Fully covered self-expanding metal stents for benign colonic strictures

• Introduction
• Patients and methods
• Study design and population
• Endoscopic procedure
• Follow-up
• Statistical analysis
• Results
• Study population and material
• Technical success of stent insertion and retrieval
• Follow-up and stent migration
• Other complications
• Discussion
• References

Background and study aims: Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) in the treatment of benign colonic strictures.

Patients and methods: All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4 – 6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence.

Results: The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (n = 18) or subocclusive symptoms (n = 25) due to anastomotic (n = 40), post-ischemic (n = 2), or post-radiation (n = 1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81 %). Migration was observed in 27 patients (63 %). The median duration of stenting was 21 days (95 %CI 17.8 – 35.4 days). Multivariate analysis showed that stents more than 20 mm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53 %), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found.

Conclusions: FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.

Introduction

Placement of a self-expanding metal stent (SEMS) is a safe and effective endoscopic procedure increasingly used to relieve colonic obstruction [1] [2]. Despite some controversies, colonic stents may provide an alternative option to emergency surgery in acute tumorous obstruction, usually with low morbidity and mortality [3]. Fully covered self-expanding metal stents (FCSEMSs) and plastic stents have recently been developed to reduce both hyperplastic (nontumorous) and tumorous tissue ingrowth. These FCSEMSs or plastic stents have several advantages over uncovered stents, including the possibility of retrieval and limited local tissue reaction, while providing alleviation of obstruction, possibly at lower costs. Consequently, they have been used in benign conditions such as colonic strictures, fistulas, perforation, and anastomotic leaks in the digestive tract [4] [5] [6] [7].

Benign colonic strictures can develop following diverticulitis, ischemic colitis, radiation colitis, or after colonic resections (anastomotic strictures), for example for rectosigmoidal carcinomas (1.5 – 4 % of patients) [8]. Surgical treatment of these strictures by further laparotomies is technically difficult because of fibrosis or inflammation. Accepted alternatives include thermal ablation using laser and argon plasma coagulation, balloon dilation, or insertion of SEMSs [9] [10] [11] [12] [13] [14] [15]. Nevertheless balloon dilation has a high recurrence rate and carries a significant risk of perforation [15]. Permanent insertion of SEMSs is associated with a high and unacceptable rate of complications, including new stricture formation and perforation [6].

There are only a few reports available in the literature on the placement of FCSEMSs in patients with benign colorectal strictures [5] [6] [7] [16]. The aim of this study was to assess the effectiveness of FCSEMSs in the management of benign colonic strictures.

Patients and methods

Study design and population

This was a multicenter retrospective study that included all patients referred for endoscopic treatment of a symptomatic benign colonic stricture to one of the 10 research endoscopy centers associated with the Research Committee of the French Society of Digestive Endoscopy (SFED) during a 6-year period from January 2005 to May 2011. All patients gave written informed consent to the colonic stent procedure and authorized the use of their personal data. The research was carried out in accordance with the Helsinki Declaration and the rules of the French National Committee for Information and Freedom (CNIL). The study is registered in the ClinicalTrial.gov database (NCT01570114).

Consecutive patients, 18 years of age and older, with a symptomatic benign colonic stricture despite optimal medical and/or endoscopic dilation therapy were included. In patients meeting the inclusion criteria, the insertion of a FCSEMS was proposed as an alternative before a potential surgical procedure in agreement with the surgeon who was caring for the patient. This was presented as a strategy for treatment in the participating centers despite the absence of international guidelines.

All strictures were confirmed to be benign by histology. In each center, a local database (report file) of FCSEMS insertion in benign situations was used to identify eligible patients. Data were collected by each local investigator after the completion of the study period according to the defined outcomes and variables. These variables included details of previous history, along with the origins and treatment (medical or endoscopic) of the colonic stenosis. Patients with previous treatment using covered or uncovered metal or plastic colonic stents were excluded from the analysis.

The primary objective of this study was to determine the clinical efficacy of FCSEMSs in the treatment of occlusive symptoms in this setting. The outcome for this purpose was symptom resolution, defined as clinical evidence (passage of stools, pain relief) and radiological evidence of colonic decompression within 48 hours of stent insertion, without the need for re-intervention. The secondary objectives were to evaluate: (i) the technical success of the procedure; (ii) the feasibility of stent retrieval; (iii) the safety of using FCSEMSs; and (iv) the recurrence of symptoms after the endoscopic procedure.

