Bridge-to-surgery stent placement versus emergency surgery for acute malignant colonic obstruction

Colon cancer: the 2023 Korean clinical practice guidelines for diagnosis and treatment

Colorectal cancer is the third most common cancer in Korea and the third leading cause of death from cancer. Treatment outcomes for colon cancer are steadily improving due to national health screening programs with advances in diagnostic methods, surgical techniques, and therapeutic agents.. The Korea Colon Cancer Multidisciplinary (KCCM) Committee intends to provide professionals who treat colon cancer with the most up-to-date, evidence-based practice guidelines to improve outcomes and help them make decisions that reflect their patients' values and preferences. These guidelines have been established by consensus reached by the KCCM Guideline Committee based on a systematic literature review and evidence synthesis and by considering the national health insurance system in real clinical practice settings. Each recommendation is presented with a recommendation strength and level of evidence based on the consensus of the committee.

Surgical treatment and overall survival in patients with right-sided obstructing colon cancer-a nationwide retrospective cohort study

PURPOSE

The aim of this study was to compare baseline characteristics, 90-day mortality and overall survival (OS) between patients with obstructing and non-obstructing right-sided colon cancer at a national level.

METHODS

All patients who underwent resection for right-sided colon cancer between January 2015 and December 2016 were selected from the Netherlands Cancer Registry and stratified for obstruction. Primary outcome was 5-year OS after excluding 90-day mortality as assessed by the Kaplan-Meier and multivariable Cox regression analysis.

RESULTS

A total of 525 patients (7%) with obstructing and 6891 patients (93%) with non-obstructing right-sided colon cancer were included. Patients with right-sided obstructing colon cancer (OCC) were older and had more often transverse tumour location, and the pathological T and N stage was more advanced than in those without obstruction (p < 0.001). The 90-day mortality in patients with right-sided OCC was higher compared to that in patients with non-obstructing colon cancer: 10% versus 3%, respectively (p < 0.001). The 5-year OS of those surviving 90 days postoperatively was 42% in patients with OCC versus 73% in patients with non-obstructing colon cancer, respectively (p < 0.001). Worse 5-year OS was found in patients with right-sided OCC for all stages. Obstruction was an independent risk factor for decreased OS in right-sided colon cancer (HR 1.79, 95% CI 1.57-2.03).

CONCLUSION

In addition to increased risk of postoperative mortality, a stage-independent worse 5-year OS after excluding 90-day mortality was found in patients with right-sided OCC compared to patients without obstruction.

Postponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study

BACKGROUND

Right-sided obstructing colon cancer is most often treated with acute resection. Recent studies on right-sided obstructing colon cancer report higher mortality and morbidity rates than those in patients without obstruction. The aim of this study is to retrospectively analyse whether it is possible to optimise the health condition of patients with acute right-sided obstructing colon cancer, prior to surgery, and whether this improves postoperative outcomes.

METHOD

All consecutive patients with high suspicion of, or histologically proven, right-sided obstructing colon cancer, treated with curative intent between March 2013 and December 2019, were analysed retrospectively. Patients were divided into two groups: optimised group and non-optimised group. Pre-operative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression.

RESULTS

In total, 54 patients were analysed in this study. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. Scheduled surgery was performed after a median of eight days (IQR 7-12). Postoperative complications were found in twelve (50%) patients in the optimised group, compared to twenty-three (77%) patients in the non-optimised group (p = 0.051). Major complications were diagnosed in three (13%) patients with optimisation, compared to ten (33%) patients without optimisation (p = 0.111). Postoperative in-hospital stay, 30-day mortality, as well as primary anastomosis were comparable in both groups.

CONCLUSION

This pilot study suggests that pre-operative optimisation of patients with obstructing right sided colonic cancer may be feasible and safe but is associated with longer in-patient stay.

A Japanese Prospective, Multicenter Study of Colonic Stenting for Palliation Using a High Axial Force Self-Expandable Metal Stent for Malignant Large Bowel Obstruction in 200 Patients

Evidence of the efficacy and safety of colorectal stent placement for palliation remains insufficient. This single-arm, prospective, multicenter study with a WallFlex enteral colonic stent included 200 consecutive patients with malignant large bowl obstruction in the palliation cohort. The technical and clinical success, as well as stent patency and complications as short-term (≤7 days) and long-term (>7 days) outcomes, of high axial force self-expandable metal stent (SEMS) placement was evaluated. The technical and clinical success rates were 98.5% and 94.5%, respectively. Non-recurrent colorectal obstruction at 1 year was 63.9%, and 71.2% of the patients remained free of recurrent colorectal obstruction until death or the last follow-up. Fifty-six patients (28.0%) received chemotherapy, and five patients were administered bevacizumab after stent placement. The overall complication rate was 47%, including four (2.0%) early-onset and ten (5.0%) late-onset perforations, mostly due to stent-edge injury. Only the use of a long SEMS was a risk factor for perforation. In conclusion, endoscopic colorectal stenting using high axial force SEMS is an effective and safe procedure for palliation in patients with malignant colorectal obstruction. However, care should be taken to avoid perforation at the stent edge when using a long SEMS.

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis

BACKGROUND

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated.

OBJECTIVE

The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer.

DATA SOURCE

A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included.

INTERVENTION

Stent or emergency resection in right-sided obstructive colon cancer.

MAIN OUTCOME MEASURES

Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent.

RESULTS

A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016).

LIMITATION

No randomized controlled trials are available.

CONCLUSION

Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis

BACKGROUND

Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent.

METHODS

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed.

RESULTS

From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01).

CONCLUSIONS

Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

Preoptimisation in patients with acute obstructive colon cancer (PREOCC) - a prospective registration study protocol

BACKGROUND

Postoperative mortality and morbidity rates are high in patients with obstructing colon cancer (OCC). Different treatment options have been evaluated over the years, mainly for left sided OCC. Optimising the preoperative health condition in elective colorectal cancer (CRC) treatment shows promising results. The aim of this study is to determine whether preoptimisation is feasible in patients with OCC, with a special interest/focus on right-sided OCC, and if, ultimately, optimisation reduces mortality and morbidity (stoma rates, major and minor complications) rates in OCC.

METHODS

This is a prospective registration study including all patients presenting with OCC in our hospital. Patients with OCC, treated with curative intent, will be screened for eligibility to receive preoptimisation before surgery. The preoptimisation protocol includes; decompression of the small bowel with a NG-tube for right sided obstruction and SEMS or decompressing ileostomy or colostomy, proximal to the site of obstruction, for left sided colonic obstructions. For the additional work-up, additional nutrition by means of parenteral feeding (for patients who are dependent on a NG tube) or oral/enteral nutrition (in case the obstruction is relieved) is provided. Physiotherapy with attention to both cardio and muscle training prior surgical resection is provided. The primary endpoint is complication-free survival (CFS) at the 90 day period after hospitalisation. Secondary outcomes include pre- and postoperative complications, patient- and tumour characteristics, surgical procedures, total in hospital stay, creation of decompressing and/or permanent ileo- or colostomy and long-term (oncological) outcomes.

DISCUSSION

Preoptimisation is expected to improve the preoperative health condition of patients and thereby reduce postoperative complications.

