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Basiliya K, Galanopoulos M, Papaefthymiou A, Webster G, Carroll N, Fearnhead NS, Corbett G. Similar success rate in proximal and distal colonic stent placement: a retrospective multi-center study. Scand J Gastroenterol 2024; 59:108-111. [PMID: 37694882 DOI: 10.1080/00365521.2023.2254877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES Stenting of malignant colon obstruction is used as a bridge to surgery or as an alternative to surgical colostomy in a palliative setting. Current guidelines recommend stent placement as the first line of treatment in colonic obstruction in both curative and palliative settings. However, it is unclear whether the location of the malignant obstruction influences the outcome of the stenting procedure. The goal of this study was to compare the outcomes of colonic stents between proximal and distal colonic strictures with regard to technical and clinical success and the risk of adverse events. METHODS A multi-center retrospective cohort was composed of patients who underwent a colonic stent placement at two tertiary hospitals between 2013 and 2021. The technical and clinical outcome, stent type used, duration of post-procedural hospital stay and complications were noted. RESULTS A total of 148 patients who underwent colonic stenting were identified. 41 patients underwent stent placement in the proximal colon and 107 patients underwent a distal stent placement. There was no difference in technical success (100% vs 96.3%, p = 0.209), clinical success (97.0% vs 89.6%, p = 0.199) or complications (24.4% vs 37.4%, p = 0,135). CONCLUSION Technical success and clinical success rates are high and do not differ between stent locations. There is no significant difference in complication rates between proximal and distal colonic stents.
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Affiliation(s)
- K Basiliya
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - M Galanopoulos
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Papaefthymiou
- Pancreaticobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Webster
- Pancreaticobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Carroll
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Department of General Surgery, Colorectal Surgery Unit, Cambridge, UK
| | - G Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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2
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Konopke R, Schubert J, Stöltzing O, Thomas T, Kersting S, Denz A. Predictive factors of early outcome after palliative surgery for colorectal carcinoma. Innov Surg Sci 2021; 5:91-103. [PMID: 34966831 PMCID: PMC8668025 DOI: 10.1515/iss-2020-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/27/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives A significant number of patients with colorectal cancer are presented with various conditions requiring surgery in an oncologically palliative setting. We performed this study to identify risk factors for early outcome after surgery to facilitate the decision-making process for therapy in a palliative disease. Methods We performed a retrospective chart review of 142 patients who underwent palliative surgery due to locally advanced, complicated, or advanced metastatic colorectal carcinoma between January 2010 and April 2018 at the "Elbland" Medical Center Riesa. We performed a logistic regression analysis of 43 factors to identify independent predictors for complications and mortality. Results Surgery included resections with primary anastomosis (n=31; 21.8%) or discontinuous resections with colostomy (n=38; 26.8%), internal bypasses (n=27; 19.0%) and stoma formation only (n=46; 32.4%). The median length of hospitalization was 12 days (2-53 days), in-hospital morbidity was 50.0% and the mortality rate was 18.3%. Independent risk factors of in-hospital morbidity were age (HR: 1.5, p=0.046) and various comorbidities of the patients [obesity (HR: 1.8, p=0.036), renal failure (HR: 1.6, p=0.040), diabetes (HR: 1.6, p=0.032), alcohol abuse (HR: 1.3, p=0.023)] as well as lung metastases (HR: 1.6, p=0.041). Arteriosclerosis (HR: 1.4; p=0.045) and arterial hypertension (HR: 1.4, p=0.042) were independent risk factors for medical complications in multivariate analysis. None of the analyzed factors predicted the surgical morbidity after the palliative procedures. Emergency surgery (HR: 10.2, p=0.019), intestinal obstruction (HR: 9.2, p=0.006) and ascites (HR: 5.0, p=0.034) were multivariate significant parameters of in-hospital mortality. Conclusions Palliatively treated patients with colorectal cancer undergoing surgery show high rates of morbidity and mortality after surgery. In this retrospective chart review, independent risk factors for morbidity and in-hospital mortality were identified that are similar to patients in curative care. An adequate selection of patients before palliative operation should lead to a better outcome after surgery. Especially in patients with intestinal obstruction and ascites scheduled for emergency surgery, every effort should be made to convey these patients to elective surgery by interventional therapy, such as a stent or minimally invasive stoma formation.
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Affiliation(s)
- Ralf Konopke
- Elblandklinikum Riesa, Zentrum für Allgemein- und Viszeralchirurgie Riesa-Meißen, Meissen, Germany
| | - Jörg Schubert
- Elblandklinikum Riesa, Klinik für Innere Medizin II, Meissen, Germany
| | - Oliver Stöltzing
- Elblandklinikum Riesa, Zentrum für Allgemein- und Viszeralchirurgie Riesa-Meißen, Meissen, Germany
| | - Tina Thomas
- Universitätsklinikum Dresden, Medizinische Klinik I, Dresden, Germany
| | - Stephan Kersting
- Universitätsmedizin Greifswald, Klinik und Poliklinik für Allgemeine Chirurgie, Viszeral-, Thorax- und Gefäßchirurgie, Greifswald, Germany
| | - Axel Denz
- Chirurgische Klinik, Universitätsklinikum Erlangen, Erlangen, Germany
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Kwaan MR, Ren Y, Wu Y, Xirasagar S. Colonic Stent Use by Indication and Patient Outcomes: A Nationwide Inpatient Sample Study. J Surg Res 2021; 265:168-179. [PMID: 33940240 DOI: 10.1016/j.jss.2021.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 02/14/2021] [Accepted: 03/22/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Colonic stent placement can avoid urgent surgery for large bowel obstruction in selected patients. Population-wide stent utilization patterns and outcomes are unknown. MATERIALS AND METHODS Using retrospective, population-based, Nationwide Inpatient Sample data, we studied patients with colonic stents discharged during 2010-2015. The primary outcome was ostomy creation during the same hospitalization. Other outcomes were perforation or peritonitis, and in-hospital death. Associations of outcomes with stent indication were investigated, adjusting for patient-, admission-, and hospital characteristics. We estimated annual population-wide stent use volumes. RESULTS Of 4257 patients with stent placement (52% male, mean age 64.6 years), 9.9% had non-metastatic colon cancer, 12.9% metastatic colon cancer, 37.8% extracolonic malignancy (ECM), and 39.3% had benign obstruction. In 8.1% of patients, ostomy creation surgery was performed. Perforation or peritonitis occurred in 16.7%, and in-hospital death in 4.5%. Relative to ECM, ostomy creation was several-fold more likely among nonmetastatic colon cancer (adjusted odds ratio (OR) 3.4; 95%CI, 2.1-5.5), metastatic colon cancer (adjusted OR 2.5; 95%CI, 1.7-3.7), and benign obstruction patients (adjusted OR 3.1; 95%CI, 2.1-4.7). Benign obstruction was associated with high risk of perforation/peritonitis (adjusted OR 3.1 relative to non-metastatic CC (95%CI, 2.1-4.5)). Perforation/peritonitis was highly associated with inpatient death (adjusted OR 6.8 (95%CI, 4.9-9.5)). Annually, about 3,580 patients underwent stent placement, with benign obstruction showing an increasing trend (P=0.0002). CONCLUSIONS Over 75% of stent placements were done for patients with benign disease and ECM obstruction. Subsequent ostomy creation during the hospitalization was least likely among ECM patients. Rates of perforation/peritonitis in benign obstructions were concerningly high. (22.2%).
