Delayed Micro-Perforation Following Endoscopic Stricturotomy: A Rare Complication Managed Medically

Document Type

Conference Proceeding

Publication Date

12-1-2023

Publication Title

Am J Gastroenterol

Abstract

Background: Small bowel and colon strictures affect approximately one-third of patients with Crohn's disease (CD). While surgery is the most definitive treatment, 28 % of patients develop postoperative complications such as bleeding, bowel leaks, and recurrent anastomotic strictures. Endoscopic balloon dilation (EBD) is a less invasive alternative that can temporarily postpone surgery but necessitates repeated treatments to maintain luminal patency. Endoscopic stricturotomy (ES) is an emerging technique that has been increasingly employed as a definite treatment for CD strictures, offering prolonged luminal patency compared to EBD and a lower risk of perforation. Methods: A 55-year-old Caucasian male with a history of ileocolonic CD had a total colectomy and ileal pouch anal anastomosis 30 years ago. Subsequently, he developed CD of the J-pouch with recurrent pouch inlet and neo-terminal ileal strictures managed with serial balloon dilations. ES was offered as an alternative to EBD. During the procedure, four consecutive chronic fibrotic strictures were seen in the neo-terminal ileum. Results: ES was accomplished by radial incisions connected by parallel incisions. The patient felt well during recovery and was discharged home. He presented to the emergency department 3 days after his procedure with abdominal pain. Computed tomography of the abdomen and pelvis (CTAP) showed multiple air-fluid collections, the largest measuring 7.5 cm in diameter in the right lower quadrant adjacent to small bowel loops, concerning for ES-induced micro-perforation. The colorectal surgery and infectious disease teams were consulted. The patient was managed medically with intravenous fluids, antibiotics, and strict bowel rest. During his 5-day hospitalization, he improved significantly and tolerated a regular diet without the need for any surgical intervention. Follow-up imaging showed stable abscesses. He was discharged home and completed 4 weeks of Ertapenem. CTAP was repeated and showed resolving abscesses. Nine months later, he remains well and has not required any further ES or EBD. Discussion: ES has gained significant attention over the recent years due to its comparable efficacy to EBD with a lower risk of perforation, approximately 1%, in contrast to the substantially higher 4-5% risk associated with EBD. Conclusions: One key advantage of ES lies in its ability to precisely control the depth and length of the incisions made during the procedure. In contrast, EBD exerts a blunt radial force that is transmitted across the entire circumference of the stricture and may overly dilate weaker stricture segments, heightening perforation risk. In our presented case, thermal injury emerged as a potential primary mechanism of delayed micro-perforation. Excessive energy use during repeated attempts to create an incision in severely inflamed or fibrotic strictures leads to heat dissipation into tissue. Treating multiple strictures concurrently also prolongs heat exposure. Fortunately, the micro-perforation was effectively managed with antibiotics, obviating the need for surgical intervention-an ultimate goal of ES.

Volume

118

Issue

12

First Page

S14

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