Anastomotic stenosis (AS) is a common postoperative complication of colorectal surgery, predominantly affecting the middle and lower rectum.1 AS poses a significant challenge for surgeons because it not only affects postoperative recovery but may also necessitate reoperation, exacerbating patient discomfort and financial burden.

Recently, endoscopic techniques have emerged as pivotal tools in the diagnosis and treatment of gastrointestinal diseases. Owing to their minimally invasive nature and swift recovery, endoscopic procedures have been used to manage anastomotic complications.2-4 Endoscopic interventions offer precise manipulation of affected areas through natural lumens, circumventing the need for abdominal incisions and thus minimizing surgical trauma and associated complications.5

Herein, we present a unique case of complete membrane anastomotic closure successfully treated using a novel endoscopic technique. Written informed consent was obtained from the patient prior to the submission of the case report, and the study was approved by the ethics committee of Guangzhou First People’s Hospital (F-2024-001-01).

A 63-year-old woman was diagnosed with familial polyposis, presenting as carcinoma in the ascending and rectosigmoid colons. On April 21, 2022, the patient underwent a laparoscopic total colectomy with ileorectal anastomosis, coupled with prophylactic ileostomy. The ileorectal anastomosis was positioned approximately 12 cm from the anus. The patient was discharged 7 days after the procedure. Despite being advised to undergo follow-up examinations, the patient did not comply.

Three months later, the patient underwent ileostomy reversal. Prior to the reversal, a comprehensive diagnostic evaluation was performed. Abdominal computed tomography, magnetic resonance imaging, barium enema, and endoscopy revealed complete membranous atresia at the ileorectal anastomosis site (Fig. 1). Owing to the significant trauma and risks associated with surgery, and with the consent of the patient and her family, we opted for endoscopic resection to address the issue. The procedure was monitored using two endoscopes, with surgery considered as an alternative approach.

To initiate the endoscopic procedure, one endoscope (Endoscope I) was inserted through the anus, and the other (Endoscope II) was introduced through the proximal ileostomy (Fig. 2A). The closed anastomosis site was visualized 12 cm from the anal side using Endoscope I. Strong illumination observed from the other side indicated thin tissue at the site of anastomotic closure (Fig. 2B). Subsequently, methylene blue was injected through Endoscope I, with immediate visualization of the needle using Endoscope II, further confirming the thinness of the closure (Fig. 2C). Under bilateral endoscopic monitoring, an incision knife was employed on the anal side to make an incision from the closed center, followed by the removal of the central tissue along the circumference of the anastomotic nail ring (Fig. 2D). After resection, the diameter of the anastomosis was approximately 2 cm, allowing smooth passage of the endoscope through the anastomosis (Fig. 2E).

After resection, plain abdominal radiography revealed no pneumoperitoneum, indicating the absence of intestinal perforation (Fig. 3A). A barium enema demonstrated a wide, patent anastomosis, confirming the success of the endoscopic resection (Fig. 3B). Three days after the procedure, an ileostomy reversal was performed, and the patient was discharged after a 7-day hospital stay. The patient remained healthy throughout the 1.5-year follow-up period.

The etiology of AS encompasses various factors, including disease-related elements such as local tumor recurrence, neoadjuvant chemoradiotherapy, and anastomotic fistula,1,6 as well as surgery-related factors such as low rectal anastomosis, ischemia of anastomotic tissue, and inappropriate use of staplers.7,8 Additionally, patient-related factors such as obesity, smoking, and postoperative loss to follow-up can contribute to this complication.6 In this case, potential factors contributing to AS included the protective ileostomy and patient’s postoperative loss to follow-up.

AS typically manifests as annular stricture or closure of the anastomosis ring around the surgical site.2 However, the distinctive feature of the AS in this case is the complete closure of the tissue at the anastomotic site, confined solely to the mucosal layer, rather than involving the entire thickness of the intestinal wall. Such a presentation is exceptionally rare. Deng et al. similarly reported two cases in which anastomotic closure occurred entirely because of a membranous structure following colostomy.2 This highlights the unusual nature of the mucosal layer-limited closure observed in this case.

For severe AS, invasive interventions are often necessary, with treatment options including endoscopic dilation or surgical revision of the anastomosis.9 Endoscopic treatments such as electrocision, balloon dilatation, and self-expanding metal stents, are typically considered as initial treatment options.10 In this case, we adopted a new endoscopic method, which involved two endoscopes entering the anus and ileostomy simultaneously. With the guidance of the two endoscopes, we identified the membrane structure or intestinal wall to avoid perforation and performed complete membranous anastomotic closure through endoscopic resection. The successful application of this method provides new treatment options for similar cases.

Compared with balloon dilation and self-expanding metal stents, this method resects the membranous anastomotic closure directly and completely, offering satisfactory results at lower costs.3 However, this technique has some limitations. A proximal ileostomy is essential for bilateral endoscopic procedures, and two experienced endoscopists are required to ensure the safety and effectiveness of the procedure.

In conclusion, we report a case of complete membranous anastomotic closure after total colectomy with prophylactic ileostomy. A novel endoscopic technique using bilateral endoscopes was successfully employed to perform closed mucosal resection and is worthy of clinical application.