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Affiliation(s)
- Mary R Kwaan
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Yang Ren
- University of South Carolina, Department of Computer Science and Engineering, Columbia, SC
| | - Yuqi Wu
- University of South Carolina, Department of Health Services Policy and Management, Columbia, SC
| | - Sudha Xirasagar
- University of South Carolina, Department of Health Services Policy and Management, Columbia, SC
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Morino M, Arezzo A, Farnesi F, Forcignanò E. Colonic Stenting in the Emergency Setting. ACTA ACUST UNITED AC 2021; 57:medicina57040328. [PMID: 33915760 PMCID: PMC8067149 DOI: 10.3390/medicina57040328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 01/10/2023]
Abstract
Nowadays, colorectal cancer (CRC) is the third most frequent cancer, and about a third of patients with CRC presents themselves with symptoms of large bowel obstruction. Historically, surgical resection was the treatment of choice for colonic obstruction, but this kind of approach is burdened by a high risk of postoperative morbidity and mortality. In recent times, the use of a colonic stent has been proposed to overcome the obstruction and transform an emergency surgical case into an elective one to avoid emergency surgery complications. Endoscopic stenting is the first-line treatment option in the palliative management of colonic obstruction, and there is sufficient scientific evidence to support this approach. However, endoscopic stent used as a bridge to surgery is not yet widely adopted because the concern was raised about the long-term survival and cancer safety of this approach. The recent scientific evidence has shown that this approach improves the short-term outcomes, such as postoperative complications and the stoma rate, without differences in long-term outcomes compared to emergency surgery. Therefore, the European Society for Gastrointestinal Endoscopy in 2020 has reconsidered stenting as a bridge to surgery as a valid alternative to emergency surgery.
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Matsuda A, Yamada T, Matsumoto S, Shinji S, Ohta R, Sonoda H, Takahashi G, Iwai T, Takeda K, Sekiguchi K, Yoshida H. Systemic Chemotherapy is a Promising Treatment Option for Patients with Colonic Stents: A Review. J Anus Rectum Colon 2021; 5:1-10. [PMID: 33537495 PMCID: PMC7843144 DOI: 10.23922/jarc.2020-061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023] Open
Abstract
Approximately 10% of patients with colorectal cancer (CRC) develop malignant large bowel obstruction (MLBO) at diagnosis. Furthermore, for 35% of patients with MLBO, curative primary tumor resection is unfeasible because of locally advanced disease and comorbidities. The practice of placing a self-expandable metallic stent (SEMS) has dramatically increased as an effective palliative treatment. Recent advances in systemic chemotherapy for metastatic CRC have significantly contributed to prolonging patients' prognosis and expanding the indications. However, the safety and efficacy of systemic chemotherapy in patients with SEMS have not been established. This review outlines the current status of this relatively new therapeutic strategy and future perspectives. Some reports on this topic have demonstrated that 1) systemic chemotherapy and the addition of molecular targeted agents contribute to prolonged survival in patients with SEMS; 2) delayed SEMS-related complications are a major concern, and this requires strict patient monitoring; however, primary tumor control by chemotherapy might result in decreased complications, especially regarding re-obstruction; and 3) using bevacizumab could be a risk factor for SEMS-related perforation, which may be lethal. Although this relatively new approach for unresectable stage IV obstructive CRC requires a well-planned clinical trial, this therapy could be promising for patients who are unideal candidates for emergency surgery and require immediate systemic chemotherapy.
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Affiliation(s)
- Akihisa Matsuda
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Yamada
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Satoshi Matsumoto
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Kamagari, Inzai, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Ryo Ohta
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiromichi Sonoda
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Goro Takahashi
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takuma Iwai
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kohki Takeda
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kumiko Sekiguchi
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Weston BR, Patel JM, Pande M, Lum PJ, Ross WA, Raju GS, Lynch PM, Coronel E, Ge PS, Lee JH. Efficacy of uncovered colonic stents for extrinsic versus intrinsic malignant large bowel obstruction. Surg Endosc 2020; 35:4511-4519. [PMID: 32909212 DOI: 10.1007/s00464-020-07965-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 08/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Previous studies evaluating self-expandable metal stents (SEMS) for management of malignant extrinsic colon obstruction have yielded conflicting results. We evaluated the efficacy of uncovered SEMS for extrinsic colon malignancy (ECM) versus intrinsic colon malignancy (ICM). METHODS Retrospective review of all patients referred for colonic SEMS at a tertiary cancer center between 2007 and 2018 was performed. Primary outcome measures were technical success, clinical success, intervention rate, and overall survival. RESULTS 138 patients with ECM and 119 patients with ICM underwent attempted stent placement. The rectum and/or sigmoid colon was the most common stricture site. Technical success was lower in the ECM group [86% vs 96% (p = .009)]. Clinical success was lower in the ECM group both at 7 days [82% vs 95% (p = .004)] and at 90 days [60% vs 86% (p < .001)]. Subsequent intervention was required more frequently [44% vs 35%; p = .23] and earlier [median 9 vs 132 days; p < .001] in the ECM group. Median overall survival in the ECM group was 92 vs 167 days. Among predictive variables analyzed, the ECM group had a higher frequency of peritoneal metastasis (87% vs 32%; p < .001), multifocal strictures with requirement for multiple stents (20% vs 6%; p = .002), sharp angulated strictures (39% vs 25%; p = .04) , and radiation therapy (21% vs 10%; p = .02). CONCLUSIONS Colonic SEMS for ECM is associated with lower technical and clinical success with earlier intervention rates compared with ICM. Our findings can be used to better inform patients and referring providers as well as guide new stent design to enhance efficacy in this population.
