Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data

Imaging of Strictures in Crohn's Disease

Crohn's disease (CD) is a chronic inflammation of the digestive tract, and it frequently affects young patients. It can involve any intestinal segment, even though it frequently affects the distal ileum. Up to 80% of patients with CD present with inflammatory behavior, and 5% to 28% develop stricturing disease. Based on the predominant mechanism causing them, strictures can be categorized as inflammatory, fibrotic, or mixed. Determining the relative amounts of inflammation and fibrosis in a stricture can influence treatment decisions. Imaging is an extremely useful tool in patients with small bowel stricturing CD to confirm the diagnosis and to evaluate disease characteristics, usually using CT or MRI. The aim of this paper is to describe how imaging can evaluate a patient with small bowel CD stricture.

A novel animal model of colonic stenosis to aid the development of new stents for colon strictures

BACKGROUND

The incidence of colonic stenosis, primarily caused by colon cancer and Crohn's disease, is increasing each year. The development of safer stents for colonic stenosis is required because perforation associated with cancer stent placement worsens the prognosis and stent placement for anastomotic stenosis due to Crohn's disease or colectomy is not first choice due to the high migration rate. The wall of the large intestine where the stent is inserted receives the complex forces from the peristaltic movement of the large intestine and stool in addition to the reaction tension of the stent, causing perforation and migration. Animal models may help develop new and safe stents, but no animal model closely reproduces the condition of human colonic stenosis. Herein, we present a novel animal model of colonic stenosis, which closely replicates the human colonic size.

METHODS

The artificial colonic stenosis model was developed by wrapping the porcine colon with a silicone sheet after laparotomy. The usefulness of the model was evaluated by investigating the availability of endoscopic stent placement, morphological maintenance of colonic stenosis, adverse effects on pigs, and modeling time. The first three and the last three modeling times were analyzed using Student's t-test.

RESULTS

Endoscopic stent placement was performed in all cases without intraoperative complications. There were no postoperative model complications or deaths. Adhesions to the surrounding tissue in the abdominal cavity of the artificial colon stenosis were slight. The morphology of the isolated artificial stenoses was completely maintained, and no necrosis or perforation was observed.

CONCLUSIONS

We developed a novel and feasible animal model of colonic stenosis using pigs. We believe that this animal model will be useful for developing a safer stent for obstruction caused by benign diseases and colon cancer.

Uncovered self-expandable metal stents for the treatment of refractory benign colorectal anastomotic stricture

Self-expandable metal stent (SEMS) placement has been suggested as a therapeutic modality for treating benign colorectal strictures. Covered stents are generally used, given the concerns regarding the efficacy and safety of uncovered stents. Hence, few studies have evaluated the efficacy and safety of uncovered SEMSs (UCSEMSs) in patients with refractory benign colorectal anastomotic strictures. In this study, 12 patients with postoperative benign symptomatic anastomotic strictures refractory to pneumatic dilation (range, 2–9) and transient indwelling-covered SEMSs were treated using UCSEMS. All enrolled patients were men (mean age, 61 years). Stent placement was successful in all 12 patients, and early clinical success was achieved in 11 (92%) patients. Four patients (25%) showed successful clinical outcomes without further intervention, but eight patients (75%) were clinically unsuccessful, and showed stricture recurrence or functional obstructive symptoms. Three patients underwent surgery, and the remaining five patients required repeat stent procedures. Despite the high reobstruction rate, the median follow-up period after UCSEMS placement was 16.7 months, demonstrating that UCSEMS may be able to achieve medium-term symptom relief without any complications. Therefore, UCSEMS may be an alternative option in exceptional circumstances in carefully selected patients, where invasive surgical treatments, such as stoma diversion, are not an option, thereby improving patients’ quality of life.