TRIAL REGISTRATION

Trial Registry: NL8266 date of registration: 06-jan-2020.

STUDY STATUS

Open for inclusion.

Recent Updates in Gastrointestinal Stent Placement from the Esophagus to the Colon: A Radiological Perspective

Fluoroscopic-guided stent placement has become an advantageous treatment option for diverse gastrointestinal disorders. In addition to palliative stent placement in patients with inoperable cancers, stenting has gradually expanded to other conditions, including as a bridge to surgery, as well as in patients' benign lesions and anastomotic strictures or leaks. This narrative review describes the indications, efficacy and safety of stent placement from the esophagus to the colon, including current recommendations, recent updates, and novel stents.

Colonic stent as a bridge to surgery versus emergency resection for right-sided malignant large bowel obstruction: a meta-analysis

BACKGROUND

Preoperative colonic stenting for malignant large bowel obstruction (MLBO), also called bridge to surgery (BTS), is considered a great substitute treatment for emergency resection (ER) in the left-sided colon. However, its efficacy in the right-sided colon remains controversial. This systematic review and meta-analysis aimed to compare the postoperative short-term outcomes between BTS and ER for right-sided MLBO.

METHODS

A comprehensive electronic literature search throughout December 2020 was performed to identify studies comparing short-term outcomes between BTS and ER for right-side MLBO. The main outcome measures were postoperative complications and mortality rates. A meta-analysis was performed using a fixed-effect or a random-effect method to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

Seven studies were included in this meta-analysis, comprising 5136 patients, of whom 1662 (32.4%) underwent BTS and 3474 (67.6%) underwent ER. This meta-analysis demonstrated that BTS resulted in reductions in postoperative complications (OR = 0.78; 95% CI: 0.66-0.92) and mortality (OR = 0.51; 95% CI: 0.28-0.92) than ER.

CONCLUSION

The results of this meta-analysis indicate that BTS for right-sided MLBO confers preferable short-term outcomes as well as for left-sided. This suggests that BTS results in a reduction of postoperative complications and mortality for right-sided MLBO than ER.

Transanal decompression tube is superior to self-expandable metallic colonic stent for malignant colorectal obstruction: a retrospective study

BACKGROUND

The surgical management of left-sided malignant large bowel obstruction (MLBO) is associated with high morbidity and mortality. Recently, self-expandable metallic colonic stent (SEMS) and transanal decompression tube (TDT) used as a 'bridge to surgery' (BTS) have been widely used. This study aims to compare the clinical outcomes and oncological safety of SEMS and TDT as BTS to transform MLBO into elective surgery.

METHODS

Between February 2013 and March 2019, 62 patients with MLBO received SEMS (n = 32) or TDT (n = 30), and elective one-stage surgery later. We evaluated decompression efficiency and oncological safety in selective operation in TDT and SEMS groups, including preoperative preparation time, surgical approach, number of lymphatic dissection and vascular invasion, ulcer formation and histopathological findings of resected specimens.

RESULTS

The preoperative preparation time in the SEMS group was shorter than that of the TDT group (P < 0.05). However, there was no significant difference between the groups in postoperative length of hospital stay (P > 0.05). The number of vascular invasions in the TDT group was less than that in the SEMS group (P < 0.05). Furthermore, the risk of wound abscess and ulcer formation in the TDT group was significantly lower than that in the SEMS group (P < 0.05).

CONCLUSION

Our findings suggest that SEMS is associated with a relatively poor oncological outcome and the placement of TDT as BTS in MLBO patients may be a better alternation.

Long-term survival after self-expanding metallic stent or stoma decompression as bridge to surgery in acute malignant large bowel obstruction

Aim

Self-expanding metallic stents (SEMS) as bridge to surgery have been questioned due to the fear of perforation and tumour spread. This study aimed to compare SEMS and stoma as bridge to surgery in acute malignant large bowel obstruction in the Swedish population.

Method

Medical records of patients identified via the Swedish Colorectal Cancer Register 2007–2009 were collected and scrutinized. The inclusion criterion was decompression intended as bridge to surgery due to acute malignant large bowel obstruction. Patients who underwent decompression for other causes or had bowel perforation were excluded. Primary endpoints were 5-year overall survival and 3-year disease-free survival. Secondary endpoints were 30-day morbidity and mortality rates.

Results

A total of 196 patients fulfilled the inclusion criterion (SEMS, 71, and stoma, 125 patients). There was no significant difference in sex, age, ASA score, TNM stage and adjuvant chemotherapy between the SEMS and stoma groups. No patient was treated with biological agents. Five-year overall survival was comparable in SEMS, 56 per cent (40 patients), and stoma groups, 48 per cent (60 patients), P = 0.260. Likewise, 3-year disease-free survival did not differ statistically significant, SEMS 73 per cent (43 of 59 patients), stoma 65 per cent (62 of 95 patients), P = 0.32. In the SEMS group, 1.4 per cent (one patient) did not fulfil resection surgery compared to 8.8 per cent (11 patients) in the stoma group (P = 0.040). Postoperative complication and 30-day postoperative mortality rates did not differ, whereas the duration of hospital stay and proportion of permanent stoma were lower in the SEMS group.

Conclusion

This nationwide registry-based study showed that long-term survival in patients with either SEMS or stoma as bridge to surgery in acute malignant large bowel obstruction were comparable. SEMS were associated with a lower rate of permanent stoma, higher rate of resection surgery and shorter duration of hospital stay.

Comparison of the prognosis of four different treatment strategies for acute left malignant colonic obstruction: a systematic review and network meta-analysis

Background

There is controversy regarding the efficacy of different treatment strategies for acute left malignant colonic obstruction. This study investigated the 5-year overall survival (OS) and disease-free survival (DFS) of several treatment strategies for acute left malignant colonic obstruction.

Methods

We searched for articles published in PubMed, Embase (Ovid), MEDLINE (Ovid), Web of Science, and Cochrane Library between January 1, 2000, and July 1, 2020. We screened out the literature comparing different treatment strategies. Evaluate the primary and secondary outcomes of different treatment strategies. The network meta-analysis summarizes the hazard ratio, odds ratio, mean difference, and its 95% confidence interval.

Results

The network meta-analysis involved 48 articles, including 8 (randomized controlled trials) RCTs and 40 non-RCTs. Primary outcomes: the 5-year overall survival (OS) and disease-free survival (DFS) of the CS-BTS strategy and the DS-BTS strategy were significantly better than those of the ES strategy, and the 5-year OS of the DS-BTS strategy was significantly better than that of CS-BTS. The long-term survival of TCT-BTS was not significantly different from those of CS-BTS and ES. Secondary outcomes: compared with emergency resection (ER) strategies, colonic stent-bridge to surgery (CS-BTS) and transanal colorectal tube-bridge to surgery (TCT-BTS) strategies can significantly increase the primary anastomosis rate, CS-BTS and decompressing stoma-bridge to surgery (DS-BTS) strategies can significantly reduce mortality, and CS-BTS strategies can significantly reduce the permanent stoma rate. The hospital stay of DS-BTS is significantly longer than that of other strategies. There was no significant difference in the anastomotic leakage levels of several treatment strategies.

