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Jimba M, Enomoto T, Saida Y. Four Cases of Proximal Release-Type Colon Stents for Obstructive Rectal Cancer. Cureus 2024; 16:e59362. [PMID: 38694633 PMCID: PMC11061818 DOI: 10.7759/cureus.59362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/04/2024] Open
Abstract
Malignant colonic obstruction can cause necrosis, bacterial translocation, electrolytic imbalance, and death; therefore, immediate decompression should be performed. Self-expandable metallic colonic stents are an established treatment for the decompression of malignant colonic obstructions. The use of stents that open from the distal side, which have been commonly used until now, requires caution because placing a stent on the dentate line can cause severe pain, and there is a possibility of cutting the stent during rectal resection of the distal side of the tumor. Therefore, we designed a new proximal-release-type colorectal stent for use in our hospital; it is 22 mm in diameter and 70 mm in length, which was placed using the over-the-wire method with a 16 Fr delivery system. We have encountered four cases in which it was appropriate as a bridge to surgical treatment. None of the patients experienced complications, such as bleeding, pain, or other incidents, after stent placement. Additionally, the stents were not affected by the surgical dissection of the rectum on the anorectal side of the tumor. Herein, we presented the four aforementioned cases and discussed the stenting techniques.
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Affiliation(s)
- Marina Jimba
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Toshiyuki Enomoto
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, JPN
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The Deployment of a Newly Developed Proximal Release-Type Colonic Stent Is Feasible for Malignant Colorectal Obstruction near the Anal Verge: A Single-Center Preliminary Study. J Clin Med 2022; 11:jcm11061675. [PMID: 35330000 PMCID: PMC8955481 DOI: 10.3390/jcm11061675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/08/2022] [Accepted: 03/15/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Colonic self-expandable metallic stents are widely used to treat malignant colorectal obstructions. Stent placement in lesions near the dentate line causes problems, including severe pain due to difficulty in positioning the stent accurately. Therefore, a proximal release-type stent was developed to overcome this issue, and this preliminary study aimed to investigate its efficacy and safety. PATIENTS AND METHODS This research enrolled eight patients with malignant colorectal obstructions up to 10 cm from the anal verge who required placement of the newly developed proximal release-type colonic stent. The primary outcome was the clinical success rate, and the secondary outcomes were the technical success and adverse events rates. RESULTS The technical and clinical success rates were 87.5% each, and the mean procedure time was 25.5 ± 22.0 min. The mean procedure time in the rectosigmoid colon was significantly longer than that in the rectum. Only one (12.5%) patient had stent migration, and neither anal pain nor tenesmus was observed. DISCUSSION The stent was highly effective in treating lesions near the anal verge, and it might contribute to the expansion of indications for colorectal stents for lesions near the dentate line. However, the indications for rectosigmoid colon lesions should be cautiously considered.
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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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Zhu Z, Li B, Liao W, Lv N, Chen Y, Shu X. Novel Predictive Nomogram for Identifying Difficult Guidewire Insertion in Patients With Malignant Colorectal Obstruction and Sphincterotome-Assisted Guidewire Insertion for Improving the Success Rate of Self-Expandable Metal Stent Insertion. Front Oncol 2020; 10:637. [PMID: 32477935 PMCID: PMC7237730 DOI: 10.3389/fonc.2020.00637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/06/2020] [Indexed: 12/18/2022] Open
Abstract
Aims: This study aimed to identify risk factors related to guidewire insertion (GWI) failure and construct a novel predictive nomogram. In addition, sphincterotome-assisted guidewire insertion (SAGWI) in difficult cases was evaluated for efficacy and safety. Methods: We reviewed the data of 509 patients with malignant colorectal obstruction who underwent endoscopic self-expandable metal stent (SEMS) insertion from 2007 to 2018 in our center, retrospectively. We identify risk factors associated with GWI failure by multivariate logistic regression analysis and construct a novel predictive nomogram. Improvements in the GWI and technical and clinical success rates were assessed for the SAGWI technique. Results: A total of 509 patients with malignant colorectal obstruction were included. Increases of 6.9% and 7.0% were found in the GWI success rate by intention-to-treat (ITT; p < 0.001) and per-protocol (PP; p < 0.001) analyses after SAGWI, respectively. Increases of 6.5% and 6.6% in the technical success rate were found by ITT (p < 0.001) and PP (p < 0.001) analyses after SAGWI, respectively. Increases of 5.8% and 6.0% in the clinical success rate were found by ITT (p < 0.001) and PP (p < 0.001) analyses after SAGWI, respectively. Regarding the GWI failure-related factors, a sharply angulated stricture was an independent risk factor, and an experienced colonoscopist was an independent protective factor. A novel effective predictive nomogram was constructed. Conclusion: The novel predictive nomogram can be conveniently used to identify difficult cases. A sharply angulated stricture and an experienced colonoscopist are independent factors related to GWI failure. The SAGWI technique is an effective and safe method for addressing technically difficult cases.
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Affiliation(s)
- Zhenhua Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Biming Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wangdi Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Nonghua Lv
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Youxiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Jung WB, Shin JY, Park JK. Comparison of short-term outcome between diverting colostomy and colonic stent as a bridge to surgery for left colonic malignant obstruction. Medicine (Baltimore) 2020; 99:e19557. [PMID: 32243372 PMCID: PMC7220496 DOI: 10.1097/md.0000000000019557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The self-expanding metallic stent (SEMS) has been comprehensively investigated as a bridge to surgery. SEMS enables the control of acute colonic obstruction. However, comparison between SEMS and diverting colostomy as another bridge procedure was still challenging issue. Thus, the aim of this study was to compare these 2 procedures.In this retrospective cohort study, patients who received diverting colostomy and SEMS for acute left colonic obstruction between February 2016 and August 2018 were included. They were classified into the colostomy group (n = 27), including 5 patients who had SEMS failure previously, and the SEMS group (n = 23). The clinicopathologic parameters, pathologic results, and short-term outcomes were compared.No significant differences were found in clinicopathologic characteristics and complication rates between the 2 groups. After the bridge procedures, the SEMS group showed a higher rate of laparoscopic colonic resection than the colostomy group (100% vs 76%, P = .023). The colostomy group showed a higher rate of rectal cancer (24.0% vs 9.1%, P = .019) and later recovery of flatus (3 vs 2 days, P = .011) than the SEMS group. Additionally, the length of resected colon was longer in the colostomy group than in the SEMS group (33.9 vs 23.4 cm, P = .007).Although SEMS might permit higher laparoscopic resection rates and faster recovery of bowel habits than diverting colostomy, SEMS showed meaningful failure rate including migration and perforation. In addition, diverting colostomy showed acceptable complication rates and feasible performance. An individualized approach is necessary considering the advantages and disadvantages of both procedures.
