Usefulness of Dennis Colorectal Tube in endoscopic decompression of acute, malignant colonic obstruction

NEW METHODS & MATERIALS Usefulness of Dennis Colorectal Tube in endoscopic decompression of acute, malignant colonic obstruction Akira Horiuchi, MD, Hironobu Maeyama, MD, Yasuhide Ochi, MD, Akio Morikawa, MD, Kouichi Miyazawa, MD Background: Colonoscopic decompression has been attempted in patients with acute colonic obstruction caused by colon cancer to avoid emergency surgery and multiple subsequent operations but has usually been unsuccessful. This is an evaluation of the usefulness of a new device for endoscopic decompression in these patients. Methods: Nine consecutive patients (6 men, 3 women; 65 to 89 years of age) with acute colonic obstruction resulting from colon cancer underwent endoscopic decompression with a Dennis Colorectal Tube. Results: In all 9 patients (1 with carcinoma of the sigmoid colon, 3 with carcinoma of descending colon, 2 with carcinoma of the transverse colon, 2 with carcinoma of the ascending colon, and 1 with carcinoma of the cecum), endoscopic decompression was successful. After decompressing and cleansing the colon for several days, a one-stage operation was possible in all patients. Conclusion: Dennis Colorectal Tube is an excellent device for endoscopic decompression of acute, malignant colonic obstruction.

Historically, obstructing carcinoma of the left colon has been treated by using a staged surgical procedure, namely, proximal colostomy or resection of the tumor with a colostomy. Definitive treatment is reserved for later procedures, which usually entails 2 or 3 laparotomies. To avoid emergency surgery and multiple operations for acute colonic obstruction, colonoscopic decompression of the obstructed sigmoid or left colon has been attempted by inserting a tube proximal to the obstruction.1,2 However, this procedure was often unsuccessful because of difficulty in straightening the sigmoid Received October 23, 2000. For revision December 14, 2000. Accepted April 13, 2001. From the Departments of Gastroenterology and Surgery, Showa Inan General Hospital, Komagane, and the Second Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan. Reprint requests: Akira Horiuchi, MD, Department of Gastroenterology, Showa Inan General Hospital, 3230 Akaho, Komagane 399-4191, Japan. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/69/116456 doi:10.1067/mge.2001.116456 VOLUME 54, NO. 2, 2001

Figure 1. Dennis Colorectal Tube inserted through sliding tube. Tip of the tube is tapered.

colon. The development of a new device and techniques developed for its use have made it possible to endoscopically decompress the obstructed colon, irrespective of the site of the obstruction. PATIENTS AND METHODS Endoscopic decompression of the obstructed colon has been performed since 1999 on 9 consecutive patients (6 men, 3 women; age 65 to 89 years) with colon carcinoma. All 9 patients had abdominal pain, vomiting, and constipation, and in each case examination disclosed a distended, tympanic abdomen. Plain abdominal radiographs showed a distended large bowel. In all patients, a diagnosis was made by abdominal CT. Subsequently, a soapsuds enema was administered to all patients. The Dennis Colorectal Tube (DCT) (Nippon Sherwood, Tokyo, Japan) is shown in Figure 1. It has an outer diameter of 7.3 mm and is 120 cm in length. It is placed through a sliding tube (overtube) 20 mm in outer diameter and 26 cm in length (ST-C3S, Olympus Optical Co., Ltd., Tokyo, Japan) during the procedure (Fig. 1). The technique for use of the DCT is illustrated in Figures 2 and 3. A colonoscope (CP230I; Olympus) is advanced to the site of the tumor. Water-soluble contrast medium is injected proximal to the stricture (Figs. 2A, 3B). A small black opening or escaping gas bubbles serves to identify the obstructed lumen (Fig. 3A). Under fluoroscopic and endoscopic guidance, a 0.052-inch guidewire, 350 cm in length, is introduced through the tumor beyond the point of obstruction (Figs. 2B, 3C). The sliding tube is kept on the colonoscope but outside the patient until needed. After the guidewire is placed and the sliding tube inserted, the colonoscope is withdrawn (Figs. 2C, 3D). Under fluoroscopy, a well-lubricated DCT is introduced over the guidewire and through the sliding tube and is then advanced beyond the tumor. The balloon at the tip of the DCT is then expanded with 30 mL of saline solution to fix the DCT in place. The sliding tube is withdrawn (Figs. 2E and 3F). The immediate escape of air and liquid feces through the DCT indicates successful decompression. If difficulty is encountered in advancing the DCT proximal to the tumor, the colonoscope is inserted again and the tip of the DCT is advanced with the aid of grasping forceps under direct visualization (Figs. 2D, 3E). GASTROINTESTINAL ENDOSCOPY

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Figure 2. Schematic diagrams illustrating procedure for insertion of DCT. A, Colonoscope inserted and advanced to site of tumor. B, Lubricated flexible guidewire introduced through tumor beyond point of obstruction. C, Colonoscope withdrawn leaving sliding tube in place. D, Use of colonoscope to aid insertion of DCT when difficulty is encountered in inserting DCT beyond obstruction. E, DCT positioned proximally to tumor. Balloon at tip of DCT is expanded with saline solution.

