Endoscopic Mucosotomy and Lumen-Apposing Metal Stent Placement for the Management of a Closed Colorectal Anastomosis

CASE REPORT

A 58-year-old woman with a medical history of metastatic ovarian cancer status post debulking, low anterior resection, and diverting loop ileostomy was referred for a flexible sigmoidoscopy before reversal of her ileostomy 8 months after the surgery. Barium enema showed complete obstruction of the colonic anastomosis. Sigmoidoscopy revealed a scar at the site of anastomosis (5 cm from the anal verge), suggesting a complete obstruction of the anastomosis with overlying epithelialization (Figure 1). Endoscopic mucosotomy was performed with puncturing of the overlying mucosa using an injection needle, followed by endoincision using a needle knife (Figure 2). An ultrathin endoscope was passed through the mucosotomy with visualization and confirmation of the upstream colonic lumen (Figure 3). A 20 × 10 mm lumen-apposing metal stent (LAMS; Boston Scientific, Marlborough, MA) was then placed across the anastomotic stricture to re-establish the luminal continuity and effectively dilate the stricture to 20 mm (Figure 4). Repeat endoscopy 7 weeks after the procedure showed a widely patent anastomosis (Figure 5). The LAMS was removed, and the anastomosis remained patent. The patient had no procedure-related adverse events and underwent reversal of her diverting ileostomy 2 months after removal of the LAMS.

Figure 1.

Sigmoidoscopy showed scar at the site of completely closed anastomosis.

Figure 2.

(A and B) Endoscopic mucosotomy was performed with injection needle, followed by endoincision.

Figure 3.

Upstream colon was visualized using an ultrathin endoscope passed through the mucosotomy.

Figure 4.

Lumen-apposing metal stent was placed across the anastomotic stricture.

Figure 5.

Repeat endoscopy at 7 weeks showed lumen-apposing metal stent in place with a widely patent anastomosis.

DISCLOSURES

Author contributions: All authors contributed equally to this manuscript. T. Rustagi is the article guarantor.

Financial disclosure: T. Rustagi is a consultant for Boston Scientific, but this was not relevant to this manuscript.

Informed consent was obtained for this case report.