Insertion of Self Expandable Metal Stent for Malignant Stomal Obstruction in a Patient with Advanced Colon Cancer

Jeong Ook Wi; Sung Jae Shin; Jun Hwan Yoo; Jeong Woo Choi; Byung-Hyun Yoo; Sun Gyo Lim; Kee Myung Lee; Jin Hong Kim

doi:10.5946/ce.2012.45.4.448

Articles

Page Path: HOME > Clin Endosc > Volume 45(4); 2012 > Article

Case Report Insertion of Self Expandable Metal Stent for Malignant Stomal Obstruction in a Patient with Advanced Colon Cancer: Jeong Ook Wi, Sung Jae Shin, Jun Hwan Yoo, Jeong Woo Choi, Byung-Hyun Yoo, Sun Gyo Lim, Kee Myung Lee, Jin Hong Kim; Clinical Endoscopy 2012;45(4):448-450.
DOI: https://doi.org/10.5946/ce.2012.45.4.448
Published online: November 30, 2012

Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea.

Correspondence: Sung Jae Shin. Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 443-380, Korea. Tel: +82-31-219-6939, Fax: +82-31-219-5999, shsj9128@ajou.ac.kr

• Received: November 28, 2011 • Revised: February 10, 2012 • Accepted: March 10, 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

6,531 Views
40 Download
3 Crossref
4 Scopus

prev next

Full Article

Download PDF

Abstract
INTRODUCTION
CASE REPORT
DISCUSSION
NOTES
REFERENCES

Abstract

Self expandable metal stent can be used both as palliative treatment for malignant colorectal obstruction and as a bridge to surgery in patients with potentially resectable colorectal cancer. Here, we report a case of successful relief of malignant stomal obstruction using a metal stent. A 56-year-old man underwent loop ileostomy and was given palliative chemotherapy for ascending colon cancer with peritoneal carcinomatosis. Eight months after the surgery, he complained of abdominal pain and decreased fecal output. Computed tomography and endoscopy revealed malignant stomal obstruction. Due to his poor clinical condition, we inserted the stent at the stomal orifice, instead of additional surgery, and his obstructive symptoms were successfully relieved. Stent insertion is thought to be a good alternative treatment for malignant stomal obstruction, instead of surgery.
Keywords: Stents; Neoplasms; Stoma

INTRODUCTION

Malignant colonic obstruction is managed by endoscopic colon stent insertion, removal of obstructive lesion followed by reconnecting sections of the large intestine, or creation of a diverting colostomy/ileostomy. Surgery for stoma correction has also been used for malignant stomal obstruction.1 However, surgery might increase mortality and morbidity in patients with advanced cancer or poor performance status; as a result, there has been no established strategy for the management of malignant stomal obstruction.2 In such cases, stent insertion might be a reasonable alternative. We report a case of successful relief of malignant stomal obstruction using a metal stent and a review of the literature.

CASE REPORT

A 56-year-old man presented with right lower quadrant pain and abdominal distention for 2 months. Colonoscopy showed an ulcerofungating mass lesion in the ascending colon and the scope could not be passed through it. Abdominal computed tomography (CT) showed asymmetric enhancing wall thickening in the right side colon and multiple lymph node enlargements in the right side mesentery and mesenteric root. In addition, ascites were observed in the pelvis. He was diagnosed as ascending colon cancer with peritoneal carcinomatosis (stage IVb). He was initially treated by inserting self expandable metallic stent (SEMS) for colonic obstruction. Two days after the stent insertion, abdominal distention and pain were re-developed and follow-up CT showed near total obstruction at the proximal portion of the stent, suggesting stent migration. Thus, he underwent loop ileostomy and palliative chemotherapy was started after the operation.

