Technical Modification of the Double-balloon Endoscopy to Access to the Proximal Side of the Stenosis in the Distal Colon

Abstract

Stricture in the colon is one of the complications associated with various kinds of disease including inflammatory bowel disease, tumor invasion, ischemic colitis, and colonic diverticulosis. Inability of endoscopic insertion beyond the stricture is a considerable problem in these patients. Double-balloon endoscopy (Fujinon EN-450P5/20, Fuji Photo Optical Co., Ltd., Omiya, Japan) is a new system of endoscopy which enables endoscopic scrutiny of the entire small bowel. We have applied this system in a patient with a narrowing segment in the colon and succeeded in reaching to the proximal side of the stricture from oral approach through the entire small bowel. A 45-year-old man was referred to our hospital because of chronic diarrhea and abdominal fullness. A contrast study of the colon taken at the nearby practitioner revealed a severe stricture lesion from the descending colon to the recto-sigmoid colon. He required emergent hospitalization because of the bowel obstruction before we started scrutiny. Decompression with an ileus tube after the hospitalization relieved his clinical symptoms. Colonoscopy showed a stenotic lesion at the recto-sigmoid colon and further endoscopic insertion was hampered. In order to explore the oral side of the stenosis, we used double-balloon endoscopy with a new modified insertion technique. Initially the proximal end of the ileus-tube was cut off and the insertion route was changed to begin from the mouth. After the insertion of the guide wire through the ileus tube, an overtube with a balloon was inserted with the assist of both the guide-wire and ileus tube, both of which in turn were removed after the insertion of the overtube. The overtube balloon was inflated to fix the overtube tip at the terminal ileum. Finally, an enteroscope was inserted through the overtube. These procedures enabled the insertion of the endoscope to the ileum end from oral approach. The endoscope was further inserted into the colon by way of the ileocecal valve and we have succeeded in reaching to the proximal side of the colonic stricture. Cancer was observed in the descending colon along with inflammatory changes and ulcerations. Pathological findings confirmed the diagnosis of colitic cancer associated with ulcerative colitis and total colectomy was performed. In conclusion, we diagnosed a case of colitic cancer with ulcerative colitis by inserting the endoscope to the proximal side of the stricture in the colon from oral approach by using the modified double-balloon endoscopy.