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1177 Enteric Prostheses
force. There are four gold radiopaque markers –
two at each end.
The central Dacron mesh is available in 4-, 6-,
8-, and 10-cm lengths. This stent can only be
inserted using OTW method and comes preloaded
on a 12-F delivery system with 120 cm length.
The distal end of the outer sheath has a radiopaque
tungsten marker. After complete deployment, the
inner stent foreshortens by 20% and is not
reconstrainable.
SX-ELLA Stent Pyloroduodenal:
ENTERELLA
This self-expandable metal uncovered stent is made
of braided nitinol and manufactured by ELLA-CS.
s.r.o. (Hradec, Czech Republic). It does not have
any fl ares and has a round-edged con fi guration to
reduce trauma (Fig. 7.12 ). The unconstrained body
diameters are 20, 22, and 25 mm, and unconstrained
lengths are 8.2, 9.0, 11.3, and 13.5 cm. Three
radiopaque markers are placed at each stent end
and two markers at the midpoint to improve
fl uoroscopic visibility and accurate stent positioning (8 in total). A plastic repositioning loop is
attached to the proximal stent end and allows repositioning within 5 days after implantation.
This stent can be inserted TTS or OTW with a
10-F delivery system and a standard length of
210 cm, which allows passage through the working channel of an endoscope. The atraumatic tip of
the delivery system is radiopaque. It is not possible
to recapture the stent once it is partially deployed.
The stent foreshortens by approximately 40–50%.
Endo-Flex Duodenal Stent
The Endo-Flex duodenal stent is an enteral stent
from ENDO-FLEX GmbH, Voerde, Germany.
This self-expandable metal uncovered stent is
made of braided nitinol. It has fl ared ends (tulip
design) to prevent migration and round ends to
reduce the risk of tissue injury (Fig. 7.13 ). The
diameter of fl ared end is 4 mm larger than that of
the body, which has an unconstrained diameter of
20 mm. Unconstrained lengths are available in 6,
8, and 10 cm. The length of fl ares is 10 mm. There
are four tantalum radiopaque markers (two for
each end) to provide fl uoroscopic visualization.
This stent can be inserted TTS with a 10-F delivery
Fig. 7.12 SX-ELLA Stent Pyloroduodenal – ENTERELLA. A plastic repositioning loop ( arrowhead ) is attached to
the proximal stent end
Fig. 7.13 Endo-Flex duodenal stent. This uncovered stent has a fl are at both ends (tulip design) and round ends
118
C.G. Kim and I.J. Choi
system (length 180 cm). There are two stainless
steel ring markers (one close to the distal tip, one
where the stent is loaded in the system). After
complete deployment, the stent foreshortens by
approximately 40% (based on a 20-mm stent,
nominal expanded length of 60 mm). Both predeployed and expanded lengths are clearly indicated
on the product label (i.e., loaded length in applicator 104 mm, length in expanded nominal length
60 mm). Endo-Flex offers both types: reconstrainable (maximum 65%) and standard.
Aixstent
The Aixstent is a self-expandable metal-uncovered
stent made of braided nitinol manufactured by
Leufen Medical GmbH, Aachen, Germany. It has a
tulip design with fl ared ends to prevent migration
and atraumatic ends to reduce the risk of tissue
injury. The diameter of the fl ared end is 6 mm larger
Table 7.1 Characteristics of enteral stents
Covered/
Manufacturer
Wallstent Boston Scienti fi c Inc.,
Natick, MA, USA
WallFlex Boston Scienti fi c Inc.,
Natick, MA, USA
Evolution Cook Medical Inc.,
Winston-Salem, NC,
USA
Niti-S D/ComVi Taewoong Medical
Inc., Seoul, Korea
Niti-S S type Taewoong Medical
Inc., Seoul, Korea
HANAROSTENT M.I. Tech, Seoul,
Korea
BONASTENT Standard Sci-Tech
Inc., Seoul, Korea
BONASTENT
M-Duodenal
EGIS single/
double bare
EGIS single/
double covered
Hercules SP
pyloric stent
SX-ELLA stent ELLA-CS Co,
Endo-Flex ENDO-FLEX GmbH,
Standard Sci-Tech
Inc., Seoul, Korea
S&G Biotech,
Seongnam, Korea
S&G Biotech,
Seongnam, Korea
S&G Biotech,
Seongnam, Korea
Hradec, Czech
Republic
Voerde, Germany
uncovered
Uncovered No fl ares Up to 45% 70% TTS/
Uncovered Proximal Up to 45% 70% TTS/
Uncovered Proximal/
Uncovered/
partially covered
Fully covered Proximal/
Uncovered/
partially covered
Uncovered/
partially covered
Uncovered Proximal/
Uncovered No fl are Up to
Fully/partially
covered
Partially covered Proximal/
Uncovered No fl are Up to 50% Nonreconstrainable TTS/
Uncovered Proximal/
than the 20 mm diameter of the unconstrained body.