After 12 cycles of chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin, disease progression was noted and the patient developed abdominal pain with decreased stool output. Physical examination showed mildly distended abdomen with decreased bowel sounds. On palpation, there was tenderness over the peristomal region. Abdominal CT scan showed a peritoneal metastasis surrounding the stoma and diffuse dilatation of the small bowel (Fig. 1). Because a conventional colonoscope could not be passed through the stoma, we used Olympus scope GIF-XQ 260 (9.8 mm diameter; Olympus, Tokyo, Japan). Endoscopy showed obstruction of the ileostomy site by a mass (Fig. 2). The lesion was hard and it had some ulcers covered with exudates, compatible with stomal obstruction arising from carcinomatosis. Based on the patient's poor condition, surgery for stoma correction deemed inappropriate due to high risk of complication. Therefore, after the informed consent was obtained, a 60 mm length, 24 mm diameter self expandable metal stent (Niti-S colonic non TTS uncovered stent; Taewoong Medical Inc., Seoul, Korea) was implanted in the stoma under fluoroscopic guidance (Figs. 3, 4). Upon release of the stent, fecal materials poured through the stent. An anchoring suture was performed in order to prevent migration of the stent. One week later, he was discharged without a complaint of bowel obstruction, but he died one and half months after the stent placement due to the progression of the colon cancer, without clinical signs of re-obstruction.

DISCUSSION

Malignant colon obstruction is common in patients with advanced cancer, usually colorectal cancer. Acute colorectal obstruction usually requires rapid bowel decompression, such as emergency surgery, which is associated with relatively high mortality and morbidity rates. Recently introduced SEMS, however, can be used both as a palliative treatment for unresectable malignant colorectal obstruction and as a bridge to surgery in patients with potentially resectable colorectal cancer. In the bridge to surgery setting, insertion of SEMS can decompress the obstruction, provide the opportunity for bowel preparation, and make one-stage surgical resection possible, which is known to be associated with decreased morbidity, mortality, and stoma formation rate compared with emergency surgery.3-6

Adenocarcinoma may develop at a colostomy or ileostomy site as a primary tumor, a metachronous lesion, or a carcinomatosis and disseminated disease.7-9 Malignant stomal obstruction has traditionally been treated with surgery, and specific surgery has been selected based on the clinical characteristics of each patient. For example, a patient with advanced cancer could be considered as a candidate for a limited local resection, while a patient with an isolated stoma recurrence as a candidate for a broad local resection, including the abdominal wall.10 However, there is no appropriate alternative management established yet for cases where the limited local resection is technically difficult or where there is a risk of increasing the rate of resection-related complication due to the patient's poor performance status. In these settings, stent insertion might be a good therapeutic option instead of palliative surgery in malignant stomal obstruction, considering the poor prognosis and high mortality and morbidity rate of palliative surgery.

When life expectancy is short, stent migration is thought to be the more serious complication than stent re-obstruction. Therefore, to prevent stent migration, the uncovered stent was more favorable than covered stent in our patient, and anchoring suture in the distal portion of the stent, such as anchoring clips, would be also helpful to prevent the stent migration.11,12

In conclusion, SEMS insertion for malignant stomal obstruction could be an alternative treatment, instead of surgery, in patients with inoperable colon cancer or poor performance status. Further research is needed to determine the validity of SEMS in palliating obstructive symptoms compared with operative management in malignant stomal obstruction.

The authors have no financial conflicts of interest.

REFERENCES

1. Colwell J. In: Colwell J, Goldberg M, Carmel J, editors. Stomal and peristomal complications. Fecal and Urinary Diversions: Management Principles. 2004. St. Louis: Mosby; p. 308–325.
2. De Angelo DJ. In: Chang AE, Hayes DF, Pass HI, editors. Metabolic emergencies in oncology. Oncology: an Evidence-Based Approach. 2006. 1st ed. New York: Springer-Verlag; p. 1321–1331.Article
3. Khot UP, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096–1102.Article PubMed
4. Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 2007;246:24–30.Article PubMed PMC
5. Choo IW, Do YS, Suh SW, et al. Malignant colorectal obstruction: treatment with a flexible covered stent. Radiology 1998;206:415–421.Article PubMed
6. Law WL, Chu KW, Ho JW, Tung HM, Law SY, Chu KM. Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies. Dis Colon Rectum 2000;43:1522–1527.Article PubMed
7. Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562–1572.Article PubMed
8. Roberts PL, Veidenheimer MC, Cassidy S, Silverman ML. Adenocarcinoma arising in an ileostomy: report of two cases and review of the literature. Arch Surg 1989;124:497–499.Article PubMed
9. Carey PD, Suvarna SK, Baloch KG, Guillou PJ, Monson JR. Primary adenocarcinoma in an ileostomy: a late complication of surgery for ulcerative colitis. Surgery 1993;113:712–715.PubMed
10. Orkin BA, Araghizadeh F. In: Billingham RP, Kobashi KC, Peters WA, editors. Reoperative surgery for gastrointestinal stomal problems. Reoperative Pelvic Surgery. 2009. 1st ed. New York: Springer-Verlag; p. 289–305.Article
11. Baron TH, Dean PA, Yates MR 3rd, Canon C, Koehler RE. Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes. Gastrointest Endosc 1998;47:277–286.Article PubMed
12. Kim ID, Kang DH, Choi CW, et al. Prevention of covered enteral stent migration in patients with malignant gastric outlet obstruction: a pilot study of anchoring with endoscopic clips. Scand J Gastroenterol 2010;45:100–105.Article PubMed

