Video Lecture II
LGVL-II: Valuable Tips for Frustrating Situations in Colonoscopy
Troubleshooting in Difficult Colonic Stenting
Søren Meisner, M.D.
Endoscopy Unit, Bispebjerg University Hospital, Copenhagen, Denmark
Introduction
Large bowel obstruction is a common surgical emergency with a number of possible etiologies. Management
requires prompt identification and referral to further investigation and intervention. Early diagnosis and management planning is the key to reducing morbidity and mortality associated with large bowel obstruction.
Malignancy accounts for approximately 60‐70% of all cases of dynamic large bowel obstruction. Endoluminal
stenting has been shown or described to provide effective relief of obstruction with few procedural
complications. Colonic stenting can be a very difficult and demanding procedure. This abstract presents a summary of the video lecture. The video lecture is based on 6 difficult emergency cases with clinical total
obstruction.
Clinical cases
1. Case 1-tumor at the splenic flexure
Illustrate the use of Olympus UPD, facilitating the passage of the endoscope to the splenic flexure. Tumor located just oral to the flexure which is one the most difficult locations to stent. The use of marking with Lipiodol
injection is explained. The difficulty in using a straight catheter in angulated positions where the endoscope
easily slips backwards. A forceful pullback during stent deployment prevents that the stent migrates upstream.
2. Case 2-tumor at sigmoid colon
Very difficult position of the endoscope-puts tension on the sigmoid loop and the movements of the scope is
limited. Tumor is fixed transversely and very difficult to pass and delineate. Upstream severe constipation and
diverticulosis. Illustrates the use of the ERCP balloon extractor catheter to inject luminal contrast and make
very precise tumor delineation.
3. Case 3-tumor at sigmoid ‐ descending colon
Very difficult position of the endoscope-passage of guidewire and catheter is difficult. Contrast upstream
does not correspond with location of guidewire (perforation?). Explanation shown on video!
318 IDEN 2013
LGVL-II: Valuable Tips for Frustrating Situations in Colonoscopy
4. Case 4-tumor at the recto‐sigmoid
Patient was 9 months earlier stented for palliation. Presents with total stent occlusions. Illustrates the difficulties in placing stent in stent. Placement of guidewire must be through the “lumen” and NOT through any
meche holes. Very severe angulation at the tumor site contributes to the difficulties, not only passing the wire
but also getting the stent in deployment place.
5. Case 5-tumor at the splenic flexure
Again, stenting a tumor just oral at the splenic flexure. In this case, a large fixed sigmoid loop limits the movements of the tip of the endoscope. Possible misplacement of the stent-need for a second stent?
6. Case 6-tumor at sigmoid colon
Local recurrence after incomplete surgical resection. Very large fixed tumor, severe angulation makes it very
difficult to put the stent in deployment position.
Conclusions
Especially emergency colorectal stenting can be very challenging. Expertise in advanced endoscopic procedures, such as ERCP, is mandatory to maintain a high success rate and a low complication rate.
IDEN 2013
319