Post written by Mayank Goyal, MBBS, and Navtej Buttar, MD, from Mayo Clinic, Rochester, Minnesota, USA.

A 51-year-old man presented with an iatrogenic gastro-entero-colonic fistula after incorrect deployment of a colonic stent that was initially intended to bypass a malignant stenosis at the splenic flexure. The stent was uncovered but fortunately migrated.

However, the resulting fistula led to bacterial overgrowth, severe diarrhea, weight loss, and episodic feculent vomiting. This made the patient ineligible for chemotherapy, and he was a high-risk candidate for surgical intervention. We proposed a rescue solution of placing a partially covered stent to bypass the fistula, but the existing partially covered stents did not have the necessary deployment length for this approach.

We used an innovative technique by modifying a partially covered stent with a towing silk suture and integrating it into the stent delivery system. A single-balloon endoscope was passed orally, then navigated through the fistula into the colon, and eventually brought out through the anal canal to grasp the towing suture on the stent delivery shaft with toothed forceps.

Then, the stent was loaded onto a steel wire. A combined approach of gently pulling on the towing suture with the transfistula scope and applying gentle pressure from the anal side enabled the stent to bridge the fistula. This method successfully positioned the covered part of the stent across the fistula, with the uncovered sections placed proximally and distally in the colon, achieving an excellent seal.

Iatrogenic adverse events such as tumor perforations make patients ineligible for chemotherapy or oncologic surgeries. Existing devices have limitations in addressing these unusual adverse events. Rescuing these patients to return them to definitive therapy requires an innovative, out-of-the-box approach.

As described in this video, we made the simple modification to address the unique challenge and achieved a successful outcome. This information provides context and showcases the problem-solving skills and technical expertise required to use a partially covered stent with an esophageal delivery system, which has a working length of approximately 78 cm, to place the stent at the splenic flexure during colonoscopy.

From our experience, other endoscopists can learn about:

• Innovative repurposing of existing devices: This case shows how to modify existing stent delivery systems, such as a partially covered stent with an esophageal delivery system, to address challenges where standard equipment is insufficient. This approach was helpful when more extended deployment systems were unavailable.

• Combined techniques: Using oral and anal routes with a transfistula endoscope and towing suture offers a creative solution for accurate stent placement. This highlights the importance of flexibility and teamwork in complex procedures.

• Managing difficult locations: This case features strategies for treating fistulas at the splenic flexure, a challenging spot because of the colon’s shape and length. This method could be used in similar difficult situations, expanding options for endoscopists.

The decision to use this method was driven by the patient’s high risk for more invasive treatments. This emphasizes the significance of tailoring interventions to individual patient needs, particularly in high-risk cases.

Gentle pulling on the towing suture with the transfistula endoscope and gentle pushing from the anal side allowed the stent to reach across the fistula.

Read the full article online.

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