Stents are artificial devices placed inside tubular structures or organs such as channels, blood vessels, or intestines, usually to relieve or facilitate the healing of conditions like blockages or injuries. Stents can be made of plastic or metal. Plastic stents maintain a constant diameter within the structure they’re placed in, ensuring fluid flow, while metallic ones can expand to a wider diameter within hours of placement.

Metal stents are typically compressed into a cylindrical shape and, when the surrounding casing is removed, they expand like an umbrella to sit against the walls of the structure they’re placed in. Depending on their purpose, metallic stents can be used with either a partial or complete impermeable coating or without any coating at all. Intestinal stents are always metallic. Although the term “metallic” implies a rigid structure, they are actually made of bendable, soft, thin wires.

Can a stent be placed in the colon?

Like many parts of the digestive system, stents can be placed in the colon.

Why is a stent placed in the intestine?

Stents can be applied to alleviate a blockage or repair an injured area. In the event of a leak following colon surgery, a portion or the entire area can be covered with a stent to facilitate healing. While there are various methods for healing a leaky area, in suitable cases, applying a stent to the colon can promote recovery.

In colon cancer, stent placement is aimed at relieving the obstruction caused by the tumor in the intestine. Typically, surgery is the primary option for colon cancer even in cases of obstruction. However, in patients with widespread metastasis, where chemotherapy is the primary treatment, a stent can be placed in the colon to initiate treatment as soon as possible. Additionally, in cases where there is no immediate danger of death without urgent surgery, a stent may be placed in the colon as an alternative to performing an open and stomal surgery, allowing for laparoscopic and bag-free surgery instead. Once the intestine is emptied and the edema subsides within about a week, laparoscopic colon surgery can be safely performed.

How is an intestinal stent placed?

In cases of colon obstructions, a gastroenterologist or surgeon typically begins the procedure using a gastroscopy or more commonly a colonoscopy, depending on the distance of the mass from the anus. The endoscopist inserts the device through the anus and advances it to the location of the problem. The endoscope is anchored at a visible gap in the middle or edge of the mass. A special wire is then passed through this gap to advance beyond the narrowing. The pre-compressed stent, depending on the production specifications of the stent and the features of the endoscope used, is then advanced using the special wire previously inserted through the endoscope as a guide. With the assistance of a technician or nurse, the stent sheath is correctly positioned and opened in the right place and manner to ensure that the free stent sits in the lumen.

Alternatively, while the wire is held in place beyond the narrowing, the endoscope device is completely removed, and the stent is directly advanced over this wire. In this method, the colonoscope is again advanced through the anus to place the stent, ensuring it is still performed under direct vision.

After the stent is opened in the relevant area, depending on the obstruction rate of the mass and the resilience of the tissues, attempts can be made to advance the endoscopic device through the stent to the other side of the narrowing. In the presence of a tight stricture or delicate tissue, attempting passage through the stent should be avoided, as it may lead to perforation.

While the basic steps for stent placement for repairing leaks after colon surgery are similar, care must be taken to prevent the leakage area from enlarging. In such cases, coated stents are preferred so that feces can pass through the stent while the exterior coating keeps the leakage area clean. However, coated stents carry the risk of displacement. Therefore, clips called “clips” can be used to secure the stent to the intestinal wall from its edges.

Stent placement can also be considered as a treatment option for strictures developing in old surgical sites or due to inflammatory causes.

Is the patient sedated during colon stent placement?

The procedure is typically performed under sedation administered by an anesthesia team in an endoscopy unit. A patient under sedation is not in a deep enough sleep to not wake up, but they are also in a state where they won’t feel pain or discomfort. The patient naturally wakes up after the procedure.

Depending on the preference of the performing physician or the patient, colon stent placement can also be done under general anesthesia in an operating room setting.

How many days does the patient stay in the hospital after colon stent placement?

If the stent placement procedure is performed safely and there are no other issues requiring the patient to stay in the hospital, the patient can be discharged after waking up from anesthesia and undergoing a physician’s check-up. If there is suspicion of intestinal perforation during the procedure, the patient may be kept in the hospital for observation for a duration recommended by the physician.

Does the colon stent function immediately?

After stent placement for colon cancer, it may take up to 48 hours for the stent to fully expand. Gas and fecal output may begin immediately after the procedure or within hours, depending on the consistency and amount of accumulated feces, the initiation of bowel movements, and the degree of opening of the stent.

Is colon stent placement dangerous?