Unconstrained lengths are 6, 8, and 10 cm. Tantalum
radiopaque markers provide excellent fl uoroscopic
visualization. This stent can be inserted TTS with a
10-F delivery system (length 180 cm).
Summary
Recent technological advances enable relief of
gastroduodenal or proximal small bowel stenosis
using self-expandable stents as an alternative and
better option to surgery in selected patients.
Current enteral stents are fl exible for application
in angulated anatomy and have large diameters to
allow patients to tolerate solid food. Moreover,
the long-length and small-diameter slim delivery
systems allow through the scope stent placement.
Bare stents are the common type of enteral stent
provided by all manufacturers. Covered stents
were developed to prevent tumor ingrowth, which
Flare on
ends
distal
No fl are Up to 17% Nonreconstrainable TTS/
distal
Proximal/
distal
Proximal/
distal
distal
No fl are Up to
distal
distal
Shortening
rates
Up to 50% 50% TTS
Up to 60% 70% TTS/
Up to 20% 80% TTS/
Up to 30% 80% TTS/
Up to 30% 80% TTS/
32%/20%
25%/19%
Up to 20% Nonreconstrainable OTW
Up to 40% 65% TTS/
Reconstrainable point
at stent deployment
Nonreconstrainable TTS/
Nonreconstrainable TTS/
TTS/
OTW
OTW
OTW
only
OTW
OTW
OTW
OTW
OTW
OTW
OTW
only
OTW
OTW
1197 Enteric Prostheses
Table 7.2 Speci fi cations (diameter and lengths) of stents and delivery systems
Unconstrained
Name
Wallstent No fl are 20, 22 mm 6, 9 cm 3.3 mm/135
WallFlex 27 mm/15 mm 22 mm 6, 9, 12 cm 10 Fr/230 cm 10 Fr/230 cm
Evolution 27 mm/20 mm 22 mm 6, 9, 12 cm 10 Fr/230 cm N/A
Niti-S D type No fl are 18, 20, 22,
Niti-S ComVi type No fl are 18, 20 mm 6,8,10,12 cm 10.5 Fr/180 cm 10.5 Fr/135 cm
Niti-S S type 24 mm/15 mm 18, 20 mm 6,8,10,12 cm 10.5 Fr/180 cm 10.5 Fr/135 cm
HANAROSTENT
noncovered
HANAROSTENT-covered 26 mm/13 mm 20 mm 6, 8, 10, 12, 14,
BONASTENT 6 mm bigger than
BONASTENT M-Duodenal 26 mm/15 mm 22 mm 6,8, 10, 12,14,
EGIS single/double bare No fl are 18, 20, 22,
EGIS single/double covered No fl are 18, 20, 22,
Hercules SP pyloric stent 28 mm/25 mm 18 mm 9,11,13,15 cm N/A 12 Fr/120 cm
SX-ELLA stent No fl are 20, 22,25 mm 8.2, 9.0, 11.3,
Endo-Flex 24 mm/ 20 mm 6, 8, 10 cm 10 Fr/180 cm 10 Fr/180 cm
fl are diameter/
length
25 mm/13 mm 20 mm 6, 8, 10, 12, 14,
body/15 mm
Unconstrained
body diameter
24 mm
18, 20 mm 6,8, 10, 12,14,
24 mm
24 mm
Unconstrained
lengths
6,8,10,12 cm 10 Fr/180 cm 10 Fr/135 cm
16 cm
16 cm
16 cm
16 cm
6, 8, 10, 12 cm 10 Fr/180 cm 10 Fr/120 cm
6, 8, 10, 12 cm 10 Fr/180 cm 10 Fr/120 cm
13.5 cm
Delivery system diameter/length
TTS OTW
3.3mm/135 and
and 230 cm
10.2 Fr/230 cm 10.5 Fr/120 cm
10.2 Fr/230 cm 10.2 Fr/120 cm
10 Fr/180 and
230 cm
10 Fr/180 and
230 cm
10 Fr/210 cm 10 Fr/210 cm
230 cm
10 Fr/120 cm
10 Fr/120 cm
is a disadvantage of bare stents. Several unique
designs are used to minimize covered stent migration including uncovered fl ared ends, multiplelayer design (membrane between wires), and dual
stent type (outer-covered, inner bare stent). The
characteristics of enteral stents, and their
speci fi cations (diameter and lengths) and delivery systems, are summarized in Tables
7.2 , respectively. Further technological advance-
7.1 and
ments are expected to lead to improvement in
stent design to minimize tumor ingrowth and
stent migration.
