Colorectal Stenting

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British Journal of ... Australian & New Zealand Journal of Surgery 2002; 72(6):385-388. ... of subacute large bowel obstruction but due to his airways disease.
Colorectal Stenting: Initial Experience with a Combined Colonoscopic and Fluoroscopic Approach J Chuen, A Bui, R White. The Departments of Surgery and Radiology, The Northern Hospital, Epping.

Abstract Purpose: Colorectal stenting has been increasingly used as an adjunct or alternative to operative surgery in patients with acute malignant obstruction of the colon and rectum. Many descriptions of stent deployment in current literature utilise either a fluoroscopic-only or colonoscopic-only technique. This report aims to describe and highlight the advantages of a combined technique. Methodology: We describe our experience with insertion of palliative colorectal stents in two patients with malignant obstruction; one with a newly diagnosed rectosigmoid lesion and a second with local recurrence at a colorectal anastomosis. We review the short-term clinical outcome and relevant literature. Results: Using a combined technique we successfully deployed stents without complication in both patients. Procedure time in both cases were less than 60 minutes with fluoroscopic screening time of less than 10 minutes. Both patients remain unobstructed at five months after the procedure. Conclusions: In our experience, the combination of direct colonoscopic and indirect fluoroscopic visualisation minimises procedure time and fluoroscopic screening time whilst ensuring accurate placement and successful insertion. Introduction The use of an intraluminal colorectal stent was first described in 1991 by Dohmoto1 for the palliative treatment of a rectal carcinoma. Since that time numerous series have been published describing the use of self-expanding metal stents for the palliative treatment of obstructing malignant colorectal lesions and also as a bridge-to-surgery for patients presenting with acute large bowel obstruction due to a colorectal mass. 75% of colorectal cancers occur distal to the splenic flexure and the majority of these lie in the recto-sigmoid colon. These are generally readily accessible via a per-anal fluoroscopic or colonoscopic approach. 15% of patients with a colorectal cancer will present at some point with a large bowel obstruction requiring intervention. Where bleeding and pain are not major symptoms, stent deployment can be considered. Our initial experience of colorectal stenting involves two cases. Case A This 78 year old man with end-stage obstructive airways disease presented after investigation of a coin lesion in the lungfield demonstrated a stenosing adenocarcinoma of the distal sigmoid colon. He subsequently developed symptoms of subacute large bowel obstruction but due to his airways disease was deemed unfit for surgery. An initial attempt was made to pass a guidewire to the site of the lesion under fluoroscopic guidance. Unfortunately after more than 90 minutes including 57 minutes of fluoroscopic screening, the procedure was abandoned as the guidewire was unable to negotiate the tortuosity of the rectosigmoid junction. The patient returned for a second attempt with the assistance of a colonoscope, passing the guidewire and into the lesion under vision and then directed beyond the lesion under fluoroscopy. After retraction of the colonoscope, a catheter was placed for contrast injection. A stiff Amplatz wire was then changed over and the stent guided into position under vision with the colonoscope reinserted. The following figures illustrate the successful placement of a 2.5 x 9cm Boston Scientific (Natick, Massachussetts) Ultraflex PrecisionTM Self-Expanding Stent (Microvasive UC / 25-9 / 16 / 100). Total sedation time was 35 minutes, with screening time of 7 minutes. The patient remains unobstructed 6 months after the procedure.

Traditionally the advantages of fluoroscopic guidance include the ability to visualise an often tight and tortuous lumen and proximal end of a stricture with contrast injection. Problems generally arise due to inability to negotiate the rectosigmoid junction or access more proximal strictures. Perforation during guidewire manipulation and limiting radiation exposure remains a constant issue, reported at 4 percent by Khot et al’s review.7 Colonoscopically most lesions, even proximal ones, are accessible without difficulty, but negotiating a guidewire through a stenosis is done blind and without foreknowledge of the proximal extent of the stricture. Additionally, where fluoroscopy is not available, any stenting device must fit down the channel of the colonoscope. Vrazas et al 2 reported 8 stents inserted under fluoroscopy alone, with a further 5 stents inserted with colonoscopic and fluoroscopic assistance, now preferring a combined approach. In contrast, the same journal issue saw Wong et al report 16 patients where fluoroscopy alone was used.13 Apart from the reduced procedure time and radiation exposure experienced by the patient and staff, we believe that the use of colonoscopy represents a technical refinement in that under direct vision, the actual extent of tumour-affected bowel tends to extend beyond the margins seen on fluoroscopy. Therefore we prefer a 1.5 or 2cm margin of stenting rather than the manufacturer’s recommended 1cm margin when stenting under fluoroscopic control. Ultimately, while our experience of this technique is promising, it still awaits full evaluation. Further studies will need to examine the influences of case selection, long-term outcome, and costeffectiveness. Advantages to Combined-Modality Stenting • Improved ability to negotiate and straighten rectosigmoid tortuosity and access more proximal lesions • More accurate and controlled placement of the stent in relation to the pathology • Reduction in perforation risk due to better spatial visualisation and guidewire control • Reduction in procedure time and radiation exposure to patient and staff Disadvantages to Combined-Modality Stenting • Need to co-ordinate radiology, endoscopy and anaesthetic services • Increased cost of staff and equipment