Fig. 1

Computed tomography of the abdomen showed abdominal wall metastasis. Enhancing mass around the ileostomy site resulted in diffuse dilatation of the small bowel.

Fig. 2

(A) Conventional endoscopy showed obstruction of the stoma by cancer invasion. (B) The lesion was felt to be hard on palpation and it had shallow, irregular marginated ulcers covered with exudates.

Fig. 3

(A) After removing the rectal tube, (B, C) we inserted a guide wire through the obstructive lumen under endoscopy and fluoroscopic guidance. (D) Then, self expandable metallic stent was inserted over the guide wire. (E, F) The last two pictures showed the fully expanding percutaneous metal stent and fecal materials pouring from the stent's lumen.

Fig. 4

(A) Fluoroscopic view showed the release of the stent at the obstruction site and (B) the fully expanding stent contrasted by air inflation. Another stent, which had previously been inserted into the ascending colon and migrated was noted above it.

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

Endoscopic transstomal stent insertion: a novel approach for a stenosed stoma in a challenging patient
Feras Aljarad, Ashutosh Gumber, Anne Marie McLeary, Kawan Shalli
Annals of Coloproctology.2023; 39(4): 357. CrossRef
Use of metallic stents in the management of stenotic bowel stomas
Mohammad Arabi, Hasan Aljaziri, Mohammed Rashid Akhtar, Tim Fotheringham
International Journal of Gastrointestinal Intervention.2022; 11(4): 201. CrossRef
Metal Stent Insertion for Malignant Obstruction of a Colostomy
Antonios Wehbeh, Mahmoud Rahal, Hala Fatima
Cureus.2020;[Epub] CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Insertion of Self Expandable Metal Stent for Malignant Stomal Obstruction in a Patient with Advanced Colon Cancer

Clin Endosc. 2012;45(4):448-450. Published online November 30, 2012

DOI: https://doi.org/10.5946/ce.2012.45.4.448

XML Download

Figure

Related articles

Self-expandable metallic stent-induced esophagorespiratory fistulas in patients with advanced esophageal cancer

Insertion of Self Expandable Metal Stent for Malignant Stomal Obstruction in a Patient with Advanced Colon Cancer

Fig. 1 Computed tomography of the abdomen showed abdominal wall metastasis. Enhancing mass around the ileostomy site resulted in diffuse dilatation of the small bowel.

Fig. 2 (A) Conventional endoscopy showed obstruction of the stoma by cancer invasion. (B) The lesion was felt to be hard on palpation and it had shallow, irregular marginated ulcers covered with exudates.

Fig. 3 (A) After removing the rectal tube, (B, C) we inserted a guide wire through the obstructive lumen under endoscopy and fluoroscopic guidance. (D) Then, self expandable metallic stent was inserted over the guide wire. (E, F) The last two pictures showed the fully expanding percutaneous metal stent and fecal materials pouring from the stent's lumen.

Fig. 4 (A) Fluoroscopic view showed the release of the stent at the obstruction site and (B) the fully expanding stent contrasted by air inflation. Another stent, which had previously been inserted into the ascending colon and migrated was noted above it.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Insertion of Self Expandable Metal Stent for Malignant Stomal Obstruction in a Patient with Advanced Colon Cancer