LAUSR

A 66-year-old woman underwent an emergency cecostomy (which initially intended to be proximal transverse colostomy) for obstructed sigmoid colon adenocarcinoma with bladder dome infiltration. Her comorbidities included diabetes mellitus, hypertension and ischemic heart disease. She completed her neoadjuvant chemotherapy, and underwent an uneventful open anterior resection and partial cystectomy with clear surgical margin. Subsequently, she completed her adjuvant chemotherapy. Surveillance colonoscopy, computed tomography (CT) scan and distal loopogram 1 year following anterior resection were unremarkable. Closure of colostomy was performed a year later. She developed intestinal obstruction immediately following surgery. A CT scan of the abdomen revealed dilated proximal large and small bowel due to colon anastomotic stricture (Fig. 1). Emergency laparotomy revealed multiple gangrenous patch at the large bowel with purulent peritoneal contamination. Small bowel and large bowel were severely dilated as a result of a anastomotic stricture at previous colorectal end-to-side anastomosis (Figs 2,3). Proctocolectomy was performed including the entire colon and upper rectum. Both ileal and rectal end stumps were left behind followed by temporary abdominal closure using negative pressure dressing. A delayed ileorectal endto-end anastomosis was performed in 36 h interval when the physiologic parameters improved. She made a smooth recovery following the anastomosis and was discharged 5 days later. The histology of the specimen showed a benign fibrotic stricture. The occurrence of a benign anastomotic stricture after colorectal surgery is a challenging complication with an incidence rate of 3%–30%. The risk factors of developing an anastomotic stricture remain poorly understood, but it may attribute to tissue ischemia, abdominal collection, suturing technique, anastomotic tension, general nutritive status or adjuvant radiation. Circular stapling anastomosis, as in our case, was reported to have a higher risk of stenosis. This is primarily because of an overactive inflammatory response and mucosal gaps or an area of necrosis found in stapled anastomosis that may be healed by secondary intention, which leads to an increased risk of stenosis. The time of occurrence of a stricture ranges from 6 months to 11 years, with a median time of 1 year. Several case studies reported that a stricture occurs as early as less than a month. Hence, it was difficult to predict the timing of the occurrence of an anastomosis stricture post colorectal surgery. Complete colonic anastomotic stenosis obstruction was absolutely rare; hence, a high index of suspicion was required for prompt intervention. The literature reveals that complete colonic anastomotic stenosis was more common in end-to-end anastomosis, but there was no evidence to suggest that any configuration of colorectal anastomosis (side-to-side, end-to-side, side-to-end or end-to-end) may have higher tendency of anastomosis stricture. From the literature search, there was no best configuration which may completely