Introduction

Malignant colorectal obstruction is a life-threatening emergency that occurs in approximately 7-29% of patients with colorectal cancer and requires prompt intervention [1,2]. Self-expandable metal stent (SEMS) placement has become the standard endoscopic approach in this setting, serving either as a definitive palliative measure or as a bridge to elective surgery, and thereby reducing the need for emergent colostomy and its associated morbidity [3,4].

Technical success of SEMS placement depends on the ability to advance a guidewire through the obstructing lesion under endoscopic and fluoroscopic guidance. Guidewire passage fails in 10-24% of cases; failure occurs most often when the luminal orifice cannot be adequately visualized en face or when the catheter tip cannot be inserted coaxially with the luminal axis [5-7]. Beyond the risk of technical failure, colonic SEMS placement carries a non-trivial rate of adverse events; the overall complication rate approaches 25%, with reported perforation rates of roughly 9-10%, stent migration of approximately 5-9%, and re-obstruction as a leading cause of late reintervention [4,8,9]. This underscores the importance of first-pass technical success, particularly in high-risk patients who are unsuitable for salvage surgery. Several strategies have been proposed to address difficult guidewire passage, including angled-tip guidewires, patient repositioning, and sphincterotome-assisted guidewire insertion (SAGWI) [10]. The rationale for SAGWI rests on the capacity of the sphincterotome tip to be deflected, allowing the operator to insert the catheter tip coaxially into the orifice of a tortuous or eccentric stricture, an approach not possible with a rigid catheter. Although SAGWI improves technical success in observational studies [10,11], conventional sphincterotomes deflect in only a single plane through blade tension, which limits directional control when the luminal axis of the stricture deviates substantially from the endoscopic line of approach.

A rotatable sphincterotome combining a 360-degree rotatable handle with a dual-action blade mechanism allows the direction of tip deflection to be reoriented circumferentially rather than confined to a single fixed plane. This class of device has been applied in technically demanding biliary and pancreatic procedures [12-14]. Sphincterotome-assisted guidewire insertion is itself an established technique; to our knowledge, however, the use of a rotatable sphincterotome to accomplish colonic SEMS placement has not previously been reported. Here we describe such a case, in which SEMS placement for malignant colorectal obstruction was achieved with a rotatable sphincterotome after conventional catheter-based guidewire insertion had failed, and we discuss the potential role of this device relative to existing rescue techniques.