Salvage therapy for colonic mechanical obstruction

Post written by Georgios Mavrogenis, MD, from the Endoscopy Department, Mediterraneo Hospital, Athens, Greece.
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This case illustrates the endoscopic management of a 7-cm-long obstruction of the distal colon that was not amenable to stenting, dilation, or surgery.

The patient suffered from pseudo-diarrhea and gas retention. His abdomen was very distended and painful. CT scan and endoscopy disclosed a long post-radiation stricture involving the rectum and sigmoid colon. The patient was not amenable to surgery due to his altered general condition; the stricture was too long to dilate and stenting would provoke tenesmus and had a high risk of migration. We did PubMed research and discovered that percutaneous colostomy has been described for similar cases by radiology teams. In addition, endoscopic percutaneous colostomy is well known for the management of sigmoid volvulus. However, the standard endoscopic technique is associated with a 10-12% risk of peritonitis due to stool leakage or to tube dislocation. Therefore, we decided to use a double-needle suturing device to suture the anterior wall of the sigmoid colon to the anterior abdominal wall prior to performing the colostomy.

This video illustrates an alternative approach for cases of colonic obstruction, when surgery is not an option. We used a gastrostomy-gastropexy device commonly used for patients with ENT or esophageal neoplasias. The first step was to secure (seal) the area around the colostomy by placing 4 sutures (colopexy). Then, we placed the colostomy tube in the middle of the sutures. Thus, the risk of stool leakage or of tube dislocation was theoretically reduced. The tube was then used for both decompression of gas and irrigation of the stenosis. The abdomen was exsufflated, and the patient had an uneventful recovery.

Combination of colopexy with colostomy may reduce the risk of peritonitis related to this procedure. Selected cases of mechanical obstruction that are not amenable to surgery could be eventually managed with this technique.

This case was presented at the World Cup of Endoscopy at DDW 2017. Participants and judges were dressed with traditional/national suits. Therefore, I’ve chosen a 150-year-old traditional suit coming from my island, Lesvos, in Greece.

I would like to thank the two Greek Societies of Gastroenterology for supporting this presentation, Pr G.S. Raju for inspiring me and teaching me video editing,  Mr G. Fragkos for his technical assistance in this video production, and Mr A. Chatzimallis for giving me his traditional suit.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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