Interventional Medicine & Applied Science, Vol. 6 (3), pp. 131–132 (2014)
CASE REPORT
Colonic perforation as a late complication of self-expanding stent KRISHNAN GOKUL*, ELIZABETH SQUIRE, DMITRI ARTIOUKH Southport and Ormskirk NHS Trust, Southport, United Kingdom *Corresponding author: Krishnan Gokul; Southport and Ormskirk NHS Trust, Town Lane, Southport PR8 6PN, United Kingdom; E-mails: [email protected], [email protected] (Received: April 2, 2014; Revised manuscript received: May 16, 2014; Accepted: May 23, 2014) Abstract: Self-expanding metal stents are used to relieve left-sided colonic obstruction either as a palliative measure or as a bridge to surgery. While there are defi nite advantages, the procedure does have significant complications, perforation of bowel being the most common with significant morbidity and mortality. A case of late perforation due to colonic stent erosion is presented. Keywords: self-expanding metal stent, perforation, complication
particularly when combined with balloon dilatation. Thus, a randomized multicentre Dutch study for obstructed Stage IV cancers was prematurely closed due to high incidences of perforation [5]. Other immediate drawbacks of SEMS insertion are haemorrhage, incorrect placement and failure to expand (especially where obstruction is due to extrinsic compression). Late complications include stent migration, stent fracture, and recurrent obstruction due to tumour ingrowth. Deployment of the stent in a low position could result in tenesmus and faecal incontinence. In a single centre experience of 101 patients Keranen et al. [6] reported stent related mortality of 2% and complication rate of 20%. Esparrach [7] in a retrospective analysis of cases over a 5-year period reported morbidity due to stent migration (22%), obstruction (17%), tenesmus (5%). We present a case of late bowel perforation which developed in a 60-year-old man who had stenting of a high rectal tumour after a course of neoadjuvant chemoirradiation while awaiting definitive surgery. His initial CT staging was T3N2M0 and MRI staging T4N2M0. After completion of neoadjuvant therapy while awaiting surgery he presented with clinical features of acute colonic obstruction which was confirmed on plain X-ray radiology. He went on to have SEMS insertion as a bridge to planned elective surgery. Anterior resection was performed 3 weeks after insertion of the stent and 9 weeks after completion of oncological downstaging
Self-expanding metal stents (SEMS) now have an established role in the management of left-sided colonic obstruction. They can be used as a primary definitive interventional treatment in palliative management of colonic cancer. Stents are used when patients are deemed unfit for surgery or in the presence of disseminated malignancy where the primary aim is to relieve acute obstruction. The other main indication for use of SEMS is as a ‘bridge to surgery’. This obviates emergency surgery with increased morbidity and converts an emergency situation to an elective one. Elective surgery following resolution of obstruction has increased chances of restoration of bowel continuity. Deployment of SEMS is a temporizing measure which allows time to optimize the patient’s condition, carry out comprehensive oncological staging and where indicated, neoadjuvant treatment without the risk of intestinal obstruction. SEMS also eliminate the need for formation of stoma which can remain unreversed in a third of patients [1]. It is also not without its own complications including prolonged recovery and hospitalization especially in elderly patients. Once deployed the stent applies self-expansive radial forces on the tumour to create a patent bowel lumen [2, 3]. This however can lead to bowel perforation which is the most serious and main early complication of the procedure the incidence being nearly 5% [4]. Most perforations occur during introduction of the stent
DOI: 10.1556/IMAS.6.2014.3.6
131
ISSN 2061-1617 © 2014 Akadémiai Kiadó, Budapest
Gokul et al.
Fig. 1.
Stent erosion above tumour
of tumour. At laparotomy it was noted that the upper end of the stent had eroded and perforated through the intact segment of the bowel proximal to the tumour (Figs 1 and 2). There was no leakage of bowel content. The mechanism of such late perforation was completely different to the one traditionally described. It happened at the site of acute recto sigmoid angulation due to mechanical pressure of the sharp edge of the stent and gradual necrosis of the intestinal wall not affected by the tumour. The perforation did not manifest itself with the clinical picture of peritonitis because the site of the erosion was covered by parietal peritoneum in the rectovesical pouch delaying otherwise inevitable faecal contamination of the peritoneal cavity. Effects of external beam radiotherapy could have been a contributing factor.