Biological behavior exploration of a paclitaxel-eluting poly-l-lactide-coated Mg–Zn–Y–Nd alloy intestinal stent in vivo

As a new type of intestinal stent, the MAO/PLLA/paclitaxel/Mg–Zn–Y–Nd alloy stent has shown good degradability, although its biocompatibility in vitro and in vivo has not been investigated in detail. In this study, its in vivo biocompatibility was evaluated by animal study. New Zealand white rabbits were implanted with degradable intestinal Mg–Zn–Y–Nd alloy stents that were exposed to different treatments. Stent degradation behavior was observed both macroscopically and using a scanning electron microscope (SEM). Energy dispersion spectrum (EDS) and histological observations were performed to investigate stent biological safety. Macroscopic analysis showed that the MAO/PLLA/paclitaxel/Mg–Zn–Y–Nd stents could not be located 12 days after implantation. SEM observations showed that corrosion degree of the MAO/PLLA/paclitaxel/Mg–Zn–Y–Nd stents implanted in rabbits was significantly lower than that in the PLLA/Mg–Zn–Y–Nd stent group. Both histopathological testing and serological analysis of in vivo biocompatibility demonstrated that the MAO/PLLA/paclitaxel/Mg–Zn–Y–Nd alloy stents could significantly inhibit intestinal tissue proliferation compared to the PLLA/Mg–Zn–Y–Nd alloy stents, thus providing the basis for designing excellent biodegradable drug stents.

Mg–Zn–Y–Nd alloy stents coated with MAO/PLLA/paclitaxel coating were implanted into the New Zealand rabbits intestine to investigate the biocompatibility and degradation behavior.

Current status of colonic stent for obstructive colorectal cancer in Japan; a review of the literature

Colorectal cancer is the most common cancer in Japan. Approximately 10%-20% of the patients with colorectal cancer present with large bowel obstruction, and those who present with malignant colonic obstruction (MCO) require urgent decompression because MCO can cause electrolytic fluid imbalance, colonic necrosis, bacterial translocation, and death. Placement of colonic stents (self-expandable metallic stents) for MCO is a major and standard endoscopic treatment that has been available since 2012 in Japan. This review presents the current conditions and future prospects of this procedure based on the literature. The current indication of colonic stent placement is malignant colorectal stenosis. One of the purposes of using stents is palliative treatment; further, its advantages over emergency surgery with colostomy include avoidance of colostomy, relief of obstruction, shorter hospitalization, and better quality of life. In addition, stent placement can also be used as a bridge to surgery since the duration of the hospitalization is shorter and postoperative complications, colostomy rates, and mortality rates are lower with elective than with emergency surgery. Although recent studies have reported low complication rates related to colonic stents, complications may still occur, highlighting the importance of good preparation, adequate staffing, backup systems, and informed consent. The current major problem related to colonic stents is the lack of evidence on patients' long-term prognoses for bridge to surgery purposes, awaiting the results of ongoing clinical research.

The current therapeutic options for Crohn's disease: from medical therapy to intestinal transplantation

Crohn's disease (CD) has an annual incidence per 100.000 person-year of 20.2 in North America and 12.7 in Europe, and the purpose of this review is to evaluate its medical management, from diagnosis to transplant. Pharmacologic manipulation with nutritional care aims to achieve and maintain remission, but more than half of patients will undergo an intestinal resection, very often repeated over time. They could experience short bowel syndrome (SBS) requiring total parenteral nutrition (TPN). Intestinal transplantation (ITx) represents an alternative in case of irreversible intestinal failure (IF) with life-threatening TPN complications. Patient survival after ITx is 79%, 53% and 43% at 1, 3 and 5 years respectively, with no differences among ITx for other disorders. Areas covered: The research discussed medical therapy with nutritional support, evaluating the role of endoscopy, surgery and transplant in CD. A systematic literature review was conducted using the PubMed search engine up to May 31^th, 2017 without restriction of the language. The decision on paper's eligibility was reached by consensus between the 3 screening authors. Expert commentary: CD treatment is mainly medical, leaving endoscopy and surgery for a complex course. ITx represents a therapeutic option if TPN complications with IF arise.

Biodegradable Stents: An Evolution in Management of Benign Intestinal Strictures

Benign intestine strictures secondary to postoperative narrowing or inflammatory bowel disease can be managed surgically or conservatively. Some patients may not be suitable surgical candidates and some patients may choose not to have repeat surgery. Biodegradable (BD) stents offer a prolonged dilatory effect before gradual degradation and obviates the need of a second procedure for stent removal. BD stents have high technical success rates (mean, 94.4%; median, 100%; range, 86% to 100%) but widely variable clinical success rates (range, 45% to 100%). Stent migration is the most commonly reported complication (mean, 22.2%; range, 0% to 36%). In the future, with better understanding of the factors contributing to stent migration, improvement in present stent design and better anchoring techniques, the stent migration rate is expected to decrease and improve clinical outcome. The role of prophylactic BD stent placement to prevent stricture development postintestine surgery is an intriguing idea and needs to be explored. As of now, the use of BD stents is a reasonable option for patients with dilatation resistant intestinal strictures who are unfit for surgery or refuse to have surgical treatment.

Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: outcome in 29 patients

BACKGROUND

Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases.

METHODS

From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula.

RESULTS

Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6-65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus.

CONCLUSION

FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient.

Stents for colorectal obstruction: Past, present, and future

Since the development of uncovered self-expanding metal stents (SEMS) in the 1990s, endoscopic stents have evolved dramatically. Application of new materials and new designs has expanded the indications for enteral SEMS. At present, enteral stents are considered the first-line modality for palliative care, and numerous types of enteral stents are under development for extended clinical usage, beyond a merely palliative purpose. Herein, we will discuss the current status and the future development of lower enteral stents.

Techniques and principles of endoscopic treatment of benign gastrointestinal strictures

PURPOSE OF REVIEW

The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio.

RECENT FINDINGS

Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition.

SUMMARY

Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.

Role of stenting in gastrointestinal benign and malignant diseases

Advances in stents design have led to a substantial increase in the use of stents for a variety of digestive diseases. Initially developed as a non-surgical treatment for palliation of esophageal cancer, the stents now have an emerging role in the management of malignant and benign conditions as well as in all segments of the gastrointestinal tract. In this review, relevant literature search and expert opinions have been used to evaluate the key-role of stenting in gastrointestinal benign and malignant diseases.

Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease

Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.

Colonic obstruction caused by endometriosis solved with a colonic stent as a bridge to surgery

Self-expanding metal stents are an established treatment for malignant colon strictures, either as palliative treatment or as a bridge to later surgery. Little data exist regarding the use of stents for benign obstructions and the rate of subsequent complications related to the procedure is high. After reviewing the existing literature, we found only one case of stent placement in an intestinal obstruction caused by endometriosis, as a bridge to surgery. The use of prostheses in benign disease has a higher rate of complications such as stent migration and gut perforation. Such complications are even more likely to happen when the stent has been placed as a bridge to surgery and it is delayed for more than 7 days. This is the case of a young woman presenting an acute intestinal obstruction related to endometrioma. Stent placement was used in this case as a bridge to surgery with successful results.

Endoscopic stenting for recurrence-related colorectal anastomotic site obstruction: Preliminary experience

AIM: To evaluate the efficacy of stents in treating patients with anastomotic site obstructions due to cancer recurrence following colorectal surgery.

METHODS: The medical records of patients who underwent endoscopic self-expanding metal stents (SEMS) insertion for colorectal obstructions between February 2004 and January 2014 were retrospectively reviewed. During the study period, a total of 218 patients underwent endoscopic stenting for colorectal obstructions. We identified and examined the patients who underwent endoscopic stenting for obstructions caused by cancer recurrence at the anastomotic site following colorectal surgeries for primary colorectal cancer.

RESULTS: Five consecutive patients [mean age, 56.4 years (range: 39-82 years); 4 women, 1 man] underwent endoscopic stenting for obstructions caused by cancer recurrence at the anastomotic site following colorectal surgeries for primary colorectal cancer. Technical and clinical success was achieved in all 5 patients, without any early complications. During follow-up, 3 patients did not need further intervention, prior to their death, after the first stent insertion; thus, the overall success rate was 3/5 (60%). Perforations occurred in 2 patients who required a second SEMS insertion due to re-obstruction; none of the patients experienced stent migration.

CONCLUSION: SEMS placement is a promising treatment option for patients who develop obstructions of their colonic anastomosis sites due to cancer recurrence.

Uncovered Self-Expanding Metal Stent (SEMS) Four Years After Placement for Long-Term Treatment of a Benign Colonic Obstruction

Self-expanding metal stents (SEMS) have emerged as an alternative to surgery in the treatment of malignant colorectal obstructions. There is limited data about their use for benign colonic obstructions, especially in regards to safety and long-term patency. We present a case in which long-term SEMS placement proved to be a durable option for over 4 years in a patient with a benign colonic stricture.

Perforation in colorectal stenting: a meta-analysis and a search for risk factors

BACKGROUND

Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement.

OBJECTIVE

To identify risk factors for perforation from colonic stenting.