Conclusion

Comprehensive literature research, we find that CS-BTS and DS-BTS strategies can bring better 5-year OS and DFS than ER. DS-BTS strategies have a better 5-year OS than CS-BTS strategies. Without considering the hospital stays, DS-BTS strategy is the best choice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00355-2.

Biopsy sampling during self-expandable metallic stent placement in acute malignant colorectal obstruction: a narrative review

BACKGROUND

Histopathology is a crucial part of diagnosis and treatment guidance of colorectal cancer. In Denmark, it is not routine to biopsy during self-expandable metallic stent (SEMS) placement as a treatment option for acute colorectal obstruction of unknown etiology. This is due to lack of knowledge about the risks of hemorrhage, and thus the risk to aggravate the deteriorating overview conditions. Therefore, the aim of this study is to investigate whether there is evidence to avoid biopsy sampling during acute SEMS placement.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies. Studies were included if they described biopsy sampling in relation to SEMS placement. Additionally, national and international guidelines were scrutinized on Google and by visiting the websites of national and international gastrointestinal societies.

RESULTS

In total, 43 studies were included in the review. Among these, one recommended biopsy during SEMS placement, three advised against biopsy, 23 just reported biopsy was performed during the procedure, and 16 reported biopsy before or after the procedure, or the timing was not specified. Among the 12 included guidelines, only two described biopsy during SEMS placement.

CONCLUSION

The literature on the subject is limited. In 24 of the 43 included studies, biopsy sampling was done during SEMS placement without reporting a decrease in the technical success rate. The included guidelines were characterized by a general lack of description of whether biopsy during SEMS placement should be performed or not. Prospective studies are needed in order to establish the real risk of hemorrhage, if any, when a biopsy is obtained.

Treatment of afferent loop syndrome using fluoroscopic-guided nasointestinal tube placement: Two case reports

BACKGROUND

Afferent loop syndrome (ALS) is a rare mechanical complication that occurs after reconstruction of the stomach or esophagus to the jejunum, such as Billroth II gastrojejunostomy, Roux-en-Y gastrojejunostomy, or Roux-en-Y esophagoje-junostomy. Traditionally, an operation is the first choice for benign causes. However, for patients in poor physical condition who experience ALS soon after R0 resection, the type of treatment remains controversial. Here, we present an efficient conservative method to treat ALS.

CASE SUMMARY

Case 1 was a 69-year-old male patient who underwent total gastrectomy with Roux-en-Y jejunojejunostomy. On postoperative day (POD) 10 he developed symptoms of ALS that persisted and increased over 1 wk. Case 2 was a 59-year-old male patient who underwent distal gastrectomy with Billroth II gastrojejunostomy. On postoperative day POD 9 he developed symptoms of ALS that persisted for 2 wk. Both patients underwent fluoroscopic-guided nasointestinal tube placement with maintenance of continuous negative pressure suction. Approximately 20 d after the procedure, both patients had recovered well and were discharged from hospital after removal of the tube. At 3-mo follow-up, there were no signs of ALS in these two patients.

CONCLUSION

This is the first report of treating postoperative ALS by fluoroscopic-guided nasointestinal tube placement. Our cases demonstrate that this procedure is an effective and safe method to treat ALS that relieves patients’ symptoms and avoids complications caused by other invasive procedures.

A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer

BACKGROUND

Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC.

METHODS

A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to "colon tumour," "stenosis or obstruction and surgery," and "decompression or stents." All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival.

RESULTS

Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19-54%) after emergency resection, and 30% (range 7-44%) after staged treatment. The average mortality rate was 7.2% (range 0-14.5%) after emergency resection and 1.2% (range 0-6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments.

CONCLUSIONS

The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection.

Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis

PURPOSE

The placement of self-expandable metallic stents as a bridge to surgery in malignant colon obstruction is concerning due to the long-term oncological results reported in recent published studies. The aim of this study was to evaluate the oncological consequences of stent-related perforations in patients with malignant colon obstruction and potentially curable disease.

METHODS

MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed five meta-analyses to estimate the pooled effect sizes by using a random-effect model. The outcomes were global, locoregional and systemic recurrence rate and 3 and 5 year-survival rate depending on the presence or absence of stent-related perforation.

RESULTS

Thirteen studies (950 patients) were included. The overall rate of stent-related perforation was 8.9%. The global recurrence rate was significantly higher in stent-related perforation group (41.2 vs. 30.8%; OR 1.70; 95%CI: 1.02-2.84; p = 0.04). Locoregional recurrence rate was higher in the perforated group than in the non-perforated group (26.6 vs. 12.5%), with statistically significant differences (OR 2.41; 95% CI:1.33-4.34; p = 0.004). No significant differences were found in systemic recurrence rate (13.6 vs. 20.5%; OR 0.77; 95%CI: 0.35-1.7; p = 0.51); 3-year overall survival rate (65.4 vs. 74.8%; OR 0.63; 95% CI:0.29-1.39; p = 0.25) and 5-year overall survival rate (48.3 vs. 58.6%; OR 0.67; 95%CI: 0.27-1.65; p = 0.38).

CONCLUSION

Stent-related perforation is associated with an increased risk of global and locoregional recurrence. The successful placement of the stent as a bridge to surgery in the curative purpose of patients with obstructed colon cancer does not exclude the presence of underlying perforation, with the consequent danger of disease spread. PROSPERO registration number: CRD42020152817.

Fluoroscopic Stenting as a Bridge to Surgery versus Emergency Management for Malignant Obstruction of the Colon

Aim

To investigate the feasibility of a SEMS (self-expandable metallic stent) as a bridge to surgery for malignant colonic obstruction.

Methods

We retrospectively reviewed 83 patients that were in accordance with inclusion criteria; of these, 33 patients that underwent fluoroscopy-guided SEMS placement followed by elective curative resection were classified as a SEMS group and 50 patients, who received emergency surgery (ES), were classified as an ES group. The clinicopathological characteristics, surgery-related parameters, complications, and three-year survival rate were compared between the two groups.

Results

No significant differences between the two groups were observed in any of the clinicopathologic characteristics except for higher preoperative absolute neutrophil count in the ES group (P < 0.001). Compared to the ES group, the SEMS group has significantly more cases, which featured a laparoscopic approach (72.7% vs. 14.0%, P < 0.001), lower overall stoma rate (0% vs. 34.0%, P < 0.001), and lower overall postoperative morbidity (27.3% vs. 56.0%, P=0.010). The oncological outcomes did not differ significantly between the two groups in terms of three-year overall survival (P=0.125). The technical and clinical success rates of stent placement were 91.7% and 100%, respectively.

Conclusion

Patients treated with the stent-surgery approach had significant short-term superiorities and similar long-term outcomes, compared to patients who had emergency surgery alone. The SEMS is, therefore, safe and feasible as a bridge to surgery for malignant colonic obstruction.

Self-expandable Metal Stent as a Bridge to Surgery for Colorectal Cancer: Safety and Oncological Outcomes

BACKGROUND/AIM

Self-expandable metal stent (SEMS) as a bridge to surgery (BTS) for obstructive colorectal cancer (CRC) raises concerns regarding the short-term as well as oncological outcome. The present study aimed to investigate the safety of SEMS placement and risk factors of worse short-term and oncological outcomes as BTS.