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Affiliation(s)
- Brian R Weston
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA.
| | - Jigar M Patel
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Mala Pande
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Phillip J Lum
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - William A Ross
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Gottumukkala S Raju
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Patrick M Lynch
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Emmanuel Coronel
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Phillip S Ge
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Jeffrey H Lee
- Department Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
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7
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Seo SY, Kim SW. Endoscopic Management of Malignant Colonic Obstruction. Clin Endosc 2020; 53:9-17. [PMID: 31906606 PMCID: PMC7003005 DOI: 10.5946/ce.2019.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.
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Affiliation(s)
- Seung Young Seo
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital and Medical School, Jeonju, Korea
| | - Sang Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital and Medical School, Jeonju, Korea
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Søreide JA, Tholfsen T, Karlsen LN, Kvaløy JT, Kørner H. Palliative surgical outcome score (PSOS) in patients treated palliatively with self-expanding metal stent (SEMS) for malignant incurable colorectal obstruction. Surg Oncol 2019; 29:134-139. [PMID: 31196477 DOI: 10.1016/j.suronc.2019.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/07/2019] [Accepted: 04/28/2019] [Indexed: 12/11/2022]
Abstract
AIM The palliative surgical outcome score (PSOS) was proposed for evaluation of the effect of palliative surgical interventions. As a surrogate measure for successful symptom control, it is defined as the proportion of days outside the hospital of the remaining life time up to six months after a palliative intervention. In this study we evaluate the PSOS in patients treated palliatively with self-expanding metal stents (SEMSs) for incurable malignant colorectal obstruction. METHODS All eligible patients endoscopically treated with palliative intent with SEMSs were identified. Demographics and clinical characteristics, including complete follow-up, were recorded, and the PSOS was calculated. Non-parametric tests were used for comparisons, and survival was evaluated by univariable and multivariable analyses. RESULTS Between 2005 and 2013, 116 patients (median age 71.5 years; 53.4% women) were identified. Most obstructions were caused by primary colorectal cancers. Technical- and clinical success rates were 94.0% and 87.1%, respectively. Procedure-related complications occurred in 17 (14.7%) of the patients, and most were minor. A PSOS>70 (regarded as excellent palliation) was achieved in 79 (68.1%) patients. This goal was significantly more often achieved in patients who survived at least 6 months than in those with shorter survival (p < 0.001). No clinical variables at the time of the endoscopic palliative procedure could predict a PSOS>70. However, in patients who survived at least 6 months (n = 69), a PSOS>70 was independently associated with better survival in the multivariable Cox analysis. CONCLUSIONS PSOS could be used as a practical proxy or a pragmatic tool for the effectiveness of palliative interventions, when such interventions are compared. Clinical factors that could significantly add to the clinical decision-making and predict a PSOS>70 in an individual patient were not identified for this specific group of patients.
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Affiliation(s)
- Jon Arne Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tore Tholfsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Lars Normann Karlsen
- Department of Gastroenterology, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, Stavanger, Norway; Department of Mathematics and Physics, University of Stavanger, Norway
| | - Hartwig Kørner
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Regional Centre of Palliative Medicine in Western Norway, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Abstract
PURPOSE OF REVIEW Rectal cancer is predominantly a disease of older adults but current guidelines do not incorporate the associated specific challenges leading to wide variation in the delivery of cancer care to this subset of population. Here, we will review the current data available regarding the management of rectal cancer in older adults. RECENT FINDINGS The greatest challenge arises in the management of stage II/III disease as it involves tri-modality treatment that can be harder to tolerate by frail older patients. Response to neoadjuvant treatment is being used as a new marker to tailor further therapy and possibly avoid surgery. Oxaliplatin can be omitted from the adjuvant treatment without compromising outcomes. Physicians should perform geriatric assessment utilizing many validated tools available to help predict treatment tolerability and outcomes in older adults that can help personalize subsequent management. Most older adults can undergo standard therapy for stages I, II, or III rectal cancer with curative intent. Increasing evidence suggests that patients with a clinical complete response to neoadjuvant treatment may be observed closely with the possibility of avoiding surgery. Studies are evaluating alternate systemic treatments for advanced metastatic disease with the hope of maintaining quality of life without compromising cancer outcomes.
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To resect or not to resect: The hamletic dilemma of primary tumor resection in patients with asymptomatic stage IV colorectal cancer. Crit Rev Oncol Hematol 2018; 132:154-160. [PMID: 30447921 DOI: 10.1016/j.critrevonc.2018.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/05/2018] [Indexed: 02/07/2023] Open
Abstract
Primary tumor resection (PTR) in advanced asymptomatic colorectal cancer (CRC) has been a matter of intense debate for long time. With the advances in systemic treatments, this practice has decreased over the years, although it remains still pervasive. Although the removal of primary tumor has been extensively interrogated both in retrospective and prospective studies, it still remains a clinical conundrum. There are many arguments for and against PTR in CRC both from the preclinical and the clinical point of view. Two scoring models have been published aiming at identifying patients who are suitable candidate for PTR, but they deserve further investigations in larger datasets. While awaiting the results of ongoing randomized clinical trials (RCTs) on this controversial topic, both upfront systemic treatment and PTR followed by chemotherapy should be considered valid options in patients with asymptomatic mCRC. Clinical selection and a shared-decision making approach are the keys to success.
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11
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A Pediatric Nasogastroscope Facilitates Colorectal Endoscopic Stenting. Surg Laparosc Endosc Percutan Tech 2018; 28:e109-e112. [PMID: 30300253 DOI: 10.1097/sle.0000000000000574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Endoscopic placement of self-expandable metal stents (SEMSs) to relieve malignant colorectal obstruction has been widely accepted in clinical practice. Despite increasing experience, early and late complications occur with an incidence ranging from 4% to 20%. MATERIALS AND METHODS We have adopted a modification in the technique. A pediatric nasogastroscope (4.8 mm in diameter) has been used to pass the obstruction. It is possible to have a direct vision of the anatomy and pathology, and to pass the guidewire above the obstruction, through the nasogastroscope, under direct vision. Fluoroscopy was also used to follow the course of the guidewire and deployment of the stent. RESULTS Early and late complications have been reduced with the new technique. CONCLUSIONS In the most recent experience of 64 patients, early and late complications have been reduced significantly. This new technique reduces radiation exposure by 70% for the patients and for the operators.
