[Treatment of anastomotic tubular stricture after anterior resection of rectal cancer].

OBJECTIVE: To investigate the treatment of colorectal anastomotic tubular stricture after anterior resection of rectal cancer.

METHODS: A retrospective study on 23 cases of anastomotic tubular stricture after anterior resection of rectal cancer from 2008 to 2017 at the Division of Colorectal Surgery, Department of General Surgery of Peking Union Medical College Hospital was performed. The general conditions of the patients, surgical procedures of rectal cancer, perioperative treatment, specific conditions of anastomotic stricture, treatment methods and outcomes were summarized and analyzed. Anastomotic tubular stricture was defined as follows: (1) The length of scar stenosis was >1 cm with thickening anastomotic intestinal wall and a 12 mm diameter colonoscopy could not pass through the anastomosis; (2) Patients were often accompanied by left abdominal pain when exhaust and defecation, increased frequency of defecation, fecal thinning and difficulty in defecation; (3) Anastomotic stricture was indicated by anal examination, colonoscopy, transanal proctography, and rectal MRI.

RESULTS: Among 2035 patients undergoing anterior resection of rectal cancer from 2008 to 2017, 23 patients (1.1%) had anastomotic tubular stricture after operation, including 20 males and 3 females with age of 36 to 78 (58.3±10.2) years old. The anastomotic distance from the anal verge was less than 6 cm in 7 cases, 6 to 10 cm in 12 cases, and more than 10 cm in 4 cases. Twelve patients received radiotherapy, among whom 6 patients received neoadjuvant chemoradiation before surgery, and 6 patients received postoperative radiotherapy and chemotherapy. The initial treatment after anastomotic stricture: 9 cases (39.1%) underwent balloon dilation; 1 case(4.3%) underwent stenting; 1 case (4.3%) underwent transanal endoscopic microsurgery (TEM); 7 cases (30.5%) underwent permanent stoma and 5 patients (21.7%) underwent digestive tract reconstruction. Of the 12 patients receiving radiotherapy, 4 cases initially failed to undergo balloon dilatation; 1 case initially received a bare stent to relieve obstruction due to intestinal obstruction, but had re-stricture 1 month after stent removal, then was followed by permanent stoma surgery; 7 cases underwent resection of stenosis and permanent stoma, because the remaining intestine was too short for anastomosis. Of the 11 patients without radiotherapy, 5 patients were treated with balloon dilatation to relieve stenosis; 1 patient was initially treated with TEM, while posterior urethra was injured intraoperatively, and the urinary fistula finally healed with indwelling catheter; 5 patients underwent resection of the anastomotic stenosis, and no stenosis occurred after reconstruction of digestive tract, but 1 patient suffered from intraoperative presacral bleeding.

CONCLUSIONS: Balloon dilatation is considered an effective treatment of anastomotic tubular stricture following anterior resection of rectal cancer, but with the risk of re-stenosis. Stricture resection and digestive tract reconstruction can be a radical way to improve stricture but with high risk of complications.