PATIENTS AND METHODS

Twenty-four patients with obstructive CRC who underwent SEMS placement as BTS were included. Success rate of SEMS placement and 2-year relapse-free survival (RFS) rates in stage II/III BTS patients were assessed.

RESULTS

Technical and clinical success rates for SEMS placement were 100% and 87.5%, respectively. In Multivariate analyses, longer tumour length, longer interval to surgery, and angular positioning were risk factors related with the complication of stent placement. Two-year RFS rates were significantly higher in the no-complication than in the complication group (100% vs. 75%, log-rank test, p<0.01).

CONCLUSION

A long tumour length, long interval between SEMS insertion and surgery, and angular positioning of the SEMS were identified as risk factors for SEMS-related complications. Moreover, SEMS insertion and/or surgery complications were associated with worse oncological outcome in CRC patients.

Technical and Clinical Outcomes After Colorectal Stenting in Malignant Large Bowel Obstruction: A Single-Center Experience

Purpose

Malignant large bowel obstruction is a surgical emergency that requires urgent decompression. Stents are increasingly being used, though reported outcomes are variable. We describe our multidisciplinary experience in using stents to manage malignant large bowel obstruction.

Methods

All patients undergoing colorectal stent insertion for acute large bowel obstruction in a teaching hospital were included. Outcomes, complications, and length of stay (LOS) were recorded.

Results

Over a 7-year period, 73 procedures were performed on 67 patients (37 male, mean age of 76 years). Interventional radiology was involved in all cases. Endoscopic guidance was required in 24 cases (32.9%). In 18 patients (26.9%), treatment intent was to bridge to elective surgery; 16 had successful stent placement; all had subsequent curative resection (laparoscopic resection, 8 of 18; primary anastomosis, 14 of 18). Overall LOS, including both index admission and elective admission, was 16.4 days. Treatment intent was palliative in 49 patients (73.1%). In this group, stents were successfully placed in 41 of 49 (83.7%). Complication rate within 30 days was 20%, including perforation (2 patients), per rectal bleeding (2), stent migration (1), and stent passage (5). Nineteen patients (38.8%) required subsequent stoma formation (6, during same admission; 13, during subsequent admission). Overall LOS was 16.9 days.

Conclusion

In our experience colorectal stents can be used effectively to manage malignant large bowel obstruction, with only selective endoscopic input. As a bridge to surgery, most patients can avoid emergency surgery and have a primary anastomosis. In the palliative setting, the complication rate is acceptable and two-thirds avoid a permanent stoma.

Colonic stents for malignant bowel obstruction: current status and future prospects

Introduction: Although more than two decades are already passed from the first description of this technique, the debate remains open on the role of self-expanding metal stents (SEMS) placement in the management of malignant bowel obstruction (MBO). According to most recent data, SEMS placement is considered a safe and effective alternative treatment as a bridge to surgery(BTS). In addition, stent placement should be considered as primary option for palliative treatment of obstructing cancer.Areas covered: Current status, indication, technique, oncological outcomes, advantages, and risks of SEMS placement in MBO were reviewed.Expert commentary: The placement of colonic SEMS for palliation and for BTS in patients with MBO has been increasingly reported and it seems to have several advantages over emergency surgery. Substantial concerns of tumor seeding following SEMS placement, especially in case of perforation, have been raised in numerous studies. Actually, no significant differences are reported in oncologic long-term survival between patients undergoing stent placement as a BTS and those undergoing emergency surgery. Considering all the mentioned factors, indication for colorectal stenting should be evaluated only in highly specialized centers, in the context of multidisciplinary approach where risks and benefits of stenting are carefully weighed, especially in the BTS setting.

Detection of circulating colorectal cancer cells by a custom microfluid system before and after endoscopic metallic stent placement

Although the detection of circulating tumor cells (CTCs) should be crucial for future personalized medicine, no efficient and flexible methods have been established. The current study established a polymeric custom-made chip for capturing CTCs with a high efficiency and flexibility. As an example of clinical application, the effects of self-expandable metallic stent (SEMS) placement on the release of cancer cells into the blood of patients with colorectal cancer and bowel obstruction were analyzed. This was assessed as the placement of SEMS may cause mechanical damage and physical force to malignant tissue, increasing the risk of cancer cell release into the bloodstream. The present study examined the number of CTCs using a custom-made chip, before, at 24 h after and at 4 days after SEMS placement in patients with colorectal cancer. The results revealed that, among the 13 patients examined, the number of CTCs was increased in three cases at 24 h after SEMS placement. However, this increase was temporary. The number of CTCs also decreased at 4 days after stent placement in most cases. The CTC chip of the current study detected the number of CD133-positive cancer stem-like cells, which did not change, even in the patient whose total number of CTCs temporarily increased. The results indicated that this custom-made microfluid system can efficiently and flexibly detect CTCs, demonstrating its potential for obtaining information during the management of patients with cancer.

Preoperative Colonic Decompression With Decompression Tube Insertion Versus Stent Insertion in Patients With Malignant Left Colonic Obstruction

PURPOSE

To compare the clinical effectiveness of preoperative colonic decompression (PCD) performed with stent or decompression tube insertion in patients with malignant left colonic obstruction (MLCO).

MATERIALS AND METHODS

Between September 2014 and September 2018, 63 patients with MLCO underwent PCD (decompression tube: 35; stent: 28) in our center. Elective surgery was performed for patients with clinical success of PCD.

RESULTS

The rates of technical success for PCD with tube and stent insertion were 91.4% (32/35) and 96.4% (27/28), respectively (P=0.773). Clinical success rates for PCD with tube and stent insertion were 90.6% (29/32) and 85.2% (23/27), respectively (P=0.811). Tumor resection with primary anastomosis was performed in all patients with clinical success in both groups. No significant differences were found between 2 groups regarding the duration of surgery and rates of postoperative complications.

CONCLUSION

Decompression tube and stent insertion had similar effectiveness for PCD in patients with MLCO.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

Acute abdominal obstruction: Colon stent or emergency surgery? An evidence-based review

According to the American Cancer Society and Colorectal Cancer Statistics 2017, colorectal cancer (CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018. Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction (MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990s, self-expanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.

Fluoroscopy-guided long intestinal tube placement for the treatment of malignant bowel obstruction

The aim of the present study was to investigate the safety and efficacy of long intestinal tube placement under fluoroscopic guidance for the treatment of malignant bowel obstruction (MBO). The cases of 74 patients with MBO who underwent long intestinal tube placement under fluoroscopic guidance during the period between June 2015 and October 2017 were reviewed. The clinical characteristics were retrospectively analysed with respect to efficacy, safety and outcome. Long intestinal tube placement was successfully completed in all 74 patients. The mean time required for tube placement was 31.09±16.25 min and the mean insertion depth of the tube was 153±39 cm. In 58 cases, the symptoms of abdominal pain, abdominal bloating and vomiting were greatly improved following 1-3 days of tube decompression. The symptoms of the remaining 16 patients were not effectively relieved following decompression. No serious complications were observed in any patients. Overall, for patients with severe MBO, long intestinal tube placement under fluoroscopic guidance appears to be an effective and safe treatment, and it may improve quality of life.