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Lim TZ, Chan DKH, Tan KK. Endoscopic stenting should be advocated in patients with stage IV colorectal cancer presenting with acute obstruction. J Gastrointest Oncol 2018; 9:785-790. [PMID: 30505576 DOI: 10.21037/jgo.2018.06.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background It remains contentious whether endoscopic stenting or upfront surgery is more optimal in patients with metastatic colorectal cancers presenting with large bowel obstruction. Methods A retrospective review of all patients with metastatic colorectal cancer who underwent either endoscopic stenting or emergency surgery for acute large bowel obstruction was performed. Results Between January 2007 and June 2014, 66 patients, median age, 64 (range, 25-96) years, presented with acute large bowel obstruction from metastatic colorectal cancer. Forty (60.6%) patients underwent endoscopic stenting whilst the rest received immediate upfront surgical intervention. Of the 40 patients, 29 (72.5%) were successfully stented. The remaining 11 (27.5%) patients who failed endoscopic stenting required immediate emergency surgery to relieve the obstruction. Patients who failed endoscopic stenting had worse complications than those patients who had their stents successfully inserted [odds ratio (OR), 23.3; 95% confidence interval (CI), 2.29-250.00, P=0.004]. Patients who underwent emergency surgery had a longer median length of stay than patients who had successful endoscopic stenting (P=0.003). The patients that underwent successful stenting had earlier commencement of chemotherapy compared to those who had upfront surgery (P=0.02). There was no difference in stoma creation rates between patients who had emergency surgery versus those who were successfully stented. Conclusions Stenting is a safe option in patients with stage IV colorectal cancer presenting with acute large bowel obstruction. Earlier commencement of chemotherapy occurs in patients who were successfully stented. Patients who failed stenting have equivalent outcomes to those who undergone upfront emergency surgery.
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Affiliation(s)
- Tian-Zhi Lim
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Dedrick Kok Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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13
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Outcomes of stent insertion and mortality in obstructive stage IV colorectal cancer patients through 10 year duration. Surg Endosc 2018; 33:1225-1234. [PMID: 30167945 DOI: 10.1007/s00464-018-6399-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/20/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal stents are frequently used in patients with stage IV colorectal cancer with obstruction. However, there are only few studies on changes in outcomes of these patients and on the effect of stents on outcome over a long period of time with ongoing changes in therapeutic strategy, including chemotherapy. METHODS We retrospectively evaluated 353 patients with bowel obstruction in stage IV colorectal cancer who underwent colonic stenting between years 2005 and 2014. The study population was divided into three groups based on time periods: 2005-2008, 2009-2011, and 2012-2014. RESULTS The frequency of colorectal stent insertion procedure increased over the time periods (13.8%, 18.3%, and 20.8%, respectively). There were no changes in success rate and total complication rate. However, the early complication rate in the 3rd period was significantly lower than in the other periods (15.4% vs. 17.1% vs. 7.2%; P = 0.039). In the multivariate analysis, carcinomatosis (hazard ratio, 1.478; 95% confidence interval, 1.016-2.149; P = 0.041) and covered or partial-covered stent (hazard ratio, 1.733; 95% confidence interval, 1.144-2.624; P = 0.009; hazard ratio, 1.988; 95% confidence interval, 1.132-3.493; P = 0.017, respectively) were associated with increased complication rate. Stent-related perforation was an independent risk factor related with increased mortality. Although survival duration increased over time (P = 0.042), the mortality rate was unchanged across the three time periods. CONCLUSIONS Over 10 years, the targeted agent use and survival duration increased, and early complication rate was decreased, without change in late complication rate or mortality rate during the three time periods in patients with obstructive stage IV colorectal cancer and stent insertion.
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14
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Clarke L, Abbott H, Sharma P, Eglinton TW, Frizelle FA. Impact of restenting for recurrent colonic obstruction due to tumour ingrowth. BJS Open 2018; 1:202-206. [PMID: 29951623 PMCID: PMC5989957 DOI: 10.1002/bjs5.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/07/2017] [Indexed: 11/08/2022] Open
Abstract
Background Endoscopic stenting is used to palliate malignant large bowel obstruction. A proportion of patients will develop recurrent obstruction due to tumour ingrowth and require reintervention. This study aimed to assess the outcome (clinical success and complication rates) of endoscopic reintervention compared with surgical intervention in patients with stent obstruction due to tumour ingrowth. Methods This was an observational study using data from a database of patients who underwent palliative colonic stenting between January 1998 and March 2017 at Christchurch Public Hospital. Results A total of 190 patients underwent colonic stent insertion, for palliation in 182 cases. Reintervention was performed in 55 (30·2 per cent). Thirty-one patients (17·0 per cent) developed obstruction within the stent at a median of 4·6 (i.q.r. 2·3-7·7) months after the procedure. Of these, 21 had endoscopic restenting and ten underwent surgery. Restenting had technical and clinical success rates of 100 per cent, and involved a significantly shorter length of stay compared with surgery (median 2 (i.q.r. 1-4) versus 11 (6-19) days respectively; P = 0·006). Seven of the 21 patients in the restented group underwent a third palliative intervention. The overall stoma rate in the restented group was significantly lower than that in the surgical group (4 of 21 versus 10 of 10; P < 0·001). There was no difference in complications or survival between the two groups. Conclusion Among palliative patients who develop malignant stent obstruction, endoscopic restenting had a high chance of technical success. It resulted in a shorter hospital stay and lower stoma rate than those seen after surgery.
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Affiliation(s)
- L Clarke
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - H Abbott
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - P Sharma
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - T W Eglinton
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand.,Department of Surgery, University of Otago Christchurch New Zealand
| | - F A Frizelle
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand.,Department of Surgery, University of Otago Christchurch New Zealand
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15
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Outcomes and complications of self-expanding metal stent placement for malignant colonic obstruction in a single-center study. Wideochir Inne Tech Maloinwazyjne 2017; 13:53-56. [PMID: 29643958 PMCID: PMC5890838 DOI: 10.5114/wiitm.2017.70194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/08/2017] [Indexed: 12/12/2022] Open
Abstract
Introduction Approximately 20% of cases of colorectal cancer are accompanied by acute colonic obstruction. While emergency colonic surgery is associated with high mortality and morbidity rates, placement of a self-expanding metal stent (SEMS) has been suggested as an alternative method. The SEMS placement can serve as either a definitive treatment in palliative cases or a bridge to surgery. Aim To summarize the experience of our center in the treatment of malignant colonic obstruction using SEMS placement. Material and methods A retrospective review was conducted of all patients who underwent a SEMS placement for colorectal stricture in the study period. The procedures were performed under fluoroscopic guidance with colonoscopic assistance, and uncovered stents were used in all patients. Results The study population consisted of 28 patients treated with SEMS placement due to malignant colonic obstruction. The majority of procedures were performed with palliative intent. The overall technical success rate was 96.5%, and clinical success was achieved in all of the successfully placed SEMSs. One fatal complication due to colonic perforation occurred. In the bridge-to-surgery group, all patients experienced tumor resection with no stoma creation. Conclusions The SEMS placement is an optimal treatment in the vast majority of acute colonic obstruction cases. Due to the possibility of potentially fatal complications, SEMS procedures should be performed by proficient endoscopists.
