AJR 2005; 184:S56-S57
© American Roentgen Ray Society
Antegrade Ileography for Evaluating a Distal Anastomotic Stricture After Loop Ileostomy
Jakob C. L. Schutz1,
Marc S. Levine1,
Edward Y. Woo2 and
John L. Rombeau2
1 Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2 Department of Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA 19104.
Received December 18, 2003;
accepted after revision March 19, 2004.
Address correspondence to M. S. Levine
(marc.levine{at}uphs.upenn.edu).
Introduction
Loop ileostomies frequently are used for temporary diversion of the
fecal stream proximal to ileal pouch-anal anastomoses after a total colectomy
or proximal to colocolic or colorectal anastomoses after a partial colectomy
[1]. When anastomotic leaks or
strictures are suspected in these patients, water-soluble contrast material or
barium often is administered via the rectum to assess anastomotic integrity
and patency before takedown of the loop ileostomy. Antegrade ileography via
the ileostomy stoma has also been described as a radiographic technique for
evaluating postoperative complications after total colectomy and ileal
pouch-anal anastomoses, although retrograde studies are generally advocated
for better distention of the ileal pouch
[2,
3]. One case in the surgical
literature reports successful endoscopic dilatation of an anastomotic coloanal
stricture via antegrade intubation of the distal limb of a loop ileostomy
[4].
Case Report
We report a patient with a high-grade stricture at the colorectal
anastomosis after a rectosigmoid resection for rectal carcinoma in whom
antegrade ileography was performed via the efferent limb of the ileostomy
stoma as a novel approach for assessing the length of the stricture and
guiding patient management.
An initial water-soluble contrast enema (meglumine diatrizoate, Hypaque,
Nycomed Amersham) revealed a lumen-obliterating stricture with complete
retrograde obstruction at the anastomotic staple line
(Fig. 1A), precluding
evaluation of stricture length. This was a major concern, as the attending
surgeon preferred to dilate the stricture rather than resect it surgically
because of potential problems with scarring and adhesions in this region from
pelvic irradiation. By using the radiopaque staple line as a landmark, we were
able to show on subsequent antegrade ileography with barium sulfate (Entrobar,
Lafayette Pharmaceuticals) that this patient had an extremely short segment of
narrowing at the anastomotic staple line, causing antegrade obstruction
(Fig. 1B). The stricture,
therefore, was amenable to a fluoroscopically guided dilatation procedure,
avoiding the need for an open laparotomy
(Fig. 1C). This case
under-scores the potential value of antegrade ileography for evaluating
colonic strictures (particularly anastomotic strictures) that cannot be
adequately evaluated by conventional radiographic studies via the rectum
because of high-grade obstruction.
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Fig. 1A. —65-year-old man with high-grade stricture at colorectal
anastomosis for rectal carcinoma in whom antegrade ileography was performed to
assess length of stricture and guide patient management. Frontal spot image
from water-soluble contrast enema shows lumen-obliterating stricture with
complete retrograde obstruction at anastomotic staple line
(arrows).
|
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Fig. 1B. —65-year-old man with high-grade stricture at colorectal
anastomosis for rectal carcinoma in whom antegrade ileography was performed to
assess length of stricture and guide patient management. Frontal spot image
from antegrade ileography (by injecting barium via catheter in efferent limb
of loop ileostomy through ileocecal valve into colon) also shows complete
antegrade obstruction at anastomotic staple line (arrows). A
and B indicate presence of extremely short stricture at colorectal
anastomosis.
|
|
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Fig. 1C. —65-year-old man with high-grade stricture at colorectal
anastomosis for rectal carcinoma in whom antegrade ileography was performed to
assess length of stricture and guide patient management. Frontal spot image
from repeat water-soluble contrast enema 1 day after dilatation procedure
shows patent colorectal anastomosis, with narrowing and irregularity of
anastomotic region (arrow), most likely secondary to postprocedural
edema and inflammation.
|
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Discussion
Several technical points should be mentioned about performing antegrade
ileography via a loop ileostomy. Not infrequently, the efferent limb of the
ileostomy is recessed away from the stoma, so it can be more difficult to
cannulate than the afferent limb. Thus, a surgeon may be needed to find and
cannulate the efferent limb. It also is important to select the proper
contrast agent (barium or water-soluble contrast material) for this
examination. When a distal colonic obstruction is present, an argument can be
made for using water-soluble contrast material rather than barium because of
concern about barium inspissating above the site of obstruction. On the other
hand, we thought that barium would enable better opacification of the distal
colon and anastomotic region than water-soluble contrast material. We also
recognized that the barium could be evacuated at surgery if a long stricture
was identified at the colorectal anastomosis.
References
- Cheape JD, Hooks VH. Loop ileostomy: a reliable method of
diversion. South Med J1994; 87:370
-374[Medline]
- Thoeni RF, Fell SC, Engelstad B, Schrock TB. Ileoanal pouches:
comparison of CT, scintigraphy, and contrast enemas for diagnosing
postsurgical complications. AJR1990; 154:73
-78[Abstract/Free Full Text]
- Alfisher MM, Scholz FJ, Roberts PL, Counihan T. Radiology of ileal
pouch-anal anastomosis: normal findings, examination pitfalls, and
complications. RadioGraphics1997; 17:81
-98[Abstract]
- Reissman P, Nogueras JJ, Wexner S. Management of obliterating
stricture after coloanal anastomosis. Surg Endosc1997; 11:385
-386[Medline]
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Introduction
Case Report
