Low-pressure self-expandable metal stent insertion for obstructive colon cancer using water and gel immersion

Self-expandable metal stents (SEMSs) are commonly used as a bridge-to-surgery or palliative treatment for obstructive colorectal cancer ¹ . Although technical and clinical success rates are high, adverse events such as perforation, migration, and sepsis ^{2 3 4} may occur owing to the poor visual field due to stool and failure to identify the luminal opening of the tumor, air over-insufflation, and unreasonable guidewire manipulation. Gel immersion can be used to improve the endoscopic view ⁵ . Herein, we describe a SEMS insertion with a clear view and lower intraluminal pressure using water and gel immersion ( Video 1 ).

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Low-pressure insertion of a self-expandable metal stent for obstructive colon cancer using water and gel immersion.

Video 1

A 55-year-old woman presented with abdominal pain and nausea. She was diagnosed with bowel obstruction to sigmoid colon cancer ( Fig. 1 a ), and a SEMS was inserted as a bridge-to-surgery treatment. First, we removed the gas from the lumen and filled it with water to create underwater conditions ( Fig. 2 a, b ). Because the visual field was poor due to stool and residue, gel was injected (VISCOCLEAR; Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan). The visual field was cleared, and the endoscope reached the tumor ( Fig. 2 c, d ). As the tumor was covered with stool and mucus, it was gently washed with water and gel, and the luminal opening was identified ( Fig. 1 b , Fig. 2 e–g ). Subsequently, the catheter was inserted into the stricture and the proximal colon was confirmed via contrast ( Fig. 2 h ). A wire-guided biopsy was then performed; however, bleeding occurred. The gel injection reduced the momentum of bleeding and improved the endoscopic view ( Fig. 2 i–l ). Finally, the stent was successfully inserted (22 × 120-mm Niti-S Enteral Colonic Uncovered Stent; Taewoong Medical Co., Ltd., Seoul, Korea) ( Fig. 2 m–o ).

Fig. 1.

Computed tomography (CT) and endoscopic image of sigmoid colon cancer. a The CT image shows wall thickening of the sigmoid colon (green circle) and dilation of the proximal colon. b The luminal opening of the tumor (green dotted circle).

Fig. 2.

Schema of the low-pressure insertion of a self-expandable metal stent using water and gel immersion. a View under gas. b Removal of the gas from the lumen and filling it with water. c Injecting the gel. d The endoscopic view clearly changes. e The tumor is covered with stool and mucus. f The tumor is gently washed with water and gel. g The luminal opening is identified. h The catheter is inserted into the stricture. i A guidewire is placed. j Biopsy of the tumor. k Bleeding occurs and negatively impacts the endoscopic view. l Injecting the gel. m A colonic stent is deployed. n Careful deployment of the stent continued. o The stent is inserted successfully.

In conclusion, low-pressure insertion of a SEMS with water and gel immersion may prevent air over-insufflation and ensure a good endoscopic field view. This method may reduce patient discomfort and enable safe stent insertion.

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