University of Alabama at Birmingham School of Medicine Birmingham, AL
Introduction: Recurrent malignant anastomotic strictures, especially close to the rectum, are challenging to treat. Lumen-apposing metal stents (LAMS) have been increasingly used for benign strictures. Data in malignant strictures is limited. We report a case successfully treated by non-cautery enhanced LAMS.
Case Description/Methods: A 54-year-old man with a history of rectosigmoid adenocarcinoma post low anterior resection, adjuvant chemoradiation, and local recurrence with progression to peritoneal carcinomatosis presented with the complaints of intermittent nausea, vomiting, and abdominal distention.
A small bowel follow-through did not show an obstruction but a Gastrograffin enema revealed a rectosigmoid anastomotic stricture. Sigmoidoscopy confirmed a high-grade stricture, 0.4 cm (diameter) x < 1 cm (length) at an end-to-end colo-colonic anastomosis, 10 cm from the anus. This was balloon dilated to 16.5 mm using an over-the-wire technique and traversed showing severe upstream colonic dilation. Stricture biopsies showed evidence of at least high-grade dysplasia. Symptoms improved for a month after which they recurred. Interval positron emission tomography scan revealed hypermetabolic recurrent rectosigmoid tumor.
After a multidisciplinary discussion, he was deemed a high-surgical risk candidate. Due to proximity to the anus and long-term life expectancy, a LAMS placement was planned. Stricturogram on repeat colonoscopy using a dual-channel gastroscope confirmed < 1 cm length stricture. A 20 x 10 mm LAMS system was exchanged over-the-wire. Using a non-cautery technique both flanges were deployed across the stricture, followed by balloon dilation to 18 mm with improvement in luminal narrowing and decompression of the upstream colon. At 5-month follow-up, the patient continues to do well with the resolution of obstructive symptoms.
Discussion: Malignant recurrence at post-surgical anastomotic sites is difficult to manage surgically, especially with peritoneal involvement. Palliative endoscopic options are limited to dilation or uncovered self-expanding metal stents (uSEMS). Due to their longer length, the role of uSEMS is limited in strictures close to the anus (< 10 cm) due to the occurrence of pain and tenesmus. LAMS with their short length and fully covered nature can provide a longer-lasting alternative with the avoidance of adverse effects. To our knowledge, this is the first report using LAMS for a distal colonic malignant post-surgical anastomotic stricture.
