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Safety of early surgery after self-expandable metallic stenting for obstructive left-sided colorectal cancer. Surg Endosc 2023; 37:3873-3883. [PMID: 36717427 DOI: 10.1007/s00464-023-09891-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/15/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Self-expanding metallic stenting (SEMS) is usual for the temporary resolution of obstructive left-sided colorectal cancer (CRC) as a bridge to elective surgery. However, there is no consensus regarding adequate time intervals from stenting to radical surgery. The aim of this study was to identify the optimal time interval that results in favorable short- and long-term outcomes. METHODS Data on patients with obstructive left-sided CRC who underwent elective radical surgery after clinically successful SEMS deployment in five tertiary referral hospitals from 2004 to 2016 were analyzed, retrospectively. An inverse probability treatment-weighted propensity score analysis was used to minimize bias. Postoperative short- and long-term outcomes were compared between two groups: an early surgery (within 8 days) group and delayed surgery (after 8 days) group. RESULTS Of 311 patients, 148 (47.6%) underwent early and 163 (52.4%) underwent delayed surgery. The median surgery interval was 9.0 days. After adjustment, the groups had similar patient and tumor characteristics. In terms of short-term outcomes, there was no difference in hospitalization length or postoperative complications. No deaths were observed. With a median follow-up of 71.0 months, no significant difference was observed between the groups in 5-year overall survival (early vs. delayed surgery: 79.6% vs. 71.3%, P = 0.370) and 5-year disease-free survival (early vs. delayed surgery: 59.1% vs. 60.4%, P = 0.970). CONCLUSIONS In obstructive left-sided CRC, the time interval between SEMS and radical surgery did not significantly influence short- and long-term outcomes. Therefore, early surgery after SEMS could be suggested if there is no reason to postpone surgery for preoperative medical optimization.
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Lueders A, Ong G, Davis P, Weyerbacher J, Saxe J. Colonic stenting for malignant obstructions-A review of current indications and outcomes. Am J Surg 2022; 224:217-227. [DOI: 10.1016/j.amjsurg.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/08/2021] [Accepted: 12/27/2021] [Indexed: 11/01/2022]
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Kwon SJ, Yoon J, Oh EH, Kim J, Ham NS, Hwang SW, Park SH, Ye BD, Byeon JS, Myung SJ, Yang SK, Yang DH. Factors Associated with Clinical Outcomes of Palliative Stenting for Malignant Colonic Obstruction. Gut Liver 2021; 15:579-587. [PMID: 33115967 PMCID: PMC8283298 DOI: 10.5009/gnl20145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 11/25/2022] Open
Abstract
Background/Aims Self-expandable metal stents (SEMSs) can be applied to relieve colorectal obstruction secondary to incurable primary colorectal cancer or extracolonic malignancy. We aimed to identify factors associated with clinical success and the reintervention-free survival (RFS) after palliative stenting. Methods Cases of palliative SEMS placement between 2005 and 2019 were retrieved from the institutional database and reviewed retrospectively. Logistic regression and log-rank testing followed by Cox proportional hazard analyses were performed to investigate the predictors of the clinical success of palliative stenting and factors associated with RFS, respectively. Results A total of 593 patients underwent palliative stenting for malignant colonic obstruction (MCO). The technical and clinical success rates were 92.9% and 83.5%, respectively. Peritoneal carcinomatosis was a predictor of clinical failure (odds ratio, 0.33; 95% confidence interval [CI], 0.17 to 0.65) in the multivariate analysis. Peritoneal carcinomatosis (hazard ratio [HR], 2.48; 95% CI, 1.69 to 3.64) and stent expansion >90% on day 1 (HR, 1.62; 95% CI, 1.05 to 2.50) were associated with a shorter RFS. Neither clinical success nor RFS was associated with extracolonic malignancy. Re-obstruction, stent migration, and perforation were responsible for most reinterventions after clinically successful palliative stenting. Conclusions In patients requiring palliative stenting for MCO, peritoneal carcinomatosis was associated with both clinical failure and short RFS. Stent expansion >90% on postprocedural day 1 was another predictor of a short RFS after clinically successful stenting. A large prospective study is warranted to establish factors associated with RFS after successful palliative stenting for MCO.
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Affiliation(s)
- Sang-Jae Kwon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiyoung Yoon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hye Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeongseok Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nam Seok Ham
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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4
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Trabulsi NH, Halawani HM, Alshahrani EA, Alamoudi RM, Jambi SK, Akeel NY, Farsi AH, Nassif MO, Samkari AA, Saleem AM, Malibary NH, Abbas MM, Gianotti L, Lamazza A, Yoon JY, Farsi NJ. Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis. Saudi J Gastroenterol 2021; 27:127-135. [PMID: 33976008 PMCID: PMC8265400 DOI: 10.4103/sjg.sjg_506_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients. METHODS We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates. RESULTS We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I2 = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I2 = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I2 = 79.3%, P < 0.001). CONCLUSION The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.
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Affiliation(s)
- Nora H. Trabulsi
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Address for correspondence: Dr. Nora H. Trabulsi, Department of Surgery, Faculty of Medicine, King Abdulaziz University, PO Box 21589, Jeddah 80200, Saudi Arabia. E-mail:
| | - Hajar M. Halawani
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Rawan M. Alamoudi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sama K. Jambi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nouf Y. Akeel
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali H. Farsi
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed O. Nassif
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali A. Samkari
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdulaziz M. Saleem
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nadim H. Malibary
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad M. Abbas
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Luca Gianotti
- Department of Surgery, School of Medicine and Surgery, University of Milano-Bicocca, and San Gerardo Hospital, Monza, Italy
| | - Antonietta Lamazza
- Department Pietro Valdoni-Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Nada J. Farsi
- Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
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Veld JV, Beek KJ, Consten EC, ter Borg F, van Westreenen HL, Bemelman WA, van Hooft JE, Tanis PJ. Definition of large bowel obstruction by primary colorectal cancer: A systematic review. Colorectal Dis 2021; 23:787-804. [PMID: 33305454 PMCID: PMC8248390 DOI: 10.1111/codi.15479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/10/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
AIM Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies. METHOD A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements. RESULTS A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07). CONCLUSION In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.
