Biodegradable stent insertion for ischaemic colorectal strictures: Tiger country

We describe our initial experience with the use of biodegradable (BD) stents in benign ischemic colorectal strictures with two cases. The first case is of a 40-year-old male with a history of retroperitoneal sarcoma who developed a benign stricture in the descending colon postsurgical and radiotherapy treatment. Balloon dilation was required in order to pass the delivery system. The patient experienced significant pain postdeployment and post procedure computed tomography scan demonstrated a small perforation requiring an emergency laparotomy. The second case is a 61-year-old male with a history of retroperitoneal sarcoma who also developed an ischemic stricture in the descending colon after surgical excision. Using a combined fluoroscopic and endoscopic approach 3 separate BD stents were inserted over a 17-month period improving clinical symptoms of intermittent obstruction. These symptoms reoccurred after stent disintegration and the patient was definitively managed surgically with colostomy formation. The use of BD stents, although appealing, does not provide an adequate long term result. Additionally, more flexible, smaller calibre systems are required for deployment in tortuous environments.

Coil occlusion of anal cushions in severe lower gastrointestinal haemorrhage

Coil occlusion of colonic vessels is uncommon due to a risk of colonic ischemia and perforation, and should only be performed as a bridge to emergent surgery. Colonic haemorrhage can occur in haemorrhoidal disease which is managed conservatively in most cases. Endovascular management of haemorrhoids has been described in a non acute setting with effective results and little complications. We present a case of a 46-year-old male admitted with haemorrhage secondary to abnormal vascular rests within the anal cushions, similar to that described in haemorrhoidal disease. Both clinical and endoscopic examination did not identify haemorrhoids; however, catheter angiogram identified ectatic distal rectal arteries with arterial blush demonstrating a haemorrhagic focus. This was subsequently embolised. The patient experienced no ischemic complications or further haemorrhage. Endovascular management in this setting has both a diagnostic and therapeutic benefit allowing rapid effective management of the patient.

Percutaneous colonic stent insertion via a radiologically placed distal 'cecostomy' tube for the management of acute malignant bowel obstruction

Percutaneous cecostomy is an uncommon procedure but is reported as an effective temporising measure to achieve acute decompression of bowel obstruction. It has been reported as a safe procedure in the setting of bowel obstruction providing relief of symptoms. The insertion of a cecostomy in the distal colon is not routinely advised as it will not allow passage of formed faeces. Cases of antegrade stenting of proximal colonic obstruction via cecostomy have been described; however, antegrade stenting of the distal colon from access in the ascending colon can be technically challenging. We describe a case of a percutaneous colostomy inserted temporally at the splenic flexure, which provided close access to an obstructing descending colonic tumour, allowing definitive management with placement of a colonic stent. This technical feasibility case provides evidence that a temporary cecostomy placed in the distal colon can be performed as a measure to facilitate definitive management.