Endoscopic Implantation of Self-expanding Metal Stents (SEMS) in Acute Malignant Colonic Obstruction

Abstract

Up to now emergency surgical decompression is considered to be the standard therapy for acute colonic obstruction caused by colorectal malignoma. However, endoscopic implantation of self-expanding metal stents (SEMS) not only allow rapid colonic decompression with the possibility of one-stage elective surgical resection several days later due to a better preoperative condition of the patient but also can serve as definitive nonsurgical palliative treatment in some patients. We analyzed our experience with SEMS in this indication since 2002. Methods: In 23 patients (15f, 3m, 36-94y) with acute malignant colonic obstruction (Rektum: 4, Sigma: 15, Descendens: 3, Transversum: 1) 30 SEMS (27 uncovered Wallstents and 3 UltraflexTM-Precision-Stents; length 60 mm (18) or 90 mm (12), diameter 18 mm(1), 20 mm (2), 22 mm (24) or 25 mm (3)) were implanted endoscopically. The tumorous stenosis could not be passed with the endoscope in 21/23 patients. All patients showed clinical signs of obstruction (abdominal pain, meteorism, vomiting) and the radiological signs of colonic ileus. Results: Endoscopic SEMS implantation was technically successful in all patients. In 19/23 patients (83%) SEMS implantation resulted in a sufficient improvement of colonic obstruction. In 10 of these 19 patients elective surgical resection was performed after a mean time of 3 days. In the remaining 9 patients (advanced tumor stage) surgery could be avoided, but one of them had to be resected due to stent overgrowth after 5 months. In 4/23 patients a sufficient colonic decompression was not achieved until the next day by SEMS implantation. In these patients surgical decompression was performed, but 2/4 patients died in the following days. In 2 patients stent migration occurred in the further course, both of them could be successfully treated by re-stenting. No major complication such as perforation or bleeding occurred. Conclusion: Endoscopic SEMS implantation is an effective, safe and minimal invasive treatment of acute malignant colonic obstruction. It allows either elective surgical resection after preoperative improvement of patient condition or can serve as definitive palliative non-surgical treatment in patients with advanced tumor stage.