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Affiliation(s)
- Joyce V. Veld
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kim J. Beek
- Department of Gastroenterology and HepatologyNWZ AlkmaarAlkmaarThe Netherlands
| | - Esther C.J. Consten
- Department of SurgeryMeander Medical CenterAmersfoortThe Netherlands,Department of SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and HepatologyDeventer HospitalDeventerThe Netherlands
| | | | - Wilhelmus A. Bemelman
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Hedenström P, Stotzer PO. Endoscopic treatment of Crohn-related strictures with a self-expandable stent compared with balloon dilation: a prospective, randomised, controlled study. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000612. [PMID: 33722805 PMCID: PMC7970316 DOI: 10.1136/bmjgast-2021-000612] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Fibrotic strictures in the gastrointestinal tract are frequent in Crohn's disease. Endoscopic dilation is a standard treatment. However, recurrence is common after dilation and there are complications such as bleeding or perforation. Endoscopic treatment using self-expandable metal stents has shown diverging results. The aim of this study was to evaluate the outcome of endoscopic treatment with a self-expandable stent in ileocecal Crohn's disease. DESIGN/METHOD Patients with Crohn's disease and a symptomatic ileocecal stricture were eligible for prospective, consecutive inclusion in a single-centre setting. Patients were randomised to treatment with either 18 mm balloon dilatation (GroupDIL) or stenting (GroupSTENT) using a 20 mm diameter, partially covered Hanarostent NCN. Patients were followed for a minimum of 24 months postendoscopy. Outcomes were technical success, adverse events and clinical success (defined as no need for repeated interventions). RESULTS Thirteen patients (GroupDIL n=6; GroupSTENT=7) were included with twelve patients (GroupDIL n=5; GroupSTENT=7) being eligible for complete follow-up. Technical success was achieved in all cases. Adverse events were border-line significantly more common in the GroupSTENT: 4/7 (57%) (pain: n=3; pain and rectal bleeding: n=1) compared with the GroupDIL: 0/5 (0%), p=0.08, which resulted in preterm termination of the study. The clinical success rate was GroupSTENT: 6/7 (86%) vs GroupDIL: 1/5 (20%), p=0.07. CONCLUSION Patients with strictures related to Crohn's disease may benefit from treatment with self-expandable metal stents rather than dilatation. However, there seems to be an increased risk for patient pain after stenting, which has to be considered and handled. TRAIL REGISTRATION NUMBER The study was registered at Clinical Trials (NCT04718493).
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Affiliation(s)
- Per Hedenström
- Intitute of Medicine, Department of Molecular and Clinical Medicine, Gothenburg University, Gothenburg, Sweden,Division of Gastroenterology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per-Ove Stotzer
- Intitute of Medicine, Department of Molecular and Clinical Medicine, Gothenburg University, Gothenburg, Sweden,Division of Gastroenterology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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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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8
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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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9
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Abstract
GOAL The aim of our prospective study was to analyze the results of endoscopic stenting to treat obstruction due to colorectal cancer and complications after colorectal resection for cancer. BACKGROUND Endoscopic stenting for obstructing colorectal cancer has become a common place in clinical practice. However, there is a 2% to 5% risk of bowel perforation, and a percentage of technical failure of 2% to 10%. MATERIALS AND METHODS In a 15-year period (August, 1999 to December, 2013), 153 patients with colorectal cancer had endoscopic placement of a self-expandable metal stent for treatment of an obstructing colorectal cancer (133 patients) or for treatment of complications after colorectal resection for cancer (20 patients). They were prospectively evaluated in a database and they form the basis of this report. RESULTS There was no case of mortality or major morbidity. Overall technical success was 94.8%. After introducing the use of a pediatric nasogastroscope to pass the obstruction (71 patients), technical success was 100%. Complications in patients in whom the stent was left in place during the follow-up were frequent, requiring a close observation. We had 20 patients with fecal obstruction, 4 cases of stent dislodgment, and 8 cases of obstruction from ingrowth of the tumor. All patients were treated successfully endoscopically. CONCLUSIONS Placement of self-expandable metal stents represents a valid technique. A proper training is required.
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10
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Imai M, Kamimura K, Takahashi Y, Sato T, Isokawa O, Maruyama M, Kobayashi T, Hayashi K, Terai S. The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine. Int J Colorectal Dis 2018; 33:189-197. [PMID: 29264760 DOI: 10.1007/s00384-017-2946-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine. METHODS We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65-99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction. RESULTS The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20-1377 days). On multivariate analysis, shorter stents (< 10 cm) yielded better outcomes than longer stents (≥ 10 cm) (P = 0.041), and the Cox proportional hazard model also indicated that shorter stents (P = 0.036) predicted longer event-free survival. CONCLUSIONS Elderly patients with malignant bowel obstruction receiving shorter stents had longer event-free survival after stenting with better general condition.
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Affiliation(s)
- Michitaka Imai
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan.
| | - Yoshifumi Takahashi
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Toshihiro Sato
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Osamu Isokawa
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Masaki Maruyama
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
- Department of Gastroenterology, Kashiwazaki Chuo Hospital, 2-1-25, Ekimae, Kashiwazaki, Niigata, Japan
| | - Takamasa Kobayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
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12
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Albrecht R, Hönicke H, Bochmann C, Settmacher U, Wirth T. [Colonic stenting: an opportunity with a risk : A critical evaluation]. Chirurg 2016; 86:787-93. [PMID: 26070274 DOI: 10.1007/s00104-015-0022-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- R Albrecht
- Klinik für Viszeral- und Gefäßchirurgie, HELIOS Klinikum Aue, Gartenstraße 6, 08280, Aue, Deutschland,
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13
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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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14
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Cetinkaya E, Dogrul AB, Tirnaksiz MB. Role of self expandable stents in management of colorectal cancers. World J Gastrointest Oncol 2016; 8:113-120. [PMID: 26798442 PMCID: PMC4714140 DOI: 10.4251/wjgo.v8.i1.113] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 10/01/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Acute malignant colorectal obstruction is a complication of colorectal cancer that can occur in 7%-29% of patients. Self-expanding metallic stent placement for malignant colorectal obstruction has gained popularity as a safe and effective procedure for relieving obstruction. This technique can be used in the palliation of malignant colorectal obstruction, as a bridge to elective surgery for resectable colorectal cancers, palliation of extracolonic malignant obstruction, and for nonmalignant etiologies such as anastomotic strictures, Crohn’s disease, radiation therapy, and diverticular diseases. Self-expanding metallic stent has its own advantages and disadvantages over the surgery in these indications. During the insertion of the self-expanding metallic stent, and in the follow-up, short term and long term morbidities should be kept in mind. The most important complications of the stents are perforation, stent obstruction, stent migration, and bleeding. Additionally, given the high risk of perforation, if a patient is treated or being considered fortreatmentwith antiangiogenic agents such as bevacizumab, it is not recommended to use self-expanding metallic stent as a palliative treatment for obstruction. Therefore, there is a need for careful clinical evaluation for each patient who is a candidate for this procedure. The purpose of this review was to evaluate self-expanding metallic stent in the management of the obstruction of the colon due to the colorectal and extracolonic obstruction.
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Thosani N, Banerjee S, Khanijow V, Rao B, Priyanka P, Ertan A, Guha S. Role of self-expanding metal stents in patients with malignant colorectal obstruction: A systematic review and meta-analysis. World J Meta-Anal 2015; 3:232-253. [DOI: 10.13105/wjma.v3.i6.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/01/2015] [Accepted: 11/04/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the safety and efficacy of self-expandable metal stents (SEMSs) for malignant colorectal obstruction.
METHODS: Data regarding technical success, clinical success, and procedure related complications were collected from included studies. DerSimonian-Laird random effects model was used to generate the overall outcome. Thirty international studies with a total of 2058 patients with malignant colorectal obstruction were included.
RESULTS: The technical and clinical success rates for SEMS placement were 94% (95%CI: 92-96) and 91% (95%CI: 88-93), respectively. Overall complication rate for SEMS was 23% (95%CI: 18-29). Stent migration 8% (95%CI: 6-10) and stent obstruction 8% (95%CI: 6-11) were the most common complications, followed by perforation 5% (95%CI: 4%-7%). Surgical or endoscopic re-interventions were needed in 14% (95%CI: 10-18) of patients. Endoscopic repeat stent placement was required in 8% (95%CI: 6-10), while surgical intervention was needed in 6% (95%CI: 4-8).
