Placement of Colonic Self-Expandable Metal Stents
Amy Hosmer, MD
The placement of self-expandable metal stent (SEMS) in the colon is performed for the palliation of malignant disease within or adjacent to the colon and for preoperative decompression. Placement of colonic SEMS for the treatment of benign disease is rarely indicated. Several FDA-approved colonic SEMS with varying deployment mechanisms and proprietary features are currently available; however, their functionality is largely similar. All currently available colonic SEMS are uncovered. Based on meta-analysis data, the overall technical and clinical success is well over 90%.1
INDICATIONS2
1. Colorectal cancer:
a. Palliation of advanced disease (partial obstruction or complete obstruction and no evidence of systemic toxicity)
b. Preoperative decompression/bridge to surgery3
2. Extracolonic pelvic malignancies (i.e., ovarian cancer, sarcomas, etc.)
CONTRAINDICATIONS
1. Benign etiologies for colonic obstruction
2. Concurrent therapy with bevacizumab (Avastin)4 or prior radiation therapy
3. Those associated with routine colonoscopy
PREPARATION
1. Consider imaging with rectal contrast (i.e., barium enema, CT scan w/ rectal contrast) prior to stent placement to provide an anatomical roadmap.
2. Cautious bowel preparation can be considered for patients with partial colonic obstruction, generally more proximally lesions.
a. For patients with subtotal or total colon obstruction, oral bowel preparations should be avoided and replaced with enema preparations to clean the colon distal to the obstruction.
3. Obtain informed consent from the patient or patient representative that outlines the possible complications of the procedure as well as alternative methods of treatment.
4. Start an intravenous line for administration of systemic sedation.
5. Consider preprocedure antibiotics in patients with complete bowel obstruction as microperforations with bacterial translocation can occur with insufflation during the procedure.
EQUIPMENT
1. Therapeutic gastroscope or pediatric/adult colonoscope with an appropriate working channel to accommodate through-the-scope colonic stent catheter
2. Carbon dioxide (CO2) insufflation, water irrigation, or air insufflation set to low if CO2 is not available (to avoid over-insufflation of the colon lumen in setting of obstruction, as may already be dilation proximal to lesion)
3. Guidewire (450 cm in length)
4. Occlusion balloon catheter (this can be utilized to confirm positioning with the colon and to define the stricture length)
5. Fluoroscopy (Stents can be placed safely without fluoroscopy by experienced endoscopists, but only in setting of incomplete obstruction with the stricture can be traversed.)
6. Water-soluble contrast
7. A variety of self-expandable metal stent lengths (6 to 12 cm in length) should be available. Currently available colonic self-expandable metal stents are uncovered.
8. Radiopaque markers, either endoclips or contrast solution for injection through a sclerotherapy needle
9. Leaded aprons for radiation safety
10. Radiation dosage badges for personnel
11. Lubricant
12. Personal protective equipmentRelated posts:
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