retrieval of migrated colonic stents from the rectum

4k14 0016 Mp 477 Tuesday Sep 16 01:08 PM SV-CVIR (v. 20, #6) 0016 (2366)

Cardiovasc Intervent Radiol (1997) 20:477–480

CardioVascularand InterventionalRadiologyq Springer-Verlag New York Inc. 1997

Technical Note

Retrieval of Migrated Colonic Stents from the Rectum

Michael H. Wholey,1 Hector Ferral,1 Ricardo Reyes,2 Jorge Lopera,1 Wilfrido Castaneda-Zuniga,1

Manual Maynar2

1Department of Interventional Radiology, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA2Department of Radiology, Hospital N.S. Del Pino, Obispo Tavira 7, E-35011 Las Palmas de Gran Canaria, Spain

Fig. 1. Six-hour post-Wallstent deployment supine abdominal filmreveals migration of the second 22 1 45-mm Wallstent to the rec-tosigmoid colon in this patient with a stricture secondary to Crohn’sdisease. Note the migrated stent has shortened and increased its di-ameter. The first stent, a 20 1 70-mm Wallstent had remained ingood position in the descending colon. Later, a second 22 1 70-mmstent was overlapped with a 3-cm margin to the first, successfullydecompressing this patient.

AbstractPalliative stenting of malignant colonic obstructionmay be complicated by stent migration. Stents that mi-grate into the rectum cannot be passed with bowelmovements and frequently cause obstruction. We pres-ent two simple means to retrieve stents from the rectumusing fluoroscopic guidance. These techniques wereused successfully without complication in four stentmigrations.

Key words: Colon, malignant stricture—Stents, com-plication—Stent migration

Since its first description by Tejero et al. [1] and Mainaret al. [2] fluoroscopically guided stenting of colonicstrictures has gained considerable interest. Stent migra-tion is a complication of colonic stenting. In our currentseries of 15 patients who received Wallstents (Schnei-der Inc., Minneapolis, MN, USA) we encountered five(26%) stent migrations, four into the rectum. We pres-ent our retrieval techniques for the latter.

Retrieval Techniques

We use two techniques for retrieving stents from therectum. Our first choice is a catheter technique, the sec-ond is retrieval by a Kelly clamp.

Catheter Technique

First, a rectal speculum, as used in standard colonos-copy, is inserted transanally (Figs. 1, 2). A 0.0359 Bent-son catheter assembly (multipurpose catheter, Cook

Correspondence to: M. Wholey, M.D.


M.H. Wholey et al.: Retrieval of Migrated Colonic Stents from the Rectum478

Fig. 2. Stent retrieval technique using a catheter. ADislodged Wallstent (arrow) in the rectum. B In vi-tro photograph shows an 8 Fr Judkins left guidingcatheter with a 0.0359 Amplatz guidewire advancedthrough the lumen of the speculum and the 22 145-mm Wallstent. C Using the guiding catheter, theguidewire has been redirected back into the specu-lum. The catheter is then removed leaving theguidewire in place. D A steady and careful pull onboth ends of the guidewire allows retraction of thestent into the speculum and subsequent removal.

Fig. 3. A A 22 1 70-mm Wall-stent has been placed across ex-trinsic compression of the recto-sigmoid colon by metastatic pros-tate cancer. Excessive barium isseen in the transverse and de-scending colon. B Six hours lateran abdominal film reveals migra-tion of the stent into the rectum.

Inc., Bloomington, IN, USA) is advanced through thestent. Usually, the stent will be aligned longitudinallyalong the rectum. If not, with gentle manipulation thestent can be properly oriented once the wire and cath-eter are advanced through it. Then the angiographiccatheter is exchanged for a 7 or 8 Fr Judkins left cor-onary catheter (Cordis, Miami, FL, USA) which is ad-vanced over the guidewire until it exits the distal endof the stent. The catheter is directed to the side and thentowards the rectal speculum. The Bentson guidewire,still inside the Judkins catheter, is exchanged for anAmplatz stiff guidewire (Meditech, Boston Scientific,Natick, MA, USA). Then both are advanced towardand into the speculum with the guidewire tip leading.The catheter is then removed. With the speculum heldin place, both ends of the guidewire were pulled, col-

lapsing the stent (Fig. 3). This allows for removal ofthe stent with the midsection as the leading edge. Afollow-up Gastrografin enema (Bristol-Meyers SquibbInc., Princeton, NJ, USA) is performed to rule out per-foration.

Forceps Technique

A Kelly clamp, aided by the operator’s index finger, isinserted transanally and is used to grasp the stent underfluoroscopic guidance (Fig. 4). Because the distal endsof the Wallstent separate or fray, the stent cannot bedirectly pulled out. Instead, a gentle rotating motion ofthe Kelly clamp, assisted by a finger or other blunt ob-ject, is performed while pulling the stent out. There is


M.H. Wholey et al.: Retrieval of Migrated Colonic Stents from the Rectum 479

Fig. 4. An alternative retrieval method involves grasping the migratedstent with curved, blunt-tipped Kelly clamps inserted transanally un-der fluoroscopic guidance. Gentle twisting and pulling of the stentassisted by an index finger is used to remove the stent.

a risk of mucosal injury from pulling the stent throughthe anus without the use of a speculum.