CONCLUSION: SEMS are effective when used as palliation or bridge to surgery for malignant colorectal obstruction with high technical and clinical success. About 14% of patients require repeat endoscopic or surgical intervention for stent failure or to manage stent related complications.
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Dumont F, Goéré D, Honoré C, Elias D. Abdominal surgical emergencies in patients with advanced cancer. J Visc Surg 2015; 152:S91-6. [PMID: 26548722 DOI: 10.1016/j.jviscsurg.2015.09.014] [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: 02/07/2023]
Abstract
Abdominal emergency in an advanced oncologic setting is defined as an acute life-threatening abdominal pathology in a patient with incurable cancer. These include bowel obstruction, infections and, more rarely, hemorrhage. To benefit the patient, surgery should both increase the survival and improve the quality of life. These two goals are of equal importance and must be achieved together. This is difficult because these patients are frail, often malnourished and have a poor performance status. They also have a high risk of post-operative morbidity and mortality, a major risk of symptom recurrence and a limited life expectancy. For patients near the end-of-life, a therapeutic decision for surgical intervention must respect ethical and legal standards. This review reports the surgical outcomes and median survival of these patients, specifies rules that must be known and respected, and presents non-operative interventional alternatives.
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Affiliation(s)
- F Dumont
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France.
| | - D Goéré
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - C Honoré
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - D Elias
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
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A Multicenter Randomized Controlled Trial of Malignant Gastric Outlet Obstruction: Tailored Partially Covered Stents (Placed Fluoroscopically) versus Standard Uncovered Stents (Placed Endoscopically). Gastroenterol Res Pract 2014; 2014:309797. [PMID: 25610459 PMCID: PMC4290140 DOI: 10.1155/2014/309797] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/24/2014] [Accepted: 11/30/2014] [Indexed: 12/27/2022] Open
Abstract
The aim of our study is to compare the efficacy and safety of “outlet-shape” tailored stents with standard stents for the management of distal gastric cancer causing gastric outlet obstructions (GOOs) with varying gastric cavity shapes and sizes. To determine the shape and size of the GOOs, stomach opacifications were performed using contrast media before stenting. Two basic shapes of the residual cavity of the proximal GOO were observed: cup shaped or approximately cup shaped and funnel shaped or approximately funnel shaped. Other shapes were not found. In the GOO tailored group, the size and shape of the proximal ends of the tailored stent were suited for the residual cavity of the proximal GOO. The tailored stents included large cup-shaped stents and large funnel-shaped stents. GOO tailored covered stents led to less restenosis and reintervention rates compared to standard uncovered stents but with the same survival.
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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: 110] [Impact Index Per Article: 11.0] [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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Kaplan J, Strongin A, Adler DG, Siddiqui AA. Enteral stents for the management of malignant colorectal obstruction. World J Gastroenterol 2014; 20:13239-13245. [PMID: 25309061 PMCID: PMC4188882 DOI: 10.3748/wjg.v20.i37.13239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/22/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the 3rd most common cancer in the United States with more than 10000 new cases diagnosed annually. Approximately 20% of patients with CRC will have distant metastasis at time of diagnosis, making them poor candidates for primary surgical resection. Similarly, 8%-25% of patients with CRC will present with bowel obstruction and will require palliative therapy. Emergent surgical decompression has a high mortality and morbidity, and often leads to a colostomy which impairs the patient’s quality of life. In the last decade, there has been an increasing use of colonic stents for palliative therapy to relieve malignant colonic obstruction. Colonic stents have been shown to be effective and safe to treat obstruction from CRC, and are now the therapy of choice in this scenario. In the setting of an acute bowel obstruction in patients with potentially resectable colon cancer, stents may be used to delay surgery and thus allow for decompression, adequate bowel preparation, and optimization of the patient’s condition for curative surgical intervention. An overall complication rate (major and minor) of up to 25% has been associated with the procedure. Long term failure of stents may result from stent migration and tumor ingrowth. In the majority of cases, repeat stenting or surgical intervention can successfully overcome these adverse effects.
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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 JP, Hong SJ, Kim SH, Choi JH, Jung HJ, Cho YH, Ko BM, Lee MS. Palliative self-expandable metal stents for acute malignant colorectal obstruction: clinical outcomes and risk factors for complications. Scand J Gastroenterol 2014; 49:967-73. [PMID: 24874189 DOI: 10.3109/00365521.2014.920914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Self-expandable metal stents (SEMSs) have been used as palliative treatment or bridge to surgery for obstructions caused by colorectal cancer (CRC). We assessed the long-term outcomes of palliative SEMSs and evaluated the risk factors influencing complications. MATERIALS AND METHODS One hundred and seventy-five patients underwent SEMS placement for acute malignant colorectal obstruction. Of the 72 patients who underwent palliative treatment for primary CRC, 30 patients received chemotherapy (CT) for primary cancer (CT group) and 42 underwent best supportive treatment (BST) without CT (BST group). RESULTS There was a significant difference in late migration between the CT group and the BST group (20.0% in CT group, 2.4% in BST group, p = 0.018). Response to CT influenced the rate of late obstruction (0% in disease control, 35.7% in disease progression, p = 0.014). However, late obstruction was not associated with stent properties, such as diameter or type (≤22 mm vs. >22 mm, 13.5% vs. 14.3%, p = 1.00; uncovered stent vs. covered stent, 15.5% vs. 7.1%, p = 0.675) and migration (≤22 mm vs. >22 mm, 16.2% vs. 2.9%, p = 0.108; uncovered stent vs. covered stent, 8.6% vs. 14.3%, p = 0.615) in palliative SEMS. CONCLUSION The administration of CT increases the rate of stent migration, and disease control by CT can reduce the risk of obstruction by maintaining the luminal patency of palliative SEMSs.
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Affiliation(s)
- Jae Pil Han
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine , Bucheon , Korea
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Moon SJ, Kim SW, Lee BI, Lim CH, Kim JS, Soo J, Park JM, Lee IS, Choi MG, Choi KY. Palliative stent for malignant colonic obstruction by extracolonic malignancy: a comparison with colorectal cancer. Dig Dis Sci 2014; 59:1891-7. [PMID: 24077942 DOI: 10.1007/s10620-013-2876-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 09/03/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Palliative self-expandable metal stent placement for colonic obstruction arising from an extracolonic malignancy might be as useful as that for colorectal cancer, but data are limited. The purposes of this study were to investigate success and complications of stent placement in patients with extracolonic malignancy and to compare long-term clinical outcomes for an extracolonic malignancy group with those for a colorectal cancer group. PATIENTS AND METHODS We reviewed short-term and long-term outcomes for patients treated with palliative stents for colonic obstruction by extracolonic malignancy (n = 44) or unresectable colorectal cancer (n = 53) from January 2006 to March 2011. RESULTS Neither the technical success (93.2 vs. 98.1 %, respectively; P = 0.326) nor clinical success (77.3 vs. 84.9 %, respectively; P = 0.433) of stent placement differed significantly in the two groups. Complications as a result of stent placement also differed only slightly in the two groups (perforation: 4.8 % (two cases) vs. 0 %, respectively; migration: 4.8 vs. 5.8 %, respectively, P = 0.343). With regard to long-term outcomes, although stent patency was shorter in the extracolonic malignancy group (P = 0.015), because overall survival in this group was also shorter (P = 0.018), it was sufficient for palliative purposes. CONCLUSIONS Palliative stent placement was equally effective and safe for treatment of colonic obstruction arising from either extracolonic malignancy or unresectable colorectal cancer. Even in cases of colonic obstruction arising from extracolonic malignancy, stent placement should be considered as primary palliative therapy.