RESULTS Endoscopic decompression was easily performed in 6 of the 9 patients (1 with carcinoma of sigmoid colon, 3 with carcinoma of descending colon, and 2 with carcinoma of transverse colon). Success in these cases could be attributed to the ability to keep the sigmoiddescending colon junction straight with the use of the sliding tube. However, the DCT was not introduced beyond the obstruction in patients with carcinoma of the ascending colon (2 patients) and the cecum (1), because the sharp turns at the splenic and hepatic flexures did not allow easy advancement of the DCT. In these cases, the colonoscope was reinserted and 230

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E the DCT advanced with the aid of a grasping forceps (Figs. 2D, 3C). A shortened, straightened position of the colonoscope within the colon aided straightening of the DCT. In addition, the use of grasping forceps made it possible for the tip of the DCT to be introduced through the stenotic tumor. Symptoms were markedly improved in all patients after placement of the DCT. Plain abdominal radiographs demonstrated a reduction in the distention VOLUME 54, NO. 2, 2001

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Figure 3. A, Colonoscopic view of carcinoma obstructing transverse colon. B, Radiographic view showing carcinoma and site of obstruction in transverse colon. Water soluble contrast has been injected. C, Colonoscopic view of guidewire introduced through tumor (sliding tube in place). D, Radiographic view of guidewire introduced through tumor with sliding tube in place. E, Colonoscopic view of tip of DCT introduced into stenotic segment with aid of grasping forceps. F, Radiograph showing DCT positioned proximally to tumor with decompression of bowel. VOLUME 54, NO. 2, 2001

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of the colon. No serious complications were encountered. Further preparation of the colon for surgery was performed by using the DCT for daily irrigation with saline solution. After decompression and cleansing of the colon, a one-stage operation was possible in all patients. The mean time from insertion of the DCT to operation was 6.2 days with a range of 4 to 10 days. DISCUSSION Acute obstruction is the presenting symptom in 15% of patients with carcinoma of the sigmoid colon.3 Many of these patients are elderly, dehydrated, suffering from electrolyte imbalance, and unstable because of concomitant diseases, which makes these patients as a group poor candidates for major surgery. The content of the colon including bacteria coupled with the friable condition of the obstructed bowel wall makes primary resection and anastomosis hazardous. The traditional approach to management is to decompress the colon by using one of various types of colostomy. Thus, 2 or 3 laparotomies are required in this group of high-risk patients. However, endoscopic treatment using the DCT provided effective decompression of the obstructed left colon and sigmoid colon and allowed for a one-stage operation. If the DCT is placed with the aid of a colonoscope and grasping forceps, endoscopic decompression of obstructed right colon may also be successful. For other disorders that result in acute colonic obstruction, such as volvulus of the sigmoid colon and colonic pseudo-obstruction, nonsurgical decompression is always preferable.4,5 Nasogastric tube decompression is frequently ineffective. Because the DCT and techniques developed for its use make it possible

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to achieve cecal decompression, this approach may also be useful for colonic pseudo-obstruction. There may be a concern that the DCT procedure would leave the patient exposed to the risk of perforation of the bowel. Although it was not sufficient for decompression, a nasogastric tube might reduce the risk of perforation. Thus, introduction of this device is recommended before endoscopic decompression when the DCT is used for right colonic obstruction. The sliding tube should never be inserted forcefully. If any resistance is encountered, further insertion of the sliding tube should be halted, especially in patients with diverticular disease, stricture, or a history of one or more abdominal operations. Endoscopic decompression with the DCT and a sliding tube is a simple and safe procedure when it is used to relieve obstruction caused by carcinoma of the left colon or sigmoid colon. This alternative approach should be considered a first-line nonsurgical treatment for decompression of the obstructed colon before contemplating surgical intervention. REFERENCES 1. Lelcuk S, Ratan J, Klausner JM, Skornick Y, Merhav A, Rozin RR. Endoscopic decompression of acute colonic obstruction. Ann Surg 1986;203:292-4. 2. Lelcuk S, Merhav A, Klausner JM, Gutman M, Greif F, Rozin R. Rectoscopic decompression of acute recto-sigmoid obstruction. Endoscopy 1987;19:209-10. 3. Ohman U. Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982;143:742-7. 4. Starling JR. Initial treatment of sigmoid volvulus by colonoscopy. Ann Surg 1979;190:36-9. 5. Nivatvongs S, Wermeullen FD, Fang DT. Colonoscopic decompression of acute pseudo-obstruction of the colon. Ann Surg 1982;196:598-600.

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