Department of Colorectal Surgery, Singapore General Hospital, Singapore City, Singapore.
Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan.
Colorectal Dis. 2021 May;23(5):1258-1261. doi: 10.1111/codi.15543. Epub 2021 Feb 12.
Anastomotic stricture following anterior resection is an uncommon but challenging problem. Endoscopic dilatation and transanal endoscopic surgery (TES) are proven methods of treatment. However, a small proportion of patients repeatedly fail transanal local therapy for underlying reasons of tension, insufficient blood supply or irradiated tissue, eventually necessitating a complete anastomotic excision. We aimed to combine transanal minimally invasive surgery (TAMIS) with an abdominal approach in redo anastomoses for severe refractory anastomotic strictures.
For the TAMIS phase, we use a Lonestar® retractor with a GelPOINT® Path transanal access platform. A circumferential full thickness rectotomy is performed and the dissection is continued proximally in the mesorectal fascial plane past the strictured segment to meet the abdominal dissection or until the peritoneal cavity is entered, facilitating mobilization of the rectum. The abdominal phase is performed as usual with sufficient mobilization of the left colon to enable tension-free redo anastomosis. An accompanying video demonstrates this technique.
Two patients with refractory anastomotic strictures following a previous low anterior resection underwent the procedure. One patient had laparoscopy followed by TAMIS and the other had TAMIS followed by laparotomy. Both cases were performed by surgeons experienced in laparoscopy and TES. One patient had postoperative ileus which resolved conservatively. Both anastomoses were widely patent on follow-up.
TAMIS combined with a conventional abdominal approach offers significant technical advantages over a totally abdominal approach for the definitive management of patients with severe anastomotic strictures refractory to first-line methods of therapy. The operator should already be proficient with TES.
前切除术吻合口狭窄虽然不常见，但却是一个具有挑战性的问题。内镜扩张和经肛门内镜手术（TES）已被证实为有效的治疗方法。然而，由于张力、血供不足或放射性组织等潜在原因，一小部分患者反复接受经肛门局部治疗失败，最终需要完全切除吻合口。我们旨在将经肛门微创手术（TAMIS）与腹部方法相结合，用于治疗严重难治性吻合口狭窄的再次吻合。
对于 TAMIS 阶段，我们使用 Lonestar®牵开器和 GelPOINT®Path 经肛门进入平台。进行环形全层直肠切开术，并在系膜筋膜平面内在直肠系膜内向上进行解剖，超过狭窄段，以与腹部解剖相遇或直至进入腹腔，从而便于直肠的游离。腹部阶段按常规进行，充分游离左半结肠以实现无张力的再次吻合。附有视频演示该技术。
两名先前接受低位前切除术的难治性吻合口狭窄患者接受了该手术。一名患者先进行腹腔镜检查，然后进行 TAMIS，另一名患者先进行 TAMIS，然后进行剖腹手术。这两种情况均由具有腹腔镜和 TES 经验的外科医生进行。一名患者术后发生肠梗阻，保守治疗后缓解。随访时，两个吻合口均通畅。
TAMIS 联合传统的腹部方法在治疗严重难治性吻合口狭窄方面具有显著的技术优势，优于完全腹部方法。手术者应已熟练掌握 TES。