Technical success was defined as a successful stent placement on the first attempt, with complete deployment and precise positioning of the stent at the location of the stenosis, which was confirmed by fluoroscopy. The outcomes measured for safety purposes were the occurrence of any complication during interventional endoscopy, stent retrieval, or during follow-up, including perforation, bleeding, migration, pain, fecal incontinence, foreign-body sensation, stent impaction, and hyperplastic tissue overgrowth. The recurrence of symptoms was defined as a new episode of occlusion or subocclusion (pain with interruption to passage of stool and gas, and imaging showing cecal dilatation) after stent retrieval or migration.

Endoscopic procedure

Senior endoscopists with experience of more than 50 colonic stent placements performed the procedure using the recommended technique of the SFED while the patients were under propofol-induced general anesthesia. Patients were placed in the left lateral decubitus or supine position. Minimal bowel cleansing was obtained using enemas and/or oral polyethylene glycol (PEG).

The endoscopes used were colonoscopes with a wide working operator channel (at least 3.8 mm). The obstruction site was visualized both by direct endoscopic observation and by the use of a water-soluble contrast agent administered into the stricture through the endoscope to highlight any possible leak. Stents were introduced over a stiff guide wire (0.035 inch) under fluoroscopic control, with or without previous dilation during the same procedure, depending on the diameter of the stricture.

Stent selection was based on the availability in each center. All stents had a nitinol component with nylon or metal loops at the proximal and/or distal ends for removal, and all had a full polyurethane or silicone covering membrane. Stents were 2 – 4 cm longer than the stricture or the fistular orifice.

The insertion of the stent was performed using the over-the-wire (OTW) or through-the-scope (TTS) techniques, depending on the material used. The stent was placed under fluoroscopic and video-endoscopic control. After stent placement, the position was checked under direct endoscopic vision. Contrast fluoroscopy was performed to confirm the efficacy of the stent (colonic clearance) and the absence of complications (perforation).

Follow-up

Patients were required to take oral osmotic laxatives regularly after the procedure. Post-stenting complications were defined as immediate (during the procedure), early (occurring ≤ 30 days after the procedure), and late (> 30 days after the procedure). Stent removal and routine follow-up endoscopy were scheduled 4 – 6 weeks after placement in most patients, but were performed earlier if complications occurred.

The actual duration of stenting was determined from the time of insertion to the time of stent removal or to the time of obtaining radiographic evidence of its migration out of the colon; this being subsequently confirmed at the time of endoscopic removal. Stent migration was defined either as radiographic evidence of total evacuation of the stent or the presence of the stent within the lower part of the digestive tract, or endoscopic visualization of the stent demonstrating movement from its initial location, or both.

All patients were followed up at regular intervals on the basis of their clinical situation. A retrospective chart review was performed to analyze the long-term outcome of the patients.

Statistical analysis

The clinical and technical success rates were defined as the number of patients presenting clinical or technical success (as defined above) divided by the total number of patients who underwent the procedure. The associations between clinical success and stent migration and potential predictive factors were studied in univariate analyses. Categorical variables were compared with chi-squared tests (or Fisher’s exact test for small samples) and continuous variables with the Mann – Whitney U test, as appropriate. The following variables were considered: stent diameter (≤ 20 mm and > 20 mm); stent length (≤ 80 mm and > 80 mm); cause of the stricture (anastomosis from oncological surgery, anastomosis from diverticular surgery, ischemia induced, and radiation induced); clinical symptoms (acute obstruction and subocclusion); previous dilation; associated leak; location of stricture (rectum, sigmoid, and transverse colon); and distance from the anal margin.

The analysis of the time to symptom recurrence due to stent migration was based on cumulative event curves estimated with the Kaplan – Meier method; survival curves were compared with the log rank test. Potential predictive factors for symptom recurrence at 6 months were also studied in univariate analyses. As all events occurred before 3 months in this study, two patients lost to follow-up at 4 and 5 months respectively were considered free of events at 6 months. A sensitivity analysis was performed considering these patients to be in the event group. 

Multivariate analyses were planned to assess predictive factors for stent migration and symptom recurrence. Stent diameter, stent length, previous dilation, and migration were put into the models, along with any variable associated with the outcome according to the results of the univariate analysis.

All tests were two sided and the significance level was set to 5 %. We used SPSS software, version 11.0 (Chicago, Illinois, USA) for the statistical analyses.

