A New Use for the Rotatable Sphincterotome as an Aid for Stenting Malignant Gastrointestinal Tract Stenoses

The technical success of expandable stent placement in the upper gastrointestinal tract (76-100 %) [1] and in the colon (83-100 %) [1] [2] mainly depends on the ability to pass a hydrophilic-coated guide wire through the tumor [3] [4]. In the standard technique, if it is not possible to pass the lesion with the endoscope, a hydrophilic biliary guide wire preloaded into a standard biliary catheter is used to traverse the stricture [1] [2] [3] [4]. However, this type of catheter does not allow selective alteration of the angle of the guide wire. The present report describes stenting in one case of esophageal neoplasm with an esophagotracheal fistula, and in three cases of obstructive colonic adenocarcinoma, with the help of a rotatable sphincterotome (Autotome Rx, Boston Scientific, Natick, Massachusetts, USA) - a new use for this device that has not previously been described.

In the patient with an esophageal neoplasm, a guide wire preloaded into a standard catheter repeatedly passed into the bronchial branch of an esophagotracheal fistula. In the patients with obstructive colonic adenocarcinoma, the stenoses were located in an angle, so that it was not possible to position the endoscope and the standard catheter directly in front of the lesion (Figure [1]). This made it impossible to pass the wire through the lumen of the tumor. Using a 0.035-inch hydrophilic guide wire (Terumo, Tokyo, Japan) preloaded into the Autotome Rx and changing the direction of the tip at the edge of the stenosis by bending and/or rotating the sphincterotome, it became possible to pass the guide wire through the stenoses in all four of these cases (Figure [2]).

Figure 1 When a stenosis is located in an angle, it is not possible to position the endoscope and the standard catheter directly in front of the lesion.

Figure 2 The lumen of the neoplasm can be successfully targeted by bending and/or turning the rotatable sphincterotome.

Rotation of a conventional sphincterotome was recently described as a method for selective intrahepatic cannulation during endoscopic retrograde cholangiopancreatography [5]. The modification of the standard technique for stenting malignant digestive tract stenoses described here, using a rotatable sphincterotome instead of a biliary catheter, has not previously been described, so far as we are aware. The technique may help achieve technical success with this procedure in selected difficult cases.

References

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