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van Halsema EE, van Hooft JE, Small AJ, Baron TH, García-Cano J, Cheon JH, Lee MS, Kwon SH, Mucci-Hennekinne S, Fockens P, Dijkgraaf MGW, Repici A. Perforation in colorectal stenting: a meta-analysis and a search for risk factors. Gastrointest Endosc 2014; 79:970-82.e7; quiz 983.e2, 983.e5. [PMID: 24650852 DOI: 10.1016/j.gie.2013.11.038] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 11/25/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement. OBJECTIVE To identify risk factors for perforation from colonic stenting. DESIGN A meta-analysis of 86 studies published between 2005 and 2011. SETTING Multicenter review. PATIENTS All patients who underwent colorectal stent placement. INTERVENTION Colorectal stent placement. MAIN OUTCOME MEASUREMENTS The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab. RESULTS A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%). LIMITATIONS Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis. CONCLUSIONS The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.
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Affiliation(s)
- Emo E van Halsema
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Aaron J Small
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd H Baron
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jesús García-Cano
- Department of Gastroenterology, Hospital Virgen de la Luz, Cuenca, Spain
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Sung Lee
- Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, Bucheon, Korea
| | - Se Hwan Kwon
- Department of Radiology, Kyung Hee University Medical Center, Seoul, Korea
| | | | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Alessandro Repici
- Department of Digestive Endoscopy, Istituto Clinico Humanitas, Milan, Italy
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The role of primary colectomy after successful endoscopic stenting in patients with obstructive metastatic colorectal cancer. Dis Colon Rectum 2014; 57:694-9. [PMID: 24807593 DOI: 10.1097/dcr.0000000000000061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although the initial clinical efficacy of self-expandable metal stents is acceptable, doubt still remains about long-term clinical outcomes and complications. OBJECTIVE The aim of this study was to evaluate the stoma formation rate and risk factors for complications after successful stenting in patients with obstructive metastatic colorectal cancer. DESIGN This was a tertiary-care center retrospective study. PATIENTS From January 2000 to December 2010, 130 patients with unresectable obstructive colorectal cancer received successful self-expandable metal stent placement. Among them, 14 patients received primary colectomy after successful stenting. INTERVENTIONS Self-expandable metal stent placement and primary colectomy were performed. MAIN OUTCOME MEASURES The stoma formation rate and complications were measured. RESULTS In patients with successful stenting, stoma formation rates at 1 and 2 years were 15.6% (95% CI, 8.74-22.4) and 24.4% (95% CI, 13.8-35.0), and the median patency duration was 157 days (range, 2-1590 days). However, long-term complications occurred in 58 patients (44.6%), including reobstruction (32.6%), stent migration (10.3%), and perforation (7.8%), and a large number of reinterventions (45.7%) and hospitalizations (37/9%) were needed to manage complications. In multivariate analysis, primary colectomy after successful endoscopic stenting was a negative predictive factor for reobstruction (OR, 0.12; 95% CI, 0.02-0.99; p = 0.04). LIMITATIONS This was a retrospective, single-center study. CONCLUSIONS To reduce stent-related late complications, primary colectomy after successful endoscopic stenting could be a therapeutic option in patients who have unresectable colorectal cancer with obstruction, especially in those who expect long-term survival.
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Choi JM, Lee C, Han YM, Lee M, Choi YH, Jang DK, Im JP, Kim SG, Kim JS, Jung HC. Long-term oncologic outcomes of endoscopic stenting as a bridge to surgery for malignant colonic obstruction: comparison with emergency surgery. Surg Endosc 2014; 28:2649-55. [PMID: 24789126 DOI: 10.1007/s00464-014-3517-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 03/10/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Self-expandable metallic stents (SEMS) are now regarded as an effective and safe intervention for malignant colorectal obstruction (MCO). However, manipulation of the tumor might lead to the spillage of tumor cells and result in distant metastases. We aimed to compare the long-term oncologic outcomes of SEMS as a bridge to surgery with those of emergency surgery for MCO. METHODS Between June 2005 and December 2011, 60 patients who underwent elective curative resection after endoscopic SEMS insertion were included in the "SEMS group". The SEMS group was matched to 180 patients who underwent emergency curative surgery for MCO during the same period ["Emergency surgery (ES) group"]. The clinicopathologic characteristics, recurrence-free survival (RFS), and overall survival (OS) were compared between the two groups. RESULTS There were no significant differences in demographics, tumor stage, location, and histology between the SEMS group and the ES group. The median follow-up times were 41.4 months (IQR, 22.2-60.0 months) for the SEMS group and 45.0 months (IQR, 20.9-68.1 months) for the ES group. The proportions of patients who received postoperative adjuvant chemotherapy were comparable (SEMS group vs. ES group, 68.3 % vs. 77.8 %; P = 0.210). The long-term prognosis did not significantly differ between two groups in either the 5-year RFS rate (79.6 % vs. 70.2 %; P = 0.218) or the 5-year OS rate (97.8 % vs. 94.3 %; P = 0.469). CONCLUSIONS Long-term oncologic outcomes of SEMS insertion as a bridge to surgery were comparable to those of primary curative surgery.
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Affiliation(s)
- Ji Min Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea,
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Cheung DY, Lee YK, Yang CH. Status and literature review of self-expandable metallic stents for malignant colorectal obstruction. Clin Endosc 2014; 47:65-73. [PMID: 24570885 PMCID: PMC3928494 DOI: 10.5946/ce.2014.47.1.65] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 12/14/2022] Open
Abstract
Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.
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Affiliation(s)
- Dae Young Cheung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong Kook Lee
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Chang Heon Yang
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
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27
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Almadi MA, Azzam N, Alharbi O, Mohammed AH, Sadaf N, Aljebreen AM. Complications and survival in patients undergoing colonic stenting for malignant obstruction. World J Gastroenterol 2013; 19:7138-7145. [PMID: 24222958 PMCID: PMC3819550 DOI: 10.3748/wjg.v19.i41.7138] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 05/22/2013] [Accepted: 08/06/2013] [Indexed: 02/07/2023] Open
Abstract
AIM: To investigate whether predicting patients that might be at a higher risk for complications might serve to improve the selection of patients undergoing colonic stenting.
METHODS: A retrospective review of consecutive patients who underwent an attempted self-expandable metal stent (SEMS) insertion for malignant colonic obstruction between November 2006 and March 2013. All patients were either referred for preoperative colonic decompression with the intent of a single surgical procedure, or for palliation of the malignant colorectal obstruction for unresectable cancer. Fisher’s test or χ2 test was performed on categorical variables, and the t test for continuous variables. Univariable and multivariable logistic regression were used to examine the association between independent variables and the presence of complications from SEMS insertion.