Fig. 2.
Conflict of interest: None.
References
*** Funding sources: None. Authors’ contribution: KG: acquisition and interpretation of data, writing of manuscript. ES: initial preparation of first draft of manuscript. DYA: study concept and design, acquisition analysis and interpretation of data, revision and approval of manuscript. All authors had access to the data and take responsibility for integrity and accuracy of data.
ISSN 2061-1617 © 2014 Akadémiai Kiadó, Budapest
Stent erosion above tumour
132
1. Deans GT, Krukowski ZH, Irvin ST: Malignant obstruction of the left colon. Br J Surg 81, 1270–1276 (1994) 2. American Society of Gastroenterology: Technology status evaluation report – Enteral stents. Gastrointestinal Endoscopy 74, 455–464 (2011) 3. Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ: Self expanding metal stents for relieving malignant colorectal obstruction. Ann Surg 246, 24–30 (2007) 4. Khot U, Lang AW, Murali K, Parker MC: Systemic review of efficacy and safety of colorectal stents. Br J Surg 89, 1096–1102 (2002) 5. van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM, Bossuyt PM, Bemelman WA: Early closure of a multicentre randomised clinical trial of endoscopic stenting versus surgery for stage IV left sided colorectal cancer. Endoscopy 40, 184–191 (2008) 6. Keränen I, Lepistö A, Udd M, Halttunen J, Kylänpää L: Stenting for malignant colorectal obstruction: A single-centre experience with 101 patients. Surg Endosc 26, 423–430 (2012) 7. Esparrach GF: The role of stents in obstructive colorectal cancer. Gastroenterol Hepatol (N Y) 6, 359–361 (2010)
Interventional Medicine & Applied Science
CASE REPORT
Colonic perforation as a late complication of self-expanding stent KRISHNAN GOKUL*, ELIZABETH SQUIRE, DMITRI ARTIOUKH Southport and Ormskirk NHS Trust, Southport, United Kingdom *Corresponding author: Krishnan Gokul; Southport and Ormskirk NHS Trust, Town Lane, Southport PR8 6PN, United Kingdom; E-mails: [email protected], [email protected] (Received: April 2, 2014; Revised manuscript received: May 16, 2014; Accepted: May 23, 2014) Abstract: Self-expanding metal stents are used to relieve left-sided colonic obstruction either as a palliative measure or as a bridge to surgery. While there are defi nite advantages, the procedure does have significant complications, perforation of bowel being the most common with significant morbidity and mortality. A case of late perforation due to colonic stent erosion is presented. Keywords: self-expanding metal stent, perforation, complication
particularly when combined with balloon dilatation. Thus, a randomized multicentre Dutch study for obstructed Stage IV cancers was prematurely closed due to high incidences of perforation [5]. Other immediate drawbacks of SEMS insertion are haemorrhage, incorrect placement and failure to expand (especially where obstruction is due to extrinsic compression). Late complications include stent migration, stent fracture, and recurrent obstruction due to tumour ingrowth. Deployment of the stent in a low position could result in tenesmus and faecal incontinence. In a single centre experience of 101 patients Keranen et al. [6] reported stent related mortality of 2% and complication rate of 20%. Esparrach [7] in a retrospective analysis of cases over a 5-year period reported morbidity due to stent migration (22%), obstruction (17%), tenesmus (5%). We present a case of late bowel perforation which developed in a 60-year-old man who had stenting of a high rectal tumour after a course of neoadjuvant chemoirradiation while awaiting definitive surgery. His initial CT staging was T3N2M0 and MRI staging T4N2M0. After completion of neoadjuvant therapy while awaiting surgery he presented with clinical features of acute colonic obstruction which was confirmed on plain X-ray radiology. He went on to have SEMS insertion as a bridge to planned elective surgery. Anterior resection was performed 3 weeks after insertion of the stent and 9 weeks after completion of oncological downstaging
