A 50 year old man has a past medical history of bilateral congenital glaucoma causing him to be legally blind and metastatic rectal cancer to the liver.
The patient's cancer was diagnosed because he had developed rectal obstruction. As a result, he underwent a diverting transverse loop colostomy. The patient had difficulty managing his ostomy because of his blindness. He requested resection of his rectal tumor in order to reverse his colostomy. Sixteen months after his previous surgery, he underwent a low anterior resection, reversal of his colostomy, and creation of a temporary loop ileostomy.
Six months later, a barium enema was performed prior to his ileostomy takedown and the barium enema showed a widely patent rectal anastomosis.
The patient was brought to the operating room for closure of his ileostomy. On post-operative day four, the patient developed nausea, vomiting, and abdominal distention.
An abdominal radiograph showed a large bowel obstruction
An abdominal CT revealed an obstruction of the transverse colon with retained contrast in the ascending colon.
A colonoscopy confirmed a complete obstruction at the prior transverse colostomy site. The patient declined surgical diversion due to difficulty caring for his previous ostomy. Endoscopic management of the obstruction was attempted under fluoroscopy, however, it was unsuccessful.
As a result, a cecostomy tube was placed for decompression.
Total parenteral nutrition was started and the patient continued to decline surgical intervention. The cecostomy fistula was allowed to mature over four weeks and then endoscopic management was reattempted.
A colonoscope was inserted through the rectum and advanced to the level of the obstruction.
The 12Fr cecostomy tube was removed and a 0.035 guidewire was inserted into the right colon. A balloon dilator was passed over the guidewire and the cecostomy fistula was sequentially dilated to 12mm. An ultra-slim gastroscope, 5.9mm in diameter, was piggybacked behind the balloon dilator into the right colon. The ultra-slim gastroscope was then advanced to the proximal side of the obstruction. Direct transillumination of both endoscopes was visualized. The sharp end of a Savary guidewire was inserted through the colonoscope and was used to pierce through the distal side of the obstruction. Using the ultra-slim gastroscope, a snare was placed around the Savary guidewire to stabilize it. Transillumination of the colonoscope is visualized in the proximal colon. The balloon dilator was advanced alongside the Savary guidewire, through the obstruction which was then dilated to 12mm.
A balloon dilator was then placed through the colonoscope and dilation again was performed. The colonoscope was then able to be advanced through the obstruction to the cecum. The ultra-slim gastroscope was then well visualized by the colonoscope. The colonoscope was then withdrawn to the site of the cecostomy fistula. The ultra-slim gastroscope was then removed from the fistula. With the colonoscope in the ascending colon, the fistula was then closed with 4 clips. The colonoscope was then withdrawn to the transverse colon. The site of the obstruction was then balloon dilated to 18mm. The patient tolerated the procedure without complication.
The next day, the patient was started on a clear liquid diet and it was advanced to a regular diet accordingly. The patient underwent a colonoscopy three weeks later and the site of the prior obstruction was widely patent. The patient remained asymptomatic and was able to reinstitute chemotherapy.
Benign colonic strictures are an infrequent complication after colonic surgery. The development of complete colonic obstruction is even rarer. In this case, we performed a rendezvous colonoscopy in order to alleviate the colonic obstruction. A retrograde colonoscopy was performed via the usual route and an antegrade colonoscopy was performed by accessing the proximal colon through the cecostomy fistula. Direct transillumination of both endoscopes was followed by puncturing the obstructing mucosa with a Savary guidewire. Balloon dilation was then performed, restoring bowel continuity. This procedure obviated the need for surgical intervention for a case of complete colonic obstruction.
Evan B. Grossman, MD,