GI Endoscopy · 2 min read
Endoscopic Placement of a Self-Expanding Metal Stent for Obstructing Sigmoid Diverticulitis
Experienced teaching points
Clinical Pearls
- Self-expanding metal stents serve as an effective bridge to surgery for decompression of benign colonic obstructions, such as those caused by diverticulitis.
- Combined endoscopic and fluoroscopic guidance is crucial for safe and accurate guidewire placement and stent deployment.
- Utilizing a transparent distal cap facilitates visualization and scope stabilization when navigating stenotic segments.
- Careful attention to stent-specific deployment mechanisms, such as markers and migration tendencies, is essential for successful placement.
- Stent placement allows for bowel decompression and improved surgical conditions, potentially avoiding emergent colostomy.
| Patient: | 72-year-old female |
| Presentation: | Abdominal pain, distention, nausea, and vomiting |
| Indication: | Acute sigmoid diverticulitis with partial bowel obstruction and significant retained stool confirmed by CT scan |
Endoscopic Findings
- A stenotic sigmoid colon due to severe diverticulitis was identified.
- The stenosis prevented passage of the therapeutic scope.
Endoscopic Technique
- The stricture site was determined under direct visualization (Panel B).
- A therapeutic gastroscope with a 3.7 mm working channel was utilized. A transparent distal cap was fitted on the scope to stabilize the tip and retract mucosal folds.
- A 0.035-inch guidewire was advanced through the stenosis using a balloon catheter (Panel C), guided by combined endoscopy and fluoroscopy (Panel D).
- Once the guidewire position proximal to the stricture was confirmed, contrast was injected to verify the luminal position. The catheter was then removed.
- A non-covered Evolution self-expanding metal stent (Cook Medical, USA) was advanced over the guidewire, through the scope, and across the stricture (Panel E).
- Deployment was performed under fluoroscopic and endoscopic visualization (Panels F, G). The yellow marker on the delivery catheter was monitored continuously to ensure proper deployment of the distal flange distal to the stricture (Panels F, H). Constant traction was maintained to counter proximal migration.
- Successful decompression was achieved, allowing the patient to undergo elective surgery after adequate bowel prep.
Discussion
This case highlights the utility of uncovered self-expanding metal stents for the decompression of benign colonic obstructions. In the setting of acute diverticulitis, partial bowel obstruction increases the risks of emergency surgery. Bridge-to-surgery stenting allows for bowel decompression and elective prep, reducing the need for an emergent colostomy.
The technique requires precise guidewire placement under dual guidance. Stabilizing the scope tip with a transparent cap is highly beneficial. Close attention to delivery device markers is essential because colonic stents tend to migrate proximally during deployment.
While self-expanding metal stents are more commonly applied in malignant obstructions, this approach demonstrates they are effective in benign stenoses under careful monitoring.
References
- van Hooft JE, van Halsema EE, Baron TH, et al. Self-expanding metal stents for obstructing benign colonic strictures: a systematic review. Endoscopy. 2012;44(6):581-591.
- Lamazza A, et al. Self expandable metal stents for left-sided colon obstruction from diverticulitis. A single center experience. Medicina (Kaunas). 2021;57:299.
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