We report an endoscopic technique used to remove a 6-cm calcific
cyst stuck in the sigmoid lumen which was causing a colonic obstruction.
The patient was a 64-year-old man with severe co-morbidities, who
presented to our institution with recurrent abdominal pain, distension, nausea,
and constipation. A CT scan showed that a previously diagnosed calcific hepatic
cyst had migrated from the sixth hepatic segment into the colonic lumen through
a fistula.
The endoscopic procedure was performed with the patient under
general anesthesia and lasted about 3 hours. The endoscopic view showed the
cyst occupying the sigmoid lumen completely. The mucosa presented erosions and
ulcers where the cyst had been lying ([Fig. 1]).
Fig. 1 Endoscopic view of the
calcified cyst with mucosal erosion where it had been lying.
The cyst was firmly attached within the lumen, and all attempts to
move it from its position failed. The decision was therefore made to attempt to
break its wall.
Argon plasma had no effect, but we were able to make a small hole by
pushing repeatedly with an endoscopic needle connected with a diathermy machine
([Fig. 2]).
Fig. 2 Creation of a small hole
by pushing with an endoscopic needle.
The hole was patiently enlarged with a balloon to allow the
endoscope into the cyst. At this point, another small hole was made from within
the cyst and a guide wire was passed through, thus encircling a part of the
cystic wall. The two ends of the wire were brought outside the patient, and a
lithotripter was mounted on them and driven through the wall, which was thus
slowly fragmented. This maneuver, repeated several times, allowed the wall of
the cyst to be broken into small pieces, which were finally removed using both
a Roth and a Dormia basket. Once the entire cyst had been removed, a full
colonoscopy was attempted, but this was not possible due to solid stools.
A full colonoscopy was repeated 1 week later and this showed partial
healing of the sigmoid mucosa and the presence of a wide fistula (about
3 cm in diameter) in the proximal transverse colon. Three months later,
the colonic mucosa had completely healed. The fistula was still present,
although reduced in diameter.
Video
1 Endoscopic removal of the
large calcified cyst impacted in the sigmoid lumen.
Endoscopy_UCTN_Code_CCL_1AD_2AJ
