel obstruction (Fig. 1) and a CT revealed an obstruction at the level of the transverse colon (Fig. 2). A colonoscopy confirmed a complete obstruction at the prior transverse colostomy site (Fig. 3). The patient declined surgical diversion due to difficulty caring for his previous ostomy. An initial attempt to alleviate the obstruction was unsuccessful, and a cecostomy tube was placed for decompression.

Figure 1.

Abdominal radiograph showing large bowel obstruction. Retained contrast from barium enema in distal colon.

Figure 2.

CT image of large bowel obstruction. Retained contrast from barium enema on the distal side of the obstruction.

Figure 3.

Colonoscopic image of the distal side of the obstruction

Total parenteral nutrition was started and the patient continued to decline surgical intervention. The cecostomy fistula was allowed to mature over four weeks and then endoscopic management was reattempted. A colonoscope (CF Q180AL, Olympus America, Center Valley, PA) was inserted through the rectum and advanced to the level of the obstruction. The 12Fr cecostomy tube was removed and a 0.035 guidewire (Hydra Jagwire guidewire, Boston Scientific, Natick, MA) was inserted into the right colon. A dilating balloon (CRE Balloon Dilator, Boston Scientific, Natick, MA) was passed over the guidewire and the cecostomy fistula was sequentially dilated to 12 mm. An ultra-slim gastroscope (5.9mm diameter) (GIF XP160, Olympus America, Center Valley, PA) was advanced through the fistula to the proximal side of the obstruction. Direct transillumination of both endoscopes was visualized. The blunt end of a Savary guidewire was inserted through the colonoscope and was used to pierce through the distal side of the obstruction (Fig. 4). Using the ultra-slim gastroscope, a snare was placed around the Savary guidewire to stabilize it. The balloon dilator was advanced alongside the Savary guidewire, through the obstruction which was then dilated to 12mm, allowing the colonoscope to be advanced to the cecum. The ultra-slim gastroscope was removed from the fistula. With the colonoscope in the ascending colon, the fistula was closed with 4 clips (Resolution Clip, Boston Scientific, Natick, MA). The transverse colon obstruction was further balloon dilated to 18mm (Fig. 5 and 6). The patient tolerated the procedure without complication.

Figure 4.

Savary guidewire piercing through the obstructing mucosa and transillumination from the colonoscope in the distal colon

Figure 5.

Balloon dilation of colonic obstruction

Figure 6.

Resolution of transverse colon obstruction after rendezvous colonoscopy

The next day, the patient was started on a clear liquid diet and it was advanced to a regular diet accordingly. The patient underwent a colonoscopy three weeks later and the site of the prior obstruction was widely patent. The patient remained asymptomatic and was able to reinstitute chemotherapy.

Discussion

After undergoing colonic resection, there is a 2% to 5% risk of developing an anastomotic stricture.^1,2 Strictures usually develop 6 to 12 months after surgery. However, strictures can form as early as 3 months or as late as a decade or more after surgery.^2,3 Benign strictures are usually a result of the proliferation of fibroblasts and cross-linking of collagen fibers.⁴ Previous studies have shown that postoperative colonic strictures are more common after anastomoses performed in the left colon.

Traditionally, postoperative colonic strictures were managed surgically. More recently, endoscopic therapy has become the preferred treatment modality with surgery being reserved for cases where endoscopic therapy is unsuccessful.⁵ Both hydrostatic “through the scope” balloon dilators and achalasia balloons can be used to dilate these strictures.^1,6,7 Dilation has good short-term success; however restenosis may occur in 14% to 25% of patients over time, and as a result, repeat dilation may be required in some cases.^1,7 Balloon dilation is a safe technique, complicated by bleeding and perforation less than 5% of the time.^1,6,7 Stricture incision with a monopolar electrosurgery snare or a needle knife, with or without balloon dilation, has also been reported as an endoscopic technique for the management of postoperative colonic strictures. In addition, corticosteroid injection into the stricture has also been used.^8,9 While self-expanding metal stents have been traditionally used for malignant strictures, there are reports of its use for severe refractory benign anastomotic strictures in poor surgical candidates.^10,11

Currently, there are only 2 other reports of endoscopic management of complete colonic obstruction in the literature.^12,13 Kaushik et al. describes a case of successful endoscopic management of a completely obstructed colonic anastomosis by using a combined antegrade-retrograde (rendezvous) endoscopic technique. Their case report describes the technique of an antegrade colonoscopy through a loop ileostomy while also performing a standard retrograde colonoscopy. A 19 gauge EUS needle was then used to puncture through the fibrous obstructing septum and balloon dilation was subsequently performed.^12,13 Dever et al. reported a case (abstract) in which antegrade per-ostomy colonoscopy and proctoscopy was performed and a 22 gauge EUS needle was used to puncture the stenosed anastomosis. Balloon dilation was then performed, followed by the backwards deployment of a polyester covered silicone self expanding stent.¹³ Combined antegraderetrograde endoscopy with dilation has previously been described for the management of complete esophageal obstruction, a complication after high dose chemotherapy and radiation therapy for the treatment of head and neck cancers.^14–17

In our case, we performed a rendezvous (antegrade-retrograde) colonoscopy following the creation of a percutaneous cecostomy fistula, and successfully alleviated a complete large bowel obstruction secondary to a benign post-operative stricture. The percutaneous cecostomy fistula, once matured, provided access for an antegrade colonoscopy, thereby allowing a rendezvous procedure. Therefore, our case describes a novel endoscopic technique for the management of benign, postoperative complete colonic obstruction, obviating the need for surgery.