Self-expanding metal stents (SEMS) now have an established role in the management of left-sided colonic obstruction. They can be used as a primary definitive interventional treatment in palliative management of colonic cancer. Stents are used when patients are deemed unfit for surgery or in the presence of disseminated malignancy where the primary aim is to relieve acute obstruction. The other main indication for use of SEMS is as a ‘bridge to surgery’. This obviates emergency surgery with increased morbidity and converts an emergency situation to an elective one. Elective surgery following resolution of obstruction has increased chances of restoration of bowel continuity. Deployment of SEMS is a temporizing measure which allows time to optimize the patient’s condition, carry out comprehensive oncological staging and where indicated, neoadjuvant treatment without the risk of intestinal obstruction. SEMS also eliminate the need for formation of stoma which can remain unreversed in a third of patients [1]. It is also not without its own complications including prolonged recovery and hospitalization especially in elderly patients. Once deployed the stent applies self-expansive radial forces on the tumour to create a patent bowel lumen [2, 3]. This however can lead to bowel perforation which is the most serious and main early complication of the procedure the incidence being nearly 5% [4]. Most perforations occur during introduction of the stent
DOI: 10.1556/IMAS.6.2014.3.6
131
ISSN 2061-1617 © 2014 Akadémiai Kiadó, Budapest
Gokul et al.
Fig. 1.
Stent erosion above tumour
of tumour. At laparotomy it was noted that the upper end of the stent had eroded and perforated through the intact segment of the bowel proximal to the tumour (Figs 1 and 2). There was no leakage of bowel content. The mechanism of such late perforation was completely different to the one traditionally described. It happened at the site of acute recto sigmoid angulation due to mechanical pressure of the sharp edge of the stent and gradual necrosis of the intestinal wall not affected by the tumour. The perforation did not manifest itself with the clinical picture of peritonitis because the site of the erosion was covered by parietal peritoneum in the rectovesical pouch delaying otherwise inevitable faecal contamination of the peritoneal cavity. Effects of external beam radiotherapy could have been a contributing factor.
Fig. 2.
Conflict of interest: None.
References
*** Funding sources: None. Authors’ contribution: KG: acquisition and interpretation of data, writing of manuscript. ES: initial preparation of first draft of manuscript. DYA: study concept and design, acquisition analysis and interpretation of data, revision and approval of manuscript. All authors had access to the data and take responsibility for integrity and accuracy of data.
ISSN 2061-1617 © 2014 Akadémiai Kiadó, Budapest
Stent erosion above tumour
132
1. Deans GT, Krukowski ZH, Irvin ST: Malignant obstruction of the left colon. Br J Surg 81, 1270–1276 (1994) 2. American Society of Gastroenterology: Technology status evaluation report – Enteral stents. Gastrointestinal Endoscopy 74, 455–464 (2011) 3. Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ: Self expanding metal stents for relieving malignant colorectal obstruction. Ann Surg 246, 24–30 (2007) 4. Khot U, Lang AW, Murali K, Parker MC: Systemic review of efficacy and safety of colorectal stents. Br J Surg 89, 1096–1102 (2002) 5. van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM, Bossuyt PM, Bemelman WA: Early closure of a multicentre randomised clinical trial of endoscopic stenting versus surgery for stage IV left sided colorectal cancer. Endoscopy 40, 184–191 (2008) 6. Keränen I, Lepistö A, Udd M, Halttunen J, Kylänpää L: Stenting for malignant colorectal obstruction: A single-centre experience with 101 patients. Surg Endosc 26, 423–430 (2012) 7. Esparrach GF: The role of stents in obstructive colorectal cancer. Gastroenterol Hepatol (N Y) 6, 359–361 (2010)
Interventional Medicine & Applied Science
