Treatment of a benign colorectal anastomotic stricture with a biodegradable stent

It is routine practice to use metal stents in the treatment of malign obstructions in the lower gastrointestinal tract [1]. However, metal stents are not suitable for benign conditions. Recently, treatment with biodegradable stents has been implemented for non-malignant diseases in the upper gastrointestinal tract [2] [3], but there is no case in the literature reporting on the use of biodegradable stents for benign conditions in the lower gastrointestinal tract. Here we describe a case with a benign stricture in a colorectal anastomosis, treated with a biodegradable stent.

A 68-year-old man underwent sigmoid stoma reversal after Hartmann’s procedure (for perforated diverticulitis). The patient developed a symptomatic stricture in the colorectal anastomosis ([Fig. 1]), and biopsies were benign. Despite three endoscopic dilations, the patient suffered from repeated symptomatic stricture recurrence.

Due to significant co-morbidity, the patient was not suitable for surgical treatment. As an alternative approach, a self-expanding biodegradable esophageal stent (SX-Ella stent; ELLA-CS, Hradec Kralove, Czech Republic) was chosen. The lumen of the stricture was less than 5 mm and was dilated up to 12 mm. The biodegradable stent was deployed in the middle of the stricture using a guide wire ([Fig. 2]). The position of the stent was monitored 4 days later and the lumen further dilated to 15 mm. The stent position was monitored 6 weeks after deployment; the stent was shown to be partially reabsorbed ([Fig. 3]). The patient was still asymptomatic and a colonoscopy revealed complete biodegradation of the stent 5 months later ([Fig. 4 a]). At this time, the lumen had reduced to 8 mm ([Fig. 4 b]) and was therefore dilated up to 18 mm. A follow-up was performed 2 years later, which revealed that the patient had no clinical symptoms although the size of the lumen had reduced.

Fig. 1 The colorectal stricture visualized by use of: a contrast colonography (the arrow indicates the stricture at the colorectal anastomosis) and b endoscopy. The 2-cm long advanced stricture had a lumen less than 5 mm in diameter.

Fig. 2 Appearance of the biodegradable stent immediately after insertion, visualized by use of: a plain abdominal radiograph (arrows indicate the stent in place) and b endoscopy.

Fig. 3 Endoscopic images 6 weeks after stenting showing partial biodegradation of the stent in the: a proximal and b distal part of the colorectal stricture.

Fig. 4 Endoscopic images 5 months after stenting, showing complete disappearance of the stent with a patent lumen in the: a proximal and b distal part of the colorectal stricture, as well as a hyperplastic tissue reaction.

This unique case demonstrates that treatment with biodegradable stents is also feasible in patients with benign strictures in the lower gastrointestinal tract.

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References

• 1 Lee J H, Ross W A, Davila R et al. Self-expandable metal stents (SEMS) can serve as a bridge to surgery or as a definitive therapy in patients with an advanced stage of cancer: clinical experience of a tertiary center.  Dig Dis Sci. 2010;  55 3530-3536
• 2 Vandenplas Y, Hauser B, Devreker T et al. A degradable esophageal stent in the treatment of a corrosive esophageal stenosis in a child.  Endoscopy. 2009;  42 E132-E133
• 3 Repici A, Vleggaar F P, Hassan C et al. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study.  Gastrointest Endosc. 2010;  72 927-934