INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer in the United States. CRC is one of the leading causes of cancer mortalities. Most patients with CRC require colectomy. The type of colectomy and application of adjuvant or neoadjuvant chemoradiation therapy depend on differentiation and stage of CRC as well as the patient’s general health conditions. Commonly performed surgery for CRC include hemicolectomy, segmental colectomy, partial colectomy, and subtotal colectomy, resulting in ileocolonic anastomosis (ICA), colocolonic anastomosis (CCA), colorectal anastomosis (CRA), or coloanal anastomosis (CAA). Laparoscopy-assisted colectomy, rather than open colectomy, is preferred for those with nonobstructed, nonperforated, nonlocally advanced colon cancers. Multivisceral resection may be needed for locally advanced and potentially resectable primary colon cancers. Some patients may need temporary or permanent ileostomy, while others require chemoradiation therapy or immunotherapy. Postsurgical anastomotic complications, including bleeding, strictures, and leaks, are common. Anatomy and intestinal blood supply of the large bowel, smoking, obesity, nutritional conditions, comorbidities, radiation exposure, surgical techniques (especially tension at the anastomosis), and expertise, are some of the risk factors for the development of these anastomotic complications. Endoscopy plays a growing role in the management of these complications. Common endoscopic treatment modalities are endoscopic clipping and cauterization of anastomotic bleeding, endoscopic balloon dilation (EBD), endoscopic stricturotomy, endoscopic strictureplasty, endoscopic stent placement, endoscopic drainage, endoscopic clipping, endoscopic sinusotomy, and endoscopic fistulotomy. Since redoing surgery for failed colorectal or CAA is often challenging, the endoscopic option should be evaluated before surgical intervention.

PREPARATION OF LOWER GASTROINTESTINAL ENDOSCOPY

Despite potentially curative surgery and the use of modern adjuvant chemoradiation, more than 40% of patients with stage II or III disease would have recurrent disease following primary therapy. Surveillance colonoscopy is required for patients after colectomy for CRC. Colonoscopy plays a key role in the surveillance, along with clinical, laboratory, and radiography assessment. The guidelines by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer recommended surveillance in patients with endoscopically resected stage I CRC, surgically resected stages II and III cancers, and stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis). Multiple professional societies proposed guidelines for surveillance interval of lower gastrointestinal (GI) endoscopy after colectomy for CRC. For example, the American Cancer Society and the US Multi-Society Task Force recommend colonoscopy at 1 year and subsequent studies dictated by prior findings. If negative, every 5 years. Proctosigmoidoscopy every 6 months for 2 to 5 years if rectal cancer and no pelvic radiation. ^, The National Comprehensive Cancer Network recommended colonoscopy in 1 year. If an advanced adenoma is detected, colonoscopy is repeated in 1 year; otherwise, repeat in 3 years. If no advanced adenoma is detected in year 4, colonoscopy is repeated every 5 years. The US Multi-Society Task Force on Colorectal Cancer recommended colonoscopy 1 year after surgery. The interval to the next colonoscopy is 3 years and then 5 years. The intervals between colonoscopies should be shorter if neoplastic polyps are detected. The purpose of surveillance after definitive therapy of CRC colon is early identification of lesions such as anastomotic recurrence ( Fig. 24.1 ) that might potentially be cured by further surgical intervention and to evaluate for second primary cancers and polyps.

Recurrent rectal cancer at the colorectal anastomosis after endoscopic full-thickness resection and subsequent surgical low anterior resection.

Some colectomy-associated complications, such as acute anastomotic leaks (AL) and acute bowel obstruction require immediate intervention. There have been concerns about the risk of disruption by flexible sigmoidoscopy and colonoscopy immediately after colectomy. There is no consensus on the postoperative cut-off point to safely perform GI endoscopy. It appears that a careful endoscopic evaluation carries a low risk of compromising the integrity of the anastomosis. A retrospective multicenter study was performed in 36 patients undergoing diagnostic flexible sigmoidoscopy and 16 patients having a colonoscopy for the suspected postoperative complication, 3 weeks after colon surgery and 104 age-and-sex matched controls. Sigmoidoscopy provided the diagnosis in 18 (54%) of 33 cases and colonoscopy provided the diagnosis in 9 (56%) of 16 cases in the study group. Two endoscopic complications, unrelated to suture breakdown, occurred in the study groups. The control groups had no endoscopic complications. Some investigators performed water-immersion endoscopies to evaluate and treat anastomotic complications (e.g., bleeding). ^,

Bowel preparation is needed, unless the lower GI endoscopy is performed in those with a diverting ostomy. To prepare endoscopic therapy of stricture and leaks, preendoscopy abdominal imaging, such as gastrografin enemas ( Fig. 24.2 ), computed tomography (CT), or magnetic resonance imaging (MRI) should be obtained to characterize the number, severity, length, and associated conditions of the anastomosis. Intraprocedural fluoroscopic guidance has been helpful.

Gastrografin enema characterizes stricture after colorectal anastomosis.