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Cao Y, Gu J, Deng S, Li J, Wu K, Cai K. 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. Int J Colorectal Dis 2019; 34:1827-1838. [PMID: 31515615 DOI: 10.1007/s00384-019-03372-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Jiang Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
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Pacheco-Barcia V, Mondéjar R, Martínez-Sáez O, Longo F, Moreno JA, Rogado J, Donnay O, Santander C, Carrato A, Colomer R. Safety and Oncological Outcomes of Bevacizumab Therapy in Patients With Advanced Colorectal Cancer and Self-expandable Metal Stents. Clin Colorectal Cancer 2019; 18:e287-e293. [DOI: 10.1016/j.clcc.2019.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 02/06/2023]
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Saida Y. Current status of colonic stent for obstructive colorectal cancer in Japan; a review of the literature. JOURNAL OF THE ANUS RECTUM AND COLON 2019; 3:99-105. [PMID: 31583324 PMCID: PMC6774736 DOI: 10.23922/jarc.2019-009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023]
Abstract
Colorectal cancer is the most common cancer in Japan. Approximately 10%-20% of the patients with colorectal cancer present with large bowel obstruction, and those who present with malignant colonic obstruction (MCO) require urgent decompression because MCO can cause electrolytic fluid imbalance, colonic necrosis, bacterial translocation, and death. Placement of colonic stents (self-expandable metallic stents) for MCO is a major and standard endoscopic treatment that has been available since 2012 in Japan. This review presents the current conditions and future prospects of this procedure based on the literature. The current indication of colonic stent placement is malignant colorectal stenosis. One of the purposes of using stents is palliative treatment; further, its advantages over emergency surgery with colostomy include avoidance of colostomy, relief of obstruction, shorter hospitalization, and better quality of life. In addition, stent placement can also be used as a bridge to surgery since the duration of the hospitalization is shorter and postoperative complications, colostomy rates, and mortality rates are lower with elective than with emergency surgery. Although recent studies have reported low complication rates related to colonic stents, complications may still occur, highlighting the importance of good preparation, adequate staffing, backup systems, and informed consent. The current major problem related to colonic stents is the lack of evidence on patients' long-term prognoses for bridge to surgery purposes, awaiting the results of ongoing clinical research.
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Affiliation(s)
- Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
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Rodrigues-Pinto E, Morais R, Coelho C, Pereira P, Repici A, Macedo G. Bridge-to-surgery versus emergency surgery in the management of left-sided acute malignant colorectal obstruction - Efficacy, safety and long-term outcomes. Dig Liver Dis 2019; 51:364-372. [PMID: 30558864 DOI: 10.1016/j.dld.2018.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/01/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Compare efficacy, safety and long-term outcomes of bridge-to-surgery and emergency surgery in acute malignant colorectal obstruction. METHODS Retrospective study of 94 consecutive patients with left-sided acute malignant colorectal obstruction treated with curative intent between 2010-2017. RESULTS 48 patients underwent stent placement and 46 underwent emergency surgery. Technical and clinical success were 100% and 87%. Laparoscopy and one-staged operation were more frequent in bridge-to-surgery (44% vs 2%, p < 0.001; 73% vs 30%, p < 0.001). Fewer permanent stomas were created in bridge-to-surgery (15% vs 35%, p = 0.013). Overall morbidity was 36%. Immediate and post-procedure stent related-complications occurred in 6% and 13%; surgery-related complications occurred in 28% (bridge-to-surgery: 15% vs emergency surgery: 41%, p = 0.004). No differences were found regarding tumor recurrence, recurrence-free survival and overall survival. R1 resection (HR 47.2, 95%CI:4.1-543.7), number of lymph nodes harvested (HR 0.9 95%CI:0.8-0.99) and adjuvant therapy (HR 0.1 95%CI:0.01-0.9) predicted recurrence-free survival; pTMN stage IV (HR 7.3, 95%CI:1.1-47.6), number of lymph nodes harvested (HR 0.90, 95%CI:0.8-0.97), adjuvant therapy (HR 0.1, 95%CI:0.02-0.4) and surgery-related complications (HR 5.3, 95%CI:1.02-27.3) influenced overall survival. CONCLUSION Stent placement has a high success, similarly to emergency surgery, being associated with higher primary anastomosis and lower stoma rates. Tumor recurrence rate, recurrence-free survival and overall survival were comparable between groups; surgery-related complications influenced overall survival.
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Affiliation(s)
| | - Rui Morais
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Catarina Coelho
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Pereira
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Alessandro Repici
- Gastroenterology, Humanitas Research Hospital & Humanitas University, Milan, Italy
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
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Risk Factors and Adequate Management for Complications of Bevacizumab Treatment Requiring Surgical Intervention in Patients With Metastatic Colorectal Cancer. Clin Colorectal Cancer 2018; 17:e639-e645. [PMID: 30031634 DOI: 10.1016/j.clcc.2018.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Bevacizumab (BV) has been approved for treating colorectal cancer since 2004. Although BV use may lead to adverse effects, few studies have reported incidences requiring surgical intervention. We aimed to identify the risk factors and adequate interventions for complications requiring surgical intervention after BV treatment. PATIENTS AND METHODS We retrospectively reviewed the records of patients with metastatic colorectal cancer treated with BV in our institute from January 2009 to December 2016. The baseline patient characteristics were used to evaluate the potential risk factors for complications requiring surgery. RESULTS Of the 1008 patients recruited for this study, 60 (5.9%) experienced complications necessitating surgery after BV therapy. Gastrointestinal perforation was the most frequently observed complication, occurring in 36 patients (3.5%), and diverting colostomy was the most commonly performed intervention (22 patients, 36.6%). Multivariate analysis helped identify poor differentiation, signet ring cell carcinoma, stent insertion status, rectal location of the primary tumor, and intact primary tumor status as the risk factors. Survival time remained unchanged regardless of a complication that required surgery. CONCLUSION Careful monitoring during BV treatment for metastatic colorectal cancer is essential for patients who have a predisposition to complications that may require surgery. After detection, adequate and timely surgical management is imperative for ensuring patient survival.
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Lee YJ, Yoon JY, Park JJ, Park SJ, Kim JH, Youn YH, Kim TI, Park H, Kim WH, Cheon JH. Clinical outcomes and factors related to colonic perforations in patients receiving self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2018; 87:1548-1557.e1. [PMID: 29452077 DOI: 10.1016/j.gie.2018.02.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/02/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although colonic perforation is a dreadful adverse event associated with stent placement, data on this topic are sparse. We aimed to investigate the clinical outcomes of colonic perforation and factors related to its occurrence in patients who received self-expandable metal stents (SEMSs) for malignant colorectal obstruction. METHODS We retrospectively reviewed the data of 474 patients with malignant colorectal obstruction who received endoscopic SEMS insertion from April 2004 to May 2011 in Severance Hospital and Gangnam Severance Hospital. Early perforation, defined as perforation occurring within 2 weeks, was assessed in bridge-to-surgery (n = 164) and palliative stent placement patient groups (n = 310). Delayed perforation was analyzed using data from the palliative stent placement group alone. RESULTS The technical and clinical success rates were 90.5% and 81.0%, respectively. Early and delayed perforations occurred in 2.7% (13/474) and 2.7% (8/301) of patients, respectively. Among 21 patients with perforation, 14 (66.7%) received emergency surgery and 5 (23.8%) died within 30 days after perforation. Regarding the perforation-related factors, age ≥70 years (odds ratio, 3.276; 95% confidence interval [CI], 1.041-10.309) and sigmoid colonic location (odds ratio, 7.706; 95% CI, 1.681-35.317) were independently associated with occurrence of early perforation. Stent location in the flexure (hazard ratio, 17.573; 95% CI, 2.004-154.093) and absence of peritoneal carcinomatosis (hazard ratio, 6.139; 95% CI, 1.150-32.776) were significantly associated with delayed perforation. CONCLUSIONS The perforation-related 30-day mortality rate was 23.8%. Older age and sigmoid colonic location were significantly associated with occurrence of early perforation, whereas flexure location and absence of peritoneal carcinomatosis were related to delayed perforation.