References
1. Topazian M, Ring E, Grendell J. Palliation of obstructing gastric cancer with steel mesh, self-expanding
endoprostheses. Gastrointest Endosc. 1992;38:58–60.
2. Keymling M, Wagner HJ, Vakil N, et al. Relief of
malignant duodenal obstruction by percutaneous
insertion of a metal stent. Gastrointest Endosc.
1993;39:439–41.
3. Kozarek RA, Ball TJ, Patterson DJ. Metallic selfexpanding stent application in the upper gastrointestinal tract: caveats and concerns. Gastrointest Endosc.
1992;38:1–6.
4. Song HY, Yang DH, Kuh JH, et al. Obstructing cancer
of the gastric antrum: palliative treatment with covered metallic stents. Radiology. 1993;187:357–8.
5. Feretis C, Benakis P, Dimopoulos C, et al. Duodenal
obstruction caused by pancreatic head carcinoma:
palliation with self-expandable endoprostheses.
Gastrointest Endosc. 1997;46:161–5.
6. Maetani I, Tada T, Shimura J, et al. Technical
modi fi cations and strategies for stenting gastric outlet
strictures using esophageal endoprostheses.
Endoscopy. 2002;34:402–6.
7. Phillips MS, Gosain S, Bonatti H, et al. Enteral stents
for malignancy: a report of 46 consecutive cases over
10 years, with critical review of complications.
J Gastrointest Surg. 2008;12:2045–50.
8. Aviv RI, Shyamalan G, Khan FH, et al. Use of stents in
the palliative treatment of malignant gastric outlet and
duodenal obstruction. Clin Radiol. 2002;57:587–92.
9. Lee JM, Han YM, Lee SY, et al. Palliation of postoperative gastrointestinal anastomotic malignant
strictures with fl exible covered metallic stents: preliminary results. Cardiovasc Intervent Radiol.
2001;24:25–30.
120
C.G. Kim and I.J. Choi
10. Kim JH, Yoo BM, Lee KJ, et al. Self-expanding coil
stent with a long delivery system for palliation of
unresectable malignant gastric outlet obstruction: a
prospective study. Endoscopy. 2001;33:838–42.
11. Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding
metal stents: experience in 36 patients. Am J
Gastroenterol. 2002;97:72–8.
12. Telford JJ, Carr-Locke DL, Baron TH, et al.
Palliation of patients with malignant gastric outlet
obstruction with the enteral Wallstent: outcomes
from a multicenter study. Gastrointest Endosc.
2004;60:916–20.
13. Soetikno RM, Lichtenstein DR, Vandervoort J, et al.
Palliation of malignant gastric outlet obstruction using
an endoscopically placed Wallstent. Gastrointest
Endosc. 1998;47:267–70.
14. Laasch HU, Martin DF, Maetani I. Enteral stents in
the gastric outlet and duodenum. Endoscopy.
2005;37:74–81.
15. Tierney W, Chuttani R, Crof fi e J, et al. Enteral stents.
Gastrointest Endosc. 2006;63:920–6.
16. Baerlocher MO, Asch MR, Dixon P, et al.
Interdisciplinary Canadian guidelines on the use of
metal stents in the gastrointestinal tract for oncological indications. Can Assoc Radiol J. 2008;59:107–22.
17. Jung GS, Song HY, Kang SG, et al. Malignant gastroduodenal obstructions: treatment by means of a
covered expandable metallic stent-initial experience.
Radiology. 2000;216:758–63.
18. Katsanos K, Sabharwal T, Adam A. Stenting of the
upper gastrointestinal tract: current status. Cardiovasc
Intervent Radiol. 2010;33:690–705.
19. van Hooft J, Mutignani M, Repici A, et al. First data
on the palliative treatment of patients with malignant
gastric outlet obstruction using the WallFlex enteral
stent: a retrospective multicenter study. Endoscopy.
