Metallic stent insertion to relieve malignant bowel obstruction in a child: a case report

Abstract

Self-expandable metallic stents (SEMS) have been widely used in adults to relieve obstruction secondary to colorectal tumours. However, there is a paucity of literature about their use in children, with only a few case reports describing stent insertion in children with benign colonic conditions. There is one case report on a malignant colonic condition in a child by Hussain et al. in the literature. However, due to the rarity of the condition, there are currently no guidelines from learned societies on colorectal SEMS placement in paediatric patients. We share our experience of using a fully covered SEMS to relieve malignant colonic obstruction in a 6 year-old-child, who was on treatment for T cell lymphoma. This was done as a bridge to surgery, thereby allowing planned surgery, and avoiding colostomy in this child, who went on to have colonic resection with primary anastomosis.

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https://doi.org/10.1177/26317745221111942
https://doi.org/10.1177/26317745221111942
Ther Adv Gastrointest
Endosc
2022, Vol. 15: 1–4
DOI: 10.1177/
26317745221111942
© The Author(s), 2022.
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THERAPEUTIC ADVANCES in
Gastrointestinal Endoscopy
Case report
We report a case of a 6-year-old boy, who was on
maintenance chemotherapy for an underlying
diagnosis of stage IV T cell lymphoma with loss of
MLH1 and PMS2 expression on lymph node
biopsy (high probability of lynch syndrome). He
presented with a 1 day history of persistent
vomiting, abdominal distention and diarrhoea.
Investigations showed a haemoglobin of 11.2 g/dl.
Renal function, serum electrolytes and liver func-
tion tests were normal. An erect abdominal X-ray
showed dilated large and small bowel, with air-
fluid levels. A contrast-enhanced computed
tomography scan of the abdomen and pelvis con-
firmed proximal descending colon obstruction sec-
ondary to an annular stenosing mass. The child
was kept nil by mouth, intravenous fluids and anal-
gesia were started and a nasogastric tube was
inserted to decompress the bowel. An urgent pae-
diatric surgical opinion was sought. A diagnosis of
possible malignant large bowel obstruction was
made and gastroenterology review was advised. The
gastroenterologist advised unprepared sigmoidos-
copy, with biopsy and possible stent insertion. The
rationale for this was that this would relieve bowel
obstruction, allow time for a definitive histologic
diagnosis of the cause of bowel obstruction to be
made and potentially allow resection of the
obstructed segment of the bowel with primary
anastomosis, thus avoiding a colostomy in this very
young child. It was decided that, since specific pae-
diatric stents were not available and adult-sized
colonic stents would be inappropriate for a child, a
fully covered biliary self-expandable metallic stent
(SEMS), which has a smaller diameter and length
of 10 mm and 6 cm, respectively, as opposed to
20 mm and 13 cm for adult colonic stents, would
be used. After informed written consent was taken
from the patient’s parents, sigmoidoscopy was per-
formed under general anaesthesia the same day and
showed a polypoid stenosing tumour at 20 cm from
the anal verge, which was biopsied (Figure 1). A
6 cm × 10 mm fully covered (adult) self-expanding
biliary metallic stent was inserted under fluoro-
scopic assistance , as showed in Figures 2–4. This
allowed virtually immediate relief of obstruction,
with drainage of close to 1500 ml of liquid stool.
No immediate complications were observed. The
patient made a good recovery and was allowed
home 3 days later. The histology subsequently
revealed the tumour to be a poorly differentiated
carcinoma with neuroendocrine differentiation.
Metallic stent insertion to relieve malignant
bowel obstruction in a child: a case report
Sundus Bilal , Saad M. Saeed , Muhammad Z. Sidique
and Muhammed A. Yusuf
Abstract: Self-expandable metallic stents (SEMS) have been widely used in adults to relieve
obstruction secondary to colorectal tumours. However, there is a paucity of literature about
their use in children, with only a few case reports describing stent insertion in children with
benign colonic conditions. There is one case report on a malignant colonic condition in a
child by Hussain et al. in the literature. However, due to the rarity of the condition, there are
currently no guidelines from learned societies on colorectal SEMS placement in paediatric
patients. We share our experience of using a fully covered SEMS to relieve malignant colonic
obstruction in a 6 year-old-child, who was on treatment for T cell lymphoma. This was done
as a bridge to surgery, thereby allowing planned surgery, and avoiding colostomy in this child,
who went on to have colonic resection with primary anastomosis.
Keywords: bowel obstruction, case report, child, colorectal cancer, stents
Received: 2 December 2021; revised manuscript accepted: 20 June 2022.
Correspondence to:
Sundus Bilal
Shaukat Khanum
Memorial Cancer Hospital
and Research Centre, 7A,
Block R-3, Johar Town,
Lahore, Punjab 54000,
Pakistan
sundus.bilal@hotmail.com
Saad M. Saeed
Muhammad Z. Sidique
Muhammed A. Yusuf
Shaukat Khanum
Memorial Cancer Hospital
and Research Centre,
Lahore, Punjab, Pakistan
11119 42CMG0010.1177/26317745221111942Therapeutic Advances in Gastrointestinal EndoscopyS Bilal, SM Saeed
research-article20222022
Case Report

