Rectal cancer is the fourth leading causes of cancer-related death around the world. Along with the advance of low anterior resection and anal retention technique for rectal cancer, the incidence of anastomotic strictures is unavoidable to be increasing. Male patients diagnosed as low rectal cancer adopted low anterior resection and stapled anastomosis, sometimes also adopted prophylactic ileostomy would be associated with the highest risk of anastomotic strictures (about 20–30%) in the population of the rectal cancer. Risks of strictures occurrence mainly located at surgery and anastomosis related aspects. First, in our study 11 cases received prophylactic ileostomy, which was usually to be performed for emergency patients with symptom of intestinal obstruction under high risk of anastomotic leakage, however, it would lead to useless related strictures when routine anal expansion was absent.
Local tumor recurrence, radiotherapy and anastomotic technique related factors such as improper stapler size and anastomosis site were also frequent causes of postoperative strictures. Certain methods were encouraged to be adopted to prevent anastomotic stricture occurrence, and if happened[15–17], it was clear that the treatment of rectal strictures should be based on its specific cause and symptom (defecation difficulty, about 5% in overall). In the current analysis, we mainly discussed the surgery and anastomosis related strictures. For these patients, anal expansion was firstly recommended, such as finger and/or instrument anal expansion weekly or every 2 to 3 weeks. Then, endoscopic techniques were advised for non-responders of expansion cases. As an effective method for most gastrointestinal disease, detailed information on stricture size, length, diameters, distance from the anus can be achieved under a direct vision. Endoscopic balloon dilation, stent placement and also scar incision were all effective methods[19–21]. Finally, colostomy was only suitable for patients suffered severely obstructive symptoms.
Besides, we developed a new method by using bipolar plasma kinetic vaporization resection. It is an effective method for benign prostatic hyperplasia with small trauma, quick recovery, repeatability and good hemostasis. Based on our experience in the 12 PAS, it presented similar advantages in above aspects, and also it had obviously advantages in its minimally invasion, repeatable treatments (when insufficient efficacy and recurrence occurred) and satisfactory haemostasis compared with other method and surgery through rectal speculum or endoscopy. However, this technique applied for rectal anastomotic strictures was only reported by our single center experience based on limited sample size. Although no bipolar plasma kinetic vaporization resection related complications was found, it should be performed with helps of a urologist. With experience in laparoscopic surgery, its training and learning curve would be short, and the key point was to carefully identify the border between scar and normal tissue. Also, additional anal expansion was still necessary to achieve the sustained efficacy. Compared with the other method, especially endoscopic dilation (which was frequently adopted in the clinic), our reported technique required general anesthesia. This contributed significantly decreased discomfort during treatment, whereas the cost and risk of anesthesia of course increased although comparative studies regarding their efficacy and safety were warranted. Meanwhile, for patients selection, this technique appeared to be more suitable for patients with hyperplastic scar with obvious space occupying findings or refractory benign strictures , whom may be hard to be treated by endoscopic methods. Thus, it may be deserved as an alternative and complementary option for non-responders of endoscopic methods. However, for the special l case, we can dig out that the therapeutic effect can only be maintained for a period of time, and then resumed in the past, Considering the patient's previous combined fistula and pelvic infection to stimulate the repeated growth of the scar, this patient May not apply to this technique.