Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes

Challenges associated with low rectal malignant obstruction stenting: a case report

An ongoing debate exists regarding the feasibility of placing self-expanding metallic stents (SEMS) within 5 cm of the anal verge. Traditionally, SEMS have been considered contraindicated for patients with a malignant rectal obstruction within this region due to potential impact on the anorectal ring or anal canal, which can cause incontinence, proctalgia, and tenesmus. However, in the case of a 63-year-old female who presented with distention, abdominal pain, and diminishing stool output, the rectal exam identified a bulky fixed mass. Imaging studies revealed large bowel obstruction and high-grade stricture, with a minuscule residual lumen. Endoscopy identified a bulky mass obscuring the lumen at 5 cm from the anal verge, and biopsy confirmed adenocarcinoma. Despite the traditionally held contraindication, a 2.5 cm × 9.0 cm colonic stent was successfully deployed, leading to brisk colonic decompression. This allowed the patient to promptly undergo chemoradiotherapy.

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Fluoroscopic Stent Placement as a Bridge to Surgery for Malignant Colorectal Obstruction: Short- and Long-Term Outcomes

Purpose

To assess the outcomes of single-stage surgery following fluoroscopic stent placement for malignant colorectal obstruction.

Materials and Methods

This retrospective study included 46 patients (28 male and 18 female; mean age, 67.2 years) who had undergone fluoroscopic stent placement followed by laparoscopic resection (n = 31) or open surgery (n = 15) for malignant colorectal obstruction. The surgical outcomes were analyzed and compared. After a mean follow-up of 38.9 months, the recurrence-free and overall survival were estimated, and prognostic factors were evaluated.

Results

The mean interval between stent placement and surgery was 10.2 days. Primary anastomosis was possible in all patients. The mean postoperative length of hospitalization was 11.0 days. Bowel perforation was detected in six patients (13.0%). During the follow-up, ten patients (21.7%) developed recurrence; these included five of the six patients with bowel perforation. Bowel perforation had a significant effect on recurrence-free survival (p = 0.010).

Conclusion

Single-stage surgery following fluoroscopic stent placement may be effective for treating malignant colorectal obstruction. Stent-related bowel perforation is a significant predictive factor for tumor recurrence.

An Unusual Complication of Self-Expandable Metal Stent Placement in Malignant Sigmoid Obstruction

Self-expandable metal stent (SEMS) for malignant colorectal obstruction is widely used as a bridge to elective surgery or palliative treatment. However, with the increasing use of SEMS for treatment, complication rates associated with stents have been raised as a concern. We experienced a rare migration-related complication that a stent partially migrated out of the anus with an incarceration. A 62-year-old man was admitted with sigmoid malignant obstruction. Due to multiple metastases, he refused to undergo colostomy, and an uncovered SEMS was placed. Subsequently, he started chemotherapy. Seven months after placement, the stent migrated into the rectum. After unsuccessful attempts to extract the stent, he sought our assistance. We observed that half of the stent was outside the anus, and a 15 mm lump of mucosa was embedded in the proximal end of the stent. After several attempts, we successfully removed the SEMS. Stent incarceration following migration is not a common occurrence, but it serves as a reminder that clinicians need to be more vigilant about complications that may arise after stent implantation. We describe this unusual complication and share our experience about the removal of the stent.

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

It has been found that 8%-29% of colorectal cancers are obstructive. The use of “stent as bridge to surgery” is one of the most debated topics in obstructive left-sided colorectal cancer management. The endoscopic placement of a self-expanding metallic stent as bridge to surgery (BTS) could turn an emergency surgery to an elective one, increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one. However, in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted. Therefore, despite the useful short-term outcomes related to BTS, the recent literature has focused on long-term outcomes investigating the disease-free survival, the recurrence rate and the overall survival. Due to discordant data, international guidelines are still conflicting, and the debate is still open. There is not agreement about using self-expanding metallic stent for BTS as the gold standard.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?

For the 8-29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation. More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used. Despite these attractive outcomes, the superiority of the BTS approach is not clearly established. Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis. For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches. This lack of consensus has spawned differing and sometimes discordant guidelines worldwide. In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic. We hope that these data will finally converge on a single set of recommendations supporting a management strategy with well-demonstrated superiority.

COMPARATIVE EVALUATION OF THE USE OF COATED AND UNCOATED SELF-EXPANDABLE METALLIC STENTS IN MALIGNANT COLORECTAL OBSTRUCTION

THE OBJECTIVE was to compare the efficacy and rate of complications in patients of groups with uncovered and covered colorectal stents.

METHODS AND MATERIALS. The study included 102 patients who were admitted for emergency with symptoms of malignant colon obstruction, who were randomly installed covered and uncovered SEMS from December 2012 to September 2017.

RESULTS. Clinical success was achieved with uncovered stents in 98 % of cases and 96 % with covered stents (relative risk (RR) 1.02). 95 % confidence interval (CI) 0.954–1.092). The incidence of complications in the group of uncovered stents was 9.8 %, in the group of covered stents – 3.9 % (RR 0.938, CI 0.841–1.046); the frequency of recurrences of obstruction did not significantly different between groups. The median duration of cumulative stent patency was 181 days in the group of uncovered stents and 218 days in the group of covered stents (p=0.427), the difference was statistically insignificant.