2007;39:434–9.
20. Lee SM, Kang DH, Kim GH, et al. Self-expanding
metallic stents for gastric outlet obstruction resulting
from stomach cancer: a preliminary study with a
newly designed double-layered pyloric stent.
Gastrointest Endosc. 2007;66:1206–10.
21. Mutignani M, Tringali A, Shah SG, et al. Combined
endoscopic stent insertion in malignant biliary and
duodenal obstruction. Endoscopy. 2007;39:440–7.
22. Moon JH, Choi HJ, Ko BM, et al. Combined endoscopic stent-in-stent placement for malignant biliary
and duodenal obstruction by using a new duodenal
metal stent (with videos). Gastrointest Endosc.
2009;70:772–7.
23. Kim JH, Song HY, Shin JH, et al. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results
and factors in fl uencing outcome in 213 patients.
Gastrointest Endosc. 2007;66:256–64.
Colonic Prostheses
Tae Il Kim
There are multiple types of commercially
available self-expandable metal stents (SEMS)
speci fi cally designed for colonic use from various manufacturers. The available stents differ in
delivery system, stent material, design, deployed
diameter and length, radial force exerted,
fl exibility, degree of shortening after expansion,
and recapturability, which are factors for consideration when selecting a colonic stent model.
These many factors might be re fl ected in developing new types of stents to improve clinical outcomes for patients and/or usability for operators.
The detailed features of each stent model, which
is available internationally, are summarized in
Table 8.1 [ 1– 8 ] .
It might be dif fi cult to make a perfect stent
with every desirable attribute that can be passed
through the channel of a colonoscope. Therefore,
we need to understand the characteristics of each
model of colon stent and to select the one best
suited for each situation. Broad experience will
be helpful in selecting the proper stent model and
understanding the delicate details of each model,
which are dif fi cult to measure or describe, such
as conformability of the deployed stent, fl exibility
of delivery system, etc.
T. I. Kim , M.D., Ph.D. ()
Division of Gastroenterology, Department of Internal
Medicine , Institute of Gastroenterology, Severance
Hospital, Yonsei University College of Medicine ,
250 Seongsanno , Seodaemun-gu, Seoul 120-752 ,
Republic of Korea
e-mail: taeilkim@yuhs.ac
8
Delivery System
Delivery systems may vary according to the
approach methods for SEMS placement, such as
through-the-scope (TTS) and non-TTS stent
placements. The delivery system for the TTS
method has a longer total working length and
smaller predeployment diameter (10 French) to
allow the passage of stents directly through the
working channel of a therapeutic colonoscope
( ³ 3.8 mm diameter).
The most important point in the delivery system is to deliver excellent sheath pushability and
allow for ef fi cient tracking and maneuverability
for deployment, especially in dif fi cult anatomical
challenges, such as acute and complex angulations. By enhancing fl exibility of the delivery
system, manufacturers attempt to minimize
trauma and to aid in traversing abnormal anatomy
without kinking. Moreover, many delivery systems are designed to be reconstrainable by recapturing the stent, when repositioning is desired
during deployment. The recapturable ranges of
the deployed portion during deployment vary
according to the stent models.
For repositioning directly after complete
deployment, with a lasso on proximal end of
some stent models, it is possible to reposition the
stent to the desired area by pulling with forceps
on the lasso. In addition, to facilitate accurate
stent placement, highly visible endoscopic and/or
fl uoroscopic markers on the delivery system or
R. Kozarek et al. (eds.), Self-Expandable Stents in the Gastrointestinal Tract,
DOI 10.1007/978-1-4614-3746-8_8, © Springer Science+Business Media New York 2013
121
122
T.I . Kim
Published data
Deployed
1, 3 , 4 ]
(Reference No.)