Results

Study population and material

During the study period, all patients (n = 43; 24 men, 19 women; mean age 67.6 ± 10.4 years) presenting with a symptomatic benign colonic stricture in any of the 10 centers were treated with a FCSEMS and included in the study ([ Table 1 ]). Their symptoms were acute obstruction (n = 18; 42 %) or subocclusion (n = 25; 58 %), induced by anastomotic strictures in most cases (oncological surgery, n = 19; diverticular surgery, n = 21), and ischemia (n = 2) or radiation therapy (n = 1) in the remainder.

An anastomotic leak was observed in the previous history of seven patients (16 %) but with no ongoing leakage at the time of the study. The majority of patients had benefitted from a previous hydraulic endoscopic dilation with a 20-mm balloon (n = 30; 70 %), with a maximum of four sessions without optimal clinical benefit.

Stent deployment was performed in the rectum in 28 patients (65 %), in the sigmoid in 14 patients (33 %), and in the transverse colon in one patient (2 %). Stents included: the Hanarostent and Choostent (M.I.Tech., Seoul, Korea) in 21 patients (49 %); the Niti-S stent (Taewoong medical, Gyeonggi-do, Korea) in 20 patients (47 %); and the esophageal fully covered Wallflex stent (Boston Scientific Corporation, Natick, Massachusetts, USA) in two patients (5 %). Stent diameters were 20 mm or less (18 – 20 mm) in 29 patients (67 %) and over 20 mm (24 – 25 mm) in the remaining 14 (32 %). The majority of stents (n = 32; 74 %) had a length of 80 mm or less (50 – 80 mm), being longer (90 – 140 mm) in 11 patients (26 %). Stents were inserted by the TTS (n = 27; 63 %) or OTW techniques (n = 16; 37 %).

Technical success of stent insertion and retrieval

All stents were easily and successfully inserted under fluoroscopic guidance ([ Table 2 ]). An immediate migration above the stenosis during stent deployment was observed in one patient, but the stent was replaced with a biopsy forceps using the loop during the same endoscopy. Stent retrieval in the 16 patients without migration was performed during a subsequent endoscopy without difficulty or complication after a mean of 31.1 ± 8.0 days (range 5 – 130 days) using biopsy forceps (n = 6) or snare (n = 10) to pull on the loop of the proximal end.

Follow-up and stent migration

Clinical success was observed in 35 patients (81 %; 95 % confidence interval [CI] 69 % – 94 %) according to the primary outcome criteria ([ Table 2 ]). In univariate analyses no statistically significant differences were found between clinical success and the potential predictive factors ([ Table 3 ]).

Among patients with a clinical response, 60 % (21 /35) experienced stent migration. Migration occurred during follow-up in a total of 27 /43 patients (63 %). Early migration (within the first 5 days) was observed in 12 patients (44 %). The median time of stent placement was 21 days (interquartile range [IQR] 5 – 35 days, 95 %CI 17.8 – 35.4 days), with a median time to migration of 11 days (IQR 2 – 28 days, 95 %CI 9.6 – 22.8 days) in the 27 patients ([ Table 2 ]).

No serious complaints were reported because of spontaneous passage of the stent, which was sometimes not even observed by patients. The symptoms of stent migration were mainly transient discomfort with a difficult defecation. There were no predictive factors for stent migration ([ Table 3 ]), or more precisely for early migration (data not shown). Of note, the migration rate for stents with a diameter ≤ 20 mm was 72 %, whereas it was only 43 % for stents with a diameter above this cut-off; however, this difference did not reach statistical significance (P = 0.062).

The mean follow-up time in this study was 16.3 ± 15.5 months (range 1 – 55 months), and recurrence of symptoms was noted in 23 patients (53 %). All recurrences occurred within the first 3 months of follow-up and were treated with surgery (n = 11; 48 %), insertion of a new stent (n = 10; 43 %), or dilation or medical treatment (n = 2; 9 %).

After 6 months of follow-up, 41 % of patients who had experienced stent migration remained free of symptom recurrence compared with 56 % of patients who had not experienced stent migration. However, in survival analyses at 6 months there was no difference between the groups with or without migration (log rank test, P = 0.298; [ Fig. 1 ]).

We did not observe that there were any factors predictive of symptom recurrence ([ Table 4 ]). Results remained similar in sensitivity analyses when the two patients lost to follow-up at 4 and 5 months were considered to have had a symptom recurrence (data not shown).

