Treatment of anastomotic stricture after rectal cancer operation by magnetic compression technique: A case report

Abstract

BACKGROUND

The treatment of postoperative anastomotic stenosis (AS) after resection of colorectal cancer is challenging. Endoscopic balloon dilation is used to treat stenosis in such cases, but some patients do not show improvement even after multiple balloon dilations. Magnetic compression technique (MCT) has been used for gastrointestinal anastomosis, but its use for the treatment of postoperative AS after colorectal cancer surgery has rarely been reported.

CASE SUMMARY

We report a 72-year-old man who underwent radical resection of colorectal cancer and ileostomy one year ago. An ileostomy closure was prepared six months ago, but colonoscopy revealed a narrowing of the rectal anastomosis. Endoscopic balloon dilation was performed three times, but colonoscopy showed no significant improvement in stenosis. The AS was successfully treated using MCT.

CONCLUSION

MCT is a minimally invasive method that can be used for the treatment of postoperative AS after colorectal cancer surgery.

Key Words: Rectostenosis, Magnetic surgery, Magnetic Surgery Clinic, Rectal cancer, Magnetic compression technique, Case report

Core Tip: Endoscopic balloon dilation of postoperative anastomotic stenosis (AS) after colorectal cancer surgery is not always effective. Repeated balloon dilation can aggravate the stenosis. Magnetic compression technique (MCT) has been used for gastrointestinal anastomosis, but its use for the treatment of postoperative AS of colorectal cancer has rarely been reported. This article reports the treatment process and outcomes of MCT for the treatment of postoperative AS after colorectal cancer surgery. Our experience suggests that MCT can be an effective treatment for postoperative AS in this setting.

INTRODUCTION

The reported incidence of anastomotic stenosis (AS) after radical resection of colorectal cancer is about 3%-30%[1]. Anastomotic fistula, infection, and ultra-low anal preservation operation are risk factors for AS[2]. The typical symptoms of rectal AS include difficulty in defecation, bloating, and anal pain[3]. As a minimally invasive treatment, endoscopic balloon dilatation is routinely performed in clinical settings[4]. However, this technique is effective only in approximately 20% of patients[5]. Repeated endoscopic balloon dilatation in patients who show poor response may aggravate stenosis. The occurrence of AS prevents ileostomy closure, greatly reducing the quality of life of patients. For patients who do not respond to endoscopic balloon dilation, we propose an endoscopy-assisted magnetic compression technique (MCT) to treat AS, which achieved satisfactory therapeutic effect after initial clinical application.

CASE PRESENTATION

Chief complaints

A 72-year-old man who underwent radical resection of rectal cancer one year ago presented with rectal stenosis for the past 6 months.

History of present illness

The patient underwent radical resection of rectal cancer and ileostomy one year ago for rectal cancer. A colonoscopy performed six months ago revealed a narrow rectal anastomosis, which did not meet the indications for ileostomy reduction surgery. After endoscopic balloon dilation was performed three times, colonoscopy showed no improvement in the rectal stenosis (Figure 1A). The patient was recommended by the endoscopist to visit the Magnetic Surgery Clinic of the First Affiliated Hospital of Xi’an Jiaotong University for further treatment.

Figure 1 Preoperative examination. A: Colonoscopy; B and C: Colonography.

History of past illness

The past medical history was unremarkable.

Personal and family history

There was no family history of this condition.

Physical examination

The patient’s vital signs were stable, and auscultation of the heart and lungs was normal. The abdomen was flat and soft with no tenderness. There was no mobile dullness and bowel sounds were normal. Ileostomy was visible in the lower right quadrant of the abdomen, and the intestinal mucosa of ileostomy was normal.

Laboratory examinations

There were no significant abnormalities in the patient’s hematological examination.

Imaging examinations

A 14Fr nasogastric tube was inserted through the anus and 80 mL iodohexol was injected. Rectal stenosis was observed by colonography (Figure 1B and C).

FINAL DIAGNOSIS

Based on the colonoscopy and colonography findings, the patient was diagnosed as having rectal AS.

