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Stricture After Transanal Double Stapled END to END Anastomosis (Eea): Rarely Symptomatic and Inversely Related to Eea Diameter
Aviad Hoffman*, Emre Balik, Garrett NASH, Tania Azarani, Victor Moon, Dovid Moradi, Daniel Feingold, Richard L. Whelan
Columbia Presbyterian, New York, NY

Introduction: Although any anastomosis can develop a stenosis, many feel the incidence is higher for double stapled EEA. Stenoses may be symptomatic, at the very least they prevent future proximal colonoscopic exams. This study’s purpose was to determine the stenosis rate after double stapled EEA in patients that routinely underwent flexible sigmoidoscopy 2-5 months after surgery. A stenosis was defined as any anastomotic narrowing that prevented passage of an adult colonoscope (diameter 1.2 cm). Materials and
Methods: Patients who had a resection and transanal EEA between 1998 and 2005 as well as a flexible sigmoidoscopy 2-5 mos. later were included. Patient and hospital charts, operative reports, and the surgery and endoscopy databases were used. Mann-Whitney and Fisher exact tests were used where appropriate (significance, p < 0.05).
Results: 266 patients (pts) met the criteria; 115 LAR (43.2%), 104 sigmoid resections (39.1%), 21 rectosigmoid (7.9%), 11 subtotal (4.1%), 8 left hemicolectomy (3%), and 7 ileorectal (2.6%). The EEA stapler sizes utilized were: 34 mm, 9 pts (3.4%); 31 mm, 170 pts (63.9%); 28 mm, 87 pts (32.7%); 25 mm, 2 pts (0.75%). Proximal diversion was carried out in 82 pts (30.8%), 66 of which have since been closed. The stenosis rate was: 34 EEA, 11% (1 pt); 31 EEA, 13.5% (23 pts); 28 EEA, 25.3% (22 pts); 25 EEA, 50% (1 pt). All pts with stenoses were dilated digitally (30.4%) or endoscopically with a balloon (69.6%) to a diameter that permitted colonoscope passage. A total of 34.7 % of EEA 31 strictures required 2 or more dilatation as compared to 54 % of the EEA 28 patients. The vast majority of patients without stomas were asymptomatic, a small percentage had mild symptoms of constipation or mild abdominal discomfort possibly attributable to the stenosis. The clinical abscess and anastomotic leak rate for the entire group was 4.9%.
Conclusion: Stricture formation varies inversely with EEA size; the 28 mm stenosis rate was almost twice the rate noted with the 31 mm stapler (25.3 vs 13.5 %, p = 0.0240). The vast majority of stenoses in non-diverted pts were asymptomatic. The number of dilatations required varied inversely with EEA diameter. Routine sigmoidoscopy after EEA is advised so as to identify and dilate stenoses so as to permit future colonoscopic examinations.

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