Endoscopic palliation of rectosigmoid malignant obstruction using self-expandable metallic stent in advanced colorectal carcinoma

Vincent Jayakumar A¹, Thinakar Mani B², Arivarasan Kulandaivelu³, Rajakumari⁴

¹Resident, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

²Senior Consultant, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

³Senior Consultant, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

⁴Resident, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

Introduction

Colorectal cancer (CRC) is among the leading causes of cancer-related morbidity and mortality worldwide¹. Malignant large bowel obstruction occurs in 8–13% of CRC patients and is typically associated with advanced or recurrent disease². Traditionally, emergency surgery was the standard treatment; however, it carries significant perioperative morbidity and mortality, particularly in elderly patients with comorbidities or metastatic disease. ³

Self-expandable metallic stents (SEMS) have emerged as a safe and effective alternative to surgery for malignant colonic obstruction. Initially used as a bridge to surgery, SEMS are now widely adopted as a palliative strategy in patients unsuitable for curative resection. ⁴⁻⁵ Endoscopic stenting offers rapid decompression, restoration of bowel continuity, and avoidance of stoma formation, thereby improving quality of life ⁶. Technical success rates exceed 90%, with shorter hospitalization and faster recovery compared with emergency surgery ⁷.

In advanced colorectal malignancy, where resection is not feasible, SEMS placement can provide durable palliation, especially in patients with poor performance status or widespread metastases ⁸. We present a case of malignant rectosigmoid obstruction in a post-hemicolectomy patient with synchronous liver metastases, successfully managed with palliative SEMS placement.

Self-expandable metallic stents (SEMS) have emerged as an effective alternative to surgery for the management of malignant colonic obstruction. Initially introduced as a bridge to surgery, SEMS placement is now widely utilized as a palliative intervention in inoperable or high-risk patients. Endoscopic stenting offers rapid decompression, restoration of bowel continuity, and avoidance of stoma formation, leading to improved quality of life. Technical success rates exceed 90%, with shorter hospital stays and faster recovery compared to emergency surgery.

We report a case of an elderly male with a history of right hemicolectomy for ascending colon carcinoma who presented with acute malignant rectosigmoid obstruction and synchronous liver metastases. In view of his advanced disease and high surgical risk, he was successfully managed with endoscopic palliative SEMS placement, achieving rapid clinical improvement and early discharge

Case Presentation

A 75-year-old male with a history of ascending colon carcinoma, diagnosed in 2014, underwent right hemicolectomy with ileocolonic anastomosis. He remained completely asymptomatic until 2023, when he developed complaints of constipation. Colonoscopy at that time revealed multiple colonic polyps in the proximal rectum and sigmoid colon. Biopsy of these lesions showed tubular adenoma with low-grade dysplasia. Abdominal ultrasonography revealed cholelithiasis and choledocholithiasis, for which he underwent ERCP with CBD stone extraction, CBD stent placement, and cholecystectomy. The patient was subsequently lost to follow-up.

Now in August 2025, he presented to the casualty with abdominal distension and pain for 10 days, followed by absence of passage of stools and vomiting for the past 4 days. On initial evaluation, he was hypotensive, tachycardic, and hypoxic. Resuscitation was initiated with intravenous fluids, inotropic support, and supplemental oxygen.

An abdominal X-ray showed markedly dilated bowel loops (Fig 1). Contrast-enhanced CT of the abdomen revealed dilated bowel loops with circumferential wall thickening and an ulcer proliferative growth in the proximal rectum causing significant luminal obstruction, along with multiple hypodense liver lesions suggestive of metastases. A diagnosis of acute intestinal obstruction secondary to malignant rectosigmoid growth with liver metastases was made.

The patient was admitted to the intensive care unit and started on intravenous fluids, broad-spectrum antibiotics, and total parenteral nutrition. Colonoscopy revealed a large ulcero proliferative rectosigmoid growth causing complete luminal obstruction. A pediatric colonoscope was used to carefully navigate through the tumor, allowing visualization of the bowel proximal to the obstruction.

A multidisciplinary team discussion was held. Considering the advanced stage of colorectal carcinoma with liver metastases and the patient’s high perioperative risk, surgical resection was deemed unsuitable. A palliative approach with self-expandable metallic stent (SEMS) placement was planned.

For the procedure, a pediatric endoscope was initially used to negotiate the stricture. Subsequently, an adult upper GI endoscope was introduced, and a guidewire was successfully passed across the lesion. Over the guidewire, a SEMS measuring 90 mm×25 mm was deployed from the proximal to the distal extent of the tumor. Deployment was smooth, with the stent well-opposed to the tumor wall and a visible luminal opening achieved. Post-operative abdominal X-ray showed a well deployed SEMS. (Fig 2).

Post-procedure, the patient passed flatus and stools within 24 hr. By postoperative day 3, he tolerated oral feeds, and his abdominal distension had markedly improved. Abodminal X-ray post SEMS placement showed well opposed in the Abdominal X-ray (Fig 3). He was discharged on postoperative day 4 and remains under regular follow-up for palliative care

Conclusion

Malignant large bowel obstruction in advanced colorectal cancer poses a major therapeutic challenge, particularly in elderly or high-risk patients. Emergency surgery in this setting is associated with significant morbidity, prolonged recovery, and impaired quality of life.³

Endoscopic SEMS placement provides an effective, minimally invasive option that rapidly relieves obstruction, avoids stoma creation, and allows early resumption of oral intake. ⁴^,⁶ In palliative cases, SEMS not only reduces hospitalization but also improves patient comfort and dignity in the advanced stages of disease.⁷^,⁸

This case highlights the value of SEMS as a primary palliative intervention in advanced, obstructing colorectal malignancy. With appropriate patient selection and multidisciplinary input, SEMS placement achieves high technical and clinical success rates, offering symptom relief and improved quality of life. Given its safety and efficacy, SEMS should be considered the preferred first-line approach in patients with malignant colonic obstruction who are unsuitable for surgery.

Self-expandable metallic stent (SEMS) placement has evolved as a valuable therapeutic option, offering both rapid decompression and restoration of bowel function without the physiological stress of surgery. In the palliative setting, SEMS avoids the need for stoma creation, minimizes hospitalization, and allows for early return to oral intake, which can significantly enhance patient comfort in the advanced stages of illness.

This case demonstrates that, with careful patient selection and a multidisciplinary approach, palliative SEMS placement can achieve excellent technical and clinical outcomes even in the presence of complete malignant obstruction. In our patient, endoscopic stenting provided immediate symptom relief, restored intestinal continuity, and allowed early discharge despite the presence of liver metastases and high surgical risk.

Given its safety profile, high success rates, and patient-centred benefits, palliative endoscopic SEMS placement should be considered the preferred first-line intervention for malignant large bowel obstruction in advanced, inoperable colorectal malignancy.

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Endoscopic palliation of rectosigmoid malignant obstruction using self-expandable metallic stent in advanced colorectal carcinoma