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Paper text:
malignant colonic obstruction is managed by endoscopic colon stent insertion , removal of obstructive lesion followed by reconnecting sections of the large intestine , or creation of a diverting colostomy / ileostomy .
surgery for stoma correction has also been used for malignant stomal obstruction.1 however , surgery might increase mortality and morbidity in patients with advanced cancer or poor performance status ; as a result , there has been no established strategy for the management of malignant stomal obstruction.2 in such cases , stent insertion might be a reasonable alternative .
we report a case of successful relief of malignant stomal obstruction using a metal stent and a review of the literature .
a 56-year - old man presented with right lower quadrant pain and abdominal distention for 2 months .
colonoscopy showed an ulcerofungating mass lesion in the ascending colon and the scope could not be passed through it .
abdominal computed tomography ( ct ) showed asymmetric enhancing wall thickening in the right side colon and multiple lymph node enlargements in the right side mesentery and mesenteric root .
he was initially treated by inserting self expandable metallic stent ( sems ) for colonic obstruction .
two days after the stent insertion , abdominal distention and pain were re - developed and follow - up ct showed near total obstruction at the proximal portion of the stent , suggesting stent migration .
after 12 cycles of chemotherapy with oxaliplatin , 5-fluorouracil and leucovorin , disease progression was noted and the patient developed abdominal pain with decreased stool output .
abdominal ct scan showed a peritoneal metastasis surrounding the stoma and diffuse dilatation of the small bowel ( fig .
1 ) . because a conventional colonoscope could not be passed through the stoma , we used olympus scope gif - xq 260 ( 9.8 mm diameter ; olympus , tokyo , japan ) .
the lesion was hard and it had some ulcers covered with exudates , compatible with stomal obstruction arising from carcinomatosis . based on the patient 's poor condition , surgery for stoma correction deemed inappropriate due to high risk of complication .
therefore , after the informed consent was obtained , a 60 mm length , 24 mm diameter self expandable metal stent ( niti - s colonic non tts uncovered stent ; taewoong medical inc . ,
seoul , korea ) was implanted in the stoma under fluoroscopic guidance ( figs . 3 , 4 ) .
one week later , he was discharged without a complaint of bowel obstruction , but he died one and half months after the stent placement due to the progression of the colon cancer , without clinical signs of re - obstruction .
acute colorectal obstruction usually requires rapid bowel decompression , such as emergency surgery , which is associated with relatively high mortality and morbidity rates .
recently introduced sems , however , can be used both as a palliative treatment for unresectable malignant colorectal obstruction and as a bridge to surgery in patients with potentially resectable colorectal cancer . in the bridge to surgery
setting , insertion of sems can decompress the obstruction , provide the opportunity for bowel preparation , and make one - stage surgical resection possible , which is known to be associated with decreased morbidity , mortality , and stoma formation rate compared with emergency surgery.3 - 6 adenocarcinoma may develop at a colostomy or ileostomy site as a primary tumor , a metachronous lesion , or a carcinomatosis and disseminated disease.7 - 9 malignant stomal obstruction has traditionally been treated with surgery , and specific surgery has been selected based on the clinical characteristics of each patient . for example , a patient with advanced cancer could be considered as a candidate for a limited local resection , while a patient with an isolated stoma recurrence as a candidate for a broad local resection , including the abdominal wall.10 however , there is no appropriate alternative management established yet for cases where the limited local resection is technically difficult or where there is a risk of increasing the rate of resection - related complication due to the patient 's poor performance status . in these settings
, stent insertion might be a good therapeutic option instead of palliative surgery in malignant stomal obstruction , considering the poor prognosis and high mortality and morbidity rate of palliative surgery . when life expectancy is short , stent migration is thought to be the more serious complication than stent re - obstruction .
therefore , to prevent stent migration , the uncovered stent was more favorable than covered stent in our patient , and anchoring suture in the distal portion of the stent , such as anchoring clips , would be also helpful to prevent the stent migration.11,12 in conclusion , sems insertion for malignant stomal obstruction could be an alternative treatment , instead of surgery , in patients with inoperable colon cancer or poor performance status .
further research is needed to determine the validity of sems in palliating obstructive symptoms compared with operative management in malignant stomal obstruction .
self expandable metal stent can be used both as palliative treatment for malignant colorectal obstruction and as a bridge to surgery in patients with potentially resectable colorectal cancer . here 
 , we report a case of successful relief of malignant stomal obstruction using a metal stent . 
 a 56-year - old man underwent loop ileostomy and was given palliative chemotherapy for ascending colon cancer with peritoneal carcinomatosis . 
 eight months after the surgery , he complained of abdominal pain and decreased fecal output . computed tomography and endoscopy revealed malignant stomal obstruction . due to his poor clinical condition , we inserted the stent at the stomal orifice , instead of additional surgery , and his obstructive symptoms were successfully relieved . 
 stent insertion is thought to be a good alternative treatment for malignant stomal obstruction , instead of surgery .