Do Self-Expanding Metal Stents as a Bridge to Surgery Benefit All Patients with Obstructive Left-Side Colorectal Cancers?

Background

Self-expanding metal stents (SEMS) have been increasingly used in patients with obstructive left-sided colorectal cancer (OLCC); however, stent-specific complications (e.g., perforations) might worsen the long-term survival outcome. Strict indication needed to be identified to confirm the benefit subgroups. This study was designed to explore the indication for emergency surgery (ES) and SEMS in patients with OLCC and to suggest optimal strategies for individuals.

Methods

After propensity score matching, 36 pairs were included. Perioperative and long-term survival outcomes (3-year overall survival (OS) and 3-year disease-free survival (DFS)) were compared between the ES and SEMS groups. Independent risk factors were evaluated among subgroups. Stratification survival analysis was performed to identify subgroups that would benefit from SEMS placement or ES.

Results

The perioperative outcomes were similar between the SEMS and ES groups. The 3-year OS was comparable between the SEMS (73.5%) and ES (60.0%) groups, and the 3-year DFS in the SEMS group (69.7%) was similar to that in the ES group (57.1%). The pT stage was an independent risk factor for 3-year DFS (p = 0.014) and 3-year OS (p = 0.010) in the SEMS group. The comorbidity status (p = 0.049) independently affected 3-year DFS in the ES group. The 3-year OS rate was influenced by the cM stage (p = 0.003). Patients with non-pT4 stages in the SEMS group showed obviously better 3-year OS (95.0%) than the other subgroups. The 3-year OS rate was 36.4% in the ES group when patients had a worse comorbidity status than their counterparts.

Conclusion

SEMS might be preferred for patients of obstructive left-sided colorectal cancer in the "high-operative risk group" with existing comorbidities or those without locally advanced invasion, such as the non-pT4-stage status.

A Pediatric Nasogastroscope Facilitates Colorectal Endoscopic Stenting

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.

Feasibility of laparoscopic surgery after stent insertion for obstructive colorectal cancer

INTRODUCTION

A growing number of patients with obstructive colorectal cancer are being treated with self-expanding metallic stents (SEMS) followed by laparoscopic resection. The aim of this study was to assess the feasibility of stent insertion and laparoscopic surgery for obstructive colorectal cancer and to compare these outcomes to regular laparoscopic surgery for non-obstructive colorectal cancer.

METHODS

We retrospectively analyzed the outcomes of patients with a malignant colonic obstruction who underwent SEMS placement followed by elective laparoscopic resection. The comparison was made between stent-laparoscopy and laparoscopy alone for non-obstructive colorectal cancer.

RESULTS

Colonic stenting as a bridge to surgery was successful in 97.1% of all cases. Fifteen patients underwent an elective laparoscopic surgery for left-sided colon and rectal cancer after SEMS. The mean interval from SEMS insertion to laparoscopic surgery was 21.5 days. There was no conversion to open surgery and no need for a diverting stoma. One patient (6.7%) experienced paralytic ileus. Our comparison of stent-laparoscopy to regular laparoscopy for non-obstructive colorectal cancer treatment showed comparable short-term postoperative outcomes with the exception of blood loss, which was greater in the stent-laparoscopy group.

CONCLUSION

Elective laparoscopic surgery after colonic stenting is a safe and feasible strategy for the treatment of an acute malignant colonic obstruction.

Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Colorectal cancer (CRC) is the third most common malignancy and the third leading cause of cancer death worldwide. Malignant colonic obstruction (MCO) due to CRC occurs in 8 % to 29 % of patients.The aim of this study was to perform a systematic review and meta-analysis of RCTs comparing colonic SEMS versus emergency surgery (ES) for MCO in palliative patients. This was the first systematic review that included only randomized controlled trials in the palliative setting.

METHODS

A literature search was performed according to the PRISMA method using online databases with no restriction regarding idiom or year of publication. Data were extracted by two authors according to a predefined data extraction form. Primary outcomes were: mean survival, 30-day adverse events, 30-day mortality and length of hospital stay. Stoma formation, length of stay on intensive care unit (ICU), technical success and clinical success were recorded for secondary outcomes. Technical success (TS) was defined as successful stent placement across the stricture and its deployment. Clinical success (CS) was defined as adequate bowel decompression within 48 h of stent insertion without need for re-intervention.

RESULTS

We analyzed data from four RCT studies totaling 125 patients. The 30-day mortality was 6.3 % for SEMS-treated patients and 6.4 % for ES-treated patients, with no difference between groups (RD: - 0.00, 95 % CI [-0.10, 0.10], I 2 : 0 %). Mean survival was 279 days for SEMS and 244 days for ES, with no significant difference between groups (RD: 20.14, 95 % CI: [-42.92, 83.21], I 2 : 44 %). Clinical success was 96 % in the ES group and 86.1 % in the SEMS group (RD: - 0.13, 95 % CI [-0.23, - 0.02], I 2 : 51 %). Permanent stoma rate was 84 % in the ES group and 14.3 % in the SEMS group (RR: 0.19, 95 % CI: [0.11, 0.33], I 2 : 28 %). Length of hospital stay was shorter in SEMS group (RD: - 5.16, 95 % CI: [-6.71, - 3.61], I 2 : 56 %). There was no significant difference between groups regarding adverse events (RD 0.18, 95 % CI: [-0.19, 0.54;]) neither regarding ICU stay. (RD: - 0.01, 95 % CI: [-0.08, 0.05], I 2 : 7 %). The most common stent-related complication was perforation (42.8 % of all AE).

CONCLUSION

Mortality, mean survival, length of stay in the ICU and early complications of both methods were similar. SEMS may be an alternative to surgery with the advantage of early hospital discharge and lower risk of permanent stoma.

Impact on surgical and oncological results of the use of colonic stents as a bridge to surgery for potentially curable occlusive colorectal neoplasms

INTRODUCTION

The outcomes of patients treated with colonic stents as a bridge to surgery (BTS) have recently been questioned in terms of safety and long-term oncologic outcomes. The aim of this study is to evaluate the effects on surgical and oncologic outcomes of colonic stents as a BTS for potentially resectable obstructive colorectal cancer.

METHODS

We conducted a retrospective analysis of patients operated on for potentially resectable obstructive colorectal cancer with or without distant disease between September 2002 and October 2015, comparing the patients treated with a colonic stent as a BTS (Stent group) with those directly operated on (Surgery group).

RESULTS

Twenty patients underwent urgent surgery, while stent placement as a BTS was attempted in 57 patients. The Stent group had more patients treated with a laparoscopic approach (64.9 vs. 5%, P<.001), higher primary anastomosis rate (91.2 vs. 55%, P=.001), less need for stomata (10.5 vs. 50%, P=.001) and shorter postoperative hospital stay (7 vs. 12 days, P=.014). Thirty-day morbidity was reduced in the Stent group, although not significantly (29.8 vs. 50%, P=.104). However, 30-day mortality was significantly lower (1.8 vs. 20%, P=.015). Regarding the long-term oncologic outcomes, no significant differences were found when comparing overall survival, disease-free survival, local recurrence-free survival, distant recurrence-free survival or progression-free survival.

