TP1.2.7The stuck colonoscope

Background

With the increased awareness and push for earlier diagnosis of colorectal cancer, the number of patients undergoing colonoscopy is increasing. Being a common condition, a number of these patients will have herniae. We describe a rare complication during a Sigmoidoscopy in a patient with an Inguinal hernia.

The case

A 75-year-old man was booked for a flexible sigmoidoscopy for rectal bleeding. The scope was successfully inserted to the Splenic flexure. During withdrawal, the scope stopped moving. It was still possible to advance the scope, but not to withdraw. The patient confirmed the presence of a left inguinal hernia. Physical examination and the position on magnetic scope imager confirmed the loop in the hernia.

Various manoeuvres to withdraw the scope were unsuccessful. A colleague was called for a second opinion. We came up with a plan to maintain a ‘long loop‘ position in the hernia, by holding the scope through the scrotum and allowing it to slide on withdrawal. This was successful and the patient was discharged.

Discussion

Incarceration of the scope in the hernia occurs when the hernial defect permits entry and exit of the scope, leaving a loop in the hernia, in a long loop position. During withdrawal, the configuration changes to a short loop, crowding the hernial defect, preventing the scope from sliding. On searching literature, we found that this technique has been described by Koltun et al and is known as the “Pulley” technique. We suggest that colonoscopists are familiar with this technique.

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.