Stents and Lasers fo r Co lo no sco pic Lesio ns Douglas G. Adler, MD and Todd H. Baron, MD Address D epar tment of Medicine, D ivision of Gastroenterology and H epatology, Mayo Medical Center, Eisenberg 8A, 200 First Street SW , Rochester, MN 55905, USA. E-mail:baron.todd@ mayo.edu Current Gastroenterology Reports 2000, 2:399–405 Current Science Inc. ISSN 1522–8037 Copyright © 2000 by Current Science Inc. Introduction Recent developments in endoscopic therapy have led to several major advances in the treatment of colonic disease. Some of the most exciting breakthroughs have been in the realm of endoscopic stenting. Although the past 10 years saw an explosion of interest in esophageal, biliary, and pancreatic stenting, it seems that the nascent field of colonic stenting is now gathering momentum. Colonic stenting of benign and malignant strictures, once thought impractical, is now proving itself to be a valid, and some- times life-saving, technique. This review focuses primarily on the use of expandable metal stents in the colon, includ- ing their indications, uses, risks, and benefits. Attention is also given to several new uses for laser therapy in the treat- ment of colonic disease, both as an independent therapeu- tic modality and as a tool to be used in certain situations alongside colonic stenting. With this article, the authors hope to give the reader an overview of the state of endo- scopic stent and laser therapy for colonic disease. Colonoscopic Stents and Colonic Obstruction Colonic obstruction More than 150,000 deaths occur worldwide each year from colorectal cancer. Despite aggressive screening and surveil- lance incentives in the United States and abroad, total or near-total colonic obstruction is still a very common scenario for the presentation of colorectal cancer. Various studies have shown that between 8% and 29% of patients will have colonic obstruction at the time of disease discov- ery [1•]. It has been known for some time that colonic obstruction caused by malignancy accounts for as much as 85% of surgical large bowel emergencies, making it the number one cause of emergency large bowel surgery [2,3•]. Indeed, up to one half of all splenic flexure tumors and one quarter of all left-sided tumors present as obstruction [1•]. Fortunately, rectosigmoid cancers, the most common subtype, present with obstruction in only 6% of cases, largely due to the wider lumen in that region of the bowel [1•]. Other, less common, causes of large bowel obstruc- tion include diverticulitis, strictures from prior radiation therapy, anastomotic strictures, or extrinsic compression from adjacent tumors, both benign and malignant. Patients with colonic obstruction are often severely dehydrated, largely due to their inability to take fluids orally. Those with malignancy are also frequently malnour- ished, due to their underlying disease state [4•]. Patients with primary colorectal cancer who present with obstruc- tion frequently harbor advanced malignancies; nearly all have Duke’s stage C or D disease [5]. These factors com- bine to make this group of patients, who are o ften badly in need of surgical decompression, poor candidates for an emergency surgical procedure. In addition, these patients almo st universally lack proper bowel preparation and have friable bowel tissue due to the obstruction itself, making them very poor candidates for surgery [4•]. Although figures vary, typical rates for surgical mortality from acute large bowel obstruction are in the range of 15% [1•]. Overview of surgical options for large bowel obstruction An appreciatio n o f the surgical o ptio ns available to patients with acute or subacute colonic obstruction is critical to understanding the potential impact that stents can have in the management of these patients. Early surgical treatment of colonic obstruction involved a “three-stage” operation. In the first stage, a decompressing colostomy was constructed. The second stage involved resection of the primary lesion, and the final stage re-anastomosed the remaining bowel and resulted in colostomy closure. Often, the first two stages were do ne at the same ho spitalizatio n as separate surgeries. This resulted in lo ng ho spital stays, o ften greater than 30 days. Up to one quarter of patients treated The use of self-expanding metal stents (SEMS) in the colon is now becoming more commonplace. These devices can be employed to decompress large bowel that has become obstructed from either benign or malignant disease. Many studies in the past year have validated the use of colonic SEMS to allow preoperative bowel preparation in resectable patients, or as an alternative to surgery in those requiring palliative therapy alone. Laser therapy has also gained new ground in recent months because it has been shown to help in recanulation of obstructed bowel to aid in SEMS placement. In addition, laser therapy alone can be used to treat some colonic lesions that had formerly been treated surgically.