Journal of Japan Society of Coloproctology

52:1070-1076, 1999

Feature II. Therapeutic colonoscopy[Invited paper]

3. Endoscopic decompression of carcinoma ileus of the left colon
Hiroshi Oka, Yasuo Ishida, Hiroshi Machida, Hisanori Izuno and Akio Nakayoshi
Department of Surgery, Showa University Fujigaoka Hospital
Operation is the therapy of choice for carcinoma ileus of the left colon, to which oroentericdecompression procedure is not applicable. All operations must be performed with considerations given toboth the resolution of obstruction and curability of carcinoma. If an operation is performed without colonicdecompression, the dilated colon will interfere with surgical procedures and may result in a lowered
curability. Endoscopic decompression therapy was first performed in 1986 by Lelcuk et al in patients withsigmoid cancer, using a balloon for dilation of the esophagus. With the device kit commercially available
today, a guide-wire is inserted beyond the stenosis site of the tumor mass under the endoscopic direct vision
and an ileus tube is placed transanally after dilation of the stenosis site with a dilator. Colonic contents inthe region proximal to the tumor mass can be removed and the symptom of ileus can be resolved by thisprocedure, thus making subsequent elective operation possible. Potential complications in the clinicalapplication of this method include colonic perforation at the time of guide-wire insertion and necrosis of thecolonic mucosa due to the pressure from a balloon, which is placed at the end of the insertion procedure.
However, the device kit commercially available today is well prepared for such complications.
From the viewpoint of therapeutic endoscopy, the endoscopic guidance technique can be applied notonly to decompression, but also to a variety of procedures, such as stenting and balloon-mediated dilation of
the stenosis occurring in postoperative mechanical anastomosis, and is reliable and effective.
Key words: Carcinoma ileus of the left colon, colonic decompression, endoscopic decompression
Introduction
History of the treatment of carcinoma ileus of
the left colon, for which colonic decompression by
the oroenteric procedure is said to be ineffective,
begins with the two-stage resection or the Hartmanresection.
The one-stage resection procedureusing intraoperative colonic cleansing methodbegan to be used in 1980, but there was no room forthe endoscopic procedure. The first endoscopic
decompression therapy was reported in 1986, when
Lelcuk et al performed colonoscopic decompression
for stenosis of the sigmoid colon1). Since then,endoscopic decompression has become widely used
as a procedure that allows the avoidance of
emergency operations, enables pretreatments andexaminations, allows the conduct of highly invasive
surgeries such as hepatectomy and combined
resection of adjacent organs as the elective curative
resections, and compensates for the shortcomings ofone-stage and two-stage operations.
In this paper, we describe practicalprocedures of the endoscopic decompression

therapy on the basis of our recent experience with acase of ileus due to sigmoid cancer.
I. Indications
Ileus due to carcinoma of the left colon iscommonly regarded as an indication for theendoscopic decompression. However, most of thecases reported have been those involving the rectumor sigmoid colon, with a few reports ofdecompression at the site of splenic flexure andalmost no reports of cases involving the descending
colon or transverse colon. Cases of severelydilated colon with deformation of the cecum orother organ usually have a complete colonicobstruction and, therefore, are indications for
surgical interventions rather than for the endoscopic
decompression. In addition, indications for theendoscopic decompression are limited to the cases
in which the area beyond the obstruction site can becontrasted by enema and the colonic lumen at thesite of obstruction can be confirmed by endoscopy.

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Journal of Japan Society of Coloproctology

II. Methods
Device
The commercially available kit consists of adecompression catheter tube (transanal ileus tube),a dilator for dilation of the obstruction site (seconddilator), a dilator for the forceps channel ofendoscope (first dilator), and a guide-wire (Fig. 1).

Insertion methods
The insertion procedure is shown below
using an actual case.
Green first dilator Guidewire

Principle of ileus tube insertion (Fig. 2)
1) The direction of the colon is confirmed by theGastrographin contrasting from the inserted
endoscope. The guide-wire attached to theforceps channel of endoscope is inserted andpassed through the site of stenosis.
2) Using this guide-wire as a guide, the firstdilator is inserted beyond the site of stenosis.
3) The endoscope and guide-wire are withdrawn,
leaving the first dilator in place.
4) Using this first dilator as a guide, the second
dilator is inserted and passed through the siteof stenosis. The site of stenosis is dilated bythis procedure.
5) The second dilator is withdrawn and the ileus
tube inserted using the first dilator as a guide.
6) The first dilator is withdrawn, leaving only theileus tube in place, and the balloon is inflated.

Guide-wire
Stenosis

Tumor
mass

52:1070-1076, 1999

Instrumental channel

Flexible part of guidewire

Figure 1

Guide-wire and dilator

The guide-wire and dilator can easily be passed throughthe forceps channel of the endoscope. Since theguide-wire can easily be bent at the region about 7 cm
from the tip, the risk for tissue penetration is very low.
The first dilator is inserted after insertion of theguide-wire. The design of first dilator has been
modified to a forceps channel-matching type to allow
subsequent withdrawal of the endoscope.