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Affiliation(s)
- Yoo Jin Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Dongsan Medical Center, Keimyung University of School of Medicine, Daegu, Korea
| | - Jin Young Yoon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyojin Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND Self-expandable metal stents are widely used to treat malignant colorectal obstruction. However, data on clinical outcomes of stent placement for rectal obstruction specifically are lacking. OBJECTIVE We aimed to investigate the clinical outcomes of self-expandable metal stents in malignant rectal obstruction in comparison with those in left colonic obstruction and to identify factors associated with clinical failure and complication. DESIGN This was a retrospective study. SETTINGS The study was conducted at a tertiary care center. PATIENTS Between January 2005 and December 2013, medical charts of patients who underwent stent placement for malignant rectal or left colonic obstruction were reviewed retrospectively. INTERVENTION Study intervention included self-expandable metal stent placement. MAIN OUTCOME MEASURES Technical success, clinical success, and complications were measured. RESULTS Technical success rates for the 2 study groups (rectum vs left colon, 93.5% vs 93.1%; p = 0.86) did not differ significantly; however, the clinical success rate was lower in patients with rectal obstruction (85.4% vs 92.1%; p = 0.02). In addition, the complication rate was higher in patients with rectal obstruction (37.4% vs 25.1%; p = 0.01). Patients with rectal obstruction showed higher rates of obstruction because of extracolonic malignancy (33.8% vs 15.8%; p < 0.001) and stent use for palliation (78.6% vs 56.3%; p < 0.001). Multivariate analysis indicated obstruction attributed to extracolonic malignancy and covered stent usage to be independent risk factors for clinical failure. Factors predictive of complications in the palliative group were total obstruction, obstruction because of extracolonic malignancy, and covered stent usage. LIMITATIONS This was a retrospective, single-center study. CONCLUSIONS The efficacy and safety of stent placement for malignant rectal obstruction were comparable with those for left colonic obstruction. However, obstruction attributed to extracolonic malignancy, use of covered stents, and total obstruction negatively impacted clinical outcomes of self-expandable metal stent placement and must be considered by endoscopists. See Video Abstract at http://links.lww.com/DCR/A417.
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13
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Sousa M, Pinho R, Proença L, Silva J, Ponte A, Rodrigues J, Carvalho J. Predictors of Complications and Mortality in Patients with Self-Expanding Metallic Stents for the Palliation of Malignant Colonic Obstruction. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:122-128. [PMID: 28848796 DOI: 10.1159/000452697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/11/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Self-expanding metallic stents (SEMS) for palliative purposes in malignant colonic obstruction are an alternative to surgery that has gained popularity over time. METHODS We performed a retrospective study of patients submitted to SEMS for palliation of obstructing malignant colorectal cancer from 2005 to 2015 to evaluate predictive clinical factors for complications and mortality. RESULTS Forty-five patients with high rates of technical and clinical success were included (97.8 and 95.6%, respectively), with complications occurring in 17.8% (8.9% perforations, 4.4% obstructions, and 4.4% migrations). The length of the stenosis was superior in patients with complications (p = 0.01); 11.1% of patients had a re-intervention (2.2% surgery and 8.9% placement of another SEMS). Relief of obstruction without intervention was maintained until death in 77.8% of patients and in 81.4% of patients who had immediate clinical success. The mortality rate was 37.2% at 30 days, 56.5% at 60 days, and 87.5% at 1 year. There were no predictors of survival identified, including age, sex, tumor stage, metastasis, or complications of the procedure. DISCUSSION AND CONCLUSIONS In this study, SEMS placement was associated with a high rate of technical and clinical success and a low rate of complications, being an option to palliate patients with obstructive neoplasia. The length of the stenosis was associated with a greater risk of complications. The majority of stent-related complications can be managed successfully without surgery.
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Affiliation(s)
- Mafalda Sousa
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Rolando Pinho
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Luísa Proença
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Joana Silva
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Ana Ponte
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Jaime Rodrigues
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - João Carvalho
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
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Ji WB, Kwak JM, Kang DW, Kwak HD, Um JW, Lee SI, Min BW, Sung NS, Kim J, Kim SH. Clinical benefits and oncologic equivalence of self-expandable metallic stent insertion for right-sided malignant colonic obstruction. Surg Endosc 2016; 31:153-158. [PMID: 27194253 DOI: 10.1007/s00464-016-4946-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 04/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The efficacy of stenting for right-sided malignant colonic obstruction is unknown. This study aimed to evaluate the safety, feasibility, and clinical benefits of self-expandable metallic stent insertion for right-sided malignant colonic obstruction. METHODS Clinical data from patients who underwent right hemicolectomy for right colon cancer from January 2006 to July 2014 at three Korea University hospitals were retrospectively reviewed. A total of 39 patients who developed malignant obstruction in the right-sided colon were identified, and their data were analyzed. RESULTS Stent insertion was attempted in 16 patients, and initial technical success was achieved in 14 patients (87.5 %). No stent-related immediate complications were reported. Complete relief from obstruction was achieved in all 14 patients. Twenty-five patients, including two patients who failed stenting, underwent emergency surgery. In the stent group, 93 % (13/14) of patients underwent elective laparoscopic surgery, and only one surgery was converted to an open procedure. All patients in the emergency group underwent emergency surgery within 24 h of admission. In the emergency group, only 12 % (3/25) of patients underwent laparoscopic surgery, with one surgery converted to an open procedure. All patients in both groups underwent either laparoscopy-assisted or open right/extended right hemicolectomy with primary anastomoses as the first operation. The operative times, retrieved lymph nodes, and pathologic stage did not differ between the two groups. Postoperative hospital stay (9.4 ± 3.4 days in the stent group vs. 12.4 ± 5.9 in the emergency group, p = 0.089) and time to resume oral food intake (3.2 ± 2.1 days in the stent group vs. 5.7 ± 3.4 in the emergency group, p = 0.019) were shorter in the stent group. And there were no significant differences in disease-free survival and overall survival between the two groups. CONCLUSIONS Stent insertion appears to be safe and feasible in patients with right-sided colonic malignant obstruction. It facilitates minimally invasive surgery and may result in better short-term surgical outcomes.