[
length (cm) Uncovered/covered Features
6, 9, 12 Uncovered Reconstrainable (at up to
30–38% Shortening
70% of deployment)
during expansion
Radiopaque markers on
delivery system
2 ]
[
17% Shortening during
expansion
1/3 of deployment)
6, 8, 10, 12 Uncovered Reconstrainable (at up to
5 ]
[
Radiopaque markers on
stent
Reconstrainable (at up to
70% of deployment)
bare ends)
6, 8, 10, 12 Covered (silicone,
50–60% Shortening
during expansion
Radiopaque markers on
1, 2 ]
[
stent
17% Shortening during
expansion
Radiopaque markers
Reconstrainable (at up to
1/3 of deployment)
ends)
on stent
Deployed
Delivery system/
Table 8.1 Currently available self-expandable metal stents (SEMS) for colorectal obstruction
diameters/ fl are (mm)
diameter (Fr) Stent materials
Manufacturer model
TTS or OTW/10 Nitinol 25 (body)/30
Boston scienti fi c
WallFlex enteral
(proximal fl are)
colonic
22 (body)/27
(proximal fl are)
fl are
TTS or OTW/10 Nitinol 18, 20, 22, 24/no
Taewoong medical
Niti-S enteral
colonic (D-type)
ends fl are)
TTS or OTW/10, 10.5 Nitinol 18, 20/24 (both
Niti-S enteral
colonic (head type)
18, 20/no fl are 6, 8, 10, 12 Covered (PTFE, bare
layer)
TTS or OTW/10, 10.5 Nitinol (double-
ComVi Niti-S
enteral colonic
1238 Colonic Prostheses
release deployment
device
6, 8, 10 Uncovered Gun-shaped controlled-
Reconstrainable (at up to
“point of no return”)
45% Shortening during
expansion
Radiopaque markers on
stent
4, 6, 8, 10, 12 Uncovered
6, 7 ]
[
20–30% Shortening
deployment)
15, 16
during expansion
(at up to 80% of
Uncovered Reconstrainable
6, 7, 8, 9, 10,
11, 12, 13, 14,
Radiopaque markers on
stent
With or without lasso
Reconstrainable (at up to
Covered (silicone,
7, 8, 9, 10, 11,
8 ]
[
80% of deployment)
46% Shortening during
expansion
Radiopaque markers on
stent, lasso
partial)
12, 13, 14, 15
Covered (silicone) 35% Shortening during
7, 8, 9, 10, 11,
Radiopaque markers on
stent, Two lasso
expansion
12, 13, 14, 15
35–40% Shortening
during expansion
Radiopaque markers on
Uncovered
or covered
(polyurethane)
13.5
stent, lasso
fl are)
Cook endoscopy
Evolution colonic TTS or OTW/10 Nitinol 25/30 (both ends
Colonic Z-stent Non-TTS/31 Stainless steel 25/35 (both ends
fl are)
M.I.Tech
(both ends fl are)
TTS or OTW/10.2, 10.5 Nitinol 22, 24/26, 28
Hanarostent colon/
rectum (NNN)
fl are)
TTS or OTW/10.2 Nitinol 20/26 (both ends
Hanarostent colon/
rectum (NCN)
fl are)
Non-TTS/24 Nitinol 24/32 (both ends
Hanarostent colon/
rectum (CCC)
Nitinol 20, 22, 25 8.2, 9, 11.3,
Non-TTS/15, 18
(covered)
ELLA-CS
SX-ELLA
colorectal
(Enterella)
TTS through-the-scope, OTW over-the-wire, PTFE polytetra fl uoroethylene
124
Fig. 8.1 WallFlex enteral colonic stent (Boston scienti fi c). ( a ) Stent during deployment. ( b–d ) Fully deployed stent
T.I . Kim
stent de fi ne proximal, middle, and/or distal end
of the stent.
Stent Design
As for the stent material, Nitinol (metal alloy of
nickel and titanium) exhibits unique properties:
shape memory and superelasticity. Because of
their ability to conform to anatomical angulations, Nitinol stents now dominate the market.
Although the ideal stent diameter for proper
radial force is unknown, the postdeployment
diameter of colonic SEMS is usually between 18
and 30 mm. The deployed length of colonic stents
range from 4 to 16 cm, and the stent chosen
should be at least 3–4 cm longer than the obstruction to allow an adequate margin of stent, by at
least 1.5–2 cm on either side of the obstruction.
The end portion of most stents is designed to
have rounded edges to prevent mucosal injury
and complications due to the sharp end of stent
wires, and some stents are designed to have a
fl are in both or the proximal end of stent to potentially reduce the risk of migration (Figs. 8.1 , 8.2 ,
8.3 , and 8.4 ). In addition, radiopaque markers at
each end of the stent provide visualization for
accurate placement.
Many stent models have improved fl exibility,
thereby allowing the stent to fully conform to the
natural curves of the anatomy while potentially
reducing the risk of complications, such as perforation or bleeding. In particular, the D-type stents
are constructed with un fi xed individual cells,
woven with two separated wires, allowing cells
to overlap each other over a highly curved area.