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THERAPEUTIC ADVANCES in
Gastrointestinal Endoscopy
The patient then returned to the hospital 3 weeks
later, for an elective left hemicolectomy. The surgi-
cal specimen showed a poorly differentiated ade-
nocarcinoma with neuroendocrine and signet ring
cell differentiation, pT4 pN3 disease, with the
abdominal wall and left peritoneal wall deposits,
positive for metastatic disease. The patient was
restarted on chemotherapy for his underlying lym-
phoma, with a plan for possible further treatment
for his metastatic colorectal cancer (CRC).
Discussion
CRC is the third most common cancer in adults,
worldwide.1 However, it is rare in children, with
an incidence of one per million.2–4 Similarly, in
the adult population 8–13% of the patients pre-
sent with large bowel obstruction,5 although
malignant strictures are exceedingly rare in paedi-
atric patients.4,6,7 There is, therefore, a scarcity of
literature on the management of malignant bowel
obstruction in children, with no definite manage-
ment guidelines available, to date.2,3,6 A case
report exists of an infant in whom a removable
silicone stent was successfully placed for a benign
anastomotic stricture following surgery for
Hirschsprung’s disease.8 In a case series of five
patients, Lange etal.9 describe the use of metallic
stents for benign colorectal strictures with
Figure 2. After colonic stent insertion
Figure 1. Endoscopic view of the tumour. Figure 3. Guidewire passed through tumour.
Figure 4. After colonic stent placement.

S Bilal, SM Saeed et al.
journals.sagepub.com/home/cmg 3
variable results. There is just a single case report
published in 2004 by Hussain et al.10 who used
SEMS for relieving complete large bowel malig-
nant obstruction in a child. Similarly, due to its
rarity, no definitive treatment has been proposed
for children with malignant colorectal tumours
and the few case reports which do exist suggest
using adult chemotherapy protocols in children
presenting with CRC.11 Hence, one might infer
that similar management may be applied to
address malignant strictures in paediatric patients.
Historically, emergency surgery was considered
to be the treatment of choice in adults present-
ing with malignant bowel obstruction.3,4,12
However, this is associated with high morbidity
and mortality due to the hazards of operating
on patients with an unprepared bowel which
usually results in stoma formation.7,12 Metallic
stents, which have traditionally been used for
palliation, now are recommended as a bridge to
surgery for resectable obstructing colorectal
tumours.4,13 A meta-analysis by Allievi et al.7
compared the use of stents with emergency sur-
gery and found that use of the former was asso-
ciated with a shorter hospital stay, helped to
convert emergency to elective surgery, increased
the likelihood of primary anastomosis, avoided
surgery prior to diagnosis or staging, and was
associated with better quality of life.
Our institution is the largest tertiary care cancer
centre in the country and we have extensive expe-
rience in using metallic stents in adults, including
as a bridge to surgery for obstructing colorectal
tumours. Extrapolating the evidence from the lit-
erature and based upon our experience of using
stents in adults, we decided to treat malignant
bowel obstruction in this paediatric patient with
SEMS, with good effect. It is important to note
here that there are no commercially available
colonic stents for this age group6 and our adult-
sized colorectal stents appeared to be inappropri-
ate for a 6-year-old child, weighing only 15 kg.
We solved this issue using a fully covered self-
expandable biliary metallic stent, which had a
smaller diameter and length.
In conclusion, stents can be used to relieve malig-
nant bowel obstruction even in children, thereby
saving them from risks of emergency surgery, as
well as from stoma formation. Although this is a
rare condition, we feel that the use of stents is
likely to be of benefit in specialised centres such
as ours, and that this represents a useful addition
to the currently available forms of treatment for
such conditions.
This case has been reported according to case
report (CARE) guidelines 2013.14
Declarations
Ethics approval and consent to participate
Case report has been approved by the Institutional
Review Board of Shaukat Khanum Memorial
Cancer Hospital and Research Centre, Lahore.
IRB no. EX-21-10-21-01.
Consent for publication
Informed consent has been taken from the par-
ents of the patient for publication of case report
and has been documented in patient’s record,
hospital information system (HIS).
Author contribution(s)
Sundus Bilal: Writing – original draft.
Saad M. Saeed: Investigation; Methodology.
Muhammad Z. Sidique: Conceptualisation;
Writing – review & editing.
Muhammed A. Yusuf: Supervision; Writing –
review & editing.
ORCID iDs
Sundus Bilal https://orcid.org/0000-0003-
1739-5056
Saad M. Saeed https://orcid.org/0000-0002-
3112-5338
Funding
The authors received no financial support for the
research, authorship, and/or publication of this
article.
Conflict of interest statement
The authors declare that there is no conflict of
interest.
Availability of data and materials
Not applicable.
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