Case B This 53 year old man presented 6 months after a low anterior resection and postoperative chemotherapy, with local recurrence at the site of anastomosis (10cm from anal verge) and incomplete obstruction at the mid-rectum. A colonoscope was passed to the lesion and a guidewire placed at it’s distal orifice. Again this was further guided fluoroscopically and a 2.5 x 6cm BS Ultraflex PrecisionTM Stent (UC / 25-6 / 16 / 100) deployed under vision and screening. Total sedation time was 60 minutes and screening time 9 minutes. This stent remains patent 5 months later.

Case B Clockwise from top left. 1. Guidewire passed under endoscopic guidance. 2. Contrast Enema demonstrating the lesion with the guidewire in place. 3. Stent introduced over guidwire and visualised by endoscopy. 4. Deployed stent seen on ednoscopy. 5. Tightest portion of the lesion after stenting. 6. Fluoroscopy of the stent in place.

Case A Top Left: Endoscopic view of the obstructing lesion with the guidewire being advanced. Bottom Left: Fluoroscopic Contrast Enema demonstration of the lesion. Top Right: Endoscopic view of the lesion after stent deployment. Bottom Right: Fluoroscopy showing the stent in place.

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Dr Jason Chuen, General Surgical Registrar, Austin & Repatriation Medical Centre, Heidelberg, Victoria, Australia. E-mail: [email protected]. Mr Andrew Bui, Colorectal Surgeon, The Northern Hospital, Epping, Victoria, Australia. Dr Rohan White, Radiologist, The Northern Hospital, Epping, Victoria, Australia.

The use of colorectal stenting in Australia is limited. At the time of writing, the procedure has been nominated for review by the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S) but formal assessment is yet to begin. Vrazas et al2 reported the first published Australian series of 13 colorectal stents in 12 patients. Further Australian experience was reported by Young.3, 4 Overseas reports have been promising, with reported technical success rates (successful stent placement and deployment) of between 88%5 to 100%.6 Khot et al 7 report that 6% of technical failures were due to inability to negotiate the guidewire while clinical relief of obstruction within 96 hours without further intervention occures in up to 88%. While Dohmoto’s original 1991 article described deployment of an endoscope-mounted stent positioned with fluoroscopic guidance, many centres use a predominantly fluoroscopic-only approach with selective use of colonoscopic assistance for difficult or failed lesions. Where reports of combined procedures are described, comparable technical success rates have been encountered, though no formal assessment of the benefits between mode of deployment have been undertaken,6, 8-11 particularly in terms of procedure or screening time. Fluoroscopy-only deployment has been reported with average screening times of 75 minutes.5, 12

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Dohmoto M. New method - endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endocscopia Digestiva 1991; 3:1507-12. Vrazas JI, Ferris S, Bau S, Faragher I. Stenting for obstructing colorectal malignancy: an interim or definitive procedure. Australian & New Zealand Journal of Surgery 2002; 72(6):392-396. Young CJ. Video Session - How I Do It: Boston Scientific Ultraflex Precision Colonic Stent. Tripartite 2002 Colorectal Meeting. Melbourne, Australia, 2002. Young CJ, Solomon MJ. Acute malignant colorectal obstruction and self-expandable metallic stents. Australian & New Zealand Journal of Surgery 2002; 72(12):851. Camunez F, Echenagusia A, Simo G, et al. Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology 2000; 216(2):492-7. Law WL, Chu KW, Ho JW, et al. Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies. Diseases of the Colon & Rectum 2000; 43(11):1522-7. Khot UP, Lang AW, Murali K, Parker M. Systematic review of the efficacy and safety of colorectal stents. British Journal of Surgery 2002; 89(9):1096-1102. Baron TH, Dean PA, Yates MR, 3rd, et al. Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes. Gastrointestinal Endoscopy 1998; 47(3):277-86. Harris GJ, Senagore AJ, Lavery IC, Fazio VW. The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices. American Journal of Surgery 2001; 181(6):499-506. Saida Y, Sumiyama Y, Nagao J, Takase M. Stent endoprosthesis for obstructing colorectal cancers. Diseases of the Colon & Rectum 1996; 39(5):552-5. Tack J, Gevers AM, Rutgeerts P. Self-expandable metallic stents in the palliation of rectosigmoidal carcinoma: a follow-up study. Gastrointestinal Endoscopy 1998; 48(3):267-71. Mainar A, Ariza M, Tejero E, et al. Acute colorectal obstruction: treatment with self-expandable metal stents before scheduled surgery - results of a multicenter study. Radiology 1999; 210:65-69. Wong KS, Cheung DMO, Wong D. Treatment of acute malignant colorectal obstruction with self-expandable metallic stents. Australian & New Zealand Journal of Surgery 2002; 72(6):385-388.

ASC Brisbane, 5 May 2003