The most feared complication after applying a stent to the colon is perforation (tearing) of the intestine, primarily due to the tumor. Although the literature reports an increased risk of up to 20%, on average, it can be said that about 7-8 out of 100 patients who undergo stent placement are at risk of perforation. The risk is higher when stents are placed in patients receiving targeted chemotherapy (commonly known as smart drugs) such as bevacizumab.

Additionally, there is a possibility of stent migration. A displaced stent may rarely become lodged in the advanced sections of the intestine, posing a risk of perforation. Although some patients may experience mild and temporary bleeding after the procedure, it is generally not severe.

Similarly, some patients may experience some discomfort after the stent placement, but it is expected to subside quickly. However, if there is severe pain spreading across the abdomen after the procedure, the possibility of perforation should be considered, and the patient should be closely monitored and investigated.

In patients with stents, recurrent blockages may occur due to tumor growth. In such cases, reapplication of the stent may be possible, or surgery may be considered as an option.

What is the cost of colon stent placement?

Stents are mostly imported products and can vary in quality and features. The price of the procedure is determined by the specific product features needed for the patient’s condition.

If the radiological examinations show that the cancer has adhered to surrounding organs, the treatment decision depends on the organ of origin and the tissue/organ involved. In some tumors, treatment may begin with chemotherapy and/or radiotherapy, followed by surgery after a certain period, while in others, the tumors are directly removed through surgery.

Before surgery, the surgeon must make a thorough radiological assessment to determine which organs will be removed along with the organ of origin. Additionally, during radiological examinations, the possibility of detecting adhesions during surgery should be considered, and both the patient and their relatives should be prepared for the possibility of additional organ removal.

At this point, one might wonder, “Isn’t it sufficient to remove the organ of origin of the cancer?”

As expected, the adhesion of cancer to surrounding organs may indicate that cancer cells have started to penetrate the adjacent organ. Leaving the organ adhered to by cancer in place while only removing the organ of origin may lead to the spread of cancer cells into the abdominal cavity and the progression of the disease.

Another question that may arise is, “Does the adhesion of cancerous tissue to surrounding organs necessarily occur due to the progression of cancer?”

We can approach this question in two ways. If it is clearly visible on tomography or MRI that cancer has entered the surrounding organ, there is no doubt in such cases. In this group, in patients who have the chance of being operated on, cancer cells in the removed surrounding organ can be seen in pathological examination.

On the other hand, in patients where there is suspicion of adhesion radiologically, or where it is clearly visible during surgery that cancer has not penetrated, the situation may be different. It is known that cancer cells can adhere to surrounding organs through an inflammatory reaction called desmoplastic reaction. This situation is particularly observed at a higher rate if an infection has developed within the tumor or in the remaining part of the organ connected to the tumor. If desmoplastic reaction is present in the patient, removing the surrounding organ may be unnecessary and may increase the risk of surgery. On the other hand, if there is adhesion due to the tumor but it is evaluated as desmoplastic reaction and the adhered organ is left in place, the tumor will remain in the abdominal cavity. It is often not possible to make this distinction.

In scientific studies on colorectal cancer, where it is assumed that every adhesion is due to cancer, and additional organs are removed and it is checked pathologically whether there is a tumor, it has been observed that adhesion due to the tumor occurs in up to 30% of cases. In other words, in cases where there is no obvious invasion, the removal of the adhered organ is unnecessary in 70% of cases. At this point, instead of focusing on the idea that removing the adhered organ will be unnecessary in 70% of cases, it is recommended to focus on the idea that if the organ is not removed, cancer cannot be completely removed in 30% of cases. That is, it is recommended to remove the adhered organ if there is doubt during surgery.

The organ to which the cancerous tissue is adhered must be removed as a whole (en bloc). For example, in a colon tumor adhered to the uterus, the colon and uterus must be removed together without separation to prevent tumor spread. Even if the surgeon first separates the colon and then completely removes the uterus and ovaries, the risk of recurrence will be very high because cancer cells will have spread.

It has been mentioned earlier that in tumors adhered to surrounding organs, oncological treatments or direct surgery can be initiated. At this stage, treatment approaches for cancers grown according to organs can be found below with examples.

In cases of gastric cancer, if the tumor has invaded the gastric wall and adhered to surrounding tissues, chemotherapy is initiated first regardless of which tissue it adhered to. After a certain period of chemotherapy, radiological evaluations are performed to check if the tumor has shrunk. If the desired degree of shrinkage has occurred and the adhered organ can be removed along with the tumor, the patient undergoes surgery.
If necessary, the spleen, tail or body of the pancreas can be removed in gastric cancer cases. In some patients, removal of the colon, diaphragm muscle, abdominal wall, liver tissue may also be required.