ANASTOMOTIC BLEEDING

Bleeding after a colonic anastomosis is not common, usually minor, and self-limited. Massive acute bleeding from a perforating vessel or trapped mesentery usually requires urgent radiographic or surgical intervention. The frequency of postoperative bleeding after CRA ranged from 0.3% to 6.5%. It appears that low anterior resection (LAR) of rectal cancer results in a higher rate of AB, with the use of intraoperative endoscopy being a risk factor. AB can result from recurrent cancer at the anastomosis ( Fig. 24.1 ). In a retrospective study of 1390 patients with ICA, 976 with stapled end-to-side (ESA), 308 stapled side-to-side (SSA), and 108 with handsewn anastomoses (HSA), 54 (3.9%) patients experienced AB. However, there was no statistical difference in the frequency of AB. In a separate retrospective study of 350 patients with ICA, postoperative lower GI bleeding occurred in 17 patients (4.9%) who were exclusively in the ESA group. Among them, three patients had suture dehiscence. Some investigators advocated intraoperative or immediate postoperative endoscopy to evaluate the integrity of the anastomosis. In a study of 338 patients who underwent a CRA, immediate postoperative endoscopy was performed in 85 of these patients, with 5.9% requiring endoscopic intervention with a hemoclip.

A small amount of postoperative AB is usually self-limited. Persistent bleeding with hematochezia or bleeding requiring blood transfusion normally requires intervention, including interventional radiology, surgery, or endoscopy. The choice among the treatment modalities depends on the setting (inpatient vs. outpatient vs. intensive care unit), the severity of bleeding, comorbidities, and local expertise. It is generally believed that AB largely results from tissue ischemia at the anastomosis. Angiographic embolization of relevant branches of the mesenteric artery may further induce tissue ischemia, resulting in recurrent AB ( Fig. 24.3 ). Clinicians should save surgical resection and re-anastomosis as the last resort, after an attempt with endoscopic therapy.

Bleeding from ischemic ileocolonic anastomosis. (A) Blood clots at the anastomosis; (B) bleeding ischemic ulcer treated with endoscopic clipping after the clot was washed off; (C) angioembolization for recurrent bleeding after the endoscopic clipping; (D) recurrent bleeding after angioembolization treated again with endoscopic clipping.

Reported endoscopic treatment modalities include submucosal injection of diluted adrenaline (1:200 000), ^, electrocoagulation, ^, microwave coagulation, placement of hemoclips, ^{, , , ,} or biofragmentable anastomotic ring. In a retrospective study of 729 patients with left colectomy with primary anastomosis, AB occurred in 47 patients (6.4%), of whom 37 (78.7%) had an endoscopy. At the time of endoscopy, AB spontaneously stopped in nine (24.3%). Endoscopic therapy was performed using hemoclips in 10 (27.0%), mucosal sclerosis in 11 (29.7%), and both in 7 (18.9%) cases. Five (10.6%) patients with AB were reoperated because early endoscopy showed associated AL.

This author routinely uses endoscopic hemoclips and occasionally injects or sprays hypertonic glucose to control AB ( Figs. 24.4 and 24.5 ). The endoscopy may be performed as inpatient or outpatient, in endoscopy suites, operating rooms, or intensive care units. Adequate bowel preparation is important to reduce procedure time and amount of carbon dioxide insufflation and facilitate the identification of anastomosis and the source of bleeding. Various degrees of AB may be detected, ranging from pulsatile to stigmata of bleeding ( Figs. 24.6 and 24.7 ). Some patients may present with persistent low-grade AB and iron deficiency anemia without obvious hematochezia or massive bleeding. On endoscopy, there might be no obvious bleeding at the anastomosis ( Fig. 24.6 ). The endoscopist may use a “sliding by” technique to provoke and identify the bleeding source ( Fig. 24.6 ). On lower GI endoscopy, active bleeding may show large blood clots at the anastomosis. The blood clots should be washed off, to allow for the identification of bleeding ulcers or vessels and treated accordingly ( Fig. 24.7 ). This author noticed that AB is often associated with dislodged staples and removal of the staples helps control bleeding ( Fig. 24.8 ). The author has also noticed that intralesional injection of epinephrine or the use of electrocauterization can induce ischemic ulcers, causing more bleeding during the treatment or recurrent bleeding afterward. The author only uses intralesional injection of diluted epinephrine to control pulsatile bleeding nonstoppable by placement of hemoclips and injection or spray of hypertonic glucose ( Fig. 24.9 ).

Bleeding at the ileocolonic anastomosis. (A) Ischemic ulcers with bleeding vessel at the anastomosis; (B) endoscopic clipping of the bleeding vessel; (C) spray of hypertonic glucose.

Bleeding at the colocolonic anastomosis. (A) Oozing of blood along the staple line; (B) bleeding control with endoscopic clipping and injection of hypertonic glucose.

Stigmata of bleeding with endoscopic provocation in a patient with chronic iron deficiency anemia after partial colectomy for colon cancer. (A) No obvious bleeding; (B) active bleeding provoked by the “sliding by” maneuvering of endoscope; (C) endoscopic clipping of the bleeding site.

