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]).

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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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We would like to thank Editage (www.editage.jp) for English language editing.

• References

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• 2 Lee YJ, Yoon JY, Park JJ. et al. Clinical outcomes and factors related to colonic perforations in patients receiving self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2018; 87: 1548-1557
• 3 Sasaki T, Yoshida S, Isayama H. et al. Short-term outcomes of colorectal stenting using a low axial force self-expandable metal stent for malignant colorectal obstruction: a Japanese multicenter prospective study. J Clin Med 2021; 10: 4936
• 4 Tomita M, Saito S, Makimoto S. et al. Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction: pooled analysis of 426 patients from two prospective multicenter series. Surg Endosc 2019; 33: 499-509
• 5 Yano T, Takezawa T, Hashimoto K. et al. Gel immersion endoscopy: innovation in securing the visual field - Clinical experience with 265 consecutive procedures. Endosc Int Open 2021; 9: E1123-E1127

Publication History

Article published online:
16 October 2024