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ACG CASE REPORTS JOURNAL
IMAGE |ENDOSCOPY
Complete Colonic Diaphragm-Like Stricture After
Ileostomy and Sigmoidectomy for Sigmoid Colon
Perforation With Diverticulitis
Koichi Soga, MD, PhD
1
, Hiroki Mukai, MD
1
, and Naoaki Akamatsu, MD
1
1
Department of Gastroenterology, Omihachiman Community Medical Center, Omihachiman, Shiga, Japan
CASE REPORT
Anastomotic strictures occur in up to 22% of patients after colorectal resection, and up to 70% of them will eventually require surgical
intervention.
1,2
Traditionally, the approach taken in such cases has included endoscopic balloon dilation, self-expandable metal stent
insertion, or surgical intervention; however, balloon dilation remains the primary modality because of its efficacy and safety
profile.
1–3
Figure 1. Abdominal computed tomography showing (A and B) sig-
moidovesical fistula (A; arrow) with an inflammatory fibrous tissue (B;
arrowhead) because of sigmoid colon perforation with diverticulitis.
Figure 2. The schema of operation site of this patient. Red circle is
loop ileostomy as first operation, and blue slashes are sigmoidec-
tomy as secondary operation.
ACG Case Rep J 2021;8:e00693. doi:10.14309/crj.0000000000000693. Published online: November 23, 2021
Correspondence: Koichi Soga, MD, PhD (sogatti@koto.kpu-m.ac.jp).
ACG Case Reports Journal / Volume 8 acgcasereports.com 1
A 61-year-old Japanese woman underwent loop ileostomy crea-
tion and then sigmoidectomy for refractory sigmoidovesical fistula
because of sigmoid colon perforation with diverticulitis (Figures 1
and 2). We performed a colonoscopy from both the anal and oral
stoma sides before ileostomy closure surgery. We identified a
complete diaphragm-like stricture in the sigmoid colon that was
similartotheendofablindloopduringcolonoscopy,andthe
region of complete construction was whitish and surrounded by a
few xanthomas (Figure 3). Therefore, we performed an endoscopic
intervention to treat the complete colonic stricture.
First, a 23-G endoscopic injection needle was used to penetrate
the center of the blind lumen from the oral side, and then, a
pinhole was made in the stricture (Figure 3). The contrast
medium was then injected through the needle. After the posi-
tion of the proximal lumen was confirmed, an endoscopic
catheter was inserted into the pinhole that had been made in the
stricture, with a 0.025-inch guidewire (Figure 3). Finally, a
through-the-scope sequential balloon dilator (8 mm) was used
to dilate the stricture, and Amidotrizoic acid was advanced into
the opposite site (Figure 3). This intervention led to positive
outcomes. Eight days later, the colonic stricture improved.
However, the endoscope could not pass through; therefore, we
performed balloon dilatation (12.5 mm) again (Figure 4). After
2 sessions, the patient showed improvement and underwent
ileostomy closure (Figure 4).
We encountered a colonic diaphragm-like stricture after per-
forming a sigmoidectomy because of perforated colonic di-
verticulitis. Although anastomotic strictures of the colon are
common complications after colorectal surgery, such a complete
diagram-like membrane stenosis is rarely seen.
4
In this case, we
considered that because the loop ileostomy did not allow the pas-
sage of stool to the anastomotic site, a complete membrane stenosis
had formed. Despite improvements in technology and surgical
techniques, the incidence of colorectal anastomotic complications
remains stable and substantial, and the detection and treatment of
anastomotic complications remain a challenge.
5
Our endoscopic
intervention was effective in treating a diaphragm-like stricture
characterized by complete circular stenosis.
Figure 3. (A) Colonoscopy from both the anal and oral sides revealing a complete diaphragm-like stricture in the sigmoid colon. (B) An
endoscopic injection needle was used to penetrate the contralateral oral side of the colon. (C) An endoscopic catheter was used to investigate
the opposite site with a 0.025-inch guidewire. (D and E) A through-the-scope sequential balloon dilator (8 mm) was used to dilate the stricture,
and (F) Amidotrizoic acid was advanced into the opposite anal side.
Figure 4. Endoscopy showing (A) the colonic stricture had improved but did the endoscope could not pass through the site of the stricture. (B)
A balloon dilator (12.5 mm) is used to dilate the stricture. (C) After 2 sessions, the patient improved.
ACG Case Reports Journal / Volume 8 acgcasereports.com 2
Soga et al Complete Colonic Diaphragm-Like Stricture
DISCLOSURES
Author contributions: K. Soga wrote the manuscript and is the
article guarantor. H. Mukai and N. Akamatsu edited the
manuscript.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Received March 22, 2021; Accepted June 3, 2021
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Surg. 2012;25:200–3.
4. Chen TA, Hsu WL. Successful treatment of colorectal anastomotic stricture
by using sphincterotomes. Front Surg. 2014;1:22.
5. Vallance A, Wexner S, Berho M, et al. A collaborative review of the current
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Copyright: ª2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of
The American College of Gastroenterology. This is an open access article distributed
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License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work
provided it is properly cited. The work cannot be changed in any way or used com-
mercially without permission from the journal.
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Soga et al Complete Colonic Diaphragm-Like Stricture
