Post written by Andrew Alabd, MD, from Cooper University Hospital, Camden, New Jersey, USA.
A 54-year-old woman with known stage IV breast cancer presented with colonic obstruction and was found to have proximal, middle, and distal colonic strictures that were all secondary to metastatic breast cancer.
An upper endoscope was advanced up to the proximal stricture, marking each of the 3 strictures with endoclips fluoroscopically. A guidewire was then introduced through the endoscope, past the oral end of the proximal stricture, and coiled into the proximal colon. The upper endoscope was exchanged for an adult colonoscope, which was then advanced over the guidewire to the distal stricture.
The middle and distal strictures were dilated using a wire-guided controlled radial expansion 10- to 12-mm balloon, allowing for colonoscope advancement to the proximal stricture. A 12-mm biliary balloon was used to inject contrast under fluoroscopy, revealing a tight 60-mm stenosis. Next, an uncovered self-expanding metallic stent (SEMS) was bridged across the stricture and deployed under endoscopic and fluoroscopic guidance. A 12-mm balloon was again advanced over the wire.
The endoscope was slowly withdrawn to the middle stricture, and another uncovered SEMS was deployed in the same fashion, covering middle and distal strictures. Carbon dioxide insufflation was used, and the colonoscopy easily traversed the stents into the descending colon. Contrast was injected through the stent, demonstrating stents in place, and the procedure was concluded without complications.
Stent placement has been used for colonic obstruction, but the ability to palliate a patient with multilevel metastases via endoscopy has not been described previously.
In this case, we demonstrated the successful use of multilevel SEMSs for colonic obstructions in a patient with metastatic cancer to the colon. The video illustrates how dilating the distal stricture using a wire-guided controlled radial expansion balloon allowed for colonoscope passage and facilitated the deployment of the stent, and that the same technique can be repeated for other obstructions.
Stent placement of multilevel colonic obstructions via endoscopy to palliate a patient with multilevel metastases is safe and effective when done under fluoroscopic and endoscopic guidance. The procedure can be successfully performed with only water insufflation and under fluoroscopic guidance.
Endoscopic view showing balloon dilation of the distal stricture.
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