Successful Colonic Self-Expandable Metal Stent Placement Using a Rotatable Sphincterotome After Conventional Guidewire Insertion Failure: A Case Report.

Self-expandable metal stent (SEMS) placement is the standard endoscopic treatment for malignant colorectal obstruction, but its technical success depends on successful guidewire passage, which may fail when a sharply angulated or eccentrically oriented stricture prevents the operator from aligning the catheter tip coaxially with the luminal course. We report a 90-year-old woman with complete transverse colon obstruction caused by an adenocarcinoma near the hepatic flexure, in whom guidewire passage across the tumor was achieved with a rotatable sphincterotome after conventional catheter-based attempts had failed. Despite the use of an angled hydrophilic guidewire, catheter torque, repeated tip re-angulation, and patient repositioning, a standard catheter could not be advanced coaxially into the eccentric residual lumen. A rotatable sphincterotome, whose bending plane can be reoriented circumferentially, allowed the catheter tip to be brought coaxial with the eccentric orifice, so that the guidewire could be advanced across the stricture and a colonic SEMS deployed. The advantage over a conventional catheter or a bare guidewire lay in a steerable, mechanically supported tip that provided directional control aligned with the luminal course. Computed tomography on postprocedure day 1 confirmed resolution of the obstruction, and the patient resumed oral intake the same day. This rotatable sphincterotome, previously applied in biliary and pancreatic procedures, may serve as a rescue tool for technically difficult colonic stenting when the catheter tip cannot be inserted coaxially into the stricture orifice.