RESULTS: SEMS insertion was attempted in 73 patients. Males comprised 55.71% and the mean age was 67.41 ± 12.41 years. Of these, 65.15% underwent subsequent surgery, while 34.85% received SEMS as palliation for advanced disease. Extracolonic tumors were only 4.76%. The majority of patients had stage IV disease (63.83%), while the remainder had stage III (36.17%). SEMS were successfully inserted in 93.85% (95%CI: 87.85%-99.85%). Perforations occurred in 4.10%, SEMS migration in 8.21%, and stent re-occlusion from ingrowth occurred in 2.74% of patients. The mean duration of follow up for the patients was 13.52 ± 17.48 mo (range 0-73 mo). None of the variables: age, sex, time between the onset of symptoms to SEMS insertion, time between SEMS insertion and surgery, length of the stenosis, location of the stenosis, albumin level, or receiving neoadjuvant chemotherapy, could predict the development of complications from either SEMS insertion nor prolonged survival.
CONCLUSION: None of the variables could predict the development of complications or survival. Further studies are required to identify patients who would benefit the most from SEMS.
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García-Cano J. Colorectal stenting as first-line treatment in acute colonic obstruction. World J Gastrointest Endosc 2013; 5:495-501. [PMID: 24147193 PMCID: PMC3797902 DOI: 10.4253/wjge.v5.i10.495] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 06/16/2013] [Accepted: 08/13/2013] [Indexed: 02/05/2023] Open
Abstract
Tumoral obstructions in almost the entire gastrointestinal tract can be resolved with interventional digestive endoscopy techniques. Self-expanding metal stent (SEMS) insertion in the obstructed colon is a minimally invasive and relatively simple procedure providing an effective first-line treatment for relief of acute malignant obstruction symptoms and serving either as a preoperative or “bridge to surgery” procedure or as palliative definitive care. This technique was introduced in the early 1990s. Although there is still debate about its real value, a lot of reports have been published since then and the procedure is advocated by many surgical groups as the method of choice for the initial treatment of left-sided tumoral colonic obstruction. Before the procedure, colonic obstruction has to be diagnosed by abdominal radiographs, water contrast enema and/or a computed tomography scan. The greatest information is provided by the latter and it is perhaps the method of choice prior to stenting. Skills and training are mandatory, as in all interventional procedures. The key step for success is to cross the malignant stricture with a guidewire. Care must be taken not to over insufflate an obstructed colon during the procedure. SEMS slide over the guidewire through the endoscope working channel or in parallel, outside the endoscope. An average 7% perforation rate has been reported during the procedure and other minor complications can appear in the follow up. However, as a whole, this technique seems to compare favorably with surgery.
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Self-expandable metallic stents in patients with stage IV obstructing colorectal cancer. World J Surg 2013; 36:2931-6. [PMID: 22960673 DOI: 10.1007/s00268-012-1767-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of the present study was to analyze the results of our experience with elective placement of self-expandable metallic stents (SEMS) in patients with stage IV obstructing colorectal cancer. A systematic review of the literature was also carried out to analyze the factors influencing the results of SEMS placement and to determine if there has been any improvement in the more recent period. MATERIALS AND METHODS The results of a personal series of 100 patients were analyzed. There was no case of mortality or major morbidity. The systematic review included 27 articles published from April 2007 to December 2011. RESULTS In our experience the technical success rate was 96% and the clinical success rate was 92%. During the follow-up period a repeat colonoscopy was needed in 31% of the patients for recurrent symptoms of obstruction due to fecal impaction (19%), tumor growth (8%), or stent dislodgment (4%). Review of the literature showed similar results, with a significant improvement in the reports of the last 6 years; procedures performed on an emergency basis had poorer results. CONCLUSIONS Self-expandable metallic stent placement offers a valid alternative to surgery in patients with obstructing stage IV colorectal cancer, but careful follow-up is required.
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Choi JH, Lee YJ, Kim ES, Choi JH, Cho KB, Park KS, Jang BK, Chung WJ, Hwang JS. Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction. Surg Endosc 2013; 27:3220-7. [PMID: 23494513 DOI: 10.1007/s00464-013-2897-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 02/15/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications. METHODS Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy. RESULTS A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100% and the clinical success rate 94.1%. Overall complications were observed in 49 patients (32.2%) during the follow-up period (median, 98 days; interquartile range, 19-302 days). Obstruction (17.1%), migration (7.9%), perforation (5.2%), bleeding (1.3%), and tenesmus (0.7%) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan-Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group. CONCLUSIONS Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.
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Affiliation(s)
- Jae Hyuk Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, 194 Dong San-dong, Jung-gu, Daegu 700-712, South Korea
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Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: A systematic review and meta-analysis. Surg Oncol 2013. [PMID: 23183301 DOI: 10.1016/j.suronc.2012.10.003] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kim JY, Kim SG, Im JP, Kim JS, Jung HC. Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction. Surg Endosc 2012; 27:272-7. [PMID: 22773238 DOI: 10.1007/s00464-012-2439-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 05/31/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMS) have been used as a bridging or palliative treatment for malignant colorectal obstruction. Colonic obstruction also may arise from advanced extracolonic malignancy, but the clinical outcomes of stent placement for extracolonic malignancy are unclear. This study compared the clinical outcomes of SEMS between patients with colorectal cancer and those with extracolonic malignancy. METHODS Patients who underwent endoscopic SEMS placement for a malignant colorectal obstruction were enrolled at Seoul National University Hospital from April 2005 and August 2011. Their medical records were retrospectively reviewed in terms of success rate, complications, and duration of stent patency. RESULTS Endoscopic SEMS placements were performed for colorectal cancer in 149 patients and for extracolonic malignancy in 60 patients. The causes of obstruction in extracolonic malignancy were advanced gastric cancer in 39 patients (65%), pancreatic cancer in nine patients (15%), ovarian cancer in three patients (5%) and other causes in nine patients (15%). The clinical success rates were similar between the two groups (92.6 vs 86.7%; p = 0.688), and multivariate analysis showed no significant risk factor for unsuccessful endoscopic SEMS placement. Reobstruction in palliative endoscopic SEMS placement occurred for 16 patients with colorectal cancer (21.9%) and 18 patients with extracolonic malignancy (30%) during a median follow-up period of 90 days (p = 0.288). The rates did not differ significantly between the two groups (4.1 vs 8.3%; p = 0.467). The median duration of stent patency was 193 ± 42 days for the patients with colorectal cancer and 186 ± 31 days for the patients with extracolonic malignancy (p = 0.253). The duration of stent patency was not affected by underlying malignancy, previous surgery, or palliative chemotherapy. CONCLUSIONS Endoscopic SEMS placement is highly effective and comparable for palliation of obstruction in extracolonic malignancy and colorectal cancer in terms of clinical success, complications, and duration of patency.
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Affiliation(s)
- Ji Yeon Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine and Hospital, Seoul, Korea.
