Fluoroscopic management of complications after colorectal stent placement

Abstract

Colorectal self-expanding metal stents have been widely used as a bridge to surgery in patients with acute malignant colonic obstruction by allowing a single-stage operation, or as a definitive palliative procedure in patients with inoperable tumors. Colonic stents are placed under either fluoroscopic or combined endoscopic and fluoroscopic guidance, with similar technical-success and complication rates. Placement of colonic stents is a very safe procedure with a low procedure-related mortality rate, but serious complications can develop and reinterventions are not uncommon. Most of the complications can be treated by minimally invasive or conservative techniques, while surgical interventions are required for most patients with perforation.

Keywords: Colorectal cancer; Complications; Self-expandable metal stents.

Fig. 1

A 64-year-old female with acute left colonic obstruction from a rectosigmoid cancer. (A) AP plain film of the abdomen shows severe dilatation of the intestinal loops. (B) Spot radiograph obtained during fluoroscopy-guided stent placement shows the guide wire outside the colonic lumen (arrow) as a result of iatrogenic perforation. (C) Spot radiograph shows that the position of the guide wire was corrected to the intraluminal position. (D) Radiograph after Wallstent deployment showing the stent in an adequate position. The acute obstruction resolved with no signs of peritonitis, and the stent was used for long-term palliation.

Fig. 2

A 55-year-old female with an obstructing sigmoid carcinoma. (A) Lateral radiograph after Wallstent deployment shows inadequate expansion of the proximal end of the stent (arrow). The design of the Wallstent is associated with a higher incidence of inadequate stent expansion either when the stent is too short or when it is not adequately centered in the obstruction. (B) Plain radiograph obtained 24 hours after the procedure shows persistent collapse of the proximal end of the Wallstent, with persisting intestinal obstruction. (C) Reintervention involved the placement of an overlapping Wallstent. Radiograph shows the second stent placed proximally (arrows). (D) AP radiograph obtained 24 hours after the reintervention shows adequate expansion of the two stents with resolution of the intestinal obstruction. Note the interval placement of a double-J right ureteral stent.

Fig. 3

A 72-year-old male with obstructing colon carcinoma of the hepatic flexure. Severe tortuosity of the left colon prevented stent deployment using a transanal approach. (A) Radiograph shows cecostomy access created after deployment of two T-fasteners (arrows). (B) Hydrosoluble contrast-agent enema shows that the proximal lesion (arrow) was spanned by the guide wire. (C) Radiograph shows deployment of the Wallstent. (D) Oblique projection of the hydrosoluble contrast-agent enema showing adequate expansion of the stent. Note that the pigtail catheter (arrow) was left in place until the cecostomy access tract healed. (E) Control barium enema showing the contrast agent passing adequately through the stented area (arrow).

Fig. 4

Photographs of two colonic stents with retrieval systems consisting of a drawstring suture (arrow). (A) Ella stent (CS-ELLA, Czech Republic). (B) Song's colonic stent.

Fig. 5

A 61-year-old female with obstructing carcinoma of the sigmoid colon. (A) AP radiograph shows a Wallflex stent (Boston Scientific) successfully placed for palliation in the rectosigmoid colon. (B) Lateral and AP (C) radiographs taken 6 days later show migration of the stent into the rectum. (D) Radiograph taken 9 days after stent placement shows absence of the migrated stent due to its spontaneous passage. The bowel obstruction was relieved and the patient underwent elective surgical resection 1 week later.

Fig. 6

(A) Axial CT scan shows a migrated Wallstent (arrow) that had been placed in the rectosigmoid colon 24 hours earlier. (B) Radiograph shows the use of forceps under fluoroscopic guidance to grab and collapse the stent. (C) Photograph shows the use of a speculum to protect the anal mucosa when forceps are used to remove a migrated Wallstent.

Fig. 7

Lateral radiograph shows the finger technique used to remove migrated stents. Under fluoroscopic guidance and using radiation-reducing gloves, the stent is carefully collapsed and retrieved using one finger. This technique is not recommended when removing a Wallstent since there is a high risk of the sharp ends of the stent accidentally injuring the fingers of the operator.

Fig. 8

Hydrosoluble contrast-agent enema during stent deployment shows frank perforation with extravasation of the contrast agent (arrows). Emergency surgery was performed.

Fig. 9

(A) Hydrosoluble contrast-agent enema during stent deployment shows limited perforation (arrow). (B) A delayed film shows focalized collection of the contrast agent (arrow). (C) The stent was deployed and the patient was carefully observed for signs of peritonitis. Radiograph showing the stent in an adequate position. The patient underwent elective surgery 12 days later, during which a limited area of inflammation was noted around the perforation.

Fig. 10

A 65-year-old male underwent palliative placement of a Memotherm (Bard, Billerica, MA, USA) colonic stent. The patient presented with signs of intestinal obstruction at 6 months after placement. Radiograph shows that the stent had fractured at several locations. The patient was treated surgically.

Fig. 11

A metallic stent had been placed in the descending colon of a 54-year-old patient 6 months earlier. (A) Computed tomography axial image shows a large tumoral mass (asterisk) in the descending colon with occlusion of the stent lumen. (B) Surgical specimen shows the Wallstent with occlusion of the lumen due to tumor ingrowth.