Teaching Case

The patient presented with increasing left iliac fossa pain and a 3-day history of absolute constipation.

The patient presented with increasing left iliac fossa pain and a 3-day history of absolute constipation.

Following fluid resuscitation, plain abdominal radiographs with subsequent single contrast enema were obtained (Fig. 1). These demonstrated distal descending colon obstruction with the classic apple core shouldered appearance of a malignant stricture.

Following these studies a 22mm, 12cm enteral stent was placed under fluoroscopic guidance alone across the stricture with relief of symptoms. Subsequently the patient had an elective primary anastomosis following staging investigations prior to surgery.

Large bowel obstruction is a frequent acute presentation of colonic carcinoma. Rapid intervention is required to stabilise the patient, initially with fluid resuscitation, to maintain hydration and electrolyte balance, and placement of a nasogastric tube, followed by relief of the obstruction. Traditionally this has been with urgent surgery, but unfortunately this has an established mortality (3-11%) and morbidity (50%), often resulting in an initial if not life-long stoma.

Placement of a colonic stent to relieve the obstruction from a malignant stricture allows adequate preoperative staging or palliation of symptoms if the patient is considered unsuitable for surgery. If elective surgery is undertaken following stent placement, this is on a prepared bowel, increasing the likelihood of successful primary anastomosis and hence avoiding colostomy.

Stent placement can be by either both endoscopic and fluoroscopic guidance or fluoroscopic guidance alone, both approaches having a technical success rate (stent deployed across stricture) of approximately 90% and a clinical success rate (relief of obstruction) of 75-90%. Potential significant complications of stent placement are perforation (<16%), tumour ingrowth to the stent (25%), and stent migration (15-20%).