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Case Reports
, 11 (1), 61-67

Tertiary Stent-In-Stent for Obstructing Colorectal Cancer: A Case Report and Literature Review

Case Reports

Tertiary Stent-In-Stent for Obstructing Colorectal Cancer: A Case Report and Literature Review

Giuseppe Vanella et al. World J Gastrointest Endosc.


Background: Self-expandable metal stents (SEMSs) are frequently used in the setting of palliation for occluding, inoperable colorectal cancer (CRC). Among possible complications of SEMS positioning, re-obstruction is the most frequent. Its management is controversial, potentially involving secondary stent-in-stent placement, which has been poorly investigated. Moreover, the issue of secondary stent-in-stent re-obstruction and of more-than-two colonic stenting has never been assessed. We describe a case of tertiary SEMS-in-SEMS placement, and also discuss our practice based on available literature.

Case summary: A 66-year-old male with occluding and metastatic CRC was initially treated by positioning of a SEMS, which had to be revised 6 mo later when a symptomatic intra-stent tumor ingrowth was treated by a SEMS-in-SEMS. We hereby describe an additional episode of intestinal occlusion due to recurrence of intra-stent tumor ingrowth. This patient, despite several negative prognostic factors (splenic flexure location of the tumor, carcinomatosis with ascites, subsequent chemotherapy that included bevacizumab and two previously positioned stents (1 SEMS and 1 SEMS-in-SEMS)) underwent successful management through the placement of a tertiary SEMS-in-SEMS, with immediate clinical benefit and no procedure-related adverse events after 150 d of post-procedural follow-up. This endoscopic management has permitted 27 mo of partial control of a metastatic disease without the need for chemotherapy discontinuation and, ultimately, a good quality of life until death.

Conclusion: Tertiary SEMS-in-SEMS is technically feasible, and appears to be a safe and effective option in the case of recurrent SEMS obstruction.

Keywords: Bevacizumab; Case report; Colorectal neoplasms; Intestinal obstruction; Palliative care; Self-expandable metallic stents.

Conflict of interest statement

Conflict-of-interest statement: The authors declare that they have no conflicts of interest.


Figure 1
Figure 1
Abdominal X-ray before and after the positioning of the third stent. A: Large bowel massive distention (long arrows) without apparent stent migration; curves highlight the profiles of the proximal edges of the first and second previously placed stents; B: The third stent placed within the two previously placed stents (short arrows indicating some of the radiopaque markers), with detention of proximal loops.
Figure 2
Figure 2
Endoscopic appearance of neoplastic stenosis before and after the third stent. A: Tumor ingrowth inside the two completely hidden previously placed stents; B: A small diameter hole inside the stenotic tract immediately after deployment of the third stent.
Figure 3
Figure 3
Intraprocedural radiological appearance of the three stents bypassing the lesion above the splenic flexure. Curves highlight the proximal edges of the first and second previously placed stents; arrows indicate some of the radiopaque markers of the third recently positioned and gradually expanding stent.

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