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16
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Newton K, Hill J. Colonic cancer: The current role of stent insertion. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Katherine Newton
- Department of General Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James Hill
- Department of General Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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17
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Fugazza A, Galtieri PA, Repici A. Using stents in the management of malignant bowel obstruction: the current situation and future progress. Expert Rev Gastroenterol Hepatol 2017; 11:633-641. [PMID: 28325090 DOI: 10.1080/17474124.2017.1309283] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The use of self-expanding metal stents (SEMS) has been considered an effective and safe alternative to emergency surgery as bridge to surgery or for palliation in advanced colorectal cancer even though more recent data have raised concerns on both early and long-term outcomes when patients are treated with bridge to surgery indications. Areas covered: A comprehensive literature review of articles on endoscopic management of malignant bowel obstruction was performed. Indication, technique, outcomes, benefits and risks of these treatments in acute malignant colonic obstruction were reviewed. The clinical effectiveness and safety of SEMS in obstructive colorectal cancer, as bridge to surgery or for palliation compared to surgery, is discussed. Expert commentary: SEMS placement, when performed in tertiary level center with appropriate expertise in colorectal stenting, may have several advantages over surgery avoiding the potential for surgical morbidity in a typically frail group of patients even though these advantages are to be carefully balanced over the risk of life-threatening, stent-related complications.
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Affiliation(s)
- Alessandro Fugazza
- a Digestive Endoscopy Unit, Division of Gastroenterology , Humanitas Research Hospital , Rozzano , Italy
| | - Piera Alessia Galtieri
- a Digestive Endoscopy Unit, Division of Gastroenterology , Humanitas Research Hospital , Rozzano , Italy
| | - Alessandro Repici
- a Digestive Endoscopy Unit, Division of Gastroenterology , Humanitas Research Hospital , Rozzano , Italy.,b Academic Department of Bioscience , Humanitas University , Rozzano , Italy
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18
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Sousa M, Pinho R, Proença L, Silva J, Ponte A, Rodrigues J, Carvalho J. Predictors of Complications and Mortality in Patients with Self-Expanding Metallic Stents for the Palliation of Malignant Colonic Obstruction. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:122-128. [PMID: 28848796 DOI: 10.1159/000452697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/11/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Self-expanding metallic stents (SEMS) for palliative purposes in malignant colonic obstruction are an alternative to surgery that has gained popularity over time. METHODS We performed a retrospective study of patients submitted to SEMS for palliation of obstructing malignant colorectal cancer from 2005 to 2015 to evaluate predictive clinical factors for complications and mortality. RESULTS Forty-five patients with high rates of technical and clinical success were included (97.8 and 95.6%, respectively), with complications occurring in 17.8% (8.9% perforations, 4.4% obstructions, and 4.4% migrations). The length of the stenosis was superior in patients with complications (p = 0.01); 11.1% of patients had a re-intervention (2.2% surgery and 8.9% placement of another SEMS). Relief of obstruction without intervention was maintained until death in 77.8% of patients and in 81.4% of patients who had immediate clinical success. The mortality rate was 37.2% at 30 days, 56.5% at 60 days, and 87.5% at 1 year. There were no predictors of survival identified, including age, sex, tumor stage, metastasis, or complications of the procedure. DISCUSSION AND CONCLUSIONS In this study, SEMS placement was associated with a high rate of technical and clinical success and a low rate of complications, being an option to palliate patients with obstructive neoplasia. The length of the stenosis was associated with a greater risk of complications. The majority of stent-related complications can be managed successfully without surgery.
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Affiliation(s)
- Mafalda Sousa
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Rolando Pinho
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Luísa Proença
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Joana Silva
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Ana Ponte
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Jaime Rodrigues
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - João Carvalho
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
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19
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Effect of preoperative colonic drainage for obstructing colorectal cancer. Int Surg 2016; 100:790-6. [PMID: 26011196 DOI: 10.9738/intsurg-d-14-00262.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Obstructing colorectal cancer (OCRC) is believed to indicate poorer long-term survival. The purpose of this study was to compare retrospectively perioperative safety and long-term results in patients undergoing surgery for OCRC following preoperative colonic decompression with that in those undergoing elective surgery alone for nonobstructing colorectal cancer (CRC). A total of 656 consecutive CRC patients undergoing colectomy between 2001 and 2011 at our institute were eligible for inclusion in the study. The patients were divided into an OCRC group, which included 104 patients undergoing colectomy with preoperative colonic decompression, and a CRC group, which included 552 patients undergoing colectomy alone. Morbidity, mortality, and prognosis were assessed. In the OCRC group, decompression was performed by nasointestinal tube in 42 patients (40.4%), transanal tube in 15 (14.4%), and colostomy in 47 (45.2%). The mortality rate was 0% in the OCRC group and 0.4% in the CRC group (2 of 552 patients). The morbidity rate was 44.8% in the OCRC group (48 of 104 patients) and 36.6% in the CRC group (202 of 552 patients). The 5-year overall survival rate was 69.5% in the OCRC group and 72.9% in the CRC group [hazard ratio 0.76; 95% confidence interval, 0.35 to 1.16; P = 0.48)]. No statistically significant difference in survival was observed between the 2 groups in stage II, III, or IV, or overall. No difference was observed in safety or survival between advanced OCRC patients undergoing preoperative colonic decompression and advanced non-obstructing CRC patients undergoing surgery alone.
