Successful management of colonic perforation with a covered metal stent
An 82-year-old man was admitted to our institution for treatment of a colonic anastomotic stricture. He had undergone a laparoscopic left hemicolectomy for cancer of the descending colon. One week after surgery, anastomosis leakage developed, and loop ileostomy was performed. Three months after ileostomy, a colonoscopic exam was performed prior to ileostomy repair, which revealed a stricture at the site of the end to end anastomosis, 17 cm from the anal verge, measuring approximately 3 mm in diameter and 8 mm in length. The patient showed no symptoms.\nAfter bowel enema, the anastomotic stricture was dilated under endoscopic and fluoroscopic guidance, and a guide wire was inserted endoscopically through the stricture site. The controlled radial expansion balloon (5.6 cm in length; CRE Wireguided Balloon Dilator, Boston Scientific Co., Natick, MA, USA) traversed the stricture under fluoroscopic guidance, and the balloon was inflated to a diameter of 15 mm. Just after balloon dilatation, sigmoidoscopy revealed a perforation adjacent to the anastomotic site (). A simple abdominal X-ray showed free air below the diaphragm. A guide wire was inserted via the scope (TTS) method, and a fully covered, colonic, SEMS, 8 cm in length and 20 mm in diameter (Hanarostent, MI Tech Co., Seoul, Korea) was inserted across the stricture under fluoroscopic guidance to completely cover the perforation ( and ). After the procedure, the patient complained of abdominal pain with no evidence of peritonitis. The patient was managed conservatively with intravenous antibiotics. An endoscopic examination 2 days after the insertion of the stent showed satisfactory re-establishment of luminal continuity (). After 4 days of fasting after the procedure, the abdominal pain resolved and gas was gone. The patient was then put on a diet and remained symptom free. Eight days after the procedure, the patient was discharged.\nThe stent was successfully removed 3 weeks after placement, with no complications. Follow-up sigmoidoscopy showed that the perforation had healed completely (). Two months after the procedure, repair of the ileostomy was performed. The patient did not complain of any difficulty with defecation, and there was no evidence of recurrence of the anastomotic stricture.