Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Enteral stents for the management of malignant colorectal obstruction

Todd H Baron, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


Enteral stents are used increasingly as a non-surgical alternative for the palliation of luminal gastrointestinal neoplasms, particularly in the esophagus and biliary tract [1]. They also have an emerging role in the treatment of obstruction in other segments of the gastrointestinal tract such as the stomach, proximal small bowel, and colon.

This topic will review the role of expandable metal stents in the management of colonic obstruction. Stenting of other portions of the gastrointestinal tract is discussed elsewhere. (See "Use of expandable stents in the esophagus" and "Enteral stents for the palliation of malignant gastroduodenal obstruction" and "Overview of pancreatic stenting and its complications" and "Treatment options for locally advanced cholangiocarcinoma", section on 'Stenting'.)


There are two major indications for colonic stenting in patients with colorectal cancer: palliation of advanced disease and preoperative decompression [2]. In the latter case, placement of a stent can convert a surgical procedure from an emergent two-step procedure (including a colostomy) into an elective one-step resection with a primary anastomosis, which can be performed laparoscopically. However, studies suggest increased morbidity compared with surgery, so we suggest that it be reserved for patients who are at increased risk for complications of emergency surgery (eg, patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery. (See 'Stenting for acute obstruction' below.)

Colonic stenting can be performed in many patients with a partial obstruction or with complete obstruction if there are no signs of systemic toxicity. However emergency surgery is recommended in patients with complete colonic obstruction with evidence of systemic toxicity, as these patients may have ischemia and/or a perforation. (See "Overview of the management of primary colon cancer".)

