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Rectal strictures are uncommon and may occur as
a complication of radiation therapy, ischemia, or inflammatory
disease. However,
they most commonly develop after surgical procedures that include
the construction of an anastomosis.
Fluoroscopically guided balloon dilation has proved to be a
safe and effective procedure for treating rectal strictures.
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The procedure is most easily performed with the
patient in a lateral position.
To opacify the stricture, a small amount of dilute barium
suspension is injected into the rectum through a shortened 10 to
14 French feeding tube or angiographic catheter. In patients with a low anastomosis, the catheter can usually
be advanced with finger guidance through the strictured
anastomosis. When the
stricture is more proximal, it may be preferable to use a
steerable catheter (Biliary Stone Removal, Medi-tech, Inc.,
Watertown, MA) to negotiate the posteroanterior angulation of the
proximal rectum. After
the catheter is positioned at the stricture orifice or across the
stricture, a J-shaped guide wire is introduced through the
catheter and advanced at least 20 cm proximal to the narrowing or
as far as necessary to obtain a good purchase for catheter
exchange. The
introducer catheter is exchanged for the balloon catheter that is
positioned astride the stricture.
Multiple inflations with incrementally increasing pressures
are performed as described for other strictures of the
gastrointestinal tract.
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Most dilations can be performed with
fixed-diameter polyethylene balloon catheters of the Gruntzig
type. Again, in cases
of severe stenosis, the dilation may have to be initiated with a
small-diameter balloon (6-10 mm), subsequently followed at the
same session by one of greater diameter (20 mm).
As rectal anastomoses greater than 20 mm in diameter are
frequently created, attempts should be made to dilate the
stricture to the original size of the anastomosis.
In these cases, a second 20 mm balloon may be placed after
initial inflation with a first balloon, and the two balloons
inflated simultaneously ("kissing balloons" technique).
Alternatively, a 30 mm pneumatic balloon catheter (Rigiflex
Achalasia Dilator, Microvasive Inc., Milford, MA) can be used.
The decision to use a 30 mm balloon or two 20 mm balloons
simultaneously may depend on whether dilation of a stricture with
a single 20 mm balloon can be accomplished easily, and whether it
is felt that further stretching of the stricture could be
performed safely. A
problem with the paired balloon technique is that stretching
occurs predominantly in one direction, as the two balloons form an
oval shape; however, in our experience the final shape of the
stricture does not appear to have an effect on the clinical
results.
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After
the maximal achievable or desirable diameter of the rectum is
obtained, barium suspension is injected into the rectal lumen to
verify that no perforation has occurred.
We have not found that antibiotics are necessary during or
after the procedure. In patients who do not have a diverting
intestinal ostomy, stool softeners and bulk forming laxatives
should be prescribed to prevent constipation and allow the
stricture to be dilated naturally by the fecal stream.
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