Unlock the Best Colon Stent Diet: Essential Tips for Faster Recovery and Comfort

Colonic endoluminal stent placement is a commonly utilized and effective endoscopic approach for the management of malignant large bowel obstruction, and is an emerging approach for the management of some benign etiologies of large bowel obstruction. This article aims to provide a comprehensive overview of colon stent procedures, utilization patterns, and dietary recommendations following stent placement.

Introduction to Colonic Stents

Colonic stents have been integrated into clinical practice since they were first described in the 1990s, traditionally as a bridge to the surgical resection of a malignant lesion or for palliation in patients whose colorectal malignancy was not amenable to surgical resection.In the United States, where colorectal carcinoma is common, the incidence of large bowel obstruction in patients with colon cancer ranges up to 29%. Colonic stent placement allows improvement in the patient’s clinical condition, adequate oncological staging, good colonic preparation, performance of an elective surgery by an experienced surgical team, the possibility of a laparoscopic approach, and shorter latency to the initiation of chemotherapy.

Since their introduction in the 1990s, colonic stents have been refined to include self-expanding elements and to enhance the ease of endoscopic deployment. Trials have been conducted to evaluate the role of these colonic self-expanding metallic stents (SEMSs) as a bridge to surgical intervention for malignant large bowel obstruction, and findings have supported the superiority of endoscopic stent placement as an initial intervention relative to direct emergent surgical intervention. There is also an emerging role of colonic endoluminal stent placement in benign large bowel obstruction. Indeed, SEMS placement has been reported for the management of large bowel obstruction due to diverticulitis, inflammatory bowel disease, anastomotic colonic strictures and endometriosis.

Colonic Stent Utilization Patterns

A study was conducted to assess colonic stent utilization patterns in a tertiary care academic medical center over the past 10 years. The study retrospectively extracted data from a prospectively maintained endoscopy database and the STAnford Research Repository (STARR). The endoscopy database and search tool were used to identify all patients who underwent endoscopic colonic stent placement and to identify the characteristics of these patients and stent placement procedures.

The frequency of colonic stent placement procedures increased significantly over time, when analyzed by stratified annual procedure volume and by comparison of the procedure volume for the initial 5-year interval (23 colonic stent procedures) relative to the latter 5-year interval (49 colonic stent procedures) (p = 0.03). The median age of patients who underwent colonic stent placement was significantly lower in the latter 5 years, compared with the initial 5 years of the study period (mean of 81.41 vs. 58.73 years, respectively, p < 0.001). The increased diversity of indications for colonic stent placement was noted over time. Colonic stent placement procedures were exclusively performed for malignant indications during the first half of the study period (23 colonic stent procedures). During the last half of the study period, 16.3% (8/49) of colonic stent placement procedures were performed for benign indications.

Indications for Colonic Stent Placement

Colonic stent placement has been integrated into clinical practice since it was first described in the 1990s, traditionally as a bridge to the surgical resection of a malignant lesion or for palliation in patients whose colorectal malignancy was not amenable to surgical resection.

The analysis of patients with benign indications for colonic stent placement (n = 8) was notable for a range of indications, including large bowel obstruction due to diverticulitis, inflammatory bowel disease, anastomotic colonic strictures and endometriosis. Technical success was 100% and 7/8 (87.5%) of patients experienced clinical improvement in their symptoms following colonic stent placement. Of these procedures, 75% (6/8) were performed as a bridge to surgical intervention, and 25% (2/8) were placed with a definitive intent for stricture therapy.

Colonic Stent Placement Procedure

Colonoscopy and flexible sigmoidoscopy with stent placement were performed using standard techniques. All procedures during the study period were performed with anesthesia support (monitored anesthesia care or general anesthesia). Prior to colonic stent placement procedures, all patients undergo cross-sectional imaging for assessment of the site and characteristics of colonic obstruction. In preparation for the procedure, for patients who have a bowel obstruction, oral bowel preparation is avoided and, instead, serial tap water enemas are administered to the patient to clear stool burden distal to the site of colonic obstruction.