Compared to the single wire type, this speci fi c
construction allows D-type stents to have notable
fl exibility and conformability, which can prevent
abrupt luminal narrowing at fl exed areas of the
colon (Fig. 8.2 ). During expansion, most of the
stents have shortening in length. The shortening
rates will vary between 20% and 45%, contingent
upon stent model.
Uncovered/Covered Stent
One of important factors of stent type utilized,
which is directly comparable and related with
clinical outcomes, is whether the prosthesis is
uncovered/covered. Even though both types of
1258 Colonic Prostheses
Fig. 8.2 ( a , b ) Niti-S enteral colonic (D-type) and ( c , d )
ComVi enteral colonic stent (TaeWoong Medical,
Gyeonggi-Do, Korea)
stents show similar technical and clinical success
rates, they present unique advantages and disadvantages. Covered stents have the advantage of
less frequent stent occlusion by tumor ingrowth
and the disadvantage of a high risk of stent migration, whereas uncovered stents are associated
with less stent migration but are more prone to
tumor ingrowth. Although a recent randomized
prospective study, comparing the uncovered
Wall fl ex stent and the covered ComVi stent,
showed the same results as those mentioned
above, neither stent type differed with respect to
overall complication rate and stent patency duration, suggesting both types are suitable for relieving malignant colorectal obstruction [
1 ] .
Furthermore, the ComVi stent (double-layered
combination covered stents) was designed to prevent both tumor ingrowth by incorporation of an
interposing membrane and stent migration with
the outer uncovered wire designed to embed in
the colorectal cancer [ 2 ] . However, this new type
of colonic stent could not overcome the shortcoming of the covered stent: more frequent stent
migration [ 1, 2 ] .
As for the material of the covered stent membrane, the polytetra fl uoroethylene (PTFE) membrane, with its strong physical and chemical
resistance, is highly biocompatible and may prevent tumor ingrowth and membrane deformation.
Silicone rubber, with nonreactive, stable, and resis-
Fig. 8.3 ( a ) Evolution colonic and ( b ) Colonic Z-stent (Cook Endoscopy) (Courtesy of Cook Medical Incorporated,
Bloomington, IN)
126
T.I . Kim
Fig. 8.4 ( a , b ) Hanarostent colon/rectum, uncovered, with/without lasso, ( c ) Hanarostent Colon/rectum, covered, TTS
delivery, and ( d ) Hanarostent Colon/rectum, covered, non-TTS delivery (MI Tech). TTS, through-the-scope
tant properties to endure extreme environments
and its ease of manufacturing and shaping, is also
being used as a membrane in covered stents.
Conclusion
Several types of colon stents have been developed,
and each type and design of stent has unique characteristics. However, it is dif fi cult to prove that
these properties make a difference in the outcome
of patients or improve maneuverability for its
operators. We need to understand the features of
each stent through experience, and estimate their
effect on clinical outcomes and ease of insertion
to develop a new and ideal stent design.
References
1. Park S, Cheon JH, Park JJ, et al. Comparison of
ef fi cacies between stents for malignant colorectal
obstruction: a randomized, prospective study.
Gastrointest Endosc. 2010;72:304–10.
2. Moon CM, Kim TI, Lee MS, et al. Comparison of a
newly designed double-layered combination covered
stent and D-weave uncovered stent for decompression
of obstructive colorectal cancer: a prospective multicenter study. Dis Colon Rectum. 2010;53:1190–6.
3. Repici A, De Caro G, Luigiano C, et al. Wall fl ex
colonic stent placement for management of malignant
colonic obstruction: a prospective study at two centers.
Gastrointest Endosc. 2008;67:77–84.
4. 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 leftsided colorectal cancer. Endoscopy. 2008;40:184–91.
5. 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;36:426–31.
6. Im J, Kim S, Kang H, et al. Clinical outcomes and patency of self-expanding metal stents in patients with
malignant colorectal obstruction: a prospective single
center study. Int J Colorectal Dis. 2008;23:789–94.
7. Suh J, Kim S, Cho Y, et al. Effectiveness of stent placement for palliative treatment in malignant colorectal
obstruction and predictive factors for stent occlusion.
Surg Endosc. 2010;24:400–6.
8. Scharf J-G, Ramadori G, Becker H, Muller A.
Implantation of a colorectal stent as a therapeutic
approach in the treatment of esophageal leakage. BMC
Gastroenterol. 2007;7:10.