Management of Colonic Stent-Induced Luminal Obstruction Using Argon Plasma Coagulation

Abstract

The use of argon plasma coagulation (APC) to modify metal stents has been reported in a handful of case reports, and the experience is limited to APC transection of distally migrated biliary elgiloy-based Wallstents. To our knowledge, the use of APC to relieve obstruction induced by nitinol-based Ultraflex stents in the colon has not been described. Case reports: Case 1: A 52 y/o male underwent placement of an Ultraflex Precision colonic stent (8.7 cm long, 30 mm flare diameter, 25 mm body diameter) for an obstructing recto-sigmoid cancer. Difficulty with stooling recurred 3 months later. At endoscopy, the distal end of the stent was angulated and abutted against the rectal wall, causing an obstruction. The wire strands of the stent that were not embedded in tissue were trimmed using contact APC at 90 W and 2 L/min flow rate, with relief of obstruction (see Figures) and continued ease of defecation at 1 month follow-up. Case 2: A 78 y/o male underwent palliative stenting of a 5-cm long, obstructing recto-sigmoid cancer using a similar sized Ultraflex colonic stent, as described above. Obstructive symptoms, however, recurred 2 weeks later due to impingement of the proximal aspect of the stent against the contralateral wall of the sigmoid colon. Successful piecemeal sectioning of the stent was performed using APC, with significant improvement in stooling and abdominal distention. The patient subsequently died from metastatic complications 5 weeks later.Figure 1Figure 2Discussion: Colonic obstruction may occur from protusion or angulation of the proximal or distal aspects of metal stents opposing the colonic wall. In this setting, APC at high power and flow rate appears effective and safe in trimming or transecting the free nitinol wire strands to relieve the stent-induced obstruction. [figure 1][figure 2]