In multivariate analyses none of the variables tested were associated with symptom recurrence. We observed, however, a protective effect of a larger stent diameter (odds ratio [OR] 0.22, 95 %CI 0.05 – 0.98) with regard to stent migration, which did reach statistical significance ([ Table 5 ]).

Other complications

Two immediate complications (5 %) were observed during stent insertion: a cecal upstream perforation subsequent to increased pressure that required surgery and a mild episode of bleeding that was treated endoscopically. Other early complications included abdominal pain requiring analgesic treatment and impaction of a stent in the rectum due to migration that required surgery after failure of endoscopic retrieval. No fatalities (even postsurgical in patients with complications) or late complications had been recorded by the end of the study. No significant tissue hyperplasia was reported on either the upper or lower flare of the stent on retrieval.

Discussion

Benign strictures are a relatively common complication of colorectal anastomosis, ischemic colitis, diverticulitis, or radiotherapy. The commonest therapeutic approach to resolution of symptomatic stricture is endoscopy-guided balloon dilation, which has variable results [13] [15]. Despite its simplicity and immediate efficacy in up to 80 % of cases, this technique requires several treatment sessions and is associated with a significant rate of recurrent benign anastomotic stenosis [11] [15].

The use of FCSEMSs for benign strictures has been regarded as controversial; most previously published data report the results from uncovered stents that are generally inserted for short periods to decompress acute bowel obstruction in malignant disease. A significant morbidity has been observed in cases of benign stricture treated with uncovered stents: Small et al. [5] described major complications (perforation, migration, and re-obstruction) in 38 % of the patients who benefitted from uncovered stent placement for this indication. There is limited literature regarding the use of FCSEMSs in benign colorectal disease. This study reports the results of the largest series to date.

FCSEMSs offer various advantages, in part because of the removal technology in this area. The insertion is easily performed with a high rate of success (all of our patients). This can be explained by better examination conditions with easier cannulation of the lumen. Most strictures treated in our study had a distal location, in the rectosigmoid junction, and were anastomotic in nature, providing comfortable endoscopic access. The flexibility of the metal stents used and their insertion through the working channel may also account for the ease of their deployment. Indeed, the rigid nature of the first plastic stent (Polyflex) to be used for the management of postoperative anastomotic strictures was a limiting factor for the treatment of strictures in the proximal colon [17] [18].

The removability of FCSEMSs was confirmed by their easy extraction using the loop in all of our patients. The cover prevents granulation within the stent mesh, and no hyperplastic tissue was observed at either end of the stent when extraction was performed within 6 weeks of placement (mean of 31 days), which therefore reduced the risk of impaction.

The immediate clinical success rate was high, with obstructive symptoms relieved in more than 80 % of patients. This success rate is thus comparable to those in the prospective literature for uncovered metal stents used as a “bridge to surgery” or as palliative treatment in patients with a tumorous obstruction [19].

The results observed are particularly interesting given that two-thirds of the study population had failed hydraulic dilations and would usually be difficult to manage. A history of a previous dilation was not predictive of clinical failure after stenting. In these conditions, the use of FCSEMSs may be considered, even for strictures that are refractory to the usual techniques of endoscopic dilation, therefore avoiding more invasive surgical treatment. Interestingly, no patient factors or variables relating to the type of stenosis or equipment were predictive of clinical failure. Stent migration, even at an early stage, did not alter its effectiveness. However, the design of our study (open labeled, with no control group) and the number of patients included may prevent us from drawing definitive conclusions.

As expected, the migration rate was high, with stent migration occurring in more than 63 % of patients. This rate is higher than that for uncovered metal stents, which are however not removable and cannot be used for temporary indications. Geiger et al. in a case report and review of the literature [6] exposed a high propensity for migration of polyester-covered stents (67 %) and covered metal stents (50 %). However, a stent duration of 5 days in their experience was sufficient to obtain a permanent cure. In agreement with these data, the migration (early and overall) in our present study did not reduce the clinical efficacy or affect the recurrence rate of obstructive symptoms.

This reflects a significant variability in the response and minimal duration of stenting. A healing time after scar-tissue disruption with the stent in place does not seem to be essential. Migration was not influenced by prior dilations, whatever the number of previous sessions. Use of a larger diameter of stent appeared, not surprisingly, to reduce the risk of migration. Stents more than 20 mm wide resulted in a significantly lower spontaneous expulsion rate. In the majority of patients, migration was safe and asymptomatic, with the exception of one instance that was complicated by impaction and required surgery.