CONCLUSION. The use of double covered and double uncovered stents is equally effectively and safely for patients with malignant colorectal obstruction. The frequency of reobstructions did not exceed 4 % and did not differ in the groups of covered and uncovered stents. The choice of the type of stent should be determined individually depending on the clinical situation.

Use of esophageal stents to relieve dysphagia during neoadjuvant therapy prior to esophageal resection: a systematic review

Esophageal cancer stenting offers symptomatic relief for patients suffering from dysphagia. There are limited data to support their use to relieve dysphagia and improve nutrition during neoadjuvant therapy with some concern that they may negatively impact oncological outcomes. The aim of this systematic review was to quantify the impact of esophageal stents on outcomes prior to resection with curative intent. A literature search was performed using Embase, Medline, PubMed, PubMed Central, the Cochrane library for articles pertaining to esophageal stent use prior to or during neoadjuvant chemotherapy or chemoradiotherapy in patients planned for curative esophagectomy. Data extracted included basic demographics, clinical, nutritional and oncologic outcomes. A total of 9 studies involving 465 patients were included. Esophageal stent use resulted in a significant improvement in mean dysphagia scores in the immediate post stent period but failed to demonstrate any positive changes in weight, body mass index (BMI) or albumin. Only 33% of stented patients ultimately progressed to potential curative surgical resection and stents were associated with reduced R0 resection rates and lower overall survival. This systematic review shows that, although esophageal stenting is associated with improvements in dysphagia during neoadjuvant therapy, their effect on improving patient nutritional status is less clear and they may be associated with poorer long-term oncological outcomes. Stents should be used with caution in patients who are being considered for potentially curative resection of esophageal malignancies and other strategies of nutritional supplementation should be considered.

Long-term tumour outcomes of self-expanding metal stents as 'bridge to surgery' for the treatment of colorectal cancer with malignant obstruction: a systematic review and meta-analysis

PURPOSE

To explore the long-term oncological results of self-expanding metal stents (SEMS) as a surgical transition compared with those of simple emergency surgery.

METHODS

A systematic review of studies involving long-term tumour outcomes comparing SEMS with emergency surgery was conducted. All studies included information on 3-year and 5-year survival rates, 3-year and 5-year disease-free survival (DFS) rates, and local and overall recurrence rates; the results were expressed as odds ratios.

RESULTS

Overall, 24 articles and 2508 patients were included, including 5 randomised controlled trials, 3 prospective studies, and 16 retrospective studies. The 3-year survival rate (odds ratio (OR) = 0.88, 95% confidence interval (CI) 0.69-1.12, P = 0.05), 5-year survival rate (OR = 0.91, 95% CI 0.70-1.17, P = 0.67), 3-year DFS rate (OR = 1.14, 95% CI 0.91-1.42, P = 0.65), 5-year DFS rate (OR = 1.35, 95% CI 0.91-2.02, P = 0.17), overall recurrence rate (OR 1.04, 95% CI 0.77-1.41, P = 0.14), and local recurrence rate (OR 1.37, 95% CI 0.84-2.23, P = 0.92) were determined. There was no significant difference between the randomised and observational studies in the subgroup analysis, and the 5-year survival rate was higher in studies with a stent placement success rate of ≥ 95%.

CONCLUSION

SEMS implantation was a viable alternative in malignant left colon obstruction as a transition to surgery; its long-term survival results, including 5-year DFS and overall survival, were equivalent to those of emergent surgery.

Outcomes following colonic stenting for malignant left-sided bowel obstruction: a systematic review of randomised controlled trials

PURPOSE

Malignant bowel obstruction is a common presentation and is associated with high morbidity and mortality. Emergency resection is the traditional treatment modality. In recent years, colonic stenting as a bridge to surgery has become more prevalent. However, there is considerable debate surrounding its use. The aim of this review was to examine the technical and clinical success of self-expanding metal stent (SEMS) as a bridge to surgery for obstructing colorectal tumours.

METHODS

We systematically reviewed randomised controlled trials using PubMed, Cochrane and SCOPUS databases. Included studies must have compared outcomes in SEMS as a bridge to surgery with those proceeding straight to emergency resection.

RESULTS

A total of 1245 studies were identified. After removal of duplicates and non-relevant studies, we identified seven articles which met the predefined criteria. This review observed that 81% of SEMS were technically successful, with 76% of patients having restoration of gastrointestinal function. Iatrogenic perforation rate was 5%. One-fifth of patients required emergency surgery following stent placement, and permanent stoma rate was 8.7%.

CONCLUSION

This study observed that SEMS as a bridge to surgery is associated with good technical and clinical success, with low rates of perforation and permanent stoma. SEMS should be part of the treatment armamentarium for obstructing colorectal neoplasms, but careful patient selection and institutional expertise are important factors for success.