Self-Expandable Metal Stents in the Management of Benign and Malignant Colorectal Obstruction

Abstract

Background: Self-expandable metal stents (SEMS) can be used to relieve benign and malignant colorectal obstruction. Aim: To determine the feasibility, efficacy, and outcomes of SEMS for colorectal obstruction. Methods: Retrospective chart review of patients who underwent endoscopic SEMS placement under fluoroscopic guidance at a cancer center from 2001 to 2007. Results: 43 patients (21M, 22F), mean age 60 yr (24-82) underwent 46 procedures. 42 patients had SEMS placement for palliation and 1 as a bridge to surgery. Cancer type included: 26 colorectal, and 16 metastatic (4 gastric, 3 ovarian, 3 lung, 2 pancreatic, 1 esophageal/prostate/small bowel/unknown). 1 patient had a benign sigmoid stricture in the setting of ALL. Stricture location: 10 rectum, 23 sigmoid, 3 descending, 2 splenic flexure, 3 transverse, 1 hepatic flexure, 1 ascending. Wallstents were placed in 63% and Ultraflex and Wallflex in the rest. Technical success was achieved in all cases. 3 patients required multiple stents due to immediate proximal migration, lack of full stent expansion, and deployment failure. Clinical success was achieved in 39/43 cases (91%). One patient continued to have obstructive symptoms and required APC tumor ablation. 2 perforations were detected immediately and at 5 days, resulting in 1 death and 1 emergent surgery. One patient presenting with obstruction and free air failed to have relief of obstruction after palliative stenting. Mean follow-up was 114 days (2-1210). In 2 cases (4.6%), the stents migrated distally to the rectum at 4 and 20 days, and were removed successfully with a snare. One went to surgery and the second required no further intervention. One patient with a rectosigmoid tumor developed pain after stent placement. Endoscopic removal of the stent was unsuccessful. 2 patients (4.6%) had stent occlusion from tumor ingrowth at 3.5 and 8.5 mo. and were treated with repeat stenting. There were 27 deaths, all from metastatic disease and multiorgan failure unrelated to stent placement except for the 1 case of procedure related perforation. Conclusions: Placement of SEMS for the treatment of colorectal obstruction is feasible and safe. In our institution where SEMS are primarily used to palliate terminal disease, technical and clinical success rates were high without significant morbidity and mortality. On long term follow-up, patients died from their advanced disease without recurrent obstruction or stent-related complications.