Treatment of Colorectal Stricture After Circular Stapling Anastomoses

Performing an end-to-end low rectal anastomosis with the linear single stapling technique was first reported in 1979 (Ravitch & Steichen, 1979). An improved circular stapling technique for anterior resection of the rectum, i.e. double stapling technique, overcoming the problems of insertion of the purse-string on the rectum stump and of disparity in size between the rectum and colon was introduced (Knight & Griffen, 1980). Although conventional double stapling technique is mainly performed for tumors greater than 6 cm from the anal verge (Shrikhande et al., 2007), recent prospective case series have described a variation of double stapling technique for ultra-low anterior resection involving vertical transaction of the rectum followed by an anastomosis with a circular stapler which results in a vertically oriented elliptical anastomotic orifice (Sato et al., 2007). Thus, circular stapling anastomosis of the rectum has been widely used and has been regarded as a safe and quick technique, however, the development of anastomotic strictures is the major post-operative complication of this procedure. (Blamey & Lee, 1982; Cade et al., 1981; Fain et al., 1975; Kumar et al., 2011; Kyzer & Gordon, 1992; Leff et al., 1982; Luchtefeld et al., 1989; Marchena et al., 1997; Smith, 1981; Vezeridis et al., 1982). It has been reported that the circular stapled anastomosis has a higher stricture rate than a handsewn anastomosis in the colon (Brennan et al., 1982; Dziki et al., 1991; MacRae & McLeod, 1998; Polglase et al., 1981) and that the incidence of the stricture after the double stapling technique varies from 0 to 30% (Blamey & Lee, 1982; Cade et al., 1981; Gordon & Vasilevsky, 1984; Kumar et al., 2011; Kyzer & Gordon, 1992; Luchtefeld et al., 1989; Marchena et al., 1997; Smith, 1981). The complication of anastomotic stricture associated with stapling is harmful and distressing for patients with anterior resection of the rectum. Dilation is the only treatment and is variously used with techniques such as digital, a sigmoidscope, an esophageal dilator, or balloon dilators. (Cade et al., 1981; Leff et al.,1982; Luchtefeld et al., 1989; Moran et al., 1992; Smith, 1981; Verma et al., 1990; Vezeridis et al., 1982; Whitworth et al., 1988). These techniques, however, have their drawbacks, that is, digital or sigmoidscopic dilation has insufficient effects, and esophageal and balloon dilators need fluoroscopy and other optional equipments, and recurrence is common. Dilators can dilate the deformed and