Age and Ageing Advance Access originally published online on July 10, 2007
Age and Ageing 2007 36(5):593-595; doi:10.1093/ageing/afm080
Case Reports |
Colonic stenting: an alternative to surgery in the elderly
1 Department of Geriatric Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
2 Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
3 Department of Radiology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
Address correspondence to: Dr Tom Downes. Tel: 0114 2713645; Fax: 114 2715981. Email: Tom.Downes{at}sth.nhs.uk
Abstract
This case report describes the management of a frail older patient presenting with a rare case of an obstructing right-sided colonic lesion, combined with complex co-morbidities. The report briefly discusses use of colonic stenting in right colonic lesions as well as palliative management of colonic tumours in general.
Keywords: colonic stents, self-expandablemetallic stents (SEMS), right sided colonic tumours, palliation, elderly
Self-expandable metal stents (SEMS) are now a safe and alternative treatment option to relieve malignant luminal obstruction and can be used as a bridge to surgery for left-sided colonic obstruction, or to avoid colostomy during palliation [1]. Acute left-sided colorectal malignant obstruction presents as the first symptom in approximately 15–20% of colorectal cancers [2]. The first stents used in the large bowel were designed for vascular or oesophageal use [3], but are now specifically designed for placement in the colon. Although SEMS are well reported in relieving obstruction in diverticular, anastomotic or malignant left-sided strictures [3–6], there is little evidence of their use in right-sided colonic lesions.
This case report describes the management of a frail older patient presenting with a rare case of an obstructing right-sided colonic lesion along with challenging co-morbidity
A 90-year-old woman was admitted with a dizzy episode shortly after getting out of bed. On systems enquiry it transpired there was some recent weight loss and a 2-month history of diarrhoea without melaena or blood per rectum.
She was referred to AICS (Assessment and Integrated Care Scheme) for multidisciplinary assessment. Prior to admission she had been living alone in her own home with support from her two daughters. Her home was equipped with a stair lift and she had been independent regarding activities of daily living.
On abdominal examination a mass was palpable in the right upper quadrant.
Investigations revealed anaemia with haemoglobin of 9.2 g/dl. Liver function tests were normal. Ultrasound of the abdomen revealed an 8 cm tumour at the hepatic flexure confirmed on CT scan as an 8 cm mass in keeping with tumour (Appendix 1, available online). During the admission she developed pain and swelling of her right calf, and Doppler confirmed a non-occlusive DVT in the superficial femoral vein. While undergoing investigations she started to develop bowel obstruction with abdominal distension and vomiting.
Due to low creatinine clearance a 1 mg/kg daily dose of enoxaparin was used for anticoagulation, with monitoring of anti-Xa levels. The haemoglobin slowly dropped from 9.2 to 8.7 to 7.6 g/dl, after which, she was transfused 2 units of blood. An IVC filter was inserted due to difficulties maintaining the haemoglobin with anticoagulation, and following this, low dose (40 mg) enoxaparin was given with planned weekly haemoglobin checks.
Both, the patient and medical team, felt surgical intervention was not appropriate. Colonic stenting was offered as a palliative option for symptom control. A pyloric stent was inserted (Figure 1, see also Appendix 2 available online) under radiological guidance and direct endoscopic visualisation (through-the-scope technique).
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The obstructive symptoms rapidly improved over 48 h, and after referral to the palliative care team, she was discharged with a homecare package. The patient was maintained in her own home with the support of family, carers and palliative care team. She died peacefully at home a few weeks after discharge from hospital with her symptoms well controlled.
In the UK, approximately 34,000 patients are diagnosed with colorectal cancer each year [7]. Colonic obstruction is almost exclusively associated with tumours in the recto-sigmoid region, and acute colonic obstruction has a high mortality (12%) and morbidity (39%) [3]. This is the first report to describe stent insertion for imminent obstruction in a right-sided colonic tumour.
The combined radiological and endoscopic, or, through-the-scope technique (TTS) is safer, permits acquisition of histopathology at the time of insertion and also permits stent stabilisation with the use of colonic endoclips to prevent migration as right-sided stents (by nature of the anatomy) are at increased risk of migration. Complications of the procedure include colonic perforation, bleeding, pain, tumour ingrowth and with tight strictures, stenting may not be technically possible [8, 9]. Stent-induced ulcers have also been described, [10] and following stenting, the patient may experience frequent loose or liquid stools [8].
However, relief of obstructive symptoms, relief of pain with reduced recovery time and hospital stay provide significant benefits to the patient, and enabled this lady to spend the remainder of her life at home supported by her family.
- Self-expandable metal stents (SEMS) are a safe treatment option to relieve malignant luminal obstruction.
- Combined radiological and endoscopic stenting techniques are likely to reduce complication rates.
- Palliative stenting of colonic obstruction can reduce hospitalisation and morbidity in terminally ill older patients.
None.
Supplementary data for this article are available online at http://ageing.oxfordjournals.org.
References
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