Morbidity and mortality are substantially higher for emergent surgery than for elective surgery. In one review, morbidity and mortality for patients requiring emergency operation were approximately 39 and 12 percent, respectively, compared with 23 and 3.5 percent for patients who were treated on an elective basis [3]. In other reports, more than one-half of patients undergoing emergency surgery for colon cancer required a stoma [3-5]. Even with contemporary surgical procedures, mortality rates are approximately 4 percent [6], and are even higher in patients with advanced tumor stage and those with comorbidities [7]. In addition, patients who undergo surgery with a primary anastomosis appear to have a higher survival rate than those treated by initial tumor resection and subsequent reversal of the diverting colostomy, such as may be required after emergency surgery in the unprepared bowel [8]. A cost-effectiveness analysis concluded that colonic stent insertion followed by elective surgery was more effective and less costly than emergency surgery [9].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Apr 2017. | This topic last updated: Jan 21, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Simmons DT, Baron TH. Technology insight: Enteral stenting and new technology. Nat Clin Pract Gastroenterol Hepatol 2005; 2:365.
  2. van Hooft JE, van Halsema EE, Vanbiervliet G, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2014; 46:990.
  3. Leitman IM, Sullivan JD, Brams D, DeCosse JJ. Multivariate analysis of morbidity and mortality from the initial surgical management of obstructing carcinoma of the colon. Surg Gynecol Obstet 1992; 174:513.
  4. Scott NA, Jeacock J, Kingston RD. Risk factors in patients presenting as an emergency with colorectal cancer. Br J Surg 1995; 82:321.
  5. Gandrup P, Lund L, Balslev I. Surgical treatment of acute malignant large bowel obstruction. Eur J Surg 1992; 158:427.
  6. Deans GT, Krukowski ZH, Irwin ST. Malignant obstruction of the left colon. Br J Surg 1994; 81:1270.
  7. Riedl S, Wiebelt H, Bergmann U, Hermanek P Jr. [Postoperative complications and fatalities in surgical therapy of colon carcinoma. Results of the German multicenter study by the Colorectal Carcinoma Study Group]. Chirurg 1995; 66:597.
  8. Fielding LP, Wells BW. Survival after primary and after staged resection for large bowel obstruction caused by cancer. Br J Surg 1974; 61:16.
  9. Targownik LE, Spiegel BM, Sack J, et al. Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004; 60:865.
  10. Baron TH, Dean PA, Yates MR 3rd, et al. Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes. Gastrointest Endosc 1998; 47:277.
  11. Pothuri B, Guirguis A, Gerdes H, et al. The use of colorectal stents for palliation of large-bowel obstruction due to recurrent gynecologic cancer. Gynecol Oncol 2004; 95:513.
  12. Kim JH, Ku YS, Jeon TJ, et al. The efficacy of self-expanding metal stents for malignant colorectal obstruction by noncolonic malignancy with peritoneal carcinomatosis. Dis Colon Rectum 2013; 56:1228.
  13. Adler DG, Baron TH. Endoscopic palliation of colorectal cancer. Hematol Oncol Clin North Am 2002; 16:1015.
  14. Small AJ, Baron TH. Comparison of Wallstent and Ultraflex stents for palliation of malignant left-sided colon obstruction: a retrospective, case-matched analysis. Gastrointest Endosc 2008; 67:478.
  15. Toth E, Nielsen J, Nemeth A, et al. Treatment of a benign colorectal anastomotic stricture with a biodegradable stent. Endoscopy 2011; 43 Suppl 2 UCTN:E252.
  16. Repici A, Adler DG, Gibbs CM, et al. Stenting of the proximal colon in patients with malignant large bowel obstruction: techniques and outcomes. Gastrointest Endosc 2007; 66:940.
  17. Song HY, Kim JH, Kim KR, et al. Malignant rectal obstruction within 5 cm of the anal verge: is there a role for expandable metallic stent placement? Gastrointest Endosc 2008; 68:713.
  18. Mauro MA, Koehler RE, Baron TH. Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 2000; 215:659.
  19. Baron TH, Rey JF, Spinelli P. Expandable metal stent placement for malignant colorectal obstruction. Endoscopy 2002; 34:823.
  20. Tack J, Gevers AM, Rutgeerts P. Self-expandable metallic stents in the palliation of rectosigmoidal carcinoma: a follow-up study. Gastrointest Endosc 1998; 48:267.
  21. Repici A, Reggio D, De Angelis C, et al. Covered metal stents for management of inoperable malignant colorectal strictures. Gastrointest Endosc 2000; 52:735.
  22. Rey JF, Romanczyk T, Greff M. Metal stents for palliation of rectal carcinoma: a preliminary report on 12 patients. Endoscopy 1995; 27:501.
  23. Spinelli P, Mancini A. Use of self-expanding metal stents for palliation of rectosigmoid cancer. Gastrointest Endosc 2001; 53:203.
  24. Camúñez F, Echenagusia A, Simó G, et al. Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology 2000; 216:492.
  25. Dohmoto M, Hünerbein M, Schlag PM. Application of rectal stents for palliation of obstructing rectosigmoid cancer. Surg Endosc 1997; 11:758.
  26. Coco C, Cogliandolo S, Riccioni ME, et al. Use of a self-expanding stent in the palliation of rectal cancer recurrences. A report of three cases. Surg Endosc 2000; 14:708.
  27. Tamim WZ, Ghellai A, Counihan TC, et al. Experience with endoluminal colonic wall stents for the management of large bowel obstruction for benign and malignant disease. Arch Surg 2000; 135:434.
  28. Mainar A, De Gregorio Ariza MA, Tejero E, et al. Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery--results of a multicenter study. Radiology 1999; 210:65.
  29. Binkert CA, Ledermann H, Jost R, et al. Acute colonic obstruction: clinical aspects and cost-effectiveness of preoperative and palliative treatment with self-expanding metallic stents--a preliminary report. Radiology 1998; 206:199.
  30. Law WL, Choi HK, Lee YM, Chu KW. Palliation for advanced malignant colorectal obstruction by self-expanding metallic stents: prospective evaluation of outcomes. Dis Colon Rectum 2004; 47:39.