Our study is the first to present long-term data on FCSEMSs for benign indications. Relapse rates were high and no predictive factors were observed. All recurrences occurred early, in the first 3 months, therefore allowing prediction of long-term recovery (16.3 ± 15.5 months) for patients with clinical success that exceeded this period.

Long-term results of endoscopic dilation are lacking. Two small retrospective series using pneumatic dilation, one with 16 patients and another with 18 patients, showed low rates of recurrence (6 – 10 %) but required up to five sessions of dilation with at least one case of perforation and one significant bleeding episode [20] [21]. Araujo et al. [11] did not reveal any relationship between the number of sessions and recurrence in their experience. Suchan et al. [15] showed a lower success rate in patients who had had previous surgery for cancer, which was associated with significantly higher complication rates and frequently with recurrent benign anastomotic stenosis. The success rate and recurrence rate were statistically comparable between these groups of patients in our study. We found that 10 of 19 patients (53 %) treated with previous surgery for cancer had a recurrence compared with 10 of 21 (48 %) who had had previous surgery for benign conditions.

One potential limitation of the present study, despite this being the largest study to look at covered colonic stents for benign stricture, is the lack of power to detect predictive factors of clinical success or recurrence.

The use of FCSEMSs seems as safe as other treatments described so far for benign strictures. Only one perforation was observed, away from the stricture (a cecal upstream perforation due to increased intraluminal pressure). Future treatments of benign strictures by stenting will probably include biodegradable materials. However, initial small studies using polydioxanone stents have reported significant spontaneous migration rates, with a recurrence rate of 30 % [22] [23] [24].

In conclusion, the use of FCSEMSs in the treatment of symptomatic benign colonic strictures is safe and effective, despite a high rate of spontaneous migration. Further prospective comparative studies are needed to evaluate whether the best management is dilation or early use of a FCSEMS.

Competing interests: None.