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Affiliation(s)
- Woong Bae Ji
- Department of Surgery, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jung Myun Kwak
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, Seoul, 136-705, Republic of Korea.
| | - Dong Woo Kang
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, Seoul, 136-705, Republic of Korea
| | - Han Deok Kwak
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, Seoul, 136-705, Republic of Korea
| | - Jun Won Um
- Department of Surgery, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Sun-Il Lee
- Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Byung-Wook Min
- Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Nak Song Sung
- Department of Surgery, Konyang University Hospital, Daejeon, Republic of Korea
| | - Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, Seoul, 136-705, Republic of Korea
| | - Seon Hahn Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, Seoul, 136-705, Republic of Korea
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15
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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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Kobayashi Y, Komazawa Y, Kusunoki M, Takahashi Y, Uno G, Yuki M, Sugiyama A, Shizuku T, Kinoshita Y. Novel stenting method for malignant right colonic stenosis using ultra-thin endoscopy: Report of four cases. Dig Endosc 2015; 27:704-7. [PMID: 25630914 DOI: 10.1111/den.12450] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/26/2015] [Indexed: 02/08/2023]
Abstract
Placement of a self-expandable metallic stent (SEMS) is recognized as a safe and effective procedure for patients with malignant severe colonic stenosis. However, reports of this stent for right-sided colonic stenosis are limited, possibly as a result of technical difficulties. We report a new method for delivering SEMS to the site of right-sided colonic stenosis in four patients with malignant right-sided colonic stenosis. Technical success was obtained with sequential use of a double-balloon endoscope and ultrathin endoscope, while we also injected non-ionic contrast agent into the submucosal layer as a marker for stenting under fluoroscopy. There were no adverse events noted during the procedure and clinical improvement was seen in all four cases. In conclusion, SEMS placement for right-sided malignant colonic stenosis with our newly developed method appears to be safe and effective, and can be used for decompression of the right colon.
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Affiliation(s)
- Yoshiya Kobayashi
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Yoshinori Komazawa
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Maho Kusunoki
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Yoshiko Takahashi
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Goichi Uno
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Mika Yuki
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Akira Sugiyama
- Division of Surgery, Izumo City General Medical Center, Shimane, Japan
| | - Toshihiro Shizuku
- Division of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
| | - Yoshikazu Kinoshita
- Department of Gastroenterology and Hepatology, Shimane University, Shimane, Japan
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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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18
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Ross JP, Orkin BA. Enterocolic fistula due to a rectal stent: Case report and literature review. Ann Med Surg (Lond) 2014; 3:123-5. [PMID: 25568798 PMCID: PMC4284444 DOI: 10.1016/j.amsu.2014.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/13/2014] [Accepted: 07/19/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Self-expanding metal stents (SEMS) are successfully being used to acutely relieve obstructing colorectal cancers; yet, their use does not come without complications. Presentation of case We present a case in which a patient with a recurrent obstructing sigmoid carcinoma underwent colonic stenting for acute decompression. Two months after stent placement, an enterocolic fistula formed from erosion of the upper end of the stent. Discussion An extensive literature review revealed that fistula formation, as a complication of stent placement, is rarely reported. Presentation of the case is followed by a review of complications that may arise following SEMS placement, with a focus on enterocolic fistulae. To our knowledge, this work provides the most extensive review of the subject to date. Conclusion SEMS provide an effective, safe, and less invasive option for patients when used in the appropriate clinical context. Further reports of enterocolic fistulae as a complication of SEMS placement are necessary in order to better understand this potential adverse event. SEMS are highly effective in relieving malignant bowel obstruction. They may be used as a bridge to resection or as a final palliative option. The most common complications of SEMS include perforations and occlusions. SEMS may also be complicated by fistula formation; a finding rarely reported. This work is the most extensive review of this complication to date.
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Affiliation(s)
| | - Bruce A. Orkin
- Corresponding author. Rush University Medical Center, 1725 West Harrison Street, Suite 1138, Chicago, IL 60612, USA. Tel.: +1 312 942 7088; fax: +1 312 942 7018.
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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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Lee KM, Lim SG, Shin SJ, Kim JH, Kang DH, Kim JK, Hwang JC, Kwon CI, Cheong JY, Yoo BM. Novel method of stent insertion for malignant lower rectal obstruction with proximal releasing delivery system (with video). Gastrointest Endosc 2013; 78:930-933. [PMID: 24237948 DOI: 10.1016/j.gie.2013.08.018] [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] [Received: 06/06/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expandable metal stents are an alternative to preoperative and palliative colostomy for patients with malignant colorectal obstruction. However, self-expandable metal stent placement is considered unsuitable or contraindicated for patients with malignant lower rectal obstruction within 5 cm of the anal verge because the exposed stent portion can irritate the distal rectum and cause anal pain and a foreign body sensation. OBJECTIVE To describe our experience with 6 patients with malignant lower rectal obstruction who underwent stent insertion with a proximal releasing delivery system (PRDS). DESIGN Prospective clinical series outcome study. SETTING A tertiary-care referral university hospital. PATIENTS This study involved all patients at our center who had a malignant lower rectal obstruction within 5 cm of the anal verge caused by rectal cancer and bladder cancer. INTERVENTION Uncovered stent with the PRDS with endoscopic and fluoroscopic guidance. MAIN OUTCOME MEASUREMENTS Technical and clinical success rate, adverse event rate, and stent migration rate. RESULTS All stents were placed at the expected location. Technical and clinical success rates were 100%. Two patients reported anal pain, which was controlled with analgesics. One case of tumor ingrowth occurred after 5 months and was treated with reinsertion of a stent with the PRDS. After stent insertion, the patients received chemotherapy, chemoradiotherapy, or conservative care. LIMITATIONS Small number of patients and no comparison group. Further prospective, randomized, controlled trials are needed. CONCLUSIONS Uncovered stent insertion with the PRDS is a feasible, safe, and effective treatment for the patient with malignant lower rectal obstruction within 5 cm from the anal verge.
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Affiliation(s)
- Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea; Korean Society of Gastrointestinal Stent Research Group, Seoul, South Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Sung Jae Shin
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Dae Hwan Kang
- Korean Society of Gastrointestinal Stent Research Group, Seoul, South Korea; Department of Internal Medicine, Pusan National University School of Medicine, Pusan, South Korea
| | - Jae Keun Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, South Korea
| | - Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Chang-Il Kwon
- Korean Society of Gastrointestinal Stent Research Group, Seoul, South Korea; Department of Internal Medicine, CHA University School of Medicine, Seoul, South Korea
| | - Jae Yeon Cheong
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Byung Moo Yoo
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
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21
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Warden C, Stupart D, Goldberg P. Stenting as first-line management for all patients with nonperforating left-sided obstructing colorectal cancer. Colorectal Dis 2013; 15:e389-95. [PMID: 23489764 DOI: 10.1111/codi.12206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 12/15/2012] [Indexed: 12/30/2022]
Abstract
AIM Since 2005, we have used self-expanding metal stents (SEMS) as primary treatment for all patients with left-sided obstructing colorectal cancer without evidence of perforation. The purpose of this study was to assess the safety and efficacy of this treatment. METHOD This was a prospective study of consecutive patients with left-sided obstructing colorectal cancer without perforation or peritonitis treated between January 2005 and June 2009. SEMS placement was attempted in all cases. Emergency surgery was reserved for patients in whom a stent placement failed. After successful decompression, surgery was offered to patients with potentially curable disease. RESULTS Seventy-seven patients were included, with successful SEMS placement in 60/77 (78%) patients, 25 as a bridge to surgery and 35 for palliation. Immediate complications occurred in two (3%) cases. There was no mortality. Of 35 patients in whom SEMS was for palliation, 32 (91%) avoided surgery altogether. A stoma was fashioned in 5 (8.3%) of the 60 patients who were successfully stented, and in 12 (71%) of the 17 patients in whom stenting failed (P = 0.0001). CONCLUSION A SEMS-based management protocol for patients with large bowel obstruction due to colorectal cancer is safe and effective.
