While therapeutic endoscopic ultrasound (EUS) has shown promising results as a new
modality to create EUS-guided gastroenterostomy using a lumen-apposing metal stent
(LAMS), little data exist on its use as a rendezvous technique. We present a case
of endoscopic reanastomosis using rendezvous single-balloon enteroscopy and EUS in
a patient with complete sigmoid obstruction.
A 70-year-old woman was admitted to our department for treatment of a benign sigmoid
colon obstruction. In the past, she had undergone surgical treatment for pelvic organ
prolapse. The procedure was complicated by mesh migration and rectal necrosis requiring
several surgical interventions, including an anterior resection of the rectum with
surgical colostomy formation. Because of massive postoperative adhesions and limited
abdominal access, the patient was referred for potential endoscopic treatment.
The rendezvous technique under fluoroscopic and endosonographic guidance was employed
([Video 1]). The single-balloon enteroscope (Olympus, Japan) was advanced through the colostomy
to the last part of the sigmoid colon while the echoendoscope (Pentax Medical, France;
Hitachi Aloka ultrasound systems, Japan) was advanced through the anus into the rectal
stump ([Fig. 1]). Then, about 200 ml saline was injected into the rest of sigmoid through the single-balloon
enteroscope. This allowed visualization of the fluid collection by EUS, and the optimal
position was confirmed ([Fig. 2]). When the distance between the walls of the rectum and sigmoid was below 10 mm,
a 15-mm Axios self-expandable metal stent was implanted ([Video 1]). The implantation was performed under EUS and fluoroscopy guidance ([Fig. 3, ]
[Fig. 4]). The lumen of the implanted stent was dilated with a balloon (CRE RX biliary balloon
dilatation catheter, Boston Scientific, USA). Four weeks later the stent was removed
with a visible lumen of the restored gastrointestinal tract. After 3 days the colostomy
was closed. During the 1 year of follow-up, no obstruction was observed and the function
of the gastrointestinal tract was normal. In control endoscopies, the anastomosis
was observed with a stable diameter of 20 mm.
Video 1 Endoscopic sigmoidorectal reanastomosis using a dual endoscope technique: rendezvous
single-balloon enteroscopy and endoscopic ultrasound.
Fig. 1 Rendezvous technique: the single-balloon enteroscope advanced through the colostomy
to the last part of the sigmoid colon and the echoendoscope advanced through the anus
into the rectal stump.
Fig. 2 Saline injection to create a fluid collection (blue arrow) for optimal visualization
of the procedure site. The needle of the Axios stent system is visible (red arrow).
Fig. 3 Placement of the Axios stent under fluoroscopic guidance.
Fig. 4 Echoendoscope visible from the rectum through the lumen of the Axios stent.
This case is interesting for several reasons. First, we show how simultaneous utilization
of two advanced endoscopic methods allows “roadmapping” of a complex intervention.
Second, by filling the proximal sigmoid just above the stenosis, a practical puncture
“cyst” was created to be accessed by endoscopic ultrasound. And, finally, easy placement
of a metal stent was achieved using the rendezvous method.
Based on current literature, EUS-guided procedures are associated with a lower risk
of adverse events, shortened length of hospital stay, and lower general cost compared
to surgical techniques. However, further studies are required to confirm their safety
and long-term efficacy in the field of gastrointestinal tract restoration [1]
[2]
[3].
Endoscopy_UCTN_Code_TTT_1AQ_2AF
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