• References

• 1 Bonin EA, Baron TH. Update on the indications and use of colonic stents. Curr Gastroenterol Rep 2010; 12: 374-382
  CrossrefPubMedSearch in Google Scholar
• 2 Feo L, Schaffzin DM. Colonic stents: the modern treatment of colonic obstruction. Adv Ther 2011; 28: 73-86
  CrossrefPubMedSearch in Google Scholar
• 3 Sagar J. Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev 2011; 11 CD007378
  PubMedSearch in Google Scholar
• 4 Tsereteli Z, Sporn E, Geiger TM et al. Placement of a covered polyester stent prevents complications from a colorectal anastomotic leak and supports healing: randomized controlled trial in a large animal model. Surgery 2008; 144: 786-792
  CrossrefPubMedSearch in Google Scholar
• 5 Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008; 22: 454-462
  CrossrefPubMedSearch in Google Scholar
• 6 Geiger TM, Miedema BW, Tsereteli Z et al. Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data. Int J Colorectal Dis 2008; 23: 1007-1012
  CrossrefPubMedSearch in Google Scholar
• 7 Forshaw MJ, Sankararajah D, Stewart M et al. Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes. Colorectal Dis 2006; 8: 102-111
  CrossrefPubMedSearch in Google Scholar
• 8 Lustosa SA, Matos D, Atallah AN et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2001; (3) CD003144
  PubMedSearch in Google Scholar
• 9 Curcio G, Spada M, di Francesco F et al. Completely obstructed colorectal anastomosis: a new non-electrosurgical endoscopic approach before balloon dilatation. World J Gastroenterol 2010; 16: 4751-4754
  CrossrefPubMedSearch in Google Scholar
• 10 Nguyen-Tang T, Huber O, Gervaz P et al. Long-term quality of life after endoscopic dilation of strictured colorectal or colocolonic anastomoses. Surg Endosc 2008; 22: 1660-1666
  CrossrefPubMedSearch in Google Scholar
• 11 Araujo SE, Costa AF. Efficacy and safety of endoscopic balloon dilation of benign anastomotic strictures after oncologic anterior rectal resection: report on 24 cases. Surg Laparosc Endosc Percutan Tech 2008; 18: 565-568
  CrossrefPubMedSearch in Google Scholar
• 12 Lemberg B, Vargo JJ. Balloon dilation of colonic strictures. Am J Gastroenterol 2007; 102: 2123-2125
  CrossrefPubMedSearch in Google Scholar
• 13 Garcea G, Sutton CD, Lloyd TD et al. Management of benign rectal strictures: a review of present therapeutic procedures. Dis Colon Rectum 2003; 46: 1451-1460
  CrossrefPubMedSearch in Google Scholar
• 14 Piccinni G, Nacchiero M. Management of narrower anastomotic colonic strictures. Case report and proposal technique. Surg Endosc 2001; 15: 1227
  CrossrefPubMedSearch in Google Scholar
• 15 Suchan KL, Muldner A, Manegold BC. Endoscopic treatment of postoperative colorectal anastomotic strictures. Surg Endosc 2003; 17: 1110-1113
  CrossrefPubMedSearch in Google Scholar
• 16 Keranen I, Lepisto A, Udd M et al. Outcome of patients after endoluminal stent placement for benign colorectal obstruction. Scand J Gastroenterol 2010; 45: 725-731
  CrossrefPubMedSearch in Google Scholar
• 17 Garcia-Cano J. Dilation of benign strictures in the esophagus and colon with the polyflex stent: a case series study. Dig Dis Sci 2008; 53: 341-346
  CrossrefPubMedSearch in Google Scholar
• 18 Scileppi T, Li JJ, Iswara K et al. The use of a Polyflex coated esophageal stent to assist in the closure of a colonic anastomotic leak. Gastrointest Endosc 2005; 62: 643-645
  CrossrefPubMedSearch in Google Scholar
• 19 Jimenez-Perez J, Casellas J, Garcia-Cano J et al. Colonic stenting as a bridge to surgery in malignant large-bowel obstruction: a report from two large multinational registries. Am J Gastroenterol 2011; 106: 2174-2180
  CrossrefPubMedSearch in Google Scholar
• 20 Fregonese D, Di Falco G, Di Toma F. Balloon dilatation of anastomotic intestinal stenoses: long-term results. Endoscopy 1990; 22: 249-253
  Thieme ConnectPubMedSearch in Google Scholar
• 21 Virgilio C, Cosentino S, Favara C et al. Endoscopic treatment of postoperative colonic strictures using an achalasia dilator: short-term and long-term results. Endoscopy 1995; 27: 219-222
  Thieme ConnectPubMedSearch in Google Scholar
• 22 Rejchrt S, Kopacova M, Brozik J et al. Biodegradable stents for the treatment of benign stenoses of the small and large intestines. Endoscopy 2011; 43: 911-917
  Thieme ConnectPubMedSearch in Google Scholar
• 23 Toth E, Nielsen J, Nemeth A et al. Treatment of a benign colorectal anastomotic stricture with a biodegradable stent. Endoscopy 2011; 43 (Suppl. 02) E252-E253
  Thieme ConnectPubMedSearch in Google Scholar
• 24 Perez Roldan F, Gonzalez Carro P, Villafanez Garcia MC et al. Usefulness of biodegradable polydioxanone stents in the treatment of postsurgical colorectal strictures and fistulas. Endoscopy 2012; 44: 297-300
  Thieme ConnectPubMedSearch in Google Scholar