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20
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Heriot AG. Colonic stenting in malignant large bowel obstruction: an unanswered question. ANZ J Surg 2016; 86:742-743. [PMID: 27701841 DOI: 10.1111/ans.13712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 07/05/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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21
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Öistämö E, Hjern F, Blomqvist L, Falkén Y, Pekkari K, Abraham-Nordling M. Emergency management with resection versus proximal stoma or stent treatment and planned resection in malignant left-sided colon obstruction. World J Surg Oncol 2016; 14:232. [PMID: 27577887 PMCID: PMC5006427 DOI: 10.1186/s12957-016-0994-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/23/2016] [Indexed: 01/10/2023] Open
Abstract
Background Emergency surgery for colon cancer, as a result of obstruction, has been vitiated by a high frequency of complications and poor survival. The concept of “bridge to surgery” includes either placement of self-expanding metallic stents (SEMS) or diverting stoma of an obstructing tumour and subsequent planned resection. The aim of this study was to compare acute resection with stoma or stent and later resection regarding surgical and oncological outcomes and total hospital stay. Methods This is a retrospective cohort study. All 2424 patients diagnosed with colorectal cancer during 1997–2013 were reviewed. All whom underwent acute surgery with curative intention for left-sided malignant obstruction were included in the study. Results One hundred patients fulfilled the inclusion criteria. Among them, 57 patients were treated with acute resection and 43 with planned resection after either acute diverting colostomy (n = 23) or stent placement (n = 20). The number of harvested lymph nodes in the resected specimen was higher in the planned resection group compared with acute resection group (21 vs. 8.7; p = 0.001). Fewer patients were treated with adjuvant chemotherapy in the acute resection group than in the stoma group (14 % (8/57 patients) vs. 43 %, (10/23 patients; p = 0.024)). Patients operated with acute resection had a higher 30-day mortality rate and were more frequently left with a permanent stoma. Conclusions Decompression of emergency obstructive left colon cancer with stent or stoma and subsequent curative resection appears safer and results in a higher yield of lymph node harvest, and fewer patients are left with a permanent stoma.
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Affiliation(s)
- Emma Öistämö
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Hjern
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lennart Blomqvist
- Department of Diagnostic Radiology, Department of Molecular Medicine and Surgery Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden
| | - Ylva Falkén
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Klas Pekkari
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mirna Abraham-Nordling
- Division of Coloproctology, Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden. .,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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22
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Laasch HU, Edwards DW, Song HY. Enteral stent construction: Current principles. GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Derek W. Edwards
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Ho-Young Song
- Department of Radiology, Asan Medical Center, Seoul, Korea
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23
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Amelung FJ, Ter Borg F, Consten ECJ, Siersema PD, Draaisma WA. Deviating colostomy construction versus stent placement as bridge to surgery for malignant left-sided colonic obstruction. Surg Endosc 2016; 30:5345-5355. [PMID: 27071927 DOI: 10.1007/s00464-016-4887-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/23/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute colonic decompression using a deviating colostomy (DC) or a self-expandable metal stent (SEMS) has been shown to lead to fewer complications and permanent stomas compared to acute resection in elderly patients with malignant left-sided colonic obstruction (LSCO). However, no consensus exists on which decompression method is superior, especially in patients treated with curative intend. This retrospective study therefore aimed to compare both decompression methods in potentially curable LSCO patients. METHODS All LSCO patients treated with curative intent between 2004 and 2013 in two teaching hospitals were retrospectively identified. In one institution, a DC was the standard of care, whereas in the other all patients were treated with SEMS. RESULTS In total, 88 eligible LSCO patients with limited disease and curative treatment options were included; 51 patients had a SEMS placed and 37 patients a DC constructed. All patients eventually underwent a subsequent elective resection. In sum, 235 patients were excluded due to benign or inoperable disease. No significant differences were found for hospital stay, morbidity, disease-free and overall survival and mortality. Major complications were seen in 13/51 (25.5 %) patients in the SEMS group and were mostly due to stent dysfunction (n = 7). Also, one stent-related perforation occurred. Major complications occurred in 4/37 (10.8 %) patients in the DC group, including abdominal sepsis (n = 3) and wound dehiscence (n = 1). Long-term complication rate was significantly higher in the DC group (29.7 vs. 9.8 %, p = 0.01), mainly due to a high incisional hernia rate. Fewer patients had a temporary colostomy following elective resection after SEMS placement (62.2 vs. 17.6 %, p < 0.01). Permanent colostomy rate was not significantly different. CONCLUSION SEMS and DC are both effective decompression methods for curable LSCO patients with comparable short- and long-term oncological outcomes; however, more surgical procedures are performed after DC due to an increased number of temporary colostomies and incisional hernia repairs.
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Affiliation(s)
- Femke J Amelung
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Werner A Draaisma
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
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24
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Cézé N, Charachon A, Locher C, Aparicio T, Mitry E, Barbieux JP, Landi B, Dorval E, Moussata D, Lecomte T. Safety and efficacy of palliative systemic chemotherapy combined with colorectal self-expandable metallic stents in advanced colorectal cancer: A multicenter study. Clin Res Hepatol Gastroenterol 2016; 40:230-8. [PMID: 26500200 DOI: 10.1016/j.clinre.2015.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 07/27/2015] [Accepted: 09/07/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE Self-expandable metallic stent (SEMS) placement is an accepted palliative therapy for management of acute malignant bowel obstruction in advanced colorectal cancer. Nevertheless, data are lacking on the effects of systemic chemotherapy combined with colorectal SEMS. The aim of this study was to investigate the safety and efficacy of palliative chemotherapy for advanced colorectal cancer combined with colorectal SEMS placement. PATIENTS AND METHODS This multicentre retrospective study included all consecutive advanced colorectal cancer patients who received first-line palliative chemotherapy combined with endoscopic stenting for colorectal cancer with obstruction. We analyzed the number of cycles and the type of combination used. The primary endpoint was overall survival. Secondary endpoints included progression-free survival, response rate, grade 3-4 toxicity and the outcomes of SEMS for malignant colorectal obstruction. RESULTS A total of 38 patients were included. Among them, 25 patients received oxaliplatin and 5-fluorouracil combination chemotherapy. Objective response and stabilization occurred in 38 and 24% of patients, respectively. The median overall survival and progression-free survival from the start of chemotherapy were 18 and 5months, respectively. The objective response rate and overall disease control rate were 38 and 62%, respectively. Toxicity was generally acceptable. Major complications related to stenting included perforation (8%), stent migration (5%), and reobstruction secondary to tumor ingrowths (13%). CONCLUSIONS Chemotherapy combined with colonic stenting as a first-line treatment seems to be a valid option in advanced colorectal cancer patients with malignant colorectal obstruction.
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Affiliation(s)
- Nicolas Cézé
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Antoine Charachon
- Department of Hepatogastroenterology, Henri Mondor University Hospital, AP-HP, Créteil, France
| | - Christophe Locher
- Department of Hepatogastroenterology, General Hospital of Meaux, France
| | - Thomas Aparicio
- Department of Hepatogastroenterology, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France
| | - Emmanuel Mitry
- Department of Clinical Oncology, Institut Curie St Cloud and Versailles St-Quentin University, France
| | - Jean-Pierre Barbieux
- Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Bruno Landi
- Department of Hepatogastroenterology and Digestive Oncology, Georges Pompidou European University Hospital, AP-HP, Paris, France
| | - Etienne Dorval
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Driffa Moussata
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Thierry Lecomte
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France.