First dilator

Guide-wire
withdrawal

ForcepschannelEndoscope

Second dilator

Ileus tube
placement

Ileus tube

Lumen
expansion

BalloonFigure 2

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Obstruction/stenosis

Small space in the stenosis / obstruction
Figure 3

Endoscopic image (right) and enema image (left)

Enema image shows a circumferential stenosis in the region of sigmoid colon
16 cm from the anus. A minor flux of contrast medium is seen at theproximal side.
Narrow lumen can be confirmed in endoscopic image.

Female: 44 years old
Chief complaint: Abdominal tumor mass, abnormal
bowel movement
Medical history: The patient had melena and visited
a nearby clinic about two years ago. The enema
examination there revealed no abnormal findings
except internal hemorrhoids, and she has been on asuppository therapy since. She recently visited
this department complaining that her stools became
small in volume and caliber.
The initial
abdominal plain X-ray revealed a large mass offeces and gaseous shadows in the colon. The
endoscopy and enema examination on the day
revealed stenosis of the sigmoid colon (Fig. 3).
The stenosis site and colonic lumen were
examined colonoscopically (Fig. 4).
Gastrographin was injected from the forceps
channel of colonoscope and the magnitude ofstenosis as well as the orientation and direction of
the colon axis was determined (fig. 5-1).
Before insertion, the guide-wire was passed
inside the first dilator until the first dilator reachedabout 5 cm from the tip of guide-wire (Fig. 5-2).
The prepared guide-wire and first dilator were theninserted from the forceps channel of the endoscope.
When stenosis is present in the sigmoid colon, asliding tube may also be used if necessary.
Next, only the colonoscope was withdrawn
and the second dilator was inserted by passing thepreviously placed first dilator inside the second
dilator. About 9 mm lumen space was secured bythis procedure. The second dilator was withdrawn
after dilation (Fig. 6-3).

Obstruction/stenosis

Guidewire

Figure 4

Insertion of guide-wire from forceps
channel of endoscope

Guide-wire is passed through the colonic lumen underthe endoscopic forward and direct vision.

The transanal ileus tube was inserted beyond
the stenosis site using the first dilator as a guide.
The balloon was then inflated and placed at the site
(Fig. 6-4).
After insertion of the transanal ileus tube,
colonic cleansing was performed with Niflec, 1,000
ml initially, followed by physiological saline
solution 500 ml every 6 hours with continuous
aspiration using a properly adjusted enema syringe.
One week after the insertion, a low-anterior
resection was performed as an elective operation.
Thus, a curative operation was performed.

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Obstruction/stenosis

Sliding tube
Guidewire

Green first dilator
Figure 5

Endoscopic decompression technique (1)1. Insertion of endoscope and contrasting: Contrasting reveals a long stenosis region.
2. Insertion of guide-wire and first dilator: Endoscope is withdrawn after securing theinsertion, leaving sliding tube in place.

Resected tumor mass, the cause of thestenosis, was a large localized ulcer-type tumor
having an ulcer 7  8 cm in size.

In two-stage operations frequently employed
to avoid these problems, the risk for postoperativecomplications is apparently lowered. However,dividing an operation into two stages will lead to adelay in the resection of carcinoma. Surgicalprocedures will become more complicated becauseof colostomy in the second operation or severeorgan adhesion, which then lead to difficulties inthe systematic curative surgical therapy and, in away, to a damage to the curability of carcinoma.
Thus, there are problems in two-way operations
with respect mainly to the curability of carcinoma,such as poorer prognosis compared with that in
one-stage operations.
It can therefore beconsidered that the difference in prognosis between
colon carcinomas with and without ileus is due not
only to the difference in biological malignancy but
to these problems as well.
In general, decompression with an ileus tube
is effective and an elective operation is possible incarcinoma ileus of the right colon. In the left
colon carcinoma, on the other hand, surgery isinevitably the first choice treatment, as thedecompression therapy is generally ineffective forthis type of carcinoma.
As to the one-stage operation for carcinoma
ileus of the colon, it has been reported that theintraoperative colonic cleansing significantly

III. Discussion
Ileus has been reported to accompany about
8-23% of colon carcinoma2) and its incidence rate is
generally higher at the left side than at the right sideof the colon. A comparison of colon carcinomas
with and without ileus has shown that the positive
rate of lymph node metastasis is higher, the intrinsic
biological malignancy is higher, and prognosis is
generally poorer for the carcinoma with ileus thanthat without ileus3). In contrast, there has also
been a report that there are no differences between
the two types of colon carcinomas4).
Operations for carcinoma ileus of the colon
should be performed with considerations given toboth the resolution of ileus and curability of thecarcinoma. Without decompression, there will be
an increased risk for the development ofanastomotic leakage due to local circulatory failureand edema caused by colonic dilation. In addition,
general conditions are poor and preoperative
examinations insufficient in many of the patients,
which then lead to high operative risks. The
dilatedcolon
also
lowersintraoperative
maneuverability.

