The Transanal Approach with Laparoscopy or Laparotomy for the Treatment of Rectal Strictures in Crohn's Disease

Introduction

Crohn's disease is a common chronic inflammatory bowel disease with intestinal mucosal and extramucosal involvement. There is presently no cure for the disease but immunomodulators have vastly improved the armamentarium used for the treatment and control of symptoms. Despite advances in medical therapy, surgery still plays a significant role in the management of complicated Crohn's disease. ¹ The colon and rectum are involved in 20%–50% of patients, of which 12%–18% will develop a stricture.^2,3 Successful treatment of rectal strictures in Crohn's disease is a challenge, and methods advocated in their management include direct steroid injection, systemic infusion or local injection of tumor necrosis factor (TNF) inhibitors, endoscopic balloon dilatation, the use of rectal dilators, stricturoplasty, and proctectomy.^1,2,4–6

The transanal approach has been popularized in the management of Hirschsprung's disease in children.^7,8 We have recently reported the use of a similar technique in rectosigmoid resections for intractable idiopathic constipation ⁹ and for redo Hirschsprung's pull-throughs. ¹⁰ This technique is less invasive and can be used to remove even an inflamed and scarred rectum, and the anal sphincteric mechanism can be preserved in selected patients. In this case series we present 3 patients with Crohn's disease and rectal strictures managed with a transanal resection and compare the results to available literature.

Methods

Three patients aged 17, 17, and 21 years who had been treated for medically refractory or chronic Crohn's colitis and rectal strictures were referred to our institution. They had failed medical management, rectal dilation, and balloon dilation of the strictures. All 3 had been diverted (ileostomy in 2, colostomy in 1). One had developed a rectovesical fistula despite diversion. In each case, we performed a transanal sphincter preserving dissection ∼1.5 cm above the dentate line, in the prone position, and then packed the perineum with sterile gauze. We then flipped the patient supine and placed them in lithotomy position for intraabdominal mobilization, completion of the rectosigmoid resection, pull-through of the left colon, and coloanal anastomosis.

Results

Case 1

A 21-year-old woman was initially seen in our hospital and found to have Crohn's disease at the age of 11 years. She was managed on azathioprine and prednisone and followed for 10 years without significant active disease until 1 year prior to presentation when she developed chronic fever and weight loss. She was identified to have a rectal abscess associated with anal and rectal strictures. CT and MRI scans of the pelvis revealed fluid collections and inflammation around her upper rectum. Colonoscopy showed a strictured rectum and sigmoid at 4 and 20 cm from the anal verge, respectively, with prestenotic colonic dilatation. The strictures and rectal abscess persisted despite treatment with antibiotics and steroids, necessitating a laparoscopic diverting ileostomy. The pelvic fluid collection was noted to have resolved at the time of the laparoscopy. She responded well to the fecal diversion with weight gain but the strictures remained, as demonstrated on contrast enema (Fig. 1A, B).

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FIG. 1.

(A) Oblique view of the contrast enema showing a strictured distal rectum. (B) Anteroposterior view of the contrast enema showing strictures in the sigmoid colon and rectum.

A laparoscopic-assisted transanal resection of the rectum and sigmoid colon was done at 5 months after diversion. Laparoscopy confirmed a stricture at the mid-sigmoid colon. The descending colon, which was grossly normal, was mobilized up to the splenic flexure. Via a perineal, transanal dissection, a stricture 1 cm above the dentate line was found with a grossly diseased and friable rectum. The rectosigmoid was resected, pull-through of the descending colon was performed, and a coloanal anastomosis was done, preserving the anal canal and sphincter mechanism. The ileostomy was closed at 7 months postoperatively. She developed a recurrence of colitis in the pulled through segment at 6 months after ileostomy closure and was placed on anti-TNF therapy, in addition to metronidazole, to which she responded. She is now 13 months postileostomy reversal, is quiescent in terms of her Crohn's status, and has four formed stools daily, with no blood in the stool. She is gaining weight adequately.

Case 3

A 17-year-old boy with a history of Crohn's disease presented with intermittent crampy abdominal pain for 2 months, fever, and weight loss. Examination confirmed proctitis and a perirectal abscess. Examination under anesthesia revealed a rectal stricture 3 cm from the anal verge, and colonoscopy showed a stricture at 15 cm, beyond which the scope could not be passed. He was treated with steroids, antibiotics, and infliximab but there was no improvement, and he underwent a laparoscopic diverting ileostomy. The symptoms only improved mildly and his clinical condition was complicated by the development of a rectovesical fistula despite diversion. A transanal resection was performed. The distal stricture was contained within a large rectal inflammatory mass, which necessitated a combined laparotomy and transanal resection of the rectum and sigmoid colon with pull-through of the healthy proximal sigmoid colon. The operation was performed via a combined prone and then supine position (Figs. 2 and 3). For the transanal dissection a prone position was used, and for the colonic mobilization and coloanal anastomosis, the patient was in supine/lithotomy position. The rectovesical fistula was also repaired. He did well postoperatively, including significant weight gain and increase in linear growth. A recent contrast enema showed a normal caliber colon, examination under anesthesia demonstrated absence of a stricture, and ileoscopy as well as colonoscopy showed an absence of active disease. The anal canal and sphincters were preserved and demonstrated by his ability to hold contrast. He has been followed for 1 year and is scheduled for closure of the ileostomy.