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Abstract
Acute malignant colorectal obstruction (AMCO) is an emergency associated with colorectal cancer (CRC). Emergency surgery is standard therapy for AMCO, and 1-stage surgery without colostomy is preferable, but it is occasionally difficult in the emergency setting. A self-expandable metallic stent (SEMS) enables noninvasive colonic decompression and subsequent 1-stage surgery, which has been widely applied for CRC with AMCO. However, recent accumulation of high-quality evidence has highlighted some problems and the limited efficacy of SEMS for AMCO. In palliative settings, SEMS placement reduces hospital stay and short-term complication rates, whereas it increases the frequency of long-term complications, such as delayed perforation. SEMS placement does not seem compatible with recent standard chemotherapy including bevacizumab. As a bridge to surgery, while SEMS placement provides a lower clinical success rate than emergency surgery, it can facilitate primary anastomosis without stoma. However, evidence regarding long-term survival outcomes with SEMS in both palliative and bridge to surgery settings is lacking. The efficacy of transanal colorectal tube placement, another endoscopic treatment, has been reported, but its clinical evidence level is low due to the limited number of studies. This review article comprehensively summarizes the current knowledge about surgical and endoscopic management of CRC with AMCO.
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26
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Sagar J. Role of colonic stents in the management of colorectal cancers. World J Gastrointest Endosc 2016; 8:198-204. [PMID: 26962401 PMCID: PMC4766252 DOI: 10.4253/wjge.v8.i4.198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/14/2015] [Accepted: 12/21/2015] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer is one of the commonly encountered cancers across the Western World. In United Kingdom, this constitutes third most common ranked cancer and second most common ranked cause of cancer related deaths. Its acute presentation as a malignant colonic obstruction imposes challenges in its management. Colonic stent has been used for many years to alleviate acute obstruction in such cases allowing optimisation of patient’s physiological status and adequate staging of cancer. In this review, current literature evidence regarding use of colonic stent in acute malignant colonic obstruction is critically appraised and recommendations on the use of colonic stent are advocated.
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27
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Ahn HJ, Kim SW, Lee SW, Lee SW, Lim CH, Kim JS, Cho YK, Park JM, Lee IS, Choi MG. Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery. Surg Endosc 2016; 30:4765-4775. [PMID: 26895922 DOI: 10.1007/s00464-016-4804-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with unresectable colorectal cancer (CRC) obstruction, choosing whether to perform self-expandable metal stent (SEMS) or palliative surgery is challenging, especially in those with good performance status. We aimed to compare the long-term outcomes of SEMS with those of palliative surgery in patients with unresectable CRC obstruction. METHODS This retrospective study comprised 114 patients with unresectable CRC obstruction who underwent SEMS placement (n = 73) or palliative surgery (n = 41). The main outcome measurements were success rate, adverse events, patency, and survival duration. RESULTS Early clinical success rates did not differ between SEMS and surgery. However, the rate of late adverse events was significantly higher in the SEMS group (27.4 vs. 9.8 %; P = .005). Patency duration was shorter after SEMS than after surgery (163 vs. 349 days; P < .001), even after additional intervention (202 vs. 349 days; P < .001). The median survival was significantly shorter after SEMS than after surgery (209 vs. 349 days; P = .005). Survival differed between treatments in patients with Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (P = .016) but not in those with ECOG 2 or 3 (P = .487), and this was confirmed by multivariate analysis, which showed that surgery was a significant favorable predictor of survival for patients with ECOG 0 or 1 (hazard ratio .442; 95 % confidence interval .234-.835; P = .016). CONCLUSIONS Surgery may be preferable to SEMS for the palliation of unresectable CRC obstruction in patients with good performance status, especially ECOG 0 or 1.
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Affiliation(s)
- Hyo Jun Ahn
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Woo Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Sung Won Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soon Wook Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Management of intestinal obstruction in advanced malignancy. Ann Med Surg (Lond) 2015; 4:264-70. [PMID: 26288731 PMCID: PMC4539185 DOI: 10.1016/j.amsu.2015.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 02/07/2023] Open
Abstract
Patients with incurable, advanced abdominal or pelvic malignancy often present to acute surgical departments with symptoms and signs of intestinal obstruction. It is rare for bowel strangulation to occur in these presentations, and spontaneous resolution often occurs, so the luxury of time should be afforded while decisions are made regarding surgery. Cross-sectional imaging is valuable in determining the underlying mechanism and pathology. The majority of these patients will not be suitable for an operation, and will be best managed in conjunction with a palliative medicine team. Surgeons require a good working knowledge of the mechanisms of action of anti-emetics, anti-secretories and analgesics to tailor early management to individual patients, while decisions regarding potential surgery are made. Deciding if and when to perform operative intervention in this group is complex, and fraught with both technical and emotional challenges. Surgery in this group is highly morbid, with no current evidence available concerning quality of life following surgery. The limited evidence concerning operative strategy suggests that resection and primary anastomosis results in improved survival, over bypass or stoma formation. Realistic prognostication and involvement of the patient, care-givers and the multidisciplinary team in treatment decisions is mandatory if optimum outcomes are to be achieved.
