Insertion of Self Expandable Metal Stent for Malignant Stomal Obstruction in a Patient with Advanced Colon Cancer
A 56-year-old man presented with right lower quadrant pain and abdominal distention for 2 months. Colonoscopy showed an ulcerofungating mass lesion in the ascending colon and the scope could not be passed through it. Abdominal computed tomography (CT) showed asymmetric enhancing wall thickening in the right side colon and multiple lymph node enlargements in the right side mesentery and mesenteric root. In addition, ascites were observed in the pelvis. He was diagnosed as ascending colon cancer with peritoneal carcinomatosis (stage IVb). He was initially treated by inserting self expandable metallic stent (SEMS) for colonic obstruction. Two days after the stent insertion, abdominal distention and pain were re-developed and follow-up CT showed near total obstruction at the proximal portion of the stent, suggesting stent migration. Thus, he underwent loop ileostomy and palliative chemotherapy was started after the operation.\nAfter 12 cycles of chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin, disease progression was noted and the patient developed abdominal pain with decreased stool output. Physical examination showed mildly distended abdomen with decreased bowel sounds. On palpation, there was tenderness over the peristomal region. Abdominal CT scan showed a peritoneal metastasis surrounding the stoma and diffuse dilatation of the small bowel (). Because a conventional colonoscope could not be passed through the stoma, we used Olympus scope GIF-XQ 260 (9.8 mm diameter; Olympus, Tokyo, Japan). Endoscopy showed obstruction of the ileostomy site by a mass (). The lesion was hard and it had some ulcers covered with exudates, compatible with stomal obstruction arising from carcinomatosis. Based on the patient's poor condition, surgery for stoma correction deemed inappropriate due to high risk of complication. Therefore, after the informed consent was obtained, a 60 mm length, 24 mm diameter self expandable metal stent (Niti-S colonic non TTS uncovered stent; Taewoong Medical Inc., Seoul, Korea) was implanted in the stoma under fluoroscopic guidance (, ). Upon release of the stent, fecal materials poured through the stent. An anchoring suture was performed in order to prevent migration of the stent. One week later, he was discharged without a complaint of bowel obstruction, but he died one and half months after the stent placement due to the progression of the colon cancer, without clinical signs of re-obstruction.