CONCLUSIONS

Colonic stenting as a BTS for potentially resectable obstructive colorectal cancer seems to offer better surgical and equal long-term oncologic outcomes when compared to those of patients directly operated on.

Stenting as a bridge to resection versus emergency surgery for left-sided colorectal cancer with malignant obstruction: A systematic review and meta-analysis

PURPOSE

This study aims to discuss the safety and feasibility of a combined treatment consisting of stent insertion and elective surgery for left-sided colorectal cancer with malignant obstruction.

METHODS

Randomized clinical trials (RCTs) that discussed the safety and feasibility of stenting as a bridge to surgery in malignant colorectal cancer were identified in a search of medical databases, including PubMed, Embase, Cochrane Library, and SCIENCE. Each paper's quality was assessed using the Jadad scale. A meta-analysis was conducted using RevMan 5.3, and statistical heterogeneity between RCTs was defined as I²>50%.

RESULTS

Nine RCTs included 594 patients were selected and analyzed. Of the included patients, 281 underwent stent insertion followed by elective surgery (SG group), and 313 underwent emergency surgery (EG group). The meta-analysis revealed that the patients in the SG group had a higher one-stage anastomosis rate. Patients in the SG had lower mortality rates and minor complications. There was no significant difference in anastomotic leakage between the two groups. The funnel plot showed that there was no publication bias in these outcomes.

CONCLUSION

Stenting as a bridge to surgery was safe and feasible in left-sided colorectal cancer with malignant obstruction. Compared with the patients in the EG group, the SG patients had an improved primary anastomosis rate and experienced no increase in the risk of other complications.

Long-term oncologic outcomes of stent as a bridge to surgery versus emergency surgery in malignant left side colonic obstructions: a meta-analysis

Background

The placement of a metallic stent as a bridge to surgery (SBTS) could represents an option for the treatment of left-sided malignant colonic obstruction in centres with adequate skills. Several meta-analyses demonstrated better short-term outcomes after SBTS when compared with emergency surgery (ES); however, some studies reported a higher local recurrence rate. The aim of the present review is to investigate the long-term outcomes of stent bridge to surgery as compared to ES.

Methods

A systematic review was performed to retrieve studies comparing long-term oncologic outcomes of SBTS and ES. Local and overall recurrence rate, overall and disease-free survival were retrieved and results were expressed as risk ratios.

Results

Seventeen studies and a total of 1,333 patients were included in the analysis. No significant differences were reported in recurrence rate [risk ratio (RR) =1.11; 95% confidence interval (95% CI): 0.84-1.47, P=0.47], 3-year mortality (RR =0.90; 95% CI: 0.73-1.12, P=0.34) and 5-year mortality (RR =1.00; 95% CI: 0.82-1.22, P=0.99). There were no differences among randomized and observational studies.

Conclusions

SBTS has similar long-term oncologic outcomes to ES and in centres with appropriate skill should be considered the best treatment option for left-sided malignant colonic obstructions.

The Usefulness of Intraoperative Colonic Irrigation and Primary Anastomosis in Patients Requiring a Left Colon Resection

PURPOSE

The aim of this study is to assess the short-term outcome of intraoperative colonic irrigation and primary anastomosis and to suggest the usefulness of the procedure when a preoperative mechanical bowel preparation is inappropriate.

METHODS

This retrospective study included 38 consecutive patients (19 male patients) who underwent intraoperative colonic irrigation and primary anastomosis for left colon disease between January 2010 and December 2016. The medical records of the patients were reviewed to evaluate the patients' characteristics, operative data, and postoperative short-term outcomes.

RESULTS

Twenty-nine patients had colorectal cancer, 7 patients had perforated diverticulitis, and the remaining 2 patients included 1 with sigmoid volvulus and 1 with a perforated colon due to focal colonic ischemia. A diverting loop ileostomy was created in 4 patients who underwent a low anterior resection. Complications occurred in 15 patients (39.5%), and the majority was superficial surgical site infections (18.4%). Anastomotic leakage occurred in one patient (2.6%) who underwent an anterior resection due sigmoid colon cancer with obstruction. No significant difference in overall postoperative complications and superficial surgical site infections between patients with obstruction and those with peritonitis were noted. No mortality occurred during the first 30 postoperative days. The median hospital stay after surgery was 15 days (range, 8-39 days).

CONCLUSION

Intraoperative colonic irrigation and primary anastomosis seem safe and feasible in selected patients. This procedure may reduce the burden of colostomy in patients requiring a left colon resection with an inappropriate preoperative mechanical bowel preparation.

Self-expanding metallic stent as a bridge to surgery in the treatment of left colon cancer obstruction: Cost-benefit analysis and oncologic results

INTRODUCTION

The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options.

METHODS

This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat" analysis.

RESULTS

There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes.

CONCLUSIONS

The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.

Elective Surgery After Endoscopic Self-Expandable Metallic Stent Placement for Patients With Obstructive Colon Cancer: Preoperative Systemic Evaluation and Management

One-stage curative surgical resection for obstructive colon cancer is challenging. Self-expandable metallic stents (SEMSs) are known as an alternative treatment used to avoid emergency operation. We aimed to evaluate the significance of SEMS placement as a bridge to surgery and the surgical outcomes of the elective operation. A consecutive 20 patients with obstructive colon cancer undergoing SEMS placement between June 2014 and February 2016 were included. The technical outcomes of the SEMS placement, surgical procedures, and surgical outcomes were evaluated retrospectively. Among them, 2 patients were treated with a SEMS palliatively, and the others were treated with a SEMS as a bridge to surgery. All SEMS were placed successfully at the first attempt, and there was no SEMS-related complication. Before surgery, all patients could be diagnosed histologically, and they were evaluated systemically including proximal colon or distant metastasis. The median time to operation after SEMS placement was 14 days (range 9–20 days). Seven of the 18 patients underwent a laparoscopic colectomy without conversion to laparotomy. All patients with stage II or III colon cancer underwent curative surgery, and 2 patients with stage IV colon cancer underwent a one-stage resection of the primary colon cancer and simultaneous liver metastasis after the evaluation of hepatic functional reserve. There was no mortality or SEMS-related complication in the perioperative period. SEMS placement as a bridge to surgery for patients with obstructive colon cancer is safe and effective to provide an adequate amount of time for a preoperative systemic management and evaluation.

Effect of preoperative colonic drainage for obstructing colorectal cancer

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.

Palliative Stent Insertion for Acute Malignant Colorectal Obstruction: Long-term Patency and Survival

PURPOSE

To investigate the long-term outcome of palliative stent insertion for acute malignant colorectal obstruction.

METHODS

From May 2009 to February 2015, consecutive patients with acute malignant colorectal obstruction underwent palliative stent insertion in our center. Technical success, clinical success, and long-term outcomes were analyzed retrospectively.