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van Hooft JE, van Halsema EE, Vanbiervliet G, Beets-Tan RGH, DeWitt JM, Donnellan F, Dumonceau JM, Glynne-Jones RGT, Hassan C, Jiménez-Perez J, Meisner S, Muthusamy VR, Parker MC, Regimbeau JM, Sabbagh C, Sagar J, Tanis PJ, Vandervoort J, Webster GJ, Manes G, Barthet MA, Repici A. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Gastrointest Endosc 2014; 80:747-61.e1-75. [PMID: 25436393 DOI: 10.1016/j.gie.2014.09.018] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Emo E van Halsema
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Fergal Donnellan
- UBC Division of Gastroenterology, Vancouver General Hospital, Vancouver, Canada
| | | | | | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Javier Jiménez-Perez
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Søren Meisner
- Endoscopy Unit, Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, Denmark
| | - V Raman Muthusamy
- Division of Gastroenterology and Hepatology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | | | - Jean-Marc Regimbeau
- Department of Digestive and Oncological Surgery, University Hospital of Amiens, France
| | - Charles Sabbagh
- Department of Digestive and Oncological Surgery, University Hospital of Amiens, France
| | - Jayesh Sagar
- Department of Colorectal Surgery, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jo Vandervoort
- Department of Gastroenterology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - George J Webster
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Gianpiero Manes
- Department of Gastroenterology and Endoscopy, Guido Salvini Hospital, Garbagnate Milanese/Rho, Milan, Italy
| | - Marc A Barthet
- Department of Gastroenterology, Hôpital Nord, Aix Marseille Université, Marseille, France
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30
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van den Berg MW, Ledeboer M, Dijkgraaf MGW, Fockens P, ter Borg F, van Hooft JE. Long-term results of palliative stent placement for acute malignant colonic obstruction. Surg Endosc 2014; 29:1580-5. [DOI: 10.1007/s00464-014-3845-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 08/19/2014] [Indexed: 11/27/2022]
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Lim TZ, Chan D, Tan KK. Patients who failed endoscopic stenting for left-sided malignant colorectal obstruction suffered the worst outcomes. Int J Colorectal Dis 2014; 29:1267-73. [PMID: 24986142 DOI: 10.1007/s00384-014-1948-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking. OBJECTIVES This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting. METHODS A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed. RESULTS From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25-96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61-48.8; p < 0.001) times more likely to develop severe adverse events than those who were successfully stented. The group of patients who failed stenting was also 3.3 (95 % CI, 1.19-9.20; p = 0.026) times more likely to develop severe adverse events than those operated immediately. The only factor that predicted failure of stenting was a more acute angulation between the tumour and the distal lumen. CONCLUSIONS Patients who failed endoscopic stenting fared worse than those who were successfully stented and also those who underwent emergency surgery upfront. Identification of factors that predict failures may be vital to minimise morbidity in these high-risk patients.
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Affiliation(s)
- Tian-Zhi Lim
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Han SH, Lee JH. Colonic stent-related complications and their management. Clin Endosc 2014; 47:415-9. [PMID: 25325000 PMCID: PMC4198557 DOI: 10.5946/ce.2014.47.5.415] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 12/19/2022] Open
Abstract
Since its introduction in the early 1990s, the self-expandable metal stent (SEMS) has been increasingly used for the management of malignant colorectal obstruction, not only as a palliative method but also as a preoperative treatment in surgical candidates. However, more recently, concerns have been raised over stent complication rates. Early complications include pain, perforation, and rectal bleeding, and late complications include stent migration and stent obstruction. With the increasing use of SEMS for treatment, physicians need to be more aware of complications occurring after the placement of these stents. This review covers the technical considerations and management of complications after colonic stenting.
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Affiliation(s)
- Seung-Hee Han
- Department of Gastroenterology, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Jong Hoon Lee
- Department of Gastroenterology, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
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Finlayson A, Hulme-Moir M. Palliative colonic stenting: a safe alternative to surgery in stage IV colorectal cancer. ANZ J Surg 2014; 86:773-777. [DOI: 10.1111/ans.12821] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2014] [Indexed: 01/06/2023]
Affiliation(s)
- Andrew Finlayson
- General Surgery Department; North Shore Hospital; Auckland New Zealand
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Shigeta K, Baba H, Yamafuji K, Kaneda H, Katsura H, Kubochi K. Outcomes for patients with obstructing colorectal cancers treated with one-stage surgery using transanal drainage tubes. J Gastrointest Surg 2014; 18:1507-13. [PMID: 24871080 DOI: 10.1007/s11605-014-2541-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/13/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute colorectal obstruction requires immediate surgical treatment. Although one-stage surgery with transanal drainage tubes (TDT) is reportedly safe and feasible, the long-term outcome of this procedure remains unclear. AIM To assess the outcome of one-stage surgery using TDT in the acute left colon or rectal obstructions due to colorectal carcinomas. METHODS Clinicopathological data were recorded from patients with colorectal cancer with acute obstructions between 2006 and 2013. RESULTS A total of 43 patients were enrolled including 29 males and 14 females. Among 39 patients, TDT was successful in 33 (84 %) and was incomplete in 6. Thus, 33 patients received one-stage surgery with TDT decompression, and 9 patients, including 6 with incomplete decompression, received one-stage surgery with no decompression. No significant differences in clinicopathological factors were observed between decompression and non-decompression groups. Adjusted analyses revealed that decompression using TDT was significantly associated with OS (hazard ratio 0.24; 95 % confidence interval, 0.08-0.72; p = 0.01). Furthermore, OS in the TDT decompression group was significantly longer than that in the non-decompression group (p = 0.01). CONCLUSIONS One-stage surgery with decompression using TDT may be effective to avoid stomas and to improve overall survival in patients with obstructing colorectal cancers.
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Affiliation(s)
- Kohei Shigeta
- Department of Surgery, Saitama City Hospital, 2460 Mimuro, Midori-ku, Saitama-shi, Saitama, 336-8522, Japan,
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van Halsema EE, van Hooft JE. Outcome and complications of stenting for malignant obstruction. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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36
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Meisner S. Stent for palliation of advanced colorectal cancer. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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van den Berg MW, Sloothaak DAM, Dijkgraaf MGW, van der Zaag ES, Bemelman WA, Tanis PJ, Bosker RJI, Fockens P, ter Borg F, van Hooft JE. Bridge-to-surgery stent placement versus emergency surgery for acute malignant colonic obstruction. Br J Surg 2014; 101:867-73. [PMID: 24740753 DOI: 10.1002/bjs.9521] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic self-expanding metal stent (SEMS) placement as a bridge to surgery is an option for acute malignant colonic obstruction. There is ongoing debate regarding the superiority and oncological safety of SEMS placement compared with emergency surgery. This retrospective study aimed to compare outcomes of these treatment approaches. METHODS Patients were identified from cohorts treated between 2005 and 2012 in two teaching hospitals, of which one used emergency surgery only in patients with large bowel obstruction, whereas the other attempted SEMS placement. Only patients treated with curative intent were included. RESULTS The study included 59 patients in whom SEMS placement was attempted and 51 who underwent surgery alone. The successful primary anastomosis rate was higher in the SEMS group than in the surgery-alone group among patients with left-sided obstruction (30 of 43 versus 10 of 34 respectively; P = 0.001), whereas stoma formation was less common (11 of 43 versus 23 of 34; P < 0.001). Such differences were not apparent in patients with right-sided obstruction. Secondary stoma rates were comparable between treatment approaches (left-sided: 11 of 43 versus 13 of 34, P = 0.322; right-sided: 1 of 16 versus 1 of 17, P = 1.000). There were no significant differences in morbidity, mortality, recurrence or survival. CONCLUSION Endoscopic SEMS placement increased the primary anastomosis rate in patients with left-sided large bowel obstruction.
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Affiliation(s)
- M W van den Berg
- Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Deventer, The Netherlands
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