eP673 - Revaluating the Management of Impassable Colonic Strictures in the Modern Era of Endoscopy and Imaging: A Pan Dorset Study

Purpose/Background: Current British guidelines (Association of Coloproctology of Great Britain and Ireland 2011) recommend resection for endoscopically impassable sigmoid colon strictures due to the perceived risk of malignancy. However, these recommendations are based on historical studies with low numbers. The ASCRS guidelines suggest sigmoid resection in cases of diverticulitis with a stricture. We aim to investigate the current management of this condition over the last 5 years to determine whether modern approaches have had any significant impact.Methods/Interventions: A retrospective examination was conducted by analyzing data from three medical centers located in Dorset County, situated in the southwestern region of England. This analysis involved the utilization of an electronically searchable endoscopy database and the review of patient records, CT scans, and histology reports.Results/Outcomes: Between 2017 and 2023, a total of 108 impassable sigmoid strictures were identified out of 82,385 colonoscopies. Among these, 55 were endoscopically malignant, while 53 appeared benign. Of the 53 initially benign-appearing strictures, 2 were later confirmed as malignant on biopsy, while 20 had no biopsies performed, and 31 showed benign histopathology on biopsy. Consequently, 57 patients were managed according to national cancer guidelines and excluded from further analysis. The remaining 51 patients in the study had an age range of 28 to 91 years, with a mean age of 64.17 years, and 75% of cases were female. To evaluate the colon beyond the stricture, 25 patients underwent CT Colonography, 3 had MRI, 12 had CT abdomen scans, 5 had repeat colonoscopy, 1 had flexible sigmoidoscopy, and 9 had no completion test. Importantly, no patients underwent barium enemas or plain abdominal x-rays, and some patients had multiple types of completion tests.Out of the 51 patients, 14 underwent surgery, with 3 as emergency procedures and 11 as elective operations. Among the 37 conservatively managed patients, 6 were treated endoscopically, 4 were placed under surveillance, 6 declined surgery, 2 were deemed unfit, 12 received medical management, 4 developed other malignancies, and 3 were lost to follow-up. 5.9% of these 51 strictures were eventually found to be malignantConclusion/

Discussion: Management of the impassable colonic stricture remains a clinical conundrum for the colorectal surgeon. Our findings challenge the traditional approach to these strictures. With advancements in endoscopic techniques and improvement in imaging, the risk of malignancy in impassable sigmoid strictures has significantly decreased from historical rates. Additionally, endoscopic interventions, including dilation and stenting have emerged as viable alternatives to surgery in select cases, reducing the proportion of patients requiring surgical interventions from 80% in the past to 27% in our study. Current guidelines need to be updated and we would recommend that cases are discussed at a specialist colorectal multidisciplinary team (MDT) meeting and full consideration given to the use of available imaging techniques and specialist endoscopy to determine the nature of the stricture prior to considering surgery. Larger scale studies would be helpful in forming more robust guidelines.Table summarizing clinical outcome