DESIGN

A meta-analysis of 86 studies published between 2005 and 2011.

SETTING

Multicenter review.

PATIENTS

All patients who underwent colorectal stent placement.

INTERVENTION

Colorectal stent placement.

MAIN OUTCOME MEASUREMENTS

The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab.

RESULTS

A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%).

LIMITATIONS

Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis.

CONCLUSIONS

The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.

Systematic review of self-expanding stents in the management of benign colorectal obstruction

AIM

Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction.

METHOD

A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population.

RESULTS

The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis.

CONCLUSION

Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction.

Self-expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer

AIM

To evaluate the use of self-expandable metallic stents to treat patients with symptomatic benign anastomotic stricture after colorectal resection.

METHOD

Ten patients with a benign symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent.

RESULTS

The stent was placed successfully in all 10 patients without any major morbidity. At a mean follow-up of 18 months the stenosis was resolved successfully in 7 out 10 patients (70%). The remaining three patients were subsequently treated successfully with balloon dilatation.

CONCLUSION

Self-expandable metal stents represent a valid alternative to balloon dilatation to treat patients with benign symptomatic anastomotic stricture after colorectal resection for cancer.

Treatment of anastomotic stenosis and leakage after colorectal resection for cancer with self-expandable metal stents

BACKGROUND

Self-expandable metallic stents can be used to treat patients with symptomatic anastomotic complications after colorectal resection.

METHODS

Twenty patients with symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent. Ten patients had "simple" anastomotic stricture. In the remaining 10 patients, a leak was associated with the stricture.

RESULTS

The anastomotic leakage healed without evidence of residual stricture or major fecal incontinence in 8 of 10 patients. Overall, the anastomotic stricture was resolved in 14 of the 20 patients.

CONCLUSIONS

Self-expandable metal stents represent a valid adjunctive to treat patients with symptomatic anastomotic complications after colorectal resection for cancer. They have a complementary role to balloon dilatation in case of simple anastomotic stricture, and they improve the rate of healing when the stricture is associated with a leak.

Safety and efficacy of extractible self-expandable metal stents in the treatment of Crohn's disease intestinal strictures: a prospective pilot study

BACKGROUND

Endoscopic management of Crohn's disease (CD) intestinal strictures with balloon dilation is effective; however, recurrences are frequent and require further dilations or surgery. The use of extractible metallic stents may be as effective as balloon dilation with fewer recurrences. The aim was to investigate in a prospective pilot study the feasibility and clinical effectiveness of the use of extractible stents in the treatment of CD intestinal strictures.

METHODS

In two tertiary referral centers, quiescent CD patients except for obstructive symptoms associated with intestinal stenosis of less than 50 mm length on enterography were eligible for transitory stent placement, initially planned to be retrieved after 8 weeks, which was secondarily reduced to 4 weeks after patient 3.

RESULTS

Eleven patients (six males, five females, median age 34 years [range 18-66]) were prospectively included. The sites of intestinal stenosis were an ileocolonic anastomosis, an ileosigmoidic anastomosis, and the surgically untreated terminal ileum in eight, one, and two patients, respectively. Stent placement was technically successful in 10 patients. Obstructive symptoms were relieved in 6 out of 10 patients. Two patients needed surgery related to the procedure. Six downstream migrations were observed. Only one patient could have the stent extracted as scheduled on day 28 and remains symptom-free after 73 months of follow-up.

CONCLUSIONS

Even if stenting appears an effective technique in treating symptomatic CD intestinal strictures, the procedure is associated with a prohibitively high rate of spontaneous migrations and complications.

Endoskopische Möglichkeiten der Behandlung von Nahtinsuffizienzen im Rektum

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen eine gefürchtete Komplikation der kolorektalen Chirurgie dar. Endoskopische Techniken haben sich in der Therapie der Leckagen zunehmend etabliert. In dieser Übersicht möchten wir einen Überblick der wichtigsten endoskopischen Verfahren geben. <b><i>Methode: </i></b>Systematische Recherche der vorhandenen Literatur. <b><i>Ergebnisse: </i></b>Die bedeutendsten endoskopischen Verfahren zur Behandlung der kolorektalen Anastomoseninsuffizienzen stellen die Fibrininjektion, die Vakuumschwammtherapie (Endo-Sponge), spezielle Clip-Systeme (OTSC) sowie die Stentimplantation dar. Der breiten klinischen Anwendung dieser Verfahren steht jedoch eine unzureichende Studienlage gegenüber. <b><i>Schlussfolgerung: </i></b>Die Einschätzung der Wertigkeit der einzelnen endoskopischen Verfahren untereinander und in speziellen therapeutischen Situationen hängt im Wesentlichen von der Erfahrung der Untersucher ab. Es bedarf der Durchführung randomisierter, prospektiver Studien, um diese Erfahrungen zu objektivieren.