Endoscopic removal of blood clots. (A) Endoscopic removal of a blood clot; (B) revealing of bleeding anastomotic ulcer underneath the clot.

Bleeding from dislodged staples along the colocolonic anastomosis. (A) Dislodged staples with low-grade bleeding; (B) removal of the dislodged staples with biopsy forceps.

Severe bleeding at colocolonic anastomosis. (A) Severe persistent bleeding despite the placement of endoclips; (B) injection of diluted epinephrine.

ANASTOMOTIC STRICTURES

The definition of stricture is different from clinical, endoscopic, and radiographic perspectives. From endoscopist’s perspective, the stricture is defined as a narrowed bowel lumen not traversable to an endoscope or traversable to the endoscope with resistance as defined by a consensus guideline from the Global Interventional Inflammatory Bowel Disease Group. The guideline that was proposed to define and treat Crohn’s disease (CD) may also apply to other benign or malignant primary or anastomotic strictures. Technical success is measured by the posttreatment passage of the endoscope with or without resistance of the stricture not traversable before treatment; or posttreatment passage of the scope without resistance of the stricture traversable with resistance treatment. The guideline also proposes the definition of long-term outcome measurement, that is, surgery-free survival. Length and degree of the strictures should be documented.

Colorectal anastomotic strictures following colectomy of CRC may be benign or malignant. Postoperative low GI endoscopy serves diagnostic, surveillance, or therapeutic purposes. Any colorectal anastomotic strictures in patients with colectomy for CRC who are undergoing endoscopic therapy should be biopsied to rule out recurrent CRC. Anastomotic strictures at CAA or CRA may be treated with digital dilation or bougie dilation in the clinic or examination under anesthesia (EUA). Transanal endoscopic surgery has been used for the treatment of primary or anastomotic strictures of the distal bowel. A classic example is transanal minimally invasive surgery (TAMIS) in anastomotic strictures in the distal large bowel. ^, Several methods of treatment for benign anastomotic strictures after LAR have been described. A transanal circular stapling device has also been used for the treatment of rectal anastomotic strictures. Still, these surgical approaches in the operating room were more invasive than traditional transanal endoscopy.

Risk factors for benign anastomotic strictures after colorectal surgery have been investigated. A retrospective study of 179 patients with anastomotic strictures after colectomy for CRC (59%) or diverticular diseases (23%), male sex, and longer duration from the surgery to inception are risk factors of anastomotic strictures. A nomogram study showed that the preservation left colic artery, protective stoma, AL, and anastomotic distance were independent risk factors for benign anastomotic strictures after surgery for rectal cancer. An early Cochrane review based on nine randomized controlled trials showed that anastomotic stricture was more common in stapled anastomoses than HSA.

Possible adverse events during or after EBD are postprocedural ileus, bleeding, and perforation. In patients with a prolonged procedure and excessive bloating, an endoscopist may place a decompression tube via the anus. Intraprocedural bleeding can be controlled by spray or injection of hypertonic glucose, clipping, or injection of epinephrine. Intraprocedural perforation may be managed conservatively with immediate closure with through-the-scope (TTSC) or over-the-scope (OSTC) clipping, or suturing. Of note, patients with prior pelvic radiation or antiplatelet agents are prone to the development of procedure-associated complications.

Endoscopic Balloon Dilation

Endoscopic dilation is commonly performed in patients with strictures in the GI tract. A study of EBD in 24 symptomatic patients with benign colorectal anastomotic strictures after anterior rectal resection for cancer showed a technical success in 22 (91.7%) patients. There were no procedure-related complications. The mean number of EBD sessions required was 2.3. There was no relationship between the number of dilation sessions and restenosis. A case-control study of EBD in 106 strictures in 90 patients with CD (including 52 anastomotic strictures) versus benign non-CD strictures (including 27 anastomotic strictures and five patients with colectomy for CRC) showed comparable efficacy and safety. Investigators analyzed 94 consecutive patients with colorectal anastomotic stenosis, including 68 patients with surgical resection for malignancy. EBD was performed alone in most cases or in combination with argon plasma coagulation incision. Technical success was achieved in 59% of patients with colectomy for cancer and 88% resected for a benign condition. Benign restenosis, perforation, or abscess developed in 17 patients. It appears that restenosis or adverse events were more common in those with colectomy for cancer than those with surgery for benign bowel diseases.

Almost all short (i.e., <4–5 cm in length) strictures are amenable to EBD. Retrograde EBD (i.e., traversing the endoscope through the anastomotic stricture and working backward with balloon insufflation) is preferred to antegrade EBD (i.e., pushing balloon catheter blindly forward through the stricture). The endoscopist can use non-wire-guided long (8 cm) balloons to perform retrograde EBD, or use wire-guided short (5.5 cm) balloons to perform retrograde or antegrade dilation. The size of the balloon ranges from 12 to 20 mm. It may take several sessions to achieve technical success ( Fig. 24.10 ). This author found that intralesional injection after EBD had a minimum impact on the outcome of EBD.

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