Similarly to gastric cancer, chemotherapy is initiated in cases of pancreatic cancer with cancer presence towards surrounding tissues. However, due to anatomical features, some patients with pancreatic cancer may be considered initially inoperable. In cases considered operable on the border, if sufficient shrinkage is seen after chemotherapy ± radiotherapy, surgery can be performed. In pancreatic cancer, cases may arise where the stomach, colon, or portal vein need to be removed.

In cases of colon cancer with adhesion to surrounding organs, surgery is often the first treatment option. Since the colon is in contact with a large area in the abdomen, it can invade many organs. Therefore, during interventions to eliminate colon cancer, organs such as the stomach, duodenum, small intestines, pancreas, gallbladder, liver, uterus, ovaries, bladder, and spleen may need to be removed. Although preoperative chemotherapy application for advanced colon cancers has been considered lately, it has not been widely accepted. As ongoing studies progress, the practice of starting with chemotherapy similar to stomach or pancreatic cancer may be highlighted. On the other hand, there are also studies recommending the evaluation of these patients with genetic analyses and starting immunotherapy if appropriate.

In cases of rectal cancer, when adhesion to surrounding organs is observed, it is a accepted approach to reduce the tumor by giving radiotherapy and, in some cases, chemotherapy. After treatments extended up to 6 months depending on the condition, the surgical approach is decided after radiological evaluation. Depending on the progression of rectal cancer in surrounding tissues, it is recommended to remove either the wall or the entirety of the organ to which it adhered. In rectal cancer, structures such as the prostate, seminal vesicles, bladder, coccyx or sacrum bone, vagina, uterus, and ovaries may need to be removed.

Depending on factors such as the patient’s body structure, the size of the tumor, and the surgeon’s experience, multi-organ removal surgeries can be performed openly, laparoscopically, or robotically.

In surgeries where multiple organs are removed, the duration of the operation is longer, there is more blood loss, and the need for intensive care is higher. The probability of complications during and after surgery may also be higher. Accordingly, the hospitalization period may be prolonged.

Despite all these negative situations, for effective oncological surgery, all tissues and organs in contact with cancer must be removed with clean surgical margins in patients where it is deemed necessary.

In Crohn’s surgery, different surgical approaches may be applied, taking into account the patient’s overall health, conditions for performing the surgery, and characteristics of the intestinal tissue. While surgery to widen a narrowed section of the intestine, known as strictureplasty, may be appropriate for some patients, the majority typically undergo resection, which involves cutting out the diseased portion of the intestine.

After the removal of the affected intestinal segment in Crohn’s surgery, the surgeon’s preference, depending on the disease and the patient’s condition, may involve directly reconnecting the remaining intestines or creating a temporary stoma followed by a second surgery to reconnect the intestines.

One common issue after Crohn’s surgery is the narrowing of the intestinal anastomosis line, known as anastomotic stricture. To prevent this, various methods have been tried, with Kono-S anastomosis currently standing out as the most effective. This technique, described by Japanese surgeon Kono in 2011, is technically more challenging than traditional methods, but it has attracted the attention of many colorectal surgeons performing Crohn’s surgery. Comparative studies have shown similar surgical risks in the short term, but in the long term, the incidence of anastomotic stricture and recurrence is significantly lower in patients who undergo Kono-S anastomosis. The lower recurrence of anastomotic issues also leads to a reduction in the need for reoperations in Crohn’s patients.

In the Kono-S surgery, the Crohn’s-diseased intestine is cut and removed using special surgical stapling systems called staplers. Two intestine pieces with stapled ends are left behind. Longitudinal incisions are made on both sides of the intestine, parallel to the spine, at a horizontal width of 7-8 cm, away from the intestinal vessels. The intestines are then sutured together by bringing the stapled lines of the intestines into contact. The incisions made on the back side are stitched together with absorbable sutures, forming a single layer near the stapler and a double layer on the front side. This ensures an anastomosis is created from the furthest possible point, avoiding contact with the mesentery, which some researchers consider a source of Crohn’s disease.

Crohn’s disease surgery can be performed as an open, laparoscopic, or robotic procedure. The specialized and challenging Kono-S anastomosis can be conducted manually through the incision where the intestinal piece is removed during closed surgeries, or it can be performed robotically.

This technique, which does not require special postoperative care, allows the patient to be discharged after completing standard treatment and follow-up processes. After the healing process is complete, the patient continues follow-up with a gastroenterology specialist.