RESULTS

A total of 45 patients with acute malignant colorectal obstruction underwent palliative stent insertion. Technical success was achieved in 42 of 45 patients. Clinical success was achieved in 41 of 42 patients. During a follow-up of 5 days to 25 months (mean, 6.9±4.5 mo), the cumulative 6- and 12-month patency rates were 88.6% and 72.7%, respectively. The cumulative 6- and 12-month survival rates were 60.1% and 14.3%, respectively. The independent predictor of prolonging survival was subsequent chemotherapy after stenting (P=0.017).

CONCLUSION

Palliative colorectal stent insertion can provide a good long-term outcome in patients with malignant colorectal obstruction.

[Colonic stenting: an opportunity with a risk : A critical evaluation]

BACKGROUND

Frequently, the first clinical sign of colorectal cancer is complete obstruction, which has to be considered an emergency situation. The treatment goal is to overcome ileus including reduction of the associated high morbidity and mortality. Therefore, alternative therapeutic options to emergency surgery have been sought in order to allow adequate preparation for elective surgery or stabilization of palliative patients and avoid colostoma. Therapeutic results of the placement of self-expanding metal stents (SEMS) are discussed in terms of a single-center, retrospective observational study.

METHODS

In 35 patients with a clinically manifest stenosis of colonic cancer, it was attempted to insert SEMS to treat ileus as the first therapeutic step. Therapeutic results were investigated with regard to technical and clinical success, spectrum and rate of complications, and survival time, differentiating between a palliative and curative group of patients.

RESULTS

Primary placement of a stent was achieved in 29 of 35 patients (82.9 %); 14 underwent the procedure with palliative and 15 with curative intention. Stent location was mainly the left hemicolon. In 2 of 15 patients (13.3 %), emergency surgery within 48 h was required because of complications, whereby in 13 patients (86.7 %), 6 patients (46.2 %) underwent elective open surgery and 7 patients (53.8 %) underwent a laparoscopic procedure. In all patients treated with curative intent, primary anastomosis was achieved, thus, avoiding a colostoma. Survival times of the palliative and curative patient groups were on average 7 and 28 months, respectively.

CONCLUSION

In carefully selected cases, placement of SEMS in malignant stenosis of the left hemicolon with ileus can be considered a reasonable therapeutic alternative to emergency surgery since it allows surgical intervention with curative intention under more favorable conditions and also avoids a colostoma.

Clinical benefits and oncologic equivalence of self-expandable metallic stent insertion for right-sided malignant colonic obstruction

BACKGROUND

The efficacy of stenting for right-sided malignant colonic obstruction is unknown. This study aimed to evaluate the safety, feasibility, and clinical benefits of self-expandable metallic stent insertion for right-sided malignant colonic obstruction.

METHODS

Clinical data from patients who underwent right hemicolectomy for right colon cancer from January 2006 to July 2014 at three Korea University hospitals were retrospectively reviewed. A total of 39 patients who developed malignant obstruction in the right-sided colon were identified, and their data were analyzed.

RESULTS

Stent insertion was attempted in 16 patients, and initial technical success was achieved in 14 patients (87.5 %). No stent-related immediate complications were reported. Complete relief from obstruction was achieved in all 14 patients. Twenty-five patients, including two patients who failed stenting, underwent emergency surgery. In the stent group, 93 % (13/14) of patients underwent elective laparoscopic surgery, and only one surgery was converted to an open procedure. All patients in the emergency group underwent emergency surgery within 24 h of admission. In the emergency group, only 12 % (3/25) of patients underwent laparoscopic surgery, with one surgery converted to an open procedure. All patients in both groups underwent either laparoscopy-assisted or open right/extended right hemicolectomy with primary anastomoses as the first operation. The operative times, retrieved lymph nodes, and pathologic stage did not differ between the two groups. Postoperative hospital stay (9.4 ± 3.4 days in the stent group vs. 12.4 ± 5.9 in the emergency group, p = 0.089) and time to resume oral food intake (3.2 ± 2.1 days in the stent group vs. 5.7 ± 3.4 in the emergency group, p = 0.019) were shorter in the stent group. And there were no significant differences in disease-free survival and overall survival between the two groups.

CONCLUSIONS

Stent insertion appears to be safe and feasible in patients with right-sided colonic malignant obstruction. It facilitates minimally invasive surgery and may result in better short-term surgical outcomes.

Self-expanding metallic stent improves histopathologic edema compared with transanal drainage tube for malignant colorectal obstruction

AIMS

To compare the usefulness of the self-expanding metallic stent (SEMS) with that of the transanal drainage tube (TDT) and emergency surgery after failure of decompression (ESFD) in patients with malignant colonic obstruction (MCO), and to evaluate post-decompression histopathologic changes.

METHODS

From January 2010 to June 2015, 39 patients with MCO received SEMS, TDT, and ESFD. We evaluated the outcomes including success rates of placement, clinical outcomes after decompression, and histopathologic findings of the resected specimens.

RESULTS

Technical success rates were 100% for SEMS and 78.9% for TDT. Clinical success rates were 100% for SEMS and 80.0% for TDT. Postoperative ileus was significantly less frequent after SEMS than after TDT (p = 0.014). Histopathologic edema grade was significantly lower for SEMS than for TDT and ESFD (p < 0.0001). There was no significant difference between edema grade and duration of decompression in the TDT group (p = 0.629), while all patients with SEMS were classified in a low edema grade (grade 0-2). The rate of stoma creation was significantly higher in patients with a high edema grade (grade 3) than in those with a low edema grade (grade 0-2) (p = 0.003). There was no microscopic perforation in any group.

CONCLUSION

Significantly greater resolution of histopathologic edema was achieved after placement of SEMS than after placement of TDT. These findings provide an indication of favorable clinical outcomes of SEMS in comparison with TDT and ESFD. This article is protected by copyright. All rights reserved.

Colonic stenting as a bridge to surgery for obstructive colorectal cancer: advantages and disadvantages

PURPOSE

To clarify the advantages and disadvantages of stenting as a bridge to surgery (BTS) by comparing the clinical features and outcomes of patients who underwent BTS with those of patients who underwent emergency surgery (ES).

METHODS

We assessed technical success, clinical success, surgical procedures, stoma formation, complications, clinicopathological features, and Onodera's prognostic nutritional index (OPNI) in patients who underwent BTS and those who underwent ES.

RESULTS

Twenty-six patients underwent stenting, which was successful in 22 (BTS group). The remaining four patients with unsuccessful stenting underwent emergency surgery. A total of 22 patients underwent emergency surgery (ES group). The rates of technical and clinical success were 85.0 and 81.0 %, respectively. The proportion of patients able to be treated by laparoscopic surgery (P = 0.0001) and avoid colostomy (P = 0.0042) was significantly higher in the BTS group. Although the incidence of anastomotic leakage in the two groups was not significantly different, it was significantly reduced by colonoscopic evaluation of obstructive colitis (P = 0.0251). The mean number of harvested lymph nodes (P = 0.0056) and the proportion of D3 lymphadenectomy (P = 0.0241) were significantly greater in the BTS group. Perineural invasion (PNI) was noted in 59.1 and 18.2 % of the BTS group and ES group patients, respectively (P = 0.0053). OPNI and serum albumin decreased significantly after stenting (P = 0.0084).