Biodegradable polydioxanone stents: a new option for therapy-resistant anastomotic strictures of the colon

OBJECTIVES

To assess the outcome of self-expandable, biodegradable stent insertion for anastomotic strictures following treatment for rectosigmoid carcinoma.

METHODS

Three male patients (median age 66) developed benign strictures after radiotherapy and resection of a recto-sigmoid carcinoma. These were resistant to balloon dilatation and prevented stoma reversal. Biodegradable stent insertion was performed as an experimental treatment on a named-patient basis with approval of the institutional review board. Patients had monthly follow-up with endoscopy and contrast medium enemas to monitor performance and degradation of the stents.

RESULTS

All stents were placed successfully without complications after pre-dilatation to 20 mm under fluoroscopic guidance. Stent degradation occurred in all patients 4-5 months following implantation, and long-term anastomotic patency was demonstrated in all. This allowed reversal of the colostomy and physiological defecation in two patients. Reversal was not undertaken in one due to subsequent development of liver metastases. No stent migration or occlusion occurred.

CONCLUSIONS

Biodegradable stents can maintain an adequate lumen across anastomotic strictures resistant to balloon dilatation. They seem to allow stricture re-modelling resulting in maintained dilatation after degradation. This potentially allows reversal of a colostomy, which might otherwise be prevented by stricture recurrence.

Treatment of benign colorectal strictures by temporary stenting with self-expanding stents

BACKGROUND

The application of stents in benign colorectal strictures is considered controversial. The aim of the present study was to assess effectiveness and complications associated with colorectal stent placement in benign colorectal disease.

PATIENTS AND METHODS

Fourteen patients with benign colorectal strictures who had undergone previous surgery (colorectal anastomotic stenosis, 13; neosphincter scar stenosis, one) were treated with covered self-expanding metal stent or plastic stent. Placement of the stent was performed with combined endoscopy and contrast enhanced fluoroscopy.

RESULTS

Self-expanding stents were successful implanted in all 14 patients without acute procedure-related complications. All patients experienced immediate decompression after stent placement with expansion and patency of the stent. Relief of bowel obstruction for at least 12 months was achieved in seven of 14 patients (50%). Anastomotic fistula healed in four of six patients (67%). Despite the initial success of stenting, re-operations had to be performed in two of seven patients because of late recurrence of the stricture after a mean follow-up of 37 months.

CONCLUSIONS

Temporary insertion of self-expanding stents is a safe procedure that may be effective in selected cases of benign colorectal stricture. However, repeat surgery will be necessary in a considerable number of patients due to primary or secondary failure of stenting.

Update on the indications and use of colonic stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

A clinical evaluation of endoscopically placed self-expanding metallic stents in patients with acute large bowel obstruction

BACKGROUND AND AIMS

Self-expanding metallic stents (SEMS) have since 1991 established themselves as an option in the treatment of large bowel obstruction. The aim of this study was to evaluate the use of SEMS in management of acute colorectal obstructions at a Danish Surgical Gastroenterology center.

MATERIAL AND METHODS

Retrospective review of charts from all patients who, in the period Marts 2002 to December 2007 underwent insertion of a SEMS for an acute large bowel obstruction.

RESULTS

Of 45 patients included, SEMS was intended as a bridge to surgery in 20 patients and as palliation in 25 patients. For malignant etiology, the SEMS procedure was a technical and clinical success in 97.4% of the cases. Complications occurred in 21%, mortality rate 2,6%. For benign etiology, the SEMS procedure was a technical success in 85.7%, and a clinical success in 71.4%. Complications occurred in 71.4% of the benign cases with a mortality rate of 28,6%.

CONCLUSIONS

Placement of SEMS for acute large bowel obstruction with malignant etiology is an effective and safe procedure with low mortality and morbidity. However results for benign obstructions are questionable and more research is needed to determine the role of SEMS.