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BalloonSecond large dilator

Figure 6

Endoscopic decompression technique (2)3. Insertion of second dilator: The 8 mm second dilator may resist somewhat but can beinserted by pushing it under the fluoroscopic vision.
4. Insertion of ileus tube: The tip of the first dilator is guided to reach thereduces the incidence rates of postoperativecomplications and ruptured sutures and improves
the five-year survival rate for patients who
underwent a curative operation3). It is therefore
obvious that the colonic decompression isextremely effective for the safety of operation andcurability of carcinoma.
At the same time,
however,theintraoperative
cleansingisdisadvantageous to patients with poor generalconditions because there are some problems in thisprocedure, such as prolonged operation time andpollution of the operating field. Furthermore, incase of ruptured suture in the colon, it is unlikelythat local circulatory failure can be resolved by theremoval of colonic contents alone. Thus, the ideal
treatment of carcinoma ileus of the left colon is toresolve the ileus condition first by a conservative
treatment to avoid any emergency operation, toallow the patient's general condition to improve,and then to perform a total resection of primarylesion and colonic anastomosis in a one-stage
operation after a sufficient preparation of the colon.
The meaning of endoscopic decompression
therapy lies here.
In the endoscopic
decompression for carcinoma ileus of the left colon,
a series of tubes are inserted endosmotically into
the narrow colonic lumen at the site of theileus-causing tumor, the space is widened stepwise,

and an ileus tube is finally passed through the tumor
site. Transanal colonic cleansing is then repeatedthrough the ileus tube, thus resolving the symptomof ileus. After this procedure, the colon is well
prepared for an elective operation. For the colonicdecompression, Lelcuk used a balloon for dilationof the esophagus and Fukamachi used a Nelaton
catheter5). Today, however, a device for theprocedure is commercially available as a transanal
ileus set (Create Medic Co., Ltd). The ileus tube
that is kept inserted is a 22 Fr silicone tube. Theballoon at the tip of the conventional oral ileus tube
moves forward by peristaltic movement, but that of
the transanal tube is kept at the site of stenosis andprevents the tube from coming out.
This method is generally used for stenoses
and obstructions due to ulcers in the rectum andsigmoid colon, and insertion of the tube becomes
inevitably more difficult as the site of stenosis
becomes more proximal. Therefore, we do not
actively introduce this method to the treatment oftransverse colon or descending colon with a severe
dilation in the proximal region; we usually perform
intraoperative colonic cleansing instead.
Thismethod will also be effective in the pretreatment ofrectal cancer with severe stenosis. The procedure
for colonic cleansing includes the initial injection ofNiflec 1,000 ml, followed by cleansing with-5-Journal of Japan Society of Coloproctology

52:1070-1076, 1999

physiological saline solution 500 ml every 6 hours
with careful observation of the color of cleansing
solution6).
Potential complications are perforation of thecolon caused by the tip of the guide-wire andnecrosis of the colonic mucosa due to the pressure
from the indwelling balloon7). The commerciallyavailable device kit presumes the use of acolonoscope and its guide-wire and first dilator aredesigned to pass through the forceps channel of theendoscope. In addition, the flexible tip regions ofguide-wire and first dilator have been intensively
modified for easier manipulation and higher safety(Fig. 1). Nevertheless, the risk for perforation isstill high in the case of long stenosis, stenosis at theflexure site, or local inflammation.
When
introducing this method, It is therefore important to1) critically evaluate the case for indication, 2)
grasp the conditions of obstructing site and itsproximal region by Gastrographin contrasting at thetime of insertion, and 3) prevent excessive
progression of the indwelling balloon by filling itwith diluted contrast medium.
Endoscope has become widely used in recent
years and the field of its use is being expanded fromexamination to treatment.
In particular,colonoscope is now used in a variety of procedures
including colonic mucosal resection andfull-thickness resection of the rectum by TEM8).
The endoscopic guidance can be used not only indecompression, but also in various procedures
including stenting and balloon-mediated dilation ofmembranous stenosis at the site of postoperative
mechanical anastomosis, as described in otherchapters of the present feature. Furthermore, thismethod is reliable and effective.

deformed cecum are contraindications rather thanindications for this method and, therefore, surgicalresolutions should be chosen without hesitation.

Conclusion
It is premature to consider every case ofcarcinoma ileus of the left colon as an indication for
the transanal endoscopic decompression. Cases
such as an extremely large colonic diameter and

8)

1)

2)

3)

4)

5)

6)
7)

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