Technical Success and Outcome of Self Expandable Metal Stents (SEMS) in the Colon

Abstract

Background: Self expandable metal stents (SEMS) are widely used for the treatment of benign and malignant strictures in the upper GI tact. Specially designed larger diameter stents are now also available for colonic implantation. Aims: To evaluate the technical success and outcome in a cohort of consecutive patients with strictures (malignant and benign) and anastomotic leaks. Method: Since implementation of endoscopic colonic stenting in June 2006 in our center nineteen stents were implanted in 18 patients either in the “over-the-wire” (OTW) technique or in the “trough-the-scope” (TTS) fashion. Results: The indication for colonic stent insertion was a malignant stricture in the majority of patients (n=11; m=9; f=2; mean age 73.6 years (range 61-81 years)). All patients were diagnosed with metastatic disease and were considered poor surgical candidates for palliative resection due to their low performance status (Karnofsky Index<60%). Endoscopic localisation of the stricture was as follows: rectum (n=3), sigmoid (n=3), transverse colon (n=4) and ascending colon (n=1). The technical success to traverse the stricture with a guide wire and implant the SEMS was 100%. One patient developed a late stent perforation 2 weeks after stent implantation in the sigmoid colon and underwent open resection with primary anastomosis. One stent occlusion was observed 10 months after implantation and successfully treated with endoscopic thermoablation. A total of 5 anastomotic leaks (rectum n=4, sigmoid n=1) were treated with implantation of fully covered OTW-SEMS. Complete closure was achieved in all rectal leaks, but failed in the sigmoid colon due to stent migration. All covered-SEMS were endoscopically removed after a median of 6 weeks without fistula recurrence. Furthermore two benign anastomotic strictures (post radiation (n=1, age 88) and post Hirschsprung resection (n=1; age 6)) were also treated successfully by temporary stenting with a fully covered SEMS. For this indication the covered stents remained in situ for up to 6 months without any evidence of ingrowth or significant tissue hyperplasia which facilitated endoscopic extraction without stricture recurrence during a mean follow-up of 9 months. Conclusion: Colon SEMS offer a safe minimally invasive endoscopic treatment of malignant and benign strictures and covered SEMS should now also be considered a valuable therapeutic modality for the management of rectal anstomotic leaks.