SEMS procedures were performed by endoscopists experienced over 1,000 cases of colonoscopy, over 100 cases of endoscopic retrograde cholangiopancreatography (ERCP), and over 50 cases of esophageal, duodenal, or biliary stent placement. Bowel preparation comprised enemas only. Radiographic contrast enema was not performed before the procedures. All procedures were performed in the radiology room under fluoroscopic and endoscopic guidance, while the patient was consciously sedated with midazolam. A CF-260AI or CF-HQ290AZI colonoscope (Olympus) and CO2 gas were used in all cases. The obstructive lesion was directly confirmed and marked by a clip on the anal side. Access across the stricture was achieved with a 0.025-inch guidewire (Radifocus™; Terumo), and an ERCP catheter (MTW Co.) was then inserted to the proximal lumen. The length and degree of the stricture was measured fluoroscopically using a contrast agent, and the type of SEMS was selected. The guidewire was changed to a 0.035-inch guidewire (Jagwire™; Boston Scientific), and the SEMS was placed using the through-the-scope technique (22,23). The SEMSs used were WallFlex enteral colonic stents (Boston Scientific Corporation) and Niti-S enteral colonic stents (Tae Woong Medical). All SEMSs were uncovered stents with an inner diameter of 22 mm, and a length of 60-90 mm (WallFlex) or 60-80 mm (Niti-S). Balloon dilation was not performed in any case to minimize the risk of perforation (24). Tumor biopsy was performed just after SEMS placement. These procedures basically conform to the guidelines of the Japan Colonic Stent Safe Procedure Research Group (JCSSPRG) (http://colon-stent.com/), which received support from the Japan Gastroenterological Endoscopy Society. The position of the SEMS was confirmed on plain abdominal radiography each day. After improvement of the MCRO was confirmed, a full liquid diet was resumed within 3-5 days, and the diet was gradually progressed to include solid food. Patients whose condition improved received preoperative examinations, including total colonoscopy, and were allowed to leave the hospital until elective surgery. For patients who had undergone successful SEMS placement, elective surgery was performed about 2 weeks later. Typical cases are shown in Figs. 2 and and33.

SEMS placement procedure (Case 1). (A and B) Malignant colorectal obstruction due to a sigmoid colon lesion was diagnosed using abdominal CT (axial and coronal sections). Arrows indicate the beginning of the stricture. (C) The obstructive lesion was confirmed endoscopically, and marked by a clip on the anal side. (D) An endoscopic retrograde cholangiopancreatography catheter about to be inserted across the stricture. (E) The guidewire passed the stricture through the endoscopic retrograde cholangiopancreatography catheter, and reached the oral side. (F) The length and degree of the stricture was measured fluoroscopically. The double arrows indicate the distance of the stricture. (G and H) The guidewire was changed to a 0.035-inch guidewire, and the SEMS delivery system passed the stricture using the through-the-scope technique. (I) The SEMS just after being deployed from the delivery system. (J) Stools flowed through the SEMS from the oral side. (K) Biopsy was performed from the side of the tumor just after SEMS placement. (L) The surgical specimen resected 12 days after SEMS placement as a bridge to surgery. SEMS, Self-expanding metal stent.

Self-expanding metal stent placement procedure (Case 2). (A) MCRO was diagnosed using radiography. (B) Abdominal CT (axial section) showing MCRO due to a sigmoid colon lesion. Arrows indicate the beginning of the stricture. (C) The obstructive lesion was confirmed endoscopically. (D) The obstructive lesion marked by a clip on the anal side. (E) The length and degree of the stricture were measured fluoroscopically. The double arrows indicate the distance of the stricture. (F) The guidewire was changed to a 0.035-inch guidewire, and the SEMS delivery system passed the stricture using the through-the-scope technique. (G) The SEMS was deployed from the delivery system. (H) The SEMS just after being deployed. (I) The SEMS position was confirmed as appropriate on a radiographic image. (J) Radiography performed the day after SEMS placement showed that the gas pattern was improved. (K) The obstructive lesion 5 days after SEMS placement. The colonoscope passed through the stricture and reached the cecum. (L) The surgical specimen resected 14 days after SEMS placement as a bridge to surgery. SEMS, Self-expanding metal stent; MCRO, malignant colorectal obstruction.

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