TREATMENT

The patient signed an informed consent form for treatment. After intravenous anesthesia, the patient was placed supine. The colonoscope was inserted through the ileostomy and reached above the rectal stenosis. The zebra guide wire was inserted through the colonoscopy biopsy hole, and the zebra guide wire tip was adjusted to pass through the rectal stenosis and extrude from the anus. Two magnets with a 20-mm diameter and 6-mm height were used as daughter magnets (DM) having a 4-mm central hole. The central hole of the DM was inserted into the zebra guide wire on the side of the ileostomy (Figure 2A), and the colonoscope was used to push the DM along the zebra guide wire to the upper part of the rectum stenosis (Figure 2B). Two magnetic rings with an outer diameter of 20 mm, an inner diameter of 4 mm, and a height of 6 mm were superimposed as the parent magnet (PM). The central hole of the PM was inserted into the zebra guide wire on the anal side (Figure 2C), and the colonoscope was used to push the PM along the zebra guide wire to the lower part of the rectum stenosis (Figure 2D). At this time, the DM and the PM automatically attracted each other, and the colonoscope and zebra guide wire were removed. X-ray was performed immediately to confirm that the magnets were in a good position (Figure 2E).

Figure 2 Magnet placement process. A: The daughter magnet (DM) was inserted along the zebra guide wire via ileostomy; B: Colonoscopy pushed the DM to the proximal end of the rectum stenosis; C: The parent magnet (PM) was inserted through the anus along the zebra wire; D: The PM reached the distal end of the rectum stenosis; E: The X-ray indicates the apposition of the daughter magnet and the PM. DM: Daughter magnet; PM: Parent magnet.

The patient recovered from anesthesia and resumed normal activities and oral intake. The patient was asked to pay attention to the discharge of the magnets. On the 11th day after surgery, the magnets were discharged through the anus, with detached necrotic tissue visible between the DMs and PMs (Figure 3A). An immediate colonography showed good patency of the lower rectum (Figure 3B). Colonoscopy showed good patency of the rectal anastomosis, and no ulcers, bleeding, or erosion at the magnetic anastomosis site (Figure 3C and D).

Figure 3 Postoperative examination. A: The daughter and parent magnets were discharged on the 11^th d after surgery; B: X-ray shows good rectal patency; C and D: Colonoscopic images showing good patency at the site of anastomosis. DM: Daughter magnet; PM: Parent magnet.

OUTCOME AND FOLLOW-UP

After discharge, the patient was asked to self-dilate with an 18-mm diameter anal dilator stick three times a day. The ileostomy closure surgery was completed one month later. The patient has been followed up for six months and has good bowel status.

DISCUSSION

MCT was first reported in 1978 for nonsuture microvascular anastomosis in experimental animals[6]. Later, this technique was used in coronary artery bypass surgery[7-9]. With further development, MCT has been used in digestive tract anastomosis[10-12], therapeutic fistula[13-15], and ureteral stenosis anastomosis[16,17]. The combination of MCT and endoscopic technology has greatly expanded its application for the treatment of digestive tract lesions[18,19].

The application of MCT in the digestive tract mainly focuses on gastrointestinal anastomosis. MCT has also been used for postoperative AS of colorectal cancer[20], but such studies have been rare, mainly due to the limited knowledge of surgeons and endoscopists about this technique. Previously, we reported the use of MCT for treating radiation-induced sigmoid stenosis with good long-term outcomes[21].

The MCT for the treatment of this patient had the following characteristics: First, this patient had an ileostomy, which can provide convenience for magnet placement. This patient had an easier procedure than those with rectal stenosis who did not have an ostomy. Second, the patient showed no response to repeated endoscopic balloon dilation, indicating a heavy scar in the stenosed area. Therefore, the magnet superposition scheme was adopted to increase the magnetic force between the DM and the PM. Third, there have been limited case reports of postoperative AS treated with MCT after rectal cancer surgery, and its long-term effect is unknown. Therefore, despite the good patency of the anastomosis after the discharge of magnets, in order to prevent restenosis, we recommended the patient to continue anal dilation.

CONCLUSION

This case indicates that MCT can be used as a new treatment method for patients with postoperative AS in whom endoscopic balloon dilation is not effective. It is a simple and minimally invasive treatment. The favorable outcome demonstrates that it is worth promoting.