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Razak O A, Yang SY, Cho MS, Min BS, Han YD. Palliative surgery as a bridge to systemic treatment for malignant bowel obstruction due to peritoneal metastases: A retrospective, case-control study. Asian J Surg 2023; 46:160-165. [PMID: 35260331 DOI: 10.1016/j.asjsur.2022.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND High-quality data on palliative surgery in patients with malignant bowel obstruction (MBO) caused by peritoneal metastases (PM) are lacking. We aimed to determine the utility of palliative surgery for such patients. METHODS We retrospectively analyzed patients considered for surgery for MBO, caused by PM, in our department from January 2019 to October 2020. None of them could tolerate a diet, despite conservative treatment. We investigated the clinical characteristics and perioperative outcomes and calculated overall survival (OS). Kaplan-Meier survival analysis was performed, with the log-rank test to evaluate differences in OS rates. Multivariate Cox regression was performed to determine prognostic factors. RESULTS Sixty (67%) patients underwent surgery, whereas, 30 (33%) received the best supportive care (BSC) treatment. A better (p = 0.002) median OS was observed in patients undergoing surgery (3.9 months) than in those receiving BSC (2.6 months). Severe complications were observed in 12 (20%) patients, including 30-day mortality (7 patients). Forty-eight (80%) patients in the surgery group could tolerate a diet and the hospital stay (mean ± standard deviation) was 20.0 ± 23.1 days. Re-obstruction was observed in five (8.3%) patients after 78.6 ± 63.3 days. Patients in the postoperative chemotherapy group exhibited a better (p < 0.001) median OS (12.3 months) than did those in the no-postoperative chemotherapy group (3.5 months). Only postoperative chemotherapy (hazard ratio 0.264, 95% confidence interval 0.143-0.487, p < 0.001) was identified as an independent prognostic factor. CONCLUSIONS Compared with BSC, surgery is associated with a better OS in patients with MBO due to PM. Surgery should be considered as a bridge to systemic treatment for such patients.
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Affiliation(s)
| | - Seung Yoon Yang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoon Dae Han
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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Pattarajierapan S, Sukphol N, Junmitsakul K, Khomvilai S. Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: Current evidence and prospects. World J Clin Oncol 2022; 13:943-956. [PMID: 36618077 PMCID: PMC9813833 DOI: 10.5306/wjco.v13.i12.943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/10/2022] [Accepted: 12/08/2022] [Indexed: 12/19/2022] Open
Abstract
Approximately 7%-29% of patients with colorectal cancer present with colonic obstruction. The concept of self-expandable metal stent (SEMS) insertion as a bridge to surgery (BTS) is appealing. However, concerns on colonic stenting possibly impairing oncologic outcomes have been raised. This study aimed to review current evidence on the short- and long-term oncologic outcomes of SEMS insertion as BTS for left-sided malignant colonic obstruction. For short-term outcomes, colonic stenting facilitates a laparoscopic approach, increases the likelihood of primary anastomosis without a stoma, and may decrease postoperative morbidity. However, SEMS-related perforation also increases local recurrence and impairs overall survival. Moreover, colonic stenting may cause negative oncologic outcomes even without perforation. SEMS can induce shear forces on the tumor, leading to increased circulating cancer cells and aggressive pathological characteristics, including perineural and lymphovascular invasion. The conflicting evidence has led to discordant guidelines. Well-designed collaborative studies that integrate both oncologic outcomes and data on basic research (e.g., alteration of circulating tumors) are needed to clarify the actual benefit of colonic stenting as BTS.
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Affiliation(s)
- Sukit Pattarajierapan
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Nattapanee Sukphol
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Karuna Junmitsakul
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Short-term efficacy, safety and survival of laparoscopic radical resection for colorectal cancer patients with bowel obstruction. Med Eng Phys 2022; 107:103867. [DOI: 10.1016/j.medengphy.2022.103867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/20/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022]
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Pattarajierapan S, Manomayangoon C, Tipsuwannakul P, Khomvilai S. Comparison of colonic stenting and stoma creation as palliative treatment for incurable malignant colonic obstruction. JGH Open 2022; 6:630-636. [PMID: 36091319 PMCID: PMC9446394 DOI: 10.1002/jgh3.12800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Self-expandable metal stent (SEMS) is a favorable therapeutic option for patients with incurable malignant colonic obstