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Anastomotic Occlusive Web: A Novel Endoscopic Management Technique
Swenson EA1, Tsikitis VL1* and Bakis G2
1Oregon Health & Science University- Department of Surgery, USA
2Oregon Health & Science University- Department of Gastroenterology, USA
*Corresponding author: Vassiliki Liana Tsikitis, Oregon Health & Science University Department of Surgery, Division of Colorectal Surgery, 3181 S.W. Sam Jackson Park Rd., Mail Code L223A, Portland, Oregon 97239, USA
Published: 05 May, 2016
Cite this article as: Swenson EA, Tsikitis VL, Bakis G.
Anastomotic Occlusive Web: A Novel
Endoscopic Management Technique.
Clin Surg. 2016; 1: 1014.
Clinical Image
A 46-year-old female diagnosed with invasive adenocarcinoma with moderate differentiation
underwent a laparoscopic low anterior resection with diverting loop ileostomy. Surgical pathology
confirmed a moderately differentiated 4.5cm adenocarcinoma, 0/14 lymph nodes positive, and
negative distal proximal and circumferential margins. The patient was discharged on post-operative
day three, after uneventful recovery.
Two months after her original procedure, she underwent a gastrografin enema to evaluate
patency of rectosigmoid anastomosis. The anastomosis appeared intact. No contrast, however, was
identified retrograde into the sigmoid colon or descending colon. Contrast was then infused into the
distal limb of the loop ileostomy. Transit time from the ileostomy to the presumed anastomosis was
four hours and the radiologist at the time felt the anastomosis was patent, without evidence of leak.
The ileostomy was reversed. The patient did not have return of bowel function. She developed
obstructive symptoms after post-operative day five, and a flexible sigmoidoscopy was performed,
which showed a non-patent anastomosis with possible web development at the anastomotic site.
Dilation was performed as follows: under conscious sedation, the rectum was examined with a
diagnostic gastroscope. At 6 cm from the dentate line, a pale area was seen, consistent with scarred
anastomosis or web, and no lumen was evident. It was impossible to advance a long ERCP 0.035 inch
wire through the stricture. Linear EUS was used to visualize the colon loop above the anastomosis,
which was filled with air and liquid. Using a 19 GA FNA needle, the colon loop was punctured
from the rectum, under direct EUS and fluoroscopic visualization (Figure 1 and 2). Contrast was
injected through the needle to confirm intraluminal location of the needle. A wire was inserted
through the needle and coiled in the colon. A 5-8 Fr Soehendra catheter was used to dilate the track.
A linear echoendoscope was exchanged for the gastroscope, while keeping the wire in place. A wire
guided CRE balloon was then advanced, and the anastomosis was dilated serially up to 12 mm under
fluoroscopic and endoscopic guidance. After dilation, the colon was inspected to approximately the
level of the proximal transverse colon and liquid stool was suctioned. The anastomosis was then
reexamined, and once deemed safe, was dilated to 18 mm. The patient tolerated the procedure well,
had a rapid return of bowel function, and was discharged three days later. She has had no recurrence
of obstructive symptoms in the past eight months.
Anastomotic webs are rarely seen after colorectal anastomoses.
The web was likely missed during gastrografin enema because contrast
was injected into the distal limb of the ileostomy and Hartmann’s
pouch. The contrast then eventually met and a thin web separating
the two contrast loads was not appreciated. It has been thought that
a diverting ileostomy increases the risk of web formation because
there is lack of the usual flow of bowel contents to keep the lumen
open. This report highlights an alternative endoscopic approach,
using linear EUS and fluoroscopic visualization to diagnose and
treat an occlusive web that is safe and effective [1]. EUS allows for
safe perforation of the web and subsequent dilation, as we are able
to visualize the proximal colon loop endosonographically and under
fluoroscopy, making it less likely to injure surrounding organs. Other
cases describe managing low occlusive webs with digital dilation
and higher webs with endoscopic balloon dilation. It needs to be
emphasized that these procedures should be performed by highly
experienced endoscopists [2].
Figure 1
Figure 2
Figure 2
Using a 19 GA FNA needle, the colon loop was punctured from the
rectum, under fluoroscopic visualization.
References
- Picon AL, Guillem JG. Anastomotic occlusive web following doublestapled anterior resection and fecal diversion. Surg Endosc. 1998; 12: 156- 158.
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