The colonic stent placement procedure is typically performed with the patient in the left lateral decubitus or supine position on the fluoroscopy table. The colonoscope or therapeutic gastroscope is then advanced through the colon to the site of obstruction using the water immersion technique with only minimal carbon dioxide when necessary to avoid over-distension of the colon proximal to the stricture. Once the site of obstruction is visualized, a long 0.035″ guidewire is advanced through the narrowed lumen of the colon. The location of the guidewire is evaluated on fluoroscopy images and a cannula is then advanced beyond the area of obstruction. Contrast is injected to opacify the colon proximal to the stricture, the stricture itself and the colon distal to the stricture.

Once the length and characteristics of the stricture are determined, the self-expanding metallic stent length is determined. The length is selected to allow for at least 2 cm of stent proximal to and distal to the stricture. Self-expanding metallic stents exert additional radial force following stent placement, which can help facilitate patency, but this radial force is also associated with some foreshortening of the stent. For strictures at flexures (e.g., hepatic flexure or splenic flexure), longer stents may be necessary to ensure that the full length of the stricture is traversed and to allow for foreshortening of the stent during stent expansion. At the time of stent deployment, the flexible stent deployment sheath, which is a flexible catheter that houses the SEMS, is advanced over the guidewire (the guidewire that traverses the stricture). This stent over the guidewire is advanced through the scope. Deployment is then accomplished under endoscopic and fluoroscopic guidance, with the goal of having at least 2 cm of stent proximal and 2 cm of stent distal to the stricture. Upon full deployment, fluoroscopy should demonstrate a ‘waist’ (narrowing) of the stent at the site of the stricture.

Colonic stent placement often occurs on an inpatient basis, and patients often remain admitted for at least a day following colonic stent placement to evaluate for the resolution of obstruction symptoms and to monitor any acute adverse events associated with colonic stent placement.

Types of Colonic Stents

Many metallic stents have been used for the management of colonic obstruction. Despite the commercial availability of a variety of designs, the current generation of stents continues to be modified and improved. The majority of the current stents in use are made of Nitinol or stainless steel.

The different types of metallic stents include:

Wallstent Uni Endoprosthesis (Meditech-Boston Scientific; La Garenne Colombes Cedex, France)
Colonic Z-Stent (William Cook Europe; Bjaeverskov, Denmark)
Memotherm colorectal stent (CR Bard Inc; Billerica, MA, USA)
Precision stent (Microvasive-Boston Scientific, La Garenne Colombes Cedex, France)
Stent Choostent (Life Europe; Bagnolet, France)

The Wallstent is a self-expandable stent made with a nonferromagnetic alloy. It is the most commonly used device. Advantages of this stent include the small delivery system and adequate flexibility. A disadvantage of this stent is the termination of the stent with the presence of free filaments at the ends of the stent.

Post-Procedure Diet Recommendations

At the time of discharge from the hospital, patients are advised to eat a low-residue diet with the avoidance of insoluble fiber and to take laxatives (often Miralax) to facilitate liquid/semi-liquid stool consistency (and thus avoid solid stool occluding the stent lumen).

Read also: Diet for Optimal Stent Recovery

Low-Residue Diet Explained

The low-residue diet is an eating plan used to reduce the amount of undigested food that passes through the body. It involves limiting how much fiber you eat in a day so that your body produces less stool. Certain cancer treatments irritate the digestive tract or make it difficult to pass stool. The low-residue diet can promote the movement of solid food through the digestive tract. This lessens the risk of bowel obstructions.

Key Dietary Guidelines

Limit the amount of fiber you consume in a day to 12 grams. Avoid foods with more than 2 grams of fiber per serving. Grains are a good place to start when you are looking for ways to eliminate fiber from your diet.
Staying hydrated can help you stay regular. Limit beverages containing high-fructose corn syrup to 12 ounces per day.
Raw vegetables and even certain cooked vegetables can irritate the gastrointestinal tract. Eat vegetables that are well cooked and choose fruits that have a soft texture, like melon and bananas. Avoid vegetables that can cause gas, such as broccoli, brussels sprouts, and cabbage.
Limit fats and oils to less than 8 teaspoons a day if you are having diarrhea. If you are lactose intolerant, drinking milk products from cows or goats may make diarrhea worse. Take extra care when choosing dairy products.