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Affiliation(s)
- C Warden
- Groote Schuur Hospital, Cape Town, South Africa
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22
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Okugawa T, Oshima T, Ikeo K, Kondo T, Tomita T, Fukui H, Watari J, Miwa H. Successful Self-Expandable Metallic Stent Placement for a Case of Distal Rectal Stenosis due to Gastric Cancer Metastasis. Case Rep Gastroenterol 2013; 7:214-8. [PMID: 23741209 PMCID: PMC3670628 DOI: 10.1159/000351818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 47-year-old woman was diagnosed as having advanced gastric cancer with malignant ascites. Despite chemotherapy, recurrent peritoneal dissemination was seen 1.5 years after operation. A computed tomography scan revealed rectal stenosis due to Schnitzler's metastasis. When the distance from the distal end of the obstruction to the anal verge is less than 5 cm, stent replacement has been said to be contraindicated due to the development of anal pain and foreign body sensation. Although the distance from the distal end of the obstruction to the anal verge was 4 cm in this case, a WallFlexTM colonic stent could be placed. She stayed home, and luminal patency remained until she died 270 days after stent insertion. This report demonstrates that rectal obstruction located less than 5 cm from the anal verge due to Schnitzler's metastasis could be treated by stenting without any symptomatic or technical complications.
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Affiliation(s)
- Takuya Okugawa
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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23
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Choi AR, Yoon JY, Lee HJ, Jang HW, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Clinical outcomes following secondary self-expandable metal stent (SEMS) insertion due to previous stent migration in malignant colorectal obstruction. Surg Endosc 2013; 27:3288-96. [PMID: 23519493 DOI: 10.1007/s00464-013-2907-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND There has been no research on the clinical outcomes of secondary self-expandable metal stent (SEMS) placement after initial stent migration. Therefore, this study aimed to assess the clinical outcomes of secondary SEMS placement after initial stent migration compared to the outcomes of secondary SEMS placement done for reasons other than migration and identify factors predictive of long-term outcomes. METHODS Between January 2005 and February 2011, a total of 422 patients underwent SEMS insertion for malignant colorectal obstruction at Severance Hospital. Of these, there were 98 cases of secondary SEMS placement, 38 of which were due to previous stent migration. We compared the clinical outcomes of secondary SEMS between stent migration and nonmigration groups. We also sought to identify risk factors for long-term outcomes of secondary SEMS after initial stent migration. RESULTS The baseline clinical characteristics were similar between the two groups. The technical and clinical success rates of secondary SEMS insertion in the migration and nonmigration groups were 94.7% and 83.3% (p = 0.09) and 73.7% and 53.3% (p = 0.122), respectively. In the migration group, sustained clinical success after secondary SEMS was associated with the absence of complications after insertion of the first stent (p < 0.001) and a longer time interval (more than 100 days) between the first and second stent insertion (p = 0.011). CONCLUSIONS Our data showed that secondary colorectal SEMS after stent migration is safe and effective. Moreover, the sustained clinical success of the secondary stent following migration was dependent on the outcomes of the first stent.
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Affiliation(s)
- A Ra Choi
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea
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Kim JW, Jeong JB, Lee KL, Kim BG, Jung YJ, Kim W, Kim HY, Ahn DW, Koh SJ, Lee JK. Comparison of Clinical Outcomes between Endoscopic and Radiologic Placement of Self-expandable Metal Stent in Patients with Malignant Colorectal Obstruction. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013. [DOI: 10.4166/kjg.2013.61.1.22] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Ji Won Kim
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Bong Jeong
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kook Lae Lee
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Gwan Kim
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Jin Jung
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won Kim
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hwi Young Kim
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Won Ahn
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Kyung Lee
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
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Favorable long-term clinical outcome of uncovered D-weave stent placement as definitive palliative treatment for malignant colorectal obstruction. Dis Colon Rectum 2012; 55:983-9. [PMID: 22874606 DOI: 10.1097/dcr.0b013e31825c484d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most self-expandable metallic stents for colorectal placement are uncovered because of the high migration rate of covered stents. However, the optimal stent design for colorectal use remains unclear. OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of a double-wire woven uncovered stent for definitive palliative treatment of malignant colorectal obstruction. DESIGN This study was a prospective, single-arm, observational clinical study of patients enrolled between December 2005 and September 2010. SETTINGS This study was conducted at a referral hospital in Japan. PATIENTS Twenty-four consecutive patients with malignant colorectal obstruction were included in the study. INTERVENTIONS A double-wire woven uncovered stent was placed by use of a standard through-the-scope endoscopic placement technique. MAIN OUTCOME MEASURES Technical, initial clinical, and long-term clinical success were measured. Long-term clinical success was defined as sustained relief of obstructive symptoms without reintervention until the patient's death. RESULTS The Karnofsky performance status score before stent placement was 60 (median, interquartile range, 42.5-67.5). Twenty of 24 patients had primary colorectal cancer, and 4 had extracolorectal malignancies. The site of obstruction was the ascending colon in 10 patients, descending colon in 4 patients, sigmoid colon in 7 patients, and rectum in 3 patients. Technical, initial, and long-term clinical success rates were 100%, 100%, and 83%. Median stent patency time was 149 days (interquartile range, 45-198 days). Median survival time after stent placement was 155 days (interquartile range, 68-231 days). Four patients (17%) had negative outcomes including stent occlusion by tumor ingrowth (8%) and stent migration (8%). The highest Karnofsky performance status score after stent placement was 70 (median; interquartile range, 50-70). The Karnofsky performance status score improved after stent placement (p = 0.002). LIMITATIONS This study was limited because it was a single-arm, single-center study, and it had a small sample size. CONCLUSIONS Endoscopic placement of double-wire woven uncovered stents is effective and safe as definitive palliative treatment for patients with malignant colorectal obstruction.