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Kim BC, Han KS, Hong CW, Sohn DK, Park JW, Park SC, Kim SY, Baek JY, Choi HS, Chang HJ, Kim DY, Oh JH. Clinical outcomes of palliative self-expanding metallic stents in patients with malignant colorectal obstruction. J Dig Dis 2012; 13:258-66. [PMID: 22500788 DOI: 10.1111/j.1751-2980.2012.00564.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Self-expanding metallic stents (SEMS) are useful palliative option and a bridge to surgery in malignant colorectal obstruction. The aim of this study was to evaluate the clinical outcomes of SEMS to palliate colorectal malignant obstruction. METHODS Malignant colorectal obstructive patients who underwent SEMS insertion at the National Cancer Center, Korea from January 2004 to June 2008 were enrolled in the study. Patients' clinical characteristics, outcomes and complications for palliative SEMS insertion were retrospectively analyzed. RESULTS A total of 54 patients were enrolled in the palliative SEMS group and 48 patients with obstructive CRC were included in the SEMS as the bridge to surgery group. Obstruction of the left colon occurred in 52 patients of the palliative SEMS group and all patients in SEMS as bridge to surgery group. For primary SEMS insertion, the technical success (TS) rate was 87.0% and the clinical success (CS) rate 89.4%, while the rates of early and late complications were 24.1% and 23.4%, respectively. There was no procedure-related mortality. Stent migration rate was higher in the cases treated with small diameter and covered type of stents. Median time to reobstruction and migration were 85 and 101 days, respectively. TS and CS rates for SEMS reinsertion were comparable to those for primary SEMS insertion. CONCLUSIONS Palliative SEMS are effective and favorable procedures for malignant colorectal obstruction but with some complications. Stent migration is associated with covered type and small diameter stents while other factors including length of stent and chemotherapy do not affect stent complications in the present study.
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Affiliation(s)
- Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang-si, Gyeonggi-do, Korea.
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Yoon JY, Jung YS, Hong SP, Kim TI, Kim WH, Cheon JH. Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011; 74:858-68. [PMID: 21862005 DOI: 10.1016/j.gie.2011.05.044] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 05/26/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although self-expandable metal stent (SEMS) insertion is widely used for relief of malignant colorectal obstructions, the immediate technical and clinical failure rates of SEMSs and the associated risk factors remain largely unknown. OBJECTIVE To identify rates and factors predictive of technical and clinical failure of SEMSs when their use is attempted for the decompression of malignant colorectal obstruction. DESIGN Retrospective chart review. SETTING A tertiary-care academic medical center in South Korea. PATIENTS This study involved a total of 412 patients with malignant colorectal obstruction in whom SEMS insertion was attempted. INTERVENTION Placement of colonic SEMSs. MAIN OUTCOME MEASUREMENTS Technical success and immediate and long-term clinical success rates. RESULTS Technical and clinical failures were found in 36 of 276 patients (13.0%) and 39 of 240 patients (16.3%) in the palliative group, respectively, and in 3 of 136 patients (2.2%) and 7 of 133 patients (5.3%) in the preoperative group, respectively. Factors associated with technical failure were extracolonic origin of tumor, the presence of carcinomatosis, and a proximal obstruction site. Factors associated with long-term clinical failure in the palliative group were combined dilation procedure, no additional chemotherapy, and extracolonic origin of the tumor. In the preoperative group, only older patients had both higher technical failure and clinical failure rates. LIMITATIONS This was a single-institution, retrospective analysis. CONCLUSION Although colorectal SEMS placement is generally safe and effective, it is associated with clinically important technical and clinical failure rates. The identification of risk factors for the failure of colorectal SEMSs found in this study might help physicians decide between surgical decompression and endoscopic stenting in patients with malignant colorectal obstruction.
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Affiliation(s)
- Jin Young Yoon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Al Samaraee A, McCallum IJ, Kenny L, Isreb S, Macdougall L, Hayat M, Kelly S. Colorectal stents: do we have enough evidence? Int J Surg 2011; 9:595-9. [PMID: 21930255 DOI: 10.1016/j.ijsu.2011.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 08/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of colonic stents has significantly evolved over the last few years. Emergency surgery for colonic obstructions is usually associated with significant mortality, morbidity and often stoma formation. Colonic stents provide an alternative way to relieve colonic obstruction, and hence avoiding the risks associated with emergency surgery. This literature review aims to summarize the important current evidence regarding colorectal stenting and show whether further evaluation of the procedure is required. RESULTS The available large number of non-randomized studies suggests that Self-Expandable-Metal-Stents (SEMS) placement for acute colonic obstruction could be considered as safe and effective alternative to surgery in experienced hands either as a bridge to surgery or as a palliative measure. This evidence has led to SEMS being widely adopted. However, randomized evidence has begun to show the defects that are inherent in the low level evidence that has so far supported SEMS use and it may be that reports of randomized controlled trials may clarify the patient population where SEMS placement is appropriate. CONCLUSION While we are still waiting for the outcome of the multicentre randomized controlled trials in the UK and Europe, clinicians must be aware of the current evidence limitations and apply SEMS use pragmatically.
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Affiliation(s)
- Ahmad Al Samaraee
- North Tyneside General Hospital, Mr. S. Kelly's Office, Rake Lane, North Shields, NE29 8NH, UK.
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Yoon JY, Jung YS, Hong SP, Kim TI, Kim WH, Cheon JH. Outcomes of secondary stent-in-stent self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011; 74:625-33. [PMID: 21762906 DOI: 10.1016/j.gie.2011.05.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 05/17/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although self-expandable metal stents (SEMSs) are widely used for the treatment of malignant colorectal obstruction, they often become occluded by tumor ingrowth. OBJECTIVES To determine the therapeutic effectiveness of secondary stent-in-stent SEMS insertion for the management of occluded SEMS in patients with malignant colorectal obstruction and to identify predictive factors associated with clinical outcomes in terms of immediate clinical success, stent patency, and complications. DESIGN Retrospective case series. SETTING A tertiary-care academic medical center in South Korea. PATIENTS Between November 2005 and July 2010, among a total of 309 patients who underwent SEMS insertion for unresectable malignant colorectal obstruction at Severance Hospital, 87 underwent secondary SEMS insertion. Of these, 36 patients underwent secondary SEMS placement as stent-in-stent. INTERVENTIONS Placement of secondary colorectal stent-in-stent SEMSs. MAIN OUTCOME MEASUREMENTS Immediate and long-term clinical success and complications. RESULTS Immediate clinical success was achieved in 27 of 36 patients (75%), and the median duration of stent patency was 170 days. Factors associated with immediate clinical success included a long duration between the previous stent and stent-in-stent insertion. Moreover, the absence of carcinomatosis was associated with long-term clinical success. LIMITATIONS This was a retrospective, nonrandomized, single-center study. CONCLUSIONS Secondary stent-in-stent SEMS placement led to good outcomes in patients with malignant colorectal obstruction, despite a slightly lower success rate compared with primary SEMS placement. Patency duration of the primary SEMS and carcinomatosis were important factors predictive of immediate and long-term clinical success of stent-in-stent insertion, respectively.
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Affiliation(s)
- Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seodaemugu, Seoul, Korea
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Repici A, de Paula Pessoa Ferreira D. Expandable metal stents for malignant colorectal strictures. Gastrointest Endosc Clin N Am 2011; 21:511-33, ix. [PMID: 21684468 DOI: 10.1016/j.giec.2011.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milano, Italy.