Corresponding author

• References

• 1 Bonin EA, Baron TH. Update on the indications and use of colonic stents. Curr Gastroenterol Rep 2010; 12: 374-382
  CrossrefPubMedSearch in Google Scholar
• 2 Feo L, Schaffzin DM. Colonic stents: the modern treatment of colonic obstruction. Adv Ther 2011; 28: 73-86
  CrossrefPubMedSearch in Google Scholar
• 3 Sagar J. Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev 2011; 11 CD007378
  PubMedSearch in Google Scholar
• 4 Tsereteli Z, Sporn E, Geiger TM et al. Placement of a covered polyester stent prevents complications from a colorectal anastomotic leak and supports healing: randomized controlled trial in a large animal model. Surgery 2008; 144: 786-792
  CrossrefPubMedSearch in Google Scholar
• 5 Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008; 22: 454-462
  CrossrefPubMedSearch in Google Scholar
• 6 Geiger TM, Miedema BW, Tsereteli Z et al. Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data. Int J Colorectal Dis 2008; 23: 1007-1012
  CrossrefPubMedSearch in Google Scholar
• 7 Forshaw MJ, Sankararajah D, Stewart M et al. Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes. Colorectal Dis 2006; 8: 102-111
  CrossrefPubMedSearch in Google Scholar
• 8 Lustosa SA, Matos D, Atallah AN et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2001; (3) CD003144
  PubMedSearch in Google Scholar
• 9 Curcio G, Spada M, di Francesco F et al. Completely obstructed colorectal anastomosis: a new non-electrosurgical endoscopic approach before balloon dilatation. World J Gastroenterol 2010; 16: 4751-4754
  CrossrefPubMedSearch in Google Scholar
• 10 Nguyen-Tang T, Huber O, Gervaz P et al. Long-term quality of life after endoscopic dilation of strictured colorectal or colocolonic anastomoses. Surg Endosc 2008; 22: 1660-1666
  CrossrefPubMedSearch in Google Scholar
• 11 Araujo SE, Costa AF. Efficacy and safety of endoscopic balloon dilation of benign anastomotic strictures after oncologic anterior rectal resection: report on 24 cases. Surg Laparosc Endosc Percutan Tech 2008; 18: 565-568
  CrossrefPubMedSearch in Google Scholar
• 12 Lemberg B, Vargo JJ. Balloon dilation of colonic strictures. Am J Gastroenterol 2007; 102: 2123-2125
  CrossrefPubMedSearch in Google Scholar
• 13 Garcea G, Sutton CD, Lloyd TD et al. Management of benign rectal strictures: a review of present therapeutic procedures. Dis Colon Rectum 2003; 46: 1451-1460
  CrossrefPubMedSearch in Google Scholar
• 14 Piccinni G, Nacchiero M. Management of narrower anastomotic colonic strictures. Case report and proposal technique. Surg Endosc 2001; 15: 1227
  CrossrefPubMedSearch in Google Scholar
• 15 Suchan KL, Muldner A, Manegold BC. Endoscopic treatment of postoperative colorectal anastomotic strictures. Surg Endosc 2003; 17: 1110-1113
  CrossrefPubMedSearch in Google Scholar
• 16 Keranen I, Lepisto A, Udd M et al. Outcome of patients after endoluminal stent placement for benign colorectal obstruction. Scand J Gastroenterol 2010; 45: 725-731
  CrossrefPubMedSearch in Google Scholar
• 17 Garcia-Cano J. Dilation of benign strictures in the esophagus and colon with the polyflex stent: a case series study. Dig Dis Sci 2008; 53: 341-346
  CrossrefPubMedSearch in Google Scholar
• 18 Scileppi T, Li JJ, Iswara K et al. The use of a Polyflex coated esophageal stent to assist in the closure of a colonic anastomotic leak. Gastrointest Endosc 2005; 62: 643-645
  CrossrefPubMedSearch in Google Scholar
• 19 Jimenez-Perez J, Casellas J, Garcia-Cano J et al. Colonic stenting as a bridge to surgery in malignant large-bowel obstruction: a report from two large multinational registries. Am J Gastroenterol 2011; 106: 2174-2180
  CrossrefPubMedSearch in Google Scholar
• 20 Fregonese D, Di Falco G, Di Toma F. Balloon dilatation of anastomotic intestinal stenoses: long-term results. Endoscopy 1990; 22: 249-253
  Thieme ConnectPubMedSearch in Google Scholar
• 21 Virgilio C, Cosentino S, Favara C et al. Endoscopic treatment of postoperative colonic strictures using an achalasia dilator: short-term and long-term results. Endoscopy 1995; 27: 219-222
  Thieme ConnectPubMedSearch in Google Scholar
• 22 Rejchrt S, Kopacova M, Brozik J et al. Biodegradable stents for the treatment of benign stenoses of the small and large intestines. Endoscopy 2011; 43: 911-917
  Thieme ConnectPubMedSearch in Google Scholar
• 23 Toth E, Nielsen J, Nemeth A et al. Treatment of a benign colorectal anastomotic stricture with a biodegradable stent. Endoscopy 2011; 43 (Suppl. 02) E252-E253
  Thieme ConnectPubMedSearch in Google Scholar
• 24 Perez Roldan F, Gonzalez Carro P, Villafanez Garcia MC et al. Usefulness of biodegradable polydioxanone stents in the treatment of postsurgical colorectal strictures and fistulas. Endoscopy 2012; 44: 297-300
  Thieme ConnectPubMedSearch in Google Scholar