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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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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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Cho YK, Kim SW, Lee BI, Lee KM, Lim CH, Kim JS, Chang JH, Park JM, Lee IS, Choi MG, Choi KY, Chung IS. Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction. Gut Liver 2011; 5:165-70. [PMID: 21814596 PMCID: PMC3140661 DOI: 10.5009/gnl.2011.5.2.165] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 12/20/2010] [Indexed: 12/22/2022] Open
Abstract
Background/Aims There are limited data regarding the clinical outcomes of self-expandable metal stents in the treatment of proximal colon obstruction. We compared the clinical outcomes of stent placement in patients with malignant proximal to distal colon obstructions. Methods We reviewed medical records from 37 consecutive patients from three institutions (19 men; mean age, 72 years) who underwent endoscopic stent placement at a malignant obstruction of the proximal colon. We also examined the records from 99 patients (50 men; mean age, 65 years) who underwent endoscopic stent placement for a distal colon obstruction. Technical success, clinical improvements, complications and stent patency were compared between treatments. Results The technical success rate tended to be lower in stents inserted to treat proximal colon obstructions than in those used to treat distal colon obstructions (86% vs 97%, p=0.06). Clinical improvement was achieved in 78% of patients (29/37) with proximal colonic stenting and in 91% of patients (90/99) with distal colonic stenting (p=0.08). Complications (24% vs 27%), stent migration (8% vs 8%) and stent reocclusion rates (11% vs 17%) did not differ significantly between groups. Two cases of bowel perforation related to stenting (5%) occurred in patients with proximal colonic stenting. Conclusions The technical success and clinical improvement associated with self-expandable metal stents used to treat proximal colon obstruction tend to be lower than cases of distal colon obstruction. Technical failure is an important cause of poor clinical improvement in patients with proximal colon stenting. Complication rates and stent patency appear to be similar in both groups.
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Affiliation(s)
- Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Self-expandable metal stents (SEMS) can serve as a bridge to surgery or as a definitive therapy in patients with an advanced stage of cancer: clinical experience of a tertiary cancer center. Dig Dis Sci 2010; 55:3530-6. [PMID: 20721627 DOI: 10.1007/s10620-010-1370-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 07/26/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMS) can be used to relieve benign and malignant colorectal obstruction. AIMS The aim of this study was to determine the outcomes of SEMS for malignant colorectal obstruction. METHODS Retrospective review was done of patients who underwent endoscopic SEMS placement from 2001 to 2007. RESULTS Forty-six patients (23 M), mean age 60 years (range 24-82) underwent endoscopic SEMS placement. Cancer types included: 28 colorectal, and 18 metastatic cancers. The locations of the obstruction were as follows: two in the ascending colon, one in the hepatic flexure, three in the transverse colon, two in the splenic flexure, two in the descending colon, 26 in the sigmoid colon, and ten in the rectum. In 39 of the 46 cases (84.8%), placement of a single SEMS was successful covering the entire strictures, but in seven cases, two of the stents were placed in tandem resulting in adequate overage of stricture. Technical success was achieved in all cases. Clinical success was achieved in 39 out of 46 cases (84.8%). Two perforations were detected immediately and day 5 after SEMS placement, resulting in one death and one emergent surgery. Mean follow-up was 126 days (range 2-1,210). Twenty-eight of the 46 patients (61%) died during the follow-up period with the median overall survival being 3.52 months (95% CI: 2.34-4.41 months). CONCLUSIONS Placement of SEMS for the treatment of colorectal obstruction is feasible and safe. In our institution, where SEMS are primarily used to palliate terminal disease, technical and clinical success rates were high without significant morbidity and mortality. On long-term follow-up, patients died from their advanced disease with infrequent recurrent obstruction or stent-related complications.
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Datye A, Hersh J. Colonic perforation after stent placement for malignant colorectal obstruction--causes and contributing factors. MINIM INVASIV THER 2010; 20:133-40. [PMID: 20929424 DOI: 10.3109/13645706.2010.518787] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Self-expanding metal stents (SEMS) are used to manage malignant colorectal obstruction. Colonic perforation is the most worrisome complication from colonic stenting. We reviewed causes and contributing factors of perforation with colonic stent placement in patients with malignant colorectal obstruction. Articles from both English and foreign language publications were identified from Medline. Data were collected on causes, timing, treatment and mortality related to perforation. A total of 2287 patients from 82 articles were included in this analysis, which showed an overall perforation rate of 4.9%. Perforation rates for palliation and bridge to surgery (BTS) were not significantly different (4.8% vs. 5.4%, p = 0.66); over 80% occurred within 30 days of stent placement (half during or within one day of the procedure). The mortality rate related to perforation was 0.8% per stented patient, but the mortality of patients experiencing perforation was 16.2%. There was no significant difference (p = 0.78) in the mortality rates between the palliation and the BTS group and concomitant chemotherapy, steroids, and radiotherapy are risk factors of perforation. The overall perforation related mortality is far less than that of patients undergoing emergency surgery for bowel obstruction.
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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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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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Nagula S, Ishill N, Nash C, Markowitz AJ, Schattner MA, Temple L, Weiser MR, Thaler HT, Zauber A, Gerdes H. Quality of Life and Symptom Control after Stent Placement or Surgical Palliation of Malignant Colorectal Obstruction. J Am Coll Surg 2010; 210:45-53. [DOI: 10.1016/j.jamcollsurg.2009.09.039] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Revised: 09/23/2009] [Accepted: 09/29/2009] [Indexed: 12/16/2022]
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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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Park S, Shin SJ, Ahn JB, Jeung HC, Rha SY, Lee SK, Chung HC. Benefits of recurrent colonic stent insertion in a patient with advanced gastric cancer with carcinomatosis causing colonic obstruction. Yonsei Med J 2009; 50:296-9. [PMID: 19430568 PMCID: PMC2678709 DOI: 10.3349/ymj.2009.50.2.296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 08/20/2007] [Accepted: 10/01/2007] [Indexed: 11/27/2022] Open
Abstract
Malignant obstruction develops frequently in advanced gastric cancer. Although it is primarily the gastric outlet that is obstructed, there are occasional reports of colonic obstruction. Treating intestinal obstruction usually requires emergency surgery or stent insertion. There are several kinds of complications with stent insertion, such as bowel perforation, stent migration, bleeding, abdominal pain and reobstruction. Nevertheless, endoscopic stent insertion could be a better treatment than emergency surgery in cases of malignant bowel obstruction in cancer patients with poor performance status. We report a case of advanced gastric cancer with carcinomatosis in which a recurrent colonic stent was inserted at the same site because of cancer growth into the stent. The patient maintained a good condition for chemotherapy, thus improving their chances for survival.
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Affiliation(s)
- Semi Park
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Joon Shin
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Oncology, Yonsei Cancer Center, Seoul, Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Oncology, Yonsei Cancer Center, Seoul, Korea
| | - Hei-Cheul Jeung
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Oncology, Yonsei Cancer Center, Seoul, Korea
| | - Sun Young Rha
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Oncology, Yonsei Cancer Center, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Cheol Chung
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
- Department of Oncology, Yonsei Cancer Center, Seoul, Korea
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Adoption of self-expanding metallic stents in the palliative treatment of obstructive colorectal cancer-look out for perforations! Surg Laparosc Endosc Percutan Tech 2009; 18:353-6. [PMID: 18716533 DOI: 10.1097/sle.0b013e3181761fb8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Self-expanding metallic stents (SEMSs) are increasingly used for the palliative treatment of inoperable colorectal cancer. The aim of the current study was to analyze the safety and efficacy of SEMS in the palliative treatment of obstructive colorectal cancer. Between 2003 and 2006, SEMS placement was attempted in 26 patients suffering from inoperable obstructive colorectal cancer. The recovery of the patients and the outcome of this treatment modality were analyzed prospectively. SEMS was successfully inserted in 19 (73%) of 26 patients. In 16 (84%) of these 19 cases, the placement of SEMS was the definitive treatment of colorectal obstruction and no additional surgical palliation was needed. There were 3 (16%) colonic perforations related to stent application. SEMS insertion seems to be an effective alternative in the palliative treatment of patients with malignant colorectal obstruction. However, perforation is a dangerous complication of the procedure.
