Polyflex Stent for Relief of Obstruction in a Patient With a Benign Anastomotic Colonic Stricture and Description of Nonfluoroscopic Technique

Outcomes for the use of self-expanding stents in the setting of benign disease are disappointing. The use of stents for benign colorectal obstruction is considered controversial due to a lack of data and perceived high failure and complication rates. Polyflex (Boston Scientific) stents are self-expanding plastic stents (SEPS) that are commonly used for treatment of malignant conditions of the esophagus.¹ Prior to their availability, metallic stents were considered the gold standard for the palliative treatment of obstruction due to gastrointestinal malignancies.^2-4 The potential advantages of reduced trauma and removability make polyflex stents preferable to self-expanding metal stents (SEMS) in some settings. Recent published reports have affirmed the use of polyflex stents in the treatment of benign refractory esophageal strictures.^5,6 In this report, we present a case where a polyflex stent was successfully used in management of acute lower gastrointestinal obstruction occurring as a result of a benign anastomotic colonic stricture.

Case Report

A 70-year-old African American woman was admitted to the hospital after presenting to the emergency room with complaints of severe abdominal pain, nausea, vomiting, and bloating. Her symptoms had first manifested 24 hours previously and were progressive in severity from onset. Pain was located in both iliac foassae without radiation and was described as colicky, waxing and waning in intensity from 2 to 10 on a 1–10 pain scale. Abdominal bloating, likened at onset to the feeling of fullness associated with “a Christmas-day dinner” had progressed to the point of visible distension and associated breathing difficulty. The patient had passed no stools since the onset of her symptoms but was able to pass flatus. Her medical history was significant for diverticular disease, gastroesophageal reflux disease, hypertension, glaucoma, and osteoarthritis. Her surgical history was significant for sigmoidectomy 9 months earlier, secondary to a diverticular abscess, and total abdominal hysterectomy. Bladder repair was performed during hysterectomy. In addition, the patient had undergone a carpel tunnel release, breast cyst removal, and bilateral cataract surgeries. She was taking rabeprazole (Aciphex, Eisai), fexofenadine (Allegra, Sanofi-Aventis), clopidogrel (Plavix, Sanofi-Aventis), calcium carbonate, and amlodipine/benazepril (Lotrel, Novartis) at home before admission. The patient was known to be allergic to aspirin, morphine, and codeine. She was a single non-smoker who did not consume alcohol.

On examination, the patient appeared ill, presenting with dry mucous membranes. She was afebrile with a pulse rate of 116, blood pressure of 90/40 and a respiratory rate of 22 per minute. Her oxygen saturation was 100% on room air. Head and neck examination were normal. Her chest was clear to bilateral auscultation and cardiovascular examination was normal with regular rate and rhythm, unaccompanied by murmur, gallop, or rub. The patient had a well-healed median laparotomy scar with a markedly distended abdomen. There was no evidence of herniae. On palpation, the patient was moderately to severely tender over her entire abdomen. She had voluntary guarding. However, there was no rigidity. Bowel sounds were high-pitched and rectal examination revealed an empty vault with secretions negative for occult blood. Her extremities were well-perfused and warm. The patient was awake, alert, oriented to time, place, and person with no neurological deficits. She was first seen in consultation at the practice where her sigmoidectomy was performed and, on bedside proctoscopy, a stricture was found about 10 cm from the anal verge, at the prior anastomotic site.

Laboratory evaluation revealed a leukocyte count of 10 white blood cells per mL, hematocrit of 36%, and platelet count of 187,000. Electrolytes, renal function, and liver function tests were all normal. A radiograph and subsequent computed tomography of the abdomen showed marked dilatation of the large bowel and moderate dilatation of the small bowel (Figure 1). A transition point was identified around the level of the previous sigmoidectomy site. A diagnosis of large bowel obstruction secondary to an anastomotic stricture in the distal sigmoid colon was made. The patient was systemically ill and was admitted to the surgery service. Her operative candidacy was suboptimal and the interventional gastroenterology service was consulted regarding salvage decompression.

Figure 1.

