LAUSR

Combined antegrade-retrograde dilation [1] is an established technique that has been adapted for benign colonic obstruction [2, 3] but requires use of accessory devices and predilation followed by deployment of self-expanding metal stents [2, 3]. Rendezvous sigmoidorectal reanastomosis using a lumen-apposing metal stent (LAMS) has also been described with endosonographic (EUS) guidance [4]. We hereby report a recanalization of complete stenosis of a colo-colonic anastomosis without EUS guidance. An 81-year-old woman with a history of large-bowel obstruction secondary to benign sigmoid diverticular stricture underwent a two-step diverting transverse loop colostomy creation followed by transverse loop colostomy takedown with colo-colonic anastomosis, open sigmoidectomy with colorectal anastomosis, and diverting loop ileostomy creation. Subsequent barium enema and sigmoidoscopy showed a patent colorectal anastomosis but complete stenosis of the colo-colonic anastomosis in the distal transverse colon (▶Fig. 1). Given the distant location of the stenosis from either orifice, we opted for combined antegrade-retrograde forward-viewing colonoscopy for recanalization of the colon lumen. Using fluoroscopy and transillumination, a 15×15mm LAMS (AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) was safely deployed across the stenosis (▶Fig. 2 a, b). Balloon dilation was performed within the saddle of the stent (▶Fig. 2 c). The patient was discharged home and a subsequent colonoscopy was performed 2 months later for retrieval of the LAMS and dilation of the remnant anastomosis to 18mm (▶Video 1). Given patent colocolonic and colo-rectal anastomosis, the patient underwent loop ileostomy takedown and had complete remission of symptoms with regular bowel movements. LAMS allows puncture and release in a single-step procedure, thus enabling deployment of the stent into the target lumen without prior guidewire insertion or preliminary dilation, thereby simplifying the procedure with low enteroanastomosis migration risk [5]. Although EUS guidance is typically utilized, this may be technically challenging or unavailable; however, safe LAMS deployment can be performed using only transillumination and fluoroscopy. Endoscopy_UCTN_Code_TTT_1AQ_2AF ▶ Fig. 1 Initial findings. a Barium enema with contrast filling terminating at the distal transverse colon. b Schematic diagram demonstrating anatomy of the patient’s colon. Source for ▶ Fig. 1 b: Lance Powell.