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Parnaby CN, Jenkins JT, Weston V, Wright DM, Sunderland GT. Defunctioning stomas in patients with locally advanced rectal cancer prior to preoperative chemoradiotherapy. Colorectal Dis 2009; 11:26-31. [PMID: 18462220 DOI: 10.1111/j.1463-1318.2008.01540.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE A literature search did not produce any evidence-based objective criteria to determine which patients with locally advanced rectal cancer would benefit from a defunctioning stoma prior to neoadjuvant chemoradiotherapy. Our criteria for formation of a defunctioning stoma are: faecal incontinence and inability to cannulate the tumour at colonoscopy. The aim of this study was to examine whether these current criteria are appropriate. METHOD Forty-nine consecutive locally advanced rectal cancer patients treated from February 2003 to November 2006 were identified from our colorectal database. All received long-course chemoradiotherapy (Bossett regimen) and definitive surgery was performed 6-8 weeks later. RESULTS Of the 49 patients, 31 presented with diarrhoea and two with faecal incontinence; nine patients were defunctioned by trephine stoma prior to treatment [cannulation impossible at colonoscopy (n = 8); faecal incontinence (n = 1)]. One patient with faecal incontinence refused early defunctioning stoma. Median hospital stay was 12 days (interquartile range: 7-30), and complications included pneumonia (n = 1) and peristomal cellulitis (n = 2). Of the 40 patients who went directly to neoadjuvant chemoradiotherapy, two subsequently required a defunctioning stoma for severe diarrhoeal symptoms during therapy. Eight patients had worsening diarrhoeal symptoms but tolerated treatment. Three patients, who had stoma formation, did not proceed to definitive surgery following neoadjuvant therapy: poor operative fitness (n = 2) and disease progression (n = 1). CONCLUSION Stenosis causing inability to cannulate the tumour at colonoscopy and faecal incontinence were the only objective indications for an early defunctioning stoma. Worsening diarrhoea during therapy (unless severe) did not appear to be a good indication for a defunctioning stoma.
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Affiliation(s)
- C N Parnaby
- Department of Surgery, Southern General Hospital, Glasgow, UK.
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Kim H, Kim SH, Choi SY, Lee KH, Won JY, Lee DY, Lee JT. Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts in the treatment of acute malignant colorectal obstruction. J Vasc Interv Radiol 2008; 19:1709-16. [PMID: 18845454 DOI: 10.1016/j.jvir.2008.08.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Revised: 08/15/2008] [Accepted: 08/19/2008] [Indexed: 01/23/2023] Open
Abstract
PURPOSE To evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided placement of self-expandable metallic stents and stent-grafts for acute malignant colorectal obstruction. MATERIALS AND METHODS Radiologic images and clinical reports of 42 patients (22 men, 20 women; age range, 28-93 years; median age, 65.5 years) who underwent fluoroscopically guided colorectal stent insertion without endoscopic assistance for acute malignant obstruction were reviewed retrospectively. Eighteen patients received bare stents as a bridge to surgery. Twenty-four patients received 27 insertions of either a bare stent (n = 15) or a stent-graft (n = 12) for palliation. The obstruction was located in the rectum (n = 8), sigmoid (n = 17), descending colon (n = 8), splenic flexure (n = 3), and transverse colon (n = 6). RESULTS Clinical success, defined as more than 50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 41 of the 42 patients (98%). No major procedure-related complications occurred. Minor complications occurred in eight of the 45 procedures (18%). No perioperative mortalities occurred within 1 month after surgery. In the palliative group, the median stent patency was 62 days (range, 0-1,014 days). There was no statistically significant difference in stent patency between the bare stents (range, 0-855 days; median, 68 days) and stent-grafts (range, 1-1,014 days; median, 81 days). CONCLUSIONS Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts for the relief of acute malignant colorectal obstruction was technically feasible without endoscopic assistance-even in lesions proximal to the splenic flexure and transverse colon-and clinically effective in both bridge to surgery and palliative management.
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Affiliation(s)
- Honsoul Kim
- Department of Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
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Malignant rectal obstruction within 5 cm of the anal verge: is there a role for expandable metallic stent placement? Gastrointest Endosc 2008; 68:713-20. [PMID: 18561924 DOI: 10.1016/j.gie.2007.12.051] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Accepted: 12/17/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Placement of expandable metallic stents (EMS) has been considered contraindicated for patients with malignant rectal obstruction within 5 cm of the anal verge because of the potential problems of anal pain. OBJECTIVE Our purpose was to investigate the technical feasibility, clinical effectiveness, and safety of EMS placement in patients with malignant rectal obstruction within 5 cm of the anal verge. DESIGN Retrospective study. SETTING Single tertiary referral university hospital. PATIENTS The sites of obstruction included the rectum within 5 cm (range, 25-50 mm) of the anal verge in 16 patients (group A) and more than 5 cm (range, 53-74 mm) in 14 patients (group B). INTERVENTIONS Placement of 3 types of EMS. MAIN OUTCOME MEASUREMENTS Complications including pain were evaluated and compared between 2 groups with the Fisher exact test. RESULTS The overall technical success rate was 100%. Colon perforation occurred in 2 patients, who underwent emergency surgery. Ten (62.5%) of group A and 1 (7.1%) of group B complained of pain (P = .011). In 3 of the 10 patients in group A, the pain disappeared spontaneously within a week or was tolerated by the patients without use of analgesics, although the remaining 7 patients of group A and the 1 patient in group B needed analgesics until death or elective surgery. LIMITATIONS Retrospective study. CONCLUSIONS Placement of EMS in patients with malignant rectal obstruction within 5 cm of the anal verge seems feasible and relatively safe and may provide adequate palliation and preoperative decompression of obstruction symptoms. Anal pain was tolerable to the patients with or without use of analgesics.
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Abstract
OBJECTIVE Imaging the colon in suspected acute large bowel obstruction (LBO) is traditionally carried out with a supine abdominal X-ray (AXR) and erect chest X-ray. If there is no clinical or radiological evidence to suggest a perforation, then an unprepared barium or water-soluble contrast enema (CE) can be performed to confirm the presence of and demonstrate the site of obstruction. The advent of modern, fast multidetector CT (MDCT) scanners has changed management strategies for acute abdominal conditions including suspected LBO in all groups of patients especially the elderly, infirm and those on ITU/HDU. METHOD A retrospective case note analysis was carried over a 7-year period in a single centre. The study criteria involved investigation of suspected LBO with CE, CT and MDCT. RESULTS It showed a reduction in the number of contrast enemas performed. CONCLUSION MDCT was shown to be more accurate in the diagnosis of LBO, is usually available on a 24-h basis, and in many institutions has replaced the urgent CE in this group of patients. This also has the advantage of excluding incidental findings and in staging malignant disease.
