The Strictured Anastomosis: Successful Treatment by Corticosteroid Injections—Report of Three Cases and Review of the Literature

Abstract

Clinically significant anastomotic strictures usually only occur with very low colorectal anastomoses below the level of the peritoneal reflection. The reported rate averages 8 percent and has been attributed to tissue ischemia, localized sepsis, anastomotic leak, proximal fecal diversion, radiation injury, inflammatory bowel disease, and recurrent rectal cancer. Most patients will have symptoms of obstipation, frequent small bowel movements, and bloating. Symptomatic strictures are often approached by dilation (balloon or Hegar) or less often repeat resection. Many of these patients have anastomoses that are too low to consider repeat resection. Strictureplasty with linear stapling devices, stricture resection by use of the circular stapling device, and repeat dilations have all been described. Steroid injections into the stricture have been described in strictured esophagogastric anastomoses but have not been commonly used for strictured coloproctostomies. We describe three cases of coloanal stricture following resections that were complicated by postoperative pelvic abcesses, anastomatic leaks, and pelvic fibrosis. Two cases had undergone low coloanal anastomosis that was protected by a loop ileostomy and developed as significant stricture in the early postoperative period. The third case was managed without a protective loop ileostomy. These were initially managed by repeated dilation of the anastomosis. Each episode was followed by rapid recurrence of the stricture. All patients underwent subsequent dilation with injection of 40 mg of triamcinolone acetate (divided dose in four quadrants) into the stricture and subsequent complete resolution of the stricture. Those patients with loop ileostomies had them taken down and all have been followed for up to 12 months without clinical or endoscopic evidence of recurrent stricture.

Right and Wrong Approaches To Colorectal Anastomotic Strictures: When? Which Technique?

“…[16,17] In some studies, it has been said that anastomoses under the peritoneal reflection are associated with a greater risk of stenosis. [18] In the past, surgical treatment was applied for all anastomotic strictures unresponsive to medical treatment; however, currently, noninvasive endoscopic methods have become more prominent. [19] Noninvasive methods include dilatation with polyvinyl bougies or a balloon, and the use of metallic stents in unsuccessful cases.…”

Early anastomotic stricture occurring after colectomy that responded well to Transanal decompression and local steroid therapy: A case report

“…Refractory anastomotic strictures are treated by incision of the stricture site or stent placement to avoid the need for reoperation and colostomy [1]. At present, reoperation is performed in 4% to 28% of patients with refractory strictures [6].…”

Estenosis isquémica tardía tras resección anterior de recto

“…Diversos estudios han utilizado corticoterapia, en nuestro caso la usamos en forma de enema y, aunque resultó de gran eficacia para reducir el grado de estenosis y permitir completar la endoscopia, no hemos encontrado referencias de su uso por esta vía en la estenosis isquémica de colon (17). Otros fármacos que se han sugerido con este fin han sido la PEG1 (18) o la pentoxifilina (19), administradas ambas por vía endovenosa.…”