Geisinger Medical Center Danville, PA, United States
Pranav Patel, MD, Harshit Khara, MD, FACG Geisinger Medical Center, Danville, PA
Introduction: Colonoscopy is the preferred method of colon cancer screening; however the rate of incomplete colonoscopies can range from 4% to 25%, and increases with age up to 22% to 33%. Incomplete colonoscopy can be due to redundant or tortuous colon, amongst other factors. Advances in endoscopic tools like the novel dynamic rigidizing Pathfinder overtube are available which can facilitate colonoscopy completion including therapeutic intervention. We present a difficult case of multiple incomplete colonoscopy exams in a patient with high risk features, eventually completed with the aid of the Pathfinder overtube.
Case Description/Methods: 57-year-old male was evaluated for high risk colon cancer screening due to positive Cologuard. Initial colonoscopy was incomplete due to severely redundant colon. Patient was referred to our tertiary care center for repeat attempt with advanced endoscopy. Second colonoscopy with significant looping due to large redundant colon, resulting in another incomplete colonoscopy. Maneuvers like changing to supine position, scope torsion, abdominal pressure, use of colonic overtube and Naviaid balloon-assisted colonoscopy were all unsuccessful. Hence, we performed a virtual CT colonography, which revealed a polyp in the ascending colon and markedly redundant colon (Fig 1). This prompted a third colonoscopy with another advanced provider which again showed significant looping of colon and colonoscopy was incomplete. After 3 unsuccessful conventional colonoscopies, the patient had colonoscopy with the novel rigidizing Pathfinder overtube. It was technically challenging exam requiring more than 2 hours of procedure time but resulted in successful completion with need to change to enteroscope and fluoroscopy use (Fig 2-5). Patient had 10mm polyp in ascending colon (Fig 6), removed with en-bloc endoscopic mucosal resection, revealing an adenomatous polyp with high grade dysplasia with negative margins.
Discussion: Our case highlights the benefit of the novel dynamic rigidizing Pathfinder overtube which is flexible at baseline but rigidizes to 15 times with vacuum. This can prevent abrasive maneuvers to advance the scope which can potentially reduce the risk of perforation and prolonging duration of anesthesia. There may be high risk lesions, especially in the right colon and thus reaching the cecum and performing a complete exam in imperative in our fight against colon cancer prevention, and the Pathfinder overtube may be an important tool in our armamentarium for such difficult cases.