Computed tomography scan of the abdomen with contrast showing large bowel obstruction along with moderate distension of small bowel loops.

The patient underwent colonoscopy subsequent to tap water enema and was found to have anastomotic stricture at the site of previous surgery at the distal sigmoid colon, along with evidence of mucosal changes most consistent with ischemic colitis. During colonoscopy, the anastomotic stricture was dilated using CRE balloons (Boston Scientific). However, effect was negligible and provided no visible relief of endoscopically evident luminal compromise.

Using a side-by-side endoscopic approach, a Polyflex-coated 21 mm × 90 mm stent was placed across the stricture site to achieve and maintain luminal patency. A stiff guidewire was passed across the stricture with endoscopic guidance. The endoscope was then withdrawn, leaving the guidewire in place. The scope was reinserted beside the guidewire. Under direct visualization, the polyflex stent was placed across the stricture and deployed in standard fashion, leaving a waist in the central portion of the stent (Figure 2). This resulted in rapid egress of luminal contents with evident immediate relief of abdominal distention.

Figure 2.

The polyflex stent at the site of the anastomotic stricture.

Intravenous antibiotics were started and empirically prescribed topical salicylates were started 48 hours later. The patient began tolerating a clear liquid diet well within 48 hours and was discharged home on day 6. Her short-term follow-up was remarkable for one episode of abdominal pain at two weeks, thought to be the result of resolving colitis. Abdominal x-rays showed the stent in good position and there were no features of recurrent obstruction. She was then followed for another twelve weeks, during which she remained asymptomatic. Subsequent colonoscopy demonstrated complete resolution of the previously noted mucosal changes in the rectosigmoid. The stent was completely patent and the more proximal colon was easily examined. The proximal colon segment was found to be normal and, using a jumbo snare, the stent was grasped at its midpoint and removed in toto by gentle withdrawal. The strictured area was widely patent without evidence of prior luminal compromise (see Figure 3).

Figure 3.

Normal colonic mucosa at the site of anastomotic stricture viewed at follow-up colonoscopy.

The patient has been followed for 15 months and has remained asymptomatic without recurrence of obstructive complaints. She continues to visit the gastroenterology clinic for longstanding gastroesophageal reflux symptoms.

Discussion

In the past, benign postsurgical colonic strictures have been treated endoscopically with repeated dilatation and use of SEMS.⁷ There are some case reports suggesting effective use of polyflex self-expanding stents in the treatment of anastomotic leak in the colon.⁸ SEMS have become an established treatment for malignant colonic obstruction.⁹ However; polyflex stents are less traumatic and have the advantage of easy removability, making them ideal for use in benign conditions. Our case suggests that use of polyflex stents with or without balloon stricturoplasty can be effective in treatment of a benign enteral stricture. The bulk of this stent system and lack of a through-endoscope delivery system clearly limit widespread adoption of this method for endoscopic relief of bowel obstruction. In this case, the location of the stricture was ideal for employing this stent system. Insertion of a standard endoscope beside the stent delivery system may be difficult distal to the lower oesophageal sphincter and proximal to the rectosigmoid in some patients. Endoscopic placement of polyflex stents using similar methodology without fluoroscopy has been described previously by Petruzziello and colleagues¹⁰ and later by García-Cano.¹¹ Our understanding is that the use of an endoscope-based technique with or without fluoroscopy is more effective than the traditional fluoroscopic technique alone. The internal visualization through the scope is helpful in the correct positioning of the stent and is more intuitive for most endoscopists.

The ideal period to leave the stent in place is unclear. Most authors have left the stent in anywhere from 30–90 days. Removal is easily accomplished by inverting the stent at its proximal end or by ensnaring the stent and deforming it lengthwise, allowing for relative ease of withdrawal.

Conclusion

In conclusion, endoscopically removable self-expanding enteral stents may be useful in the management of benign diseases of the rectosigmoid colon. Improvements in the design of deployment systems and the introduction of biologically absorbable materials will widen the appeal and adoption of these devices. Further studies will be useful to determine which patients are most likely to benefit from novel uses of these devices and to establish standardized practices for duration of stenting associated with the most optimal patient outcomes.