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de Gregorio MA, Laborda A, Tejero E, Miguelena JM, Carnevale FC, de Blas I, Gimenez M, Maynar M, D'Agostino H. Ten-year retrospective study of treatment of malignant colonic obstructions with self-expandable stents. J Vasc Interv Radiol 2011; 22:870-8. [PMID: 21514839 DOI: 10.1016/j.jvir.2011.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 01/07/2011] [Accepted: 02/04/2011] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To describe the use of self-expandable metallic stents to manage malignant colorectal obstructions and to compare the radiation dose between fluoroscopic guidance of stent placement and combined endoscopic and fluoroscopic guidance. MATERIALS AND METHODS From January 1998 to December 2007, 467 oncology patients undergoing colorectal stent placement in a single center were included in the study. Informed consent was obtained in all cases. All procedures were performed with fluoroscopic or combined fluoroscopic and endoscopic guidance. Inclusion criteria were total or partial colorectal obstruction of neoplastic origin. Exclusion criteria were life expectancy shorter than 1 month, suspicion of perforation, and/or severe colonic neoplastic bleeding. Procedure time and radiation dose were recorded, and technical and clinical success were evaluated. Follow-up was performed by clinical examination and simple abdominal radiographs at 1 day and at 1, 3, 6, and 12 months. RESULTS Of 467 procedures, technical success was achieved in 432 (92.5%). Thirty-five treatments (7.5%) were technical failures, and the patients were advised to undergo surgery. Significant differences in radiation dose and clinical success were found between the fluoroscopy and combined-technique groups (P < .001). Total decompression was achieved in 372 cases, 29 patients showed remarkable improvement, 11 showed slight improvement, and 20 showed clinical failure. Complications were recorded in 89 patients (19%); the most significant were perforation (2.3%) and stent migration (6.9%). Mean interventional time and radiation dose were 67 minutes and 3,378 dGy·cm(2), respectively. CONCLUSIONS Treatment of colonic obstruction with stents requires a long time in the interventional room and considerable radiation dose. Nevertheless, the clinical benefits and improvement in quality of life justify the radiation risk.
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Affiliation(s)
- Miguel A de Gregorio
- Research Group in Minimally Invasive Techniques, University of Zaragoza, Avda Miguel Servet 177, Zaragoza 50013, Spain
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Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc 2011; 73:535-42. [PMID: 21257165 DOI: 10.1016/j.gie.2010.10.052] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 10/27/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) provide a promising alternative for initial palliation of malignant bowel obstruction. However, data on the long-term outcomes of SEMSs are limited. OBJECTIVE The aim of this study was to compare the long-term outcomes of endoscopic stenting with those of surgery for palliation in patients with incurable obstructive colorectal cancer. DESIGNS AND SETTING: A retrospective study. PATIENTS From January 2000 to December 2008, patients with incurable obstructive colorectal cancer who were treated with SEMSs (n = 71) or palliative surgery (n = 73) were reviewed. INTERVENTIONS SEMS placement by using through-the-endoscope methods or surgery. MAIN OUTCOME MEASUREMENTS Success rates and complication rates. RESULTS Early success rates in the SEMS group and those in the surgery group were not different (95.8% vs 100%, P = .12), and the SEMS group had fewer early complications than the surgery group (15.5% vs 32.9%, P = .015). Although the patency duration of the first stent in the SEMS group was shorter than that in the surgery group (P < .001), the median patency duration after a second stenting was comparable to that of the surgery group (P = .239). There were more late complications in the SEMS group than in the surgery group (P = .028), but the rates of major complications did not differ between the 2 groups (P = .074). LIMITATIONS Retrospective and single-center study. CONCLUSIONS SEMSs were not only an effective and acceptable therapy for initial palliation of malignant colorectal obstruction, but they also showed long-term efficacy comparable to that with surgery.
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Schwenter F, Morel P, Gervaz P. Management of obstructive and perforated colorectal cancer. Expert Rev Anticancer Ther 2010; 10:1613-1619. [DOI: 10.1586/era.10.147] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lopera JE, De Gregorio MA. Fluoroscopic management of complications after colorectal stent placement. Gut Liver 2010; 4 Suppl 1:S9-S18. [PMID: 21103302 DOI: 10.5009/gnl.2010.4.s1.s9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Colorectal self-expanding metal stents have been widely used as a bridge to surgery in patients with acute malignant colonic obstruction by allowing a single-stage operation, or as a definitive palliative procedure in patients with inoperable tumors. Colonic stents are placed under either fluoroscopic or combined endoscopic and fluoroscopic guidance, with similar technical-success and complication rates. Placement of colonic stents is a very safe procedure with a low procedure-related mortality rate, but serious complications can develop and reinterventions are not uncommon. Most of the complications can be treated by minimally invasive or conservative techniques, while surgical interventions are required for most patients with perforation.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, UT Health Science Center at San Antonio, San Antonio, TX, USA
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Park S, Cheon JH, Park JJ, Moon CM, Hong SP, Lee SK, Kim TI, Kim WH. Comparison of efficacies between stents for malignant colorectal obstruction: a randomized, prospective study. Gastrointest Endosc 2010; 72:304-10. [PMID: 20561619 DOI: 10.1016/j.gie.2010.02.046] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 02/23/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonoscopic insertion of a self-expandable metallic stent (SEMS) has been widely performed for the treatment of malignant colorectal obstruction. Different types of stents could influence the efficacy and complication rate of stent use. OBJECTIVE To compare the efficacy and complication rates between two SEMSs, the uncovered WallFlex stent and the covered Comvi stent. DESIGN A prospective, randomized study. SETTING Tertiary-care academic medical center. PATIENTS Between 2007 and 2009, a total of 151 patients with malignant colorectal obstruction were enrolled. INTERVENTION Two types of colorectal SEMSs (the uncovered WallFlex stent by Boston Scientific Corp and the newly developed covered Comvi stent by Taewoong Medical Co) were inserted. MAIN OUTCOME MEASUREMENTS Technical success, clinical success, stent patency, and complication rate according to stent type. RESULTS Technical failure occurred in 2 patients (1.3%); one was in the WallFlex group and the other in the Comvi group. Clinical failure developed in 9 patients (6.0%): 6 patients from the WallFlex group and 3 from the Comvi group. Complications because of cancer infiltration occurred more frequently in the WallFlex group (14.5% vs 3.8%). However, the rate of stent migration was higher in the Comvi group (21.1% vs 1.8%). The mean patency of the stent did not differ between the two groups (P = .50). LIMITATIONS This was a single-center study. CONCLUSION Both uncovered WallFlex and covered Comvi stents were suitable for relieving malignant colorectal obstruction. Tumor ingrowth was more common in the WallFlex group, but stent migration was more common in the Comvi group.
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Affiliation(s)
- Semi Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Xu K, Zhang H, Feng Y, Cong JC, Chen CS, Liu EQ. Comparison of the outcomes of preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer: an analysis of 248 cases. Shijie Huaren Xiaohua Zazhi 2010; 18:736-740. [DOI: 10.11569/wcjd.v18.i7.736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of self-expanding metallic stents (SEMSs) and to compare the short- and long-term outcomes of preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer.
METHODS: Sixty-two patients who underwent SEMS insertion and 186 patients who underwent primary emergency surgery for left-sided colorectal cancer from 2000 to 2008 were retrospectively analyzed.