Results

The first patient had acute colonic obstruction second-ary to Crohn’s disease involving a 12-cm segment inthe descending and sigmoid colon; she required two 221 70-mm Wallstents for decompression prior to anelective surgical resection. The next two patients hadcolon cancer involving the rectosigmoid colon and re-quired stent placement for presurgical decompression.Either 22-mm or 24-mm 1 70-mm Wallstents wereused in these patients. The fourth patient had extrinsiccompression of the rectosigmoid from prostatic cancer.In all the cases, migration occurred within 24 hr andwas detected by follow-up abdominal x-rays. In addi-tion symptoms of colonic obstruction returned. The for-ceps technique was used in two patients, the cathetertechnique in the other two. Patients tolerated the pro-cedures without perforation.

New Wallstents, with larger diameters and lengthsif available, were placed afterwards allowing four ofthe patients to decompress and undergo either contin-

ued palliative care or elective surgical resection. Onepatient with prostate cancer did not decompress wellafter stent replacement secondary to excessive bariumenema given in the initial diagnostic study; he expiredwithin 24 hr after surgical resection.

Discussion

Stent migration is a complication of colonic stenting.Mainar, Tejero, and DeGregorio (personal communi-cation) report the largest series of colonic stent place-ment in 75 patients, which included three (4%) stentmigrations. Saida et al. [3] reported one (8%) migrationin 12 patients receiving self-expanding, stainless steelZ stents; this stent, which migrated into the rectum, wasremoved during surgical resection of the patient’s co-lonic cancer. Pinto (personal communication) in Ma-drid reported seven (20%) migrations of the 35 colonicstents placed. Canon et al. [4] reported three (23%)migrations in their series of 13 patients. One stent wasan Ultraflex stent (Microvasive, Boston Scientific)which was expelled. The other two were Wallstentswhich migrated to the rectum and required surgical re-moval.

Transanal treatment of colonic strictures or malig-nant stenoses with Wallstents requires careful place-ment within the lesion site. Normal bowel contractionscould cause stent migration especially if the selectedstent diameter is too small, if the stent length is tooshort, or if the stent is placed too distal in the lesion.Likewise, if the lesion is long and requires a secondstent, potential misplacement of the second stent couldlead to its migration. Another factor for migration isthe pathology of the lesion: benign lesions and stric-tures secondary to extrinsic tumor compression appearmore likely to cause migration, as no tumor ingrowthholds the stents in place. Finally, location of the lesionis important. We had increased risk for migration ofstents placed in the rectosigmoid junction. Unlike otherbowel segments, the rectum has a smooth, slightlycurved course to the anus. Furthermore, a tight pelvicinlet, where the sacrum and coccyx are located onlymillimeters posterior to the proximal rectum, can con-tribute to stent migration.

In four of our five migrations, colonic stents mi-grated into the rectal ampulla which resulted in obstruc-tion and sometimes painful spasm secondary to thesharp ends of the stent abutting the mucosal surface.The patients could not pass the stent during normalbowel movements. Removal of the stent must be per-formed immediately and decompression provided by areplacement stent or through surgery.

Other nonsurgical treatment options were consid-ered such as colonoscopy to help visualize the removalprocess. We did not find this necessary; furthermore,


M.H. Wholey et al.: Retrieval of Migrated Colonic Stents from the Rectum480

stool within the rectal vault would make visualizationdifficult. Another treatment option is to snare the mi-grated stent. We tried this once but because the mi-grated stents shortened in the rectal ampulla, theirdiameters exceeded the 25-mm diameter of our avail-able snares. Metallic self-expandable stents for the pal-liative treatment of acute colonic obstructions will beused more frequently as more physicians become awareof the ease and simplicity of their placement comparedwith the high mortality rate for the traditional surgicalregimen [5]. However, stent migration is a potentialcomplication and because of its size, sharp ends, andcontorted positions, a migrated Wallstent can becomelodged in the rectal ampulla. The stent can be retrievednonsurgically.

Acknowledgment. The authors received information on colonic stentplacement from personal communication with Drs. A. Mainar and E.

Tejero, Department of Surgery, Hospital Central del Insalaud de So-ria, Soria; Dr. M. DeGregorio, Saragoza; and Dr. Pinto, Madrid,Spain.

References

1. Tejero E, Mainar A, Fernandez L, Tobio R, DeGregorio M (1996)New procedure for the treatment of colorectal neoplastic obstruc-tions. Dis Colon Rectum 37:1158–1159

2. Mainar A, Tejero E, Maynar M, Ferral H, Castaneda-Zuniga W(1995) Colorectal obstruction: Treatment with metallic stents. Ra-diology 198:761–764

3. Saida Y, Sumiyama Y, Nagao J, Takase M (1994) Stent endo-prosthesis for obstructing colorectal cancers. Dis Colon Rectum39:552–555

4. Canon C, Baron T, Morgan D, Dean P, Koehler R (1997) Treat-ment of colonic obstruction with expandable metal stents. AJR168:199–205

5. Deans G, Krukowski Z, Irwin T (1994) Malignant obstruction ofthe left colon. Br J Surg 81:1270–1275

retrieval of migrated colonic stents from the rectum

Documents