Endoscopic strictureplasty for severe colonic anastomotic stricture

Benign anastomotic stricture after colonic resection usually requires surgical or endoscopic dilation. The radial incision and cutting (RIC) method was recently developed to treat resistant strictures and the recurrence rate is 28.5–44.2% [1, 2]. In this report, we developed endoscopic strictureplasty (ESP) for refractory anastomotic stricture after colorectal surgery not resolved by two RICs. A 70-year-old man with colorectal cancer at the sigmoid colon underwent surgery with end-to-end anastomosis using a circular stapling device. A colonoscopy for constipation revealed an anastomotic stricture (▶Fig. 1 a). RIC was performed twice, however, both times the stricture recurred (▶Fig. 1b, c). Therefore, ESP was performed (▶Fig. 2 a, ▶Video 1). ESP was adapted from the Heineke-Mikulicz (HM) strictureplasty, a conventional method of strictureplasty [3]. The HM strictureplasty involves resection of the tract from the serosal side, although this method uses an endoscope to resect the muscle layer from the mucosal side without full-thickness resection. First, the blade of the ITknife2 (Olympus, Tokyo, Japan) was inserted and three longitudinal incisions were made into the stricture, and the inner circular and outer longitudinal muscle layers were dissected until the subserosal layer was visualized. The incision was resutured transversely; a 30-mm endoloop (HX-400U30; Olympus) was anchored to the proximal and distal edge of the defect with a SureClip (Micro-Tech, Nanjing, China), and closed bringing both edges together. Finally, clips were applied to close the remaining defect (▶Fig. 3). The recurrence after two RICs is considered to be due to the distortion of the muscular layer. In such cases, a direct approach to the muscle layer is more effective than RIC. Closing the defect transversely allows the lumen to dilate. There was no recurrence 6 months after the procedure (▶Fig. 2b). E-Videos