RESULTS: The SEMSs were placed successfully in 61 patients, of which 14.5% developed complications such as perforating and migration. Primary anastomosis rate was higher in patients undergoing stent insertion than in those undergoing emergency surgery (87.1% vs 34.4%, P = 0.001). The complication rate was higher in patients undergoing emergency surgery than in those undergoing stent insertion (47.3% vs 17.7%, P = 0.000). No significant difference was noted in the survival curve between the two groups (P = 0.497).
CONCLUSION: Preoperative stent insertion is safe and effective in the treatment of obstructive left-sided colorectal cancer and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.
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Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010; 71:560-72. [PMID: 20189515 DOI: 10.1016/j.gie.2009.10.012] [Citation(s) in RCA: 192] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 10/08/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively. OBJECTIVE Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction. DESIGN Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008. SETTING Tertiary-care center. PATIENTS This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a "bridge to surgery." INTERVENTION Colonic SEMS placement. MAIN OUTCOME MEASUREMENTS Stricture location, stent-induced complications, time to adverse events, need for reintervention. RESULTS Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter < or = 22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation. LIMITATIONS Retrospective analysis, single institution. CONCLUSION Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.
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Affiliation(s)
- Aaron J Small
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA
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Jung MK, Park SY, Jeon SW, Cho CM, Tak WY, Kweon YO, Kim SK, Choi YH, Kim GC, Ryeom HK. Factors associated with the long-term outcome of a self-expandable colon stent used for palliation of malignant colorectal obstruction. Surg Endosc 2009; 24:525-30. [PMID: 19597776 DOI: 10.1007/s00464-009-0604-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 04/24/2009] [Accepted: 06/16/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND The placement of self-expanding metal stents (SEMS) is a safe and effective definitive procedure for the palliation of malignant colorectal obstruction. In this study, the clinical outcomes, including the technical and clinical success rates, and the risk factors associated with the long-term outcomes of palliative SEMS were evaluated. METHODS From February 2002 to April 2008, 39 patients (18 men and 21 women) with malignant colorectal obstruction underwent placement of uncovered or covered stents under fluoroscopic or endoscopic guidance. The mean age of the patients was 64.5 +/- 14.6 years (range, 37-96 years). RESULTS The technical success rate was 100% (39/39), and the clinical success rate was 87.2% (34/39). Five cases had failed relief of the obstruction due to the development of migration in two patients, two malfunctions, and one perforation. Four patients experienced late complications: migration managed with a palliative colostomy in two patients, tumor ingrowth managed successfully with a second stent in one patient, perforation with an intraabdominal abscess at the upper margin of the stent 4 months after stenting in one patient. The location of the obstruction and the length of the stent were significant factors associated with a good outcome. Shorter stents (<10 cm) had better outcomes than longer stents (>or=10 cm; p = 0.008), and patients with a distal colorectal obstruction had better outcomes than those with a proximal colorectal obstruction (p = 0.015). CONCLUSION Patients with bowel obstruction involving a short segment and those with a distal obstruction had better stent outcomes.
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Affiliation(s)
- Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, 50 Samduk-Dong 2 Ga, Chung-Gu, Daegu 700-721, South Korea
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Suh JP, Kim SW, Cho YK, Park JM, Lee IS, Choi MG, Chung IS, Kim HJ, Kang WK, Oh ST. Effectiveness of stent placement for palliative treatment in malignant colorectal obstruction and predictive factors for stent occlusion. Surg Endosc 2009; 24:400-6. [PMID: 19551432 DOI: 10.1007/s00464-009-0589-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 05/10/2009] [Accepted: 06/09/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metallic stent (SEMS) for malignant colorectal obstruction is widely used in palliative treatment and as an alternative to surgery. The aims of this study are to evaluate the effectiveness of stent placement for palliative treatment and to identify the predictive factors associated with stent occlusion. METHODS A retrospective analysis was performed in 55 patients who had undergone placement of an uncovered SEMS from February 2004 to April 2007 for palliative treatment of malignant colorectal obstruction with metastatic or locally advanced cancer that was surgically unresectable. We analyzed the technical and clinical outcomes of stent placement, complications related to the procedure, stent patency rate, and predictive factors associated with stent occlusion. RESULTS The causes of colorectal obstruction before stent placement were primary colorectal cancer in 42 patients and noncolorectal extrinsic cancer in 13 patients. The initial technical success rate was 98.2%, and the clinical success rate was 94.4%. Complications occurred in 17 patients (30.9%). These included stent occlusion (n = 8), migration (n = 6), bowel perforation (n = 1), stent distortion (n = 1), and fistula formation (n = 1). The mean and median stent patency periods were 184 days [95% confidence interval (CI), 137-230 days] and 141 days (95% CI, 69-213 days), respectively. The degree of expansion 48 h after stent placement was significantly better in the nonocclusion group than in the stent occlusion group. In the multivariate Cox proportional hazard model, insufficient stent expansion (<70%) 48 h after stent placement was significantly associated with an increase in stent occlusion during the follow-up period (odds ratio, 12.55; p = 0.002). CONCLUSIONS Uncovered SEMS placement is an effective palliative treatment for malignant colorectal obstruction. The degree of stent expansion 48 h after stent placement is significantly associated with the maintenance of stent patency and is a predictive factor for stent occlusion.
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Affiliation(s)
- Jung Pil Suh
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Tam TY, Mukherjee S, Farrell T, Morgan D, Sur R. Endoscopic brachytherapy for obstructive colorectal cancer. Brachytherapy 2009; 8:313-7. [PMID: 19211311 DOI: 10.1016/j.brachy.2008.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/06/2008] [Accepted: 12/17/2008] [Indexed: 12/20/2022]
Abstract
PURPOSE Palliation of obstructive colon cancer is often challenging. Treatment options include Yttrium aluminum garnet (YAG) laser, stent placement, and surgical intervention. High-dose-rate intraluminal brachytherapy (HDRILBT) has been used to relieve obstructive symptoms due to rectal, bronchial, and esophageal cancers. In this case report, we document the combined use of YAG laser and HDRILBT for the palliation of obstructive colon cancer at the hepatic flexure, not previously reported in the literature. METHODS AND MATERIALS The patient in this case report had a large colonic tumor at the hepatic flexure causing near complete obstruction. Stent insertion and surgery were not feasible. YAG laser was used once and 11 days later, two fractions of HDRILBT were given 1 week apart. Under endoscopic vision and fluoroscopic guidance, a 150-cm Teflon catheter was passed through the lumen of the partially obstructed bowel for purposes of HDRILBT. A total dose of 10Gy was delivered at 1cm from the center of the source axis using a high-dose-rate afterloader. RESULTS After treatment with the first fraction of HDRILBT, the tumor size decreased and the colonic lumen was significantly more patent. The patient's symptoms were significantly relieved after two fractions. Her weight increased and she was medically fit enough to undergo further chemotherapy. Further HDRILBT was not indicated. The calculated biological effective dose for the total HDRILBT treatments was well below the dose tolerances for acute effects for normal colonic tissue. CONCLUSION HDRILBT should be considered as a possible treatment option for obstructive colon cancers when stent placement or surgery is not possible.
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Affiliation(s)
- Tiffany Y Tam
- Department of Oncology, Juravinski Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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