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.
Endoscopic Placement of Self-Expandable Metal Stents for Malignant Colonic Obstruction: Long-Term Outcomes and Complication FactorsAJ Small et al. Gastrointest Endosc 71 (3), 560-72. PMID 20189515.Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect th …
Outcomes of Secondary Stent-In-Stent Self-Expandable Metal Stent Insertion for Malignant Colorectal ObstructionJY Yoon et al. Gastrointest Endosc 74 (3), 625-33. PMID 21762906.Secondary stent-in-stent SEMS placement led to good outcomes in patients with malignant colorectal obstruction, despite a slightly lower success rate compared with primar …
Predictors of Stent Dysfunction After Self-Expandable Metal Stent Placement for Malignant Gastric Outlet Obstruction: Tumor Ingrowth in Uncovered Stents and Migration of Covered StentsY Hori et al. Surg Endosc 31 (10), 4165-4173. PMID 28281116.Both U-SEMS and C-SEMS are effective with comparable patencies. Tumor ingrowth and stent migration are the main causes of stent dysfunction for U-SEMS and C-SEMS, respect …
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