Gastrointestinal Radiology > Procedures > Balloon Dilation > Balloon Dilation (6)


Fluoroscopically Guided Balloon Dilation of GI Tract Strictures

Rectum

  • Rectal strictures are uncommon and may occur as a complication of radiation therapy, ischemia, or inflammatory disease.  However, they most commonly develop after surgical procedures that include the construction of an anastomosis.  Fluoroscopically guided balloon dilation has proved to be a safe and effective procedure for treating rectal strictures.

  • The procedure is most easily performed with the patient in a lateral position.  To opacify the stricture, a small amount of dilute barium suspension is injected into the rectum through a shortened 10 to 14 French feeding tube or angiographic catheter.  In patients with a low anastomosis, the catheter can usually be advanced with finger guidance through the strictured anastomosis.  When the stricture is more proximal, it may be preferable to use a steerable catheter (Biliary Stone Removal, Medi-tech, Inc., Watertown, MA) to negotiate the posteroanterior angulation of the proximal rectum.  After the catheter is positioned at the stricture orifice or across the stricture, a J-shaped guide wire is introduced through the catheter and advanced at least 20 cm proximal to the narrowing or as far as necessary to obtain a good purchase for catheter exchange.  The introducer catheter is exchanged for the balloon catheter that is positioned astride the stricture.  Multiple inflations with incrementally increasing pressures are performed as described for other strictures of the gastrointestinal tract.

  • Most dilations can be performed with fixed-diameter polyethylene balloon catheters of the Gruntzig type.  Again, in cases of severe stenosis, the dilation may have to be initiated with a small-diameter balloon (6-10 mm), subsequently followed at the same session by one of greater diameter (20 mm).  As rectal anastomoses greater than 20 mm in diameter are frequently created, attempts should be made to dilate the stricture to the original size of the anastomosis.  In these cases, a second 20 mm balloon may be placed after initial inflation with a first balloon, and the two balloons inflated simultaneously ("kissing balloons" technique).  Alternatively, a 30 mm pneumatic balloon catheter (Rigiflex Achalasia Dilator, Microvasive Inc., Milford, MA) can be used.  The decision to use a 30 mm balloon or two 20 mm balloons simultaneously may depend on whether dilation of a stricture with a single 20 mm balloon can be accomplished easily, and whether it is felt that further stretching of the stricture could be performed safely.  A problem with the paired balloon technique is that stretching occurs predominantly in one direction, as the two balloons form an oval shape; however, in our experience the final shape of the stricture does not appear to have an effect on the clinical results.

  • After the maximal achievable or desirable diameter of the rectum is obtained, barium suspension is injected into the rectal lumen to verify that no perforation has occurred.  We have not found that antibiotics are necessary during or after the procedure. In patients who do not have a diverting intestinal ostomy, stool softeners and bulk forming laxatives should be prescribed to prevent constipation and allow the stricture to be dilated naturally by the fecal stream.

 


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