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Keywords
Terminal ileum, malignant obstruction, enteral stents,
SEMS (self-expandable metal stents)
Introduction
Self-expandable metal stents (SEMS) have been increasingly used for the relief of malignant luminal obstruction arising in the upper gastrointestinal tract, colon or rectum. However, the use of enteral stents to relieve the malignant terminal ileum (TI) stricture has not been previously reported. We describe a case of 56-year-old male presenting with small bowel obstruction arising from the metastatic pancreatic adenocarcinoma involving the terminal ileum.
Case/Body
A 56 year-old male with the history of metastatic pancreatic adenocarcinoma with peritoneal carcinomatosis was receiving chemotherapy with Gemcitabine. He presented to the emergency room with the complaint of sudden onset, severe, generalized abdominal pain, nausea, recurrent emesis and obstipation. His physical examination revealed mild tachycardia and a distended, diffusely tender abdomen without rebound tenderness but with hypoactive bowel sounds. His laboratory evaluation was notable for mild normocytic anemia, leukopenia, thrombocytopenia and lactic acidosis. An abdominal computed tomography (CT) scan revealed diffusely distended small bowel loops with a transition zone along the TI at the point of a soft tissue mass; the colon was decompressed, Figure 1.
A nasogastric tube was inserted and analgesia was provided. The following day sodium phosphate rectal enema was administered and endoscopic enteral stenting of the TI stricture was performed as described below while using cautious air insufflation. A subsequent abdominal CT scan confirmed the stent to be in excellent position across the TI and the small bowel distension had resolved, Figure 2, 3. He was discharged later that day having passed a normal stool and tolerating a soft diet. The patient was asymptomatic up to 31 days following his procedure. He ultimately succumbed to his metastatic cancer 42 days after enteral stent placement.
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Figure 1 |
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Figure 3 |
Technique
Under conscious sedation using intravenous midazolam hydrochloride and fentanyl citrate, the video adult colonoscope (Olympus CF 160, Olympus America Inc., Melville, New York) was introduced and advanced to the cecum while the patient was in left lateral decubitus position. Subsequently the patient was turned to supine position to improve the fluoroscopic orientation. An angled 0.035” glidewire (angled Glidewire, 0.035” outer diameter, 450 cm length, Microvasive, Natick, Mass) preloaded into a standard biliary catheter was advanced through the ileocecal valve and across the stricture, Figure 4. The wire was removed and water-soluble radiographic contrast was injected confirming passage of the catheter into the ileum. A standard “stiffer” 0.035” biliary guidewire was exchanged for the more flexible Glidewire, Figure 5. The biliary catheter was exchanged and a 22 mm (internal diameter) by 90 mm (length) Enteral® Wallstent was passed over the guidewire and through the working channel of the endoscope. The stent was deployed under endoscopic and fluoroscopic guidance with the proximal end in the ileum and the distal end in the ascending colon, Figure 6, 7.
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Figure 4 |
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Discussion/Summary
SEMS have been shown to be a safe and effective method for palliation of malignant upper gastrointestinal tract and colorectal obstruction1. The use of SEMS has also been reported to be effective in patients with benign intestinal strictures from Crohn’s disease2, 3. SEMS can be either covered or uncovered with the disadvantage of stent migration and tumor ingrowth respectively. The Enteral® Wallstent, an uncovered stent can be passed through the therapeutic working channel (≥4.2 mm) of the endoscope allowing lesions as far proximally or distally as those that are within reach to be treated4. Although stent placement is a technically safe procedure, the potential complications include stent malposition, perforation and bleeding. Other complications include stent migration, occlusion and fistula formation 5, 6.
Some of the technical difficulties that might be encountered during placement of an enteral stent include inability to pass a guidewire through the stricture and failure to reach the site of obstruction due to fixed, unmaneuverable angulations. These challenges can considerably increase the duration of the procedure. Overall, the enteral stents are highly successful both technically and clinically in relieving the malignant gastrointestinal obstruction thus obviating the need for the surgical intervention in the terminally ill population.
References
1.Baron TH. Enteral stents. VHJOE 2003 Vol2, Issue 4
2. Brickston SJ, Foley E, Lawrence C, Rockoff T, Shaffer HA Jr, Yeaton P. Terminal ileal stricture in Crohn's disease: treatment using a metallic enteral endoprosthesis. Dis Colon Rectum 2005 May; 48(5):1081-5
3. Matsuhashi, N, Nakajima, A, Suzuki, A, Akanuma, M, Yazaki, Y, Takazoe, M. (1997) "Nonsurgical strictureplasty for intestinal strictures in Crohn's disease: preliminary report of two cases" Gastrointest Endosc 45: 176-8
4. Simmons DT, Baron TH. Endoluminal Palliation. Gastrointest Endosc Clin N Am. 2005 Jul;15(3):467-84, viii. Review
5. Mistry, BM, Memon, MA, Silverman, R, Burton, FR, Vanna, CR, Solomon, H, Garvin, PJ. (2001) "Small bowel perforation from a migrated biliary stent." Surg Endosc 15: 1043
6. Ho, HSS, ong, HS. A rare life-threatening complication of migrated nitinol self-expanding metallic stent (Ultraflex) (2004). Surg Endosc 18:347
Disclosure:
Dr. Todd H. Baron holds research support from Boston Scientific.
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