Colonic strictures

Summary:

Post-surgical benign strictures should initially be treated with balloon dilatation, then if refractory, covered metal stent or radial incision.

20% of colonic resections are complicated by benign stricture

• First-line treatment is endoscopic balloon dilatation
• 25% of strictures are refractory to this

Post-surgical strictures seem to occur more often with

• Leaks
• Extraperitoneal rectal resections
• Radiotherapy prior to surgery
• Tension on anastomosis
• Circular endostaplers/mechanical intestinal sutures

Treat these with dilatation when

• Symptomatic
• Procedure required proximal to stricture
• Required to be traversed by colonoscope for surveillance

Factors predicting failure of balloon dilatation

• Malignant cause - be suspicious of recurrence if initial dilatation fails
• Fistulae
• >1 stricture
• Active inflammation
• Marked angulation of stenotic segment

Complications

• Minor bleeding 15%
• Perforation 1%
• Recurrence 25% long-term

Alternatives to balloon dilatation

• Self-expanding metal stents - preferred with malignant strictures
  • Uncovered - low-risk for migration but difficult to withdraw
  • Covered - easy to withdraw, high risk of migration
    • Could play a role in benign strictures refractory to dilatation
• Biodegradable stents
  • Dissolve over 10-12 weeks
  • Requires initial size of 9.4mm
• Radial incisions
  • Useful in small stenoses
  • Subsequent balloon dilatation seems to increase rate of recurrence
• Lumen-apposing metal stents
  • Idea being the shape holds them in place better