Management of malignant colorectal strictures with expandable endoprosthesis

Experience with the use of expandable stents in the management of colorectal strictures, either palliative or as a "bridge" to surgery, is accumulating. We report our experience with 13 pts treated with the Wallstent (Schneider, Minnesota) in 12 (8 enteral, 4 coated) and the Ultraflex (Microvasive, Massachusetts) in 1 (coated). There were 7 men and 6 women, mean age 51 years, with either a rectal (5) or sigmoid (8) stricture. The cancers were colorectal (10) and cervical/ovarian (3); All pts had colonic obstructive symptoms. The stent was placed under mild intravenous sedation, as an outpatient in 7. The margins of the stricture were identified with dye in 6 and external markers in 7. Dilation of the stricture was performed in 7 (balloon 2, bougies 5), to a maximum of 42 Fr. Stent placement was successful in 11 pts. In 2 pts, 1 cervical and 1 ovarian cancers, the stricture could not be negotiated (coated Wallstent 1, Ultraflex 1). Both pts underwent surgery. Of the 11 successful stent placements, the obstructive symptoms resolved in all. The mean follow-up was 7 months (range 1-13). Of the pts treated with the enteral Wallstent, repeat endoscopy in 3 revealed intrusion of the stent lumen by granulation or normal tissue and by tumor in all 3. One patient developed a rectovesical fistula 2 weeks after placement that was successfully treated with a coated Wallstent. Endoscopy in 1 pt (coated Wallstent) 12 months after placement for recurrent obstructive symptoms showed a patent stent. He was found to have peritoneal carcinomatosis. All pts have died of disease progression. There was no procedure related mortality. The 2 pts treated surgically survived 3 months postoperatively. In conclusion, this early experience demonstrates the feasibility, limitations, and efficacy of currently available expandable stents for colorectal strictures. Stent coating is necessary to prevent stent occlusion. A study of the palliation and bridging of malignant colorectal strictures is ongoing.