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FIG. 2.

The patient in the prone position used for transanal dissection.

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FIG. 3.

Commencement of the transanal rectal dissection in the prone position with preservation of the anal canal.

Discussion

Although mild cases of Crohn's strictures may respond to medical treatment, more aggressive treatment is necessary to treat recalcitrant strictures. ² The use of endoscopic balloon dilation with or without steroid injection has been advocated in the treatment of these strictures. ¹¹ However, this has not been demonstrated to be of repeated success and perforations may occur. The use of this technique in long rectal strictures often does not succeed. ¹¹ In a review of 29 upper and lower gastrointestinal tract strictures dilated through a scope balloon, a perforation rate of 10% with a long-term success rate of 76.5% was reported. ¹¹ Another technique is the use of rectal dilators, typically Hegar dilators of varying sizes, which also has variable success. In a group of 33 patients with anorectal strictures in Crohn's disease managed by dilation, 13 did not respond to dilations and had to undergo proctocolectomy. ¹² In another review of 9 patients with Crohn's disease and anorectal strictures managed with rectal dilation, 7 remained dependent on regular dilation every 2–6 months, 24–48 months after commencement of this modality of treatment. ¹³ Repeated dilation on its own is not risk free with potential morbidities including sphincter damage, perforation, and local sepsis. ¹³

Infliximab is another technique utilized in the treatment of strictures associated with Crohn's colitis. The anti-inflammatory properties of TNF inhibitors have been demonstrated to alleviate the symptoms associated with strictures.^6,14 The results tend to be unsatisfactory in patients who have fibrotic strictures, which are likely to be dense, long standing, and unrelated to previous anastomosis ⁵ as in the patients presented in this review. Local injection of infliximab is a more recent attempt at reducing the side effects of systemic infusion as well as providing a more effective alternative. Although the efficacy has been demonstrated in a small series involving short segmental strictures in patients with obstructive symptoms, ² it may not be helpful in patients with multiple or long segmental strictures, such as in two of the cases we have presented.

Strictureplasty has been used successfully for the treatment of small and large bowel strictures in Crohn's disease.^4,15 This method of course is not technically feasible in rectal strictures.

Surgery has a major role to play in the management of rectal strictures complicating Crohn's disease, especially when there is proctocolitis. ¹² This may be in the form of temporary diversion or definitive resectional treatment. Fecal diversion may be necessary to allow the inflammatory process in the colon and rectum to subside but may not be helpful for more than a temporary period of time. And despite diversion, local irritation can continue and lead to problems. Some have also reported cases illustrating that diversion in this group of patients may result in worsening of their symptoms. ¹⁶

Transanal pull-through has been popularized for the treatment of Hirschsprung's disease.^7,8 A key component of the procedure involves preservation of the anorectal sphincter mechanism. We contemplated that for those patients with a Crohn's rectal stricture, a successful transanal resection can allow for a pull-through and preclude the need for a permanent stoma. We have noted that the approach has been useful for rectosigmoid resection in other conditions such as idiopathic constipation refractory to medical management ⁹ and redo pull-throughs for Hirschsprung disease, which often have a scarred rectum or a distal pull-through segment that needs to be removed. ¹⁰ When the mobilization cannot be completed from below, laparoscopy or laparotomy can be done to achieve a complete resection of the rectum with or without adjacent colon. A common fear is fecal incontinence, but because the anal canal and sphincter mechanisms are preserved intact, the ability of the patient to maintain continence is maintained.^7–10

One of the most feared consequences of complicated Crohn's disease is the need for a permanent diversion. This is particularly so in patients with anorectal strictures in the setting of Crohn's colitis and proctitis.^1,17,18 In one review, only 34% of a group of patients with anal canal stricture and Crohn's disease avoided a permanent diversion. ¹⁹ Two of our patients were able to avoid permanent ostomy largely because the healthy segment of bowel utilized in the pull-through was anastomosed to an intact anal canal with preserved sphincter mechanisms and therefore preserved function. The first patient did well in terms of bowel function but had a flare of colitis necessitating more aggressive treatment with TNF inhibitors. We take a very aggressive postoperative strategy using both immunomodulating agents, such as methotrexate or 6-mercaptopurine, as well as anti-TNF agents to try and limit or delay postoperative recurrence.^20,21 We do not know yet whether the third patient can one day be pulled through and undiverted.

In view of the psychological and social effects of long-term stomas in children and adolescents, ²² procedures that will preserve anal canal functions and improve quality of life after a proctocolectomy for rectal strictures are worth considering in selected cases.

Conclusion

Transanal resection is a feasible approach to the surgical resection of the rectum affected by a stricture in the setting of Crohn's disease.

Disclosure Statement

No competing financial interests exist.