Practical Tips for Maintaining a Healthy Low-Fiber Diet

Include a wide variety of foods in your diet to ensure you are getting sufficient nutrients.
Incorporate well-cooked vegetables and canned or raw fruits that are soft in texture.
Enjoy small portions of fruits and vegetables in smoothies, shakes, or soups in combination with other nonfibrous ingredients.
Drinking plenty of fluids is the best way to stay regular. Exercise can also help.
Utilize kitchen tools - such as an immersion blender, food processer, or juicer - for creative ways to incorporate fruits and vegetables safely.

Foods to Favor

Grains: White rice, refined pasta, white bread, cereals with less than 1 gram of fiber per serving.
Proteins: Tender, well-cooked meats, poultry, fish, eggs, tofu.
Dairy: Milk, yogurt, cheese (if tolerated).
Fruits: Cooked or canned fruits without skin or seeds, soft raw fruits like bananas and melons.
Vegetables: Well-cooked vegetables without skin or seeds, such as carrots, green beans, and spinach.
Fats: Limited amounts of butter, margarine, and oils.

Foods to Avoid

Grains: Whole wheat bread, brown rice, whole grain pasta, high-fiber cereals.
Proteins: Tough, chewy meats, processed meats with casings.
Dairy: Dairy products if lactose intolerant.
Fruits: Raw fruits with skin or seeds, dried fruits.
Vegetables: Raw vegetables, vegetables that cause gas (broccoli, cabbage, Brussels sprouts), corn, peas.
Fats: High-fat foods, fried foods.

Additional Considerations

Some individuals have shared their personal experiences and tips for managing bowel issues post-colonic stent or related surgeries:

Avoid heavy greens, raw or lightly cooked broccoli/cabbage.
Flax seed, fruit, whole grains, soft greens/lettuce may be helpful.
Chew food well and avoid overeating.
Drink water before and after meals.
Prune juice, pears, and apples can help stimulate bowel movements.
Licorice may also be helpful for some individuals.

Potential Complications and Management

Minor complications related to colon stent placement such as mild to moderate rectal bleeding, transient anorectal pain, temporary incontinence, and fecal impaction are common in many reports. More severe life-threatening complications are also described, including procedure-related deaths. In a review by Khot and associates, 3 of 598 patients (1%) died from colon perforation and unsuccessful decompression.

Common Complications

Perforation: Occurred in 22 of 598 patients (3.6%). There was a higher incidence of perforation in the prestent dilatation group (10%).
Stent Migration: Stent migration occurred in 54 of 551 patients (9.8%). Stent migration usually occurred after an average of 3 days.
Obstruction: Obstruction after successful initial stent decompression occurred in 52 of 525 patients (9.9%). This phenomenon was related to tumor ingrowth in 32 patients, stent migration in 7 patients, and fecal impaction in 13 patients.
Bleeding: Mild to moderate low gastrointestinal bleeding occurred in 24 patients and major bleeding in 3 patients (4.5% total).
Pain: Minor abdominal or rectal pain was described in 31 of 598 patients (5.1%).

Managing Complications

Regular Monitoring: Following stent placement, patients should be monitored for any signs of complications such as abdominal pain, bleeding, or changes in bowel habits.
Medications: Medications such as stool softeners and pain relievers may be prescribed to manage symptoms and prevent further complications.
Dietary Adjustments: Adhering to a low-residue diet can help prevent fecal impaction and stent obstruction.
Follow-up Appointments: Regular follow-up appointments with the physician are essential to monitor the stent's position and function, as well as to address any concerns or complications that may arise.
Surgical Intervention: In severe cases, surgical intervention may be necessary to address complications such as perforation or stent migration.

Alternatives to Colonic Stents

While colonic stents offer several advantages, there are alternative treatment options for colonic obstruction, including:

Emergency Surgery: This involves immediate surgical intervention to relieve the obstruction, which may include removing the affected portion of the colon or creating a colostomy.
Colostomy: This involves creating an opening in the abdomen through which stool can be diverted into a bag, bypassing the obstructed area of the colon.
Balloon Dilation: This involves using a balloon catheter to widen the narrowed area of the colon, although this may not be suitable for all types of obstructions.

The choice of treatment depends on various factors, including the cause and severity of the obstruction, the patient's overall health, and the physician's expertise.

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