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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
COLON OBSTRUCTION CAUSED BY A SELF-EXPANDING STENTS Vartolomei, MD, V Chaudron, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Summary The placement of a self-expanding stent can be used in different situations of colonic obstruction. The usual indication includes obstructive cancers for which the restoration of bowel continuity permits a complete bowel preparation before an elective resection. In certain cases, a stent can be placed definitively or for benign pathologies. The use of a stent however can result in rare complications such as a bowel obstruction due to its malpositioning or a migration of the prosthesis. 2. PatientMale, 86 years old 3. Past history3.1. Medical
3.2. Surgical
4. Reason for admissionAcute abdominal obstruction 5. Present historyThe patient had a change in his general state of health. During the re-evaluation for cancer after having had surgery for two previous colon cancers, a new location of neoplasm was discovered in the proximity of the previous ileorectal anastomosis. A rectoscopy revealed a friable tumor in the high rectum. The abdominal and pelvic CT scan confirmed a new tumor. The tumor measured 4 cm without invasion of the adjacent organs. The tumor biopsies confirmed the neoplastic nature of the lesion. Due to the patient’s refusal of another surgical resection and considering the age of the patient, the placement of an expandable stent was decided upon. 6. EndoscopyA first stent was placed above the area of the tumor. A second expanding prosthesis is placed in the hope of guiding the first into the bowel lumen: it was placed in an ideal fashion, just at the level of the stenosis, which is dilated satisfactorily. 7. EvolutionIn the 24 hours following the placement of the stent, a bowel obstruction became apparent in the patient who had symptoms of abdominal pain, massive abdominal distension and vomiting necessitating the placement of nasogastric tube. 8. Plain upright abdominal filmsRevealed multiple air-fluid levels with the position of the two prostheses at 90° to one another completely obstructing the bowel lumen. 9. TreatmentEmergency exploratory laparotomy. After lysis of small bowel adhesions, the exploration found a cancer at the recto-sigmoid junction, 15 cm distant from the previous ileo-colic anastomosis. The two prostheses were palpable and at right angles, completely obstructing the bowel lumen. A rectosigmoid resection was performed. The bowel continuity was re-established by an ileo-rectal anastomosis, using the Knight method and protected by an ileostomy. 10. Examination of the operative specimenThe opening of the operative specimen confirmed the abnormal position of the two prostheses explaining the small bowel obstruction described. 11. DiscussionSelf-expandable metallic prosthesis in colon cancer The palliative treatment of obstructing colon cancer by expandable stents is actually controversial. In case of contra-indications to surgery, or patient refusal, the placement of a stent can permit the satisfactory conservation of colonic transit. In the presented case, the patient’s refusal of a surgical intervention motivated the placement of the stent. The migration of a prosthesis can be the source of different complications. These migrations can lead to an expulsion of the stent, revealing its inefficiency, or to a perforation due to its malpositioning, or, as in this case, an obstruction caused by the prosthesis. In effect, the migration of the prosthesis underneath the tumor and its displacement in a transverse direction can be the cause of a mechanical obstruction which may not be reversible. For the patient, a complete obstruction with abdominal pain may necessitate an emergency operation. In most cases, self expanding metallic stents are used to decompress the bowel in preparation for a surgical intervention. When used in this way they can replace a temporary colostomy, permitting the decompression of the bowel, with an elective tumor resection and immediate re-establishment of bowel continuity. The stents can be placed under radiologic guidance or by endoscopy and therefore can avoid general anesthesia which may be detrimental in fragile patients. In certain cases, as long as the stent has been ideally placed and is maintaining acceptable bowel transit, the prosthesis can be kept indefinitely. 12. References
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