Post written by Keshav Kukreja, MD, Aman Deep, MD, and Tomas DaVee, MD, MSCI, from the Department of Gastroenterology, USF Health Morsani College of Medicine, Tampa, Florida, and the Interventional Gastroenterology at the University of Texas (iGUT), McGovern Medical School at UTHealth, Memorial Hermann Hospital, Houston, Texas, USA.
Our video case describes a 57-year-old woman with metastatic endocervical mucinous carcinoma who presented with symptoms concerning for malignant colonic obstruction (MCO). Contrast-enhanced computed tomography revealed a high-grade stricture at the rectosigmoid junction. Her severe malnutrition (BMI 12), cachexia, and advanced malignancy precluded surgical management. As her symptoms worsened despite nasogastric decompression, colonic stent placement was requested. To minimize the risk of perforation given the location of the stricture and her frailty, a smaller 22-mm colonic stent was desired but was unavailable. Thus, we utilized a 22-mm duodenal stent, which must be reversed and reloaded prior to deployment in order to prevent downstream migration, as depicted in our video.
Endoscopic stenting for MCO can serve as an alternative to emergent surgery, as a bridge-to-surgery, or for palliation in non-surgical candidates, similar to our patient. With high mortality rates from perforation, appropriate stent selection is of utmost importance. This becomes even more crucial for obstructions at the rectosigmoid junction, which carry a higher perforation risk. If the desired colonic stent is unavailable, duodenal stents can be used, but their configuration must be reversed such that the wider antimigration flare can be released upstream to the obstruction and prevent downstream migration.
The appropriate technique for retrograde deployment of reversed and reloaded duodenal stents as an off-label therapy for urgent decompression when desired colonic stents are unavailable.
Gastroenterology is a rapidly growing field, especially with regards to advanced endoscopic therapeutic techniques. As we grow with the field, it is important to have a firm understanding of the devices and their configurations. This allows us to exert creativity and offer the best possible care for our patients.
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