  31. Clark JS, Buchanan GN, Khawaja AR, et al. Use of the Bard Memotherm self-expanding metal stent in the palliation of colonic obstruction. Abdom Imaging 2003; 28:518.
  32. Seymour K, Johnson R, Marsh R, Corson J. Palliative stenting of malignant large bowel obstruction. Colorectal Dis 2002; 4:240.
  33. Paúl L, Pinto I, Gómez H, et al. Metallic stents in the treatment of benign diseases of the colon: preliminary experience in 10 cases. Radiology 2002; 223:715.
  34. Shim CS, Cho JY, Jung IS, et al. Through-the-scope double colonic stenting in the management of inoperable proximal malignant colonic obstruction: a pilot study. Endoscopy 2004; 36:426.
  35. García-Cano J, González-Huix F, Juzgado D, et al. Use of self-expanding metal stents to treat malignant colorectal obstruction in general endoscopic practice (with videos). Gastrointest Endosc 2006; 64:914.
  36. Repici A, Fregonese D, Costamagna G, et al. Ultraflex precision colonic stent placement for palliation of malignant colonic obstruction: a prospective multicenter study. Gastrointest Endosc 2007; 66:920.
  37. Lee KM, Shin SJ, Hwang JC, et al. Comparison of uncovered stent with covered stent for treatment of malignant colorectal obstruction. Gastrointest Endosc 2007; 66:931.
  38. Meisner S, Hensler M, Knop FK, et al. Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center. Dis Colon Rectum 2004; 47:444.
  39. Law WL, Choi HK, Chu KW. Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer. Br J Surg 2003; 90:1429.
  40. Fregonese D, Naspetti R, Ferrer S, et al. Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction. Gastrointest Endosc 2008; 67:68.
  41. Repici A, De Caro G, Luigiano C, et al. WallFlex colonic stent placement for management of malignant colonic obstruction: a prospective study at two centers. Gastrointest Endosc 2008; 67:77.
  42. van Hooft JE, Fockens P, Marinelli AW, et al. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy 2008; 40:184.
  43. Cheung HY, Chung CC, Tsang WW, et al. Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial. Arch Surg 2009; 144:1127.
  44. Nagula S, Ishill N, Nash C, et al. Quality of life and symptom control after stent placement or surgical palliation of malignant colorectal obstruction. J Am Coll Surg 2010; 210:45.
  45. Lee HJ, Hong SP, Cheon JH, et al. Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc 2011; 73:535.
  46. Yoon JY, Jung YS, Hong SP, et al. Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011; 74:858.
  47. Meisner S, González-Huix F, Vandervoort JG, et al. Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients. Gastrointest Endosc 2011; 74:876.
  48. Choi JH, Lee YJ, Kim ES, et al. Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction. Surg Endosc 2013; 27:3220.
  49. Ghazal AH, El-Shazly WG, Bessa SS, et al. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg 2013; 17:1123.
  50. Tirosh D, Perry Z, Walfisch S, et al. Endoscopic self-expanding metal stents for acute colonic obstruction. Am Surg 2013; 79:30.
  51. Kavanagh DO, Nolan B, Judge C, et al. A comparative study of short- and medium-term outcomes comparing emergent surgery and stenting as a bridge to surgery in patients with acute malignant colonic obstruction. Dis Colon Rectum 2013; 56:433.
  52. Watt AM, Faragher IG, Griffin TT, et al. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 2007; 246:24.
  53. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010; 71:560.
  54. van Hooft JE, Bemelman WA, Oldenburg B, et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol 2011; 12:344.
  55. Sagar J. Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev 2011; :CD007378.
  56. Zhang Y, Shi J, Shi B, et al. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc 2012; 26:110.
  57. Sabbagh C, Browet F, Diouf M, et al. Is stenting as "a bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis. Ann Surg 2013; 258:107.
  58. Matsuda A, Miyashita M, Matsumoto S, et al. Comparison of long-term outcomes of colonic stent as "bridge to surgery" and emergency surgery for malignant large-bowel obstruction: a meta-analysis. Ann Surg Oncol 2015; 22:497.
  59. Cirocchi R, Farinella E, Trastulli S, et al. Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: a systematic review and meta-analysis. Surg Oncol 2013; 22:14.
  60. Kim BK, Hong SP, Heo HM, et al. Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery. Gastrointest Endosc 2012; 75:294.
  61. Song LM, Baron TH. Stenting for acute malignant colonic obstruction: a bridge to nowhere? Lancet Oncol 2011; 12:314.
  62. Choo IW, Do YS, Suh SW, et al. Malignant colorectal obstruction: treatment with a flexible covered stent. Radiology 1998; 206:415.
  63. Cwikiel W, Andrén-Sandberg A. Malignant stricture with colovesical fistula: stent insertion in the colon. Radiology 1993; 186:563.
  64. Park S, Cheon JH, Park JJ, et al. Comparison of efficacies between stents for malignant colorectal obstruction: a randomized, prospective study. Gastrointest Endosc 2010; 72:304.
  65. Lo SK. Metallic stenting for colorectal obstruction. Gastrointest Endosc Clin N Am 1999; 9:459.
  66. Datye A, Hersh J. Colonic perforation after stent placement for malignant colorectal obstruction--causes and contributing factors. Minim Invasive Ther Allied Technol 2011; 20:133.
  67. Manes G, de Bellis M, Fuccio L, et al. Endoscopic palliation in patients with incurable malignant colorectal obstruction by means of self-expanding metal stent: analysis of results and predictors of outcomes in a large multicenter series. Arch Surg 2011; 146:1157.
  68. Cennamo V, Fuccio L, Mutri V, et al. Does stent placement for advanced colon cancer increase the risk of perforation during bevacizumab-based therapy? Clin Gastroenterol Hepatol 2009; 7:1174.
  69. Khot UP, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002; 89:1096.
  70. Davidson R, Sweeney WB. Endoluminal stenting for benign colonic obstruction. Surg Endosc 1998; 12:353.
  71. Cascales-Sanchez P, Garcia-Olmo D, Julia-Molla E. Long-term expandable stent as a definitive treatment for benign rectal stenosis. Br J Surg 1997; 84:840.