CONCLUSIONS

The advantages of stenting as a BTS were that it avoided colostomy and allowed for laparoscopic surgery and lymphadenectomy, whereas its disadvantage lay in the decreased PNI and OPNI levels. A larger study including an analysis of prognosis is warranted.

Open surgery versus laparoscopic surgery after stent insertion for obstructive colorectal cancer

PURPOSE

To compare the outcomes of laparoscopic surgery vs. open surgery after insertion of a colonic stent for obstructive colorectal cancer.

METHODS

Between April 2005 and August 2013, 58 patients underwent surgery after the insertion of a colonic stent for obstructive colorectal cancer. We analyzed the outcomes of the patients who underwent laparoscopic surgery vs. those who underwent open surgery.

RESULTS

We compared blood loss, operative time, hospital stay, and complications in 26 patients who underwent laparoscopic surgery and 32 patients who underwent open surgery. Blood loss was significantly less in the laparoscopic surgery group, but operative time was significantly shorter in the open surgery group. The length of hospital stay was shorter in the laparoscopic surgery group than in the open surgery group, but the difference was not significant. There was no significant difference in postoperative surgical complications between the groups.

CONCLUSION

The patients who underwent laparoscopic resection had less blood loss, although no significant difference was found in postoperative morbidity or mortality. Thus, laparoscopic resection after stent insertion is a feasible and safe option for patients with obstructive colorectal cancer.

One-Stage Colectomy with Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

BACKGROUND

One-stage colectomy with intraoperative colonic irrigation (OCICI) may be useful in early resolution of acute left-sided malignant colonic obstruction (ALMCO). However, the clinical benefit of this technique has not been fully investigated.

METHODS

Between January 2007 and July 2014, 451 patients underwent left hemicolectomy or sigmoidectomy for colon cancer, of whom 25 underwent OCICI for ALMCO. The medical records of the patients who underwent OCICI for ALMCO were compared to 174 medical records of a control population (without ALMCO) who were matched for tumor characteristics.

RESULTS

There were no statistically significant differences between the two groups in regard to age, sex, American Society of Anesthesiologists Physical Status, location of tumor, preoperative CEA levels, and previous abdominal surgeries. The OCICI for ALMCO group was associated with a longer operation time (153 ± 33 vs. 111 ± 47 min, p < 0.001). However, no significant differences were found in patient morbidity, the duration of the postoperative hospital stay, or the tumor pathology between the two groups. Univariate and multivariate analyses indicated that OCICI for ALMCO did not increase the risk of postoperative morbidity in patients with left-sided colon cancer.

CONCLUSION

OCICI for ALMCO did not increase the rate of morbidity or prolong the hospital stay duration compared to treatment of a control population.

Long-term outcomes after stenting as a “bridge to surgery” for the management of acute obstruction secondary to colorectal cancer

Obstructive symptoms are present in 8% of cases at the time of initial diagnosis in cases of colorectal cancer. Emergency surgery has been classically considered the treatment of choice in these patients. However, in the majority of studies, emergency colorectal surgery is burdened with higher morbidity and mortality rates than elective surgery, and many patients require temporal colostomy which deteriorates their quality of life and becomes permanent in 10%-40% of cases. The aim of stenting by-pass to surgery is to transform emergency surgery into elective surgery in order to improve surgical results, obtain an accurate tumoral staging and detection of synchronous lesions, stabilization of comorbidities and performance of laparoscopic surgery. Immediate results were more favourable in patients who were stented concerning primary anastomosis, permanent stoma, wound infection and overall morbidity, having the higher surgical risk patients the greater benefit. However, some findings laid out the possible implication of stenting in long-term results of oncologic treatment. Perforation after stenting is related to tumoral recurrence. In studies with perforation rates above 8%, higher recurrences rates in young patients and lower disease free survival have been shown. On the other hand, after stenting the number of removed lymph nodes in the surgical specimen is larger, patients can receive adjuvant chemotherapy earlier and in a greater percentage and the number of patients who can be surgically treated with laparoscopic surgery is larger. Finally, there are no consistent studies able to demonstrate that one strategy is superior to the other in terms of oncologic benefits. At present, it would seem wise to assume a higher initial complication rate in young patients without relevant comorbidities and to accept the risk of local recurrence in old patients (> 70 years) or with high surgical risk (ASA III/IV).

Examination of Physicians' Perception of the Indications of Colorectal Stents in the Management of Malignant Large Bowel Obstruction: A Provincial Survey

Introduction. Data are conflicting when assessing indications for colorectal self-expandable metallic stents (SEMS) in managing acute malignant large bowel obstruction (MLO). In November 2014, European and American Societies published guidelines to aid in understanding which patients might benefit from colorectal stenting. Yet, there remain marked disparities in clinical practice. Methods. A web-based survey was sent to Gastroenterologists and Surgical Specialists across Quebec to assess physicians' knowledge and adherence to the indications for colonic SEMS placement in the management of MLO using eight clinical scenarios. Results. Out of 112 respondents, 74% preferred surgical intervention in young, healthy individuals with MLO. Advanced age and comorbidities motivated 56.3% (95% CI 47.1-65.5%) of participants to opt for SEMS placement. In palliative settings of patients undergoing chemotherapy including bevacizumab, a minority of respondents followed guidelines, 12.5% (95% CI 6.4-18.6%) for young patients and 25.0% for elderly patients (95% CI 17.0-33.0%). The pooled overall adherence to guidelines was 50.4% (95% CI 40.7-59.3%). Conclusion. This survey suggests that guidelines recommendations are not being implemented by at least half of specialists involved in the care of patients with MLO. Future studies should attempt to identify possible barriers responsible for this impaired knowledge translation and tailored educational initiatives planned accordingly.

Stenting as a Bridge to Surgery for Obstructive Colon Cancer: Does It Have Surgical Merit or Oncologic Demerit?

PURPOSE

To evaluate the surgical and oncologic outcomes of patients undergoing self-expandable metallic stent (SEMS) placement with elective curative surgery.

METHODS

Data from patients admitted with obstructing colon cancer between 2000 and 2012 were analyzed retrospectively. Patients underwent either SEMS placement as a bridge to surgery (stent group, n = 67) or emergency surgery (surgery group, n = 35). Surgical and oncologic outcomes of the groups were compared.

RESULTS

Placement of SEMS was technically successful in 98.5% and clinically successful in 89.6% of cases. There were eight (11.9%) stent-related complications, including three migrations (4.5%), four occlusions (6.0%), and one perforation (1.5%). The stent group had a higher laparoscopic resection rate (67.2 vs. 31.4%, p = 0.001) with a lower conversion rate (4.3 vs. 35.3%, p = 0.003). The wound infection rate was significantly higher in the surgery group (37.1 vs. 11.9%, p = 0.003) with no differences in the rate of other complications. The rates of local recurrence and distant metastasis, recurrence-free, and overall survival were not significantly different between the two groups.

CONCLUSIONS

Stenting and elective surgery was associated with a higher laparoscopy rate, a lower conversion rate, and a lower wound infection rate compared to emergency surgery but did not affect recurrence or survival.

Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction

PURPOSE

The aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction.

METHODS

From January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7-9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed.

RESULTS

Twenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1).

CONCLUSION

Decompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.