Successful endoscopic removal of a large calcified cyst impacted in the sigmoid lumen

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.

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