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Affiliation(s)
- S E Jacob
- Department of Surgery, Manchester Royal Infirmary, Manchester, UK.
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Im JP, Kim SG, Kang HW, Kim JS, Jung HC, Song IS. Clinical outcomes and patency of self-expanding metal stents in patients with malignant colorectal obstruction: a prospective single center study. Int J Colorectal Dis 2008; 23:789-94. [PMID: 18443807 DOI: 10.1007/s00384-008-0477-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUNDS AND AIMS Self-expanding metal stents (SEMS) have been used as a palliative treatment for malignant colorectal obstruction. However, the reports about primary stent patency rate and associated factors have been limited. This study was performed to evaluate clinical outcomes and factors associated with long-term complications and patency of SEMS in patients with malignant colorectal obstruction. MATERIALS AND METHODS Patients who underwent palliative endoscopic placement with uncovered SEMS for a malignant colorectal obstruction were prospectively enrolled at Seoul National University Hospital between April 2005 and August 2007. RESULTS Forty-nine patients underwent 51 SEMS placements. Obstruction sites were rectum in 15 patients (30.6%), descending or sigmoid colon in 25 (51.0%), and transverse colon in nine (18.4%), respectively. The causes of obstruction were colorectal cancer in 36 patients (73.5%), direct invasion of gastric cancer in seven (14.3%) and others in six (12.2%). Technical success was achieved in 100% and clinical success in 86%, and there was one procedure-related perforation. Re-obstruction and migration occurred in 16% and 6%, respectively, during mean follow-up period of 331 days. Median stent patency duration was 204 days, and patency rates at 30, 90, and 180 days were 91.2%, 81.0%, and 53.3%, respectively, which was not associated with patient demographics, site of obstruction, or palliative chemotherapy. CONCLUSION Endoscopic SEMS placement is a safe and effective palliative treatment for malignant colorectal obstruction, and overall long-term complication and patency were favorable irrespective of the palliative chemotherapy.
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Affiliation(s)
- Jong Pil Im
- 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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Kim TH, Song HY, Shin JH, Park IK, Kim JH, Lim JO, Kim KR, Choi EK. Usefulness of multifunctional gastrointestinal coil catheter for colorectal stent placement. Eur Radiol 2008; 18:2530-4. [DOI: 10.1007/s00330-008-1042-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 02/12/2008] [Accepted: 03/29/2008] [Indexed: 10/22/2022]
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Abstract
Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Abstract
The application of stents in the GI tract has expanded tremendously. Stent placement is the most frequently used treatment modality for palliating dysphagia from esophageal or gastric cardia cancer. Newly designed esophageal stents, including the Polyflex stent and the Niti-S double stent, have been introduced to reduce recurrent dysphagia owing to migration or nontumoral or tumor overgrowth. Stents are also the treatment of choice for esophagorespiratory fistulas, for proximal malignant lesions near the upper esophageal sphincter, for recurrent carcinoma after esophagectomy or gastrectomy and for sealing traumatic or iatrogenic nonmalignant ruptures, such as Boerhaave's syndrome and leakages following surgery. Stents in the latter patient group should be removed within 4-8 weeks after placement to prevent the formation of granulation tissue or hyperplasia at the stent ends. For gastric outlet obstruction, many case series have been published. Only two, small, randomized controlled trials have compared stent placement with gastrojejunostomy to date, and a large, randomized trial is currently being conducted in The Netherlands. Obstructive jaundice caused by a malignancy in the common bile duct can be treated effectively with plastic or metal stent placement. However, a prognostic score needs to be developed that guides a treatment decision towards using either of these stents. Finally, colonic stents are applied successfully for acute malignant obstruction as a 'bridge to surgery' in patients with tumors that are deemed to be resectable, or as a palliative treatment for patients with locally advanced or metastatic disease.
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Affiliation(s)
- Marjolein Y V Homs
- University Medical Center Utrecht, Dept of Internal Medicine, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Repici A, Fregonese D, Costamagna G, Dumas R, Kähler G, Meisner S, Giovannini M, Freeman J, Petruziello L, Hervoso C, Comunale S, Faroux R. Ultraflex precision colonic stent placement for palliation of malignant colonic obstruction: a prospective multicenter study. Gastrointest Endosc 2007; 66:920-7. [PMID: 17904133 DOI: 10.1016/j.gie.2007.03.1042] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Accepted: 03/05/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many patients who develop obstructive colonic symptoms secondary to inoperable colorectal cancer will require palliative treatment. A minimally invasive and potentially long-lasting approach is placement of nitinol self-expanding metal stents (SEMS). OBJECTIVE To determine the effectiveness and safety of a nitinol SEMS designed for colorectal use in the palliative treatment of malignant colonic obstruction. DESIGN Prospective multicenter clinical study. SETTING Nine European study centers. PATIENTS Forty-four patients with malignant colonic obstruction. INTERVENTIONS Placement of nitinol SEMS designed for colorectal use. MAIN OUTCOME MEASURES Technical success, defined as accurate SEMS deployment with adequate stricture coverage, and clinical success, defined as decompression and relief of obstructive colonic symptoms maintained without intervention or serious device-related complications. RESULTS Technical success was attained in 95% of patients, with 95% CI 85%-99%. After 6 months, the rate of clinical success was 81%, 95% CI 69%-96%. Survival at 6 months was 67%, 95% CI 54%-84%. Clinical success was maintained until death in 86% of the nonsurvivors. No perforations or SEMS-related deaths occurred. LIMITATION This investigation was nonrandomized and did not include a control group. CONCLUSIONS In a large prospective investigation, palliative placement of a nitinol SEMS designed for colorectal use was accomplished with a high rate of technical success. Durable clinical success was achieved in a high proportion of patients with low morbidity.
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Affiliation(s)
- Alessandro Repici
- Servizio di Endoscopia Digestiva, IRCCS Istituto Clinico Humanitas, Milano, Italy
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Self-expanding metal stents as nonsurgical palliative therapy for malignant colonic obstruction: time to change the standard of care? Gastrointest Endosc 2007; 66:928-30. [PMID: 17963879 DOI: 10.1016/j.gie.2007.06.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Accepted: 06/30/2007] [Indexed: 02/08/2023]
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50
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Mucci-Hennekinne S, Kervegant AG, Regenet N, Beaulieu A, Barbieux JP, Dehni N, Casa C, Arnaud JP. Management of acute malignant large-bowel obstruction with self-expanding metal stent. Surg Endosc 2007; 21:1101-3. [PMID: 17356934 DOI: 10.1007/s00464-007-9258-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 11/20/2006] [Accepted: 12/18/2006] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction. METHODS Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. RESULTS In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication. CONCLUSIONS Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.
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Affiliation(s)
- S Mucci-Hennekinne
- Department of Visceral Surgery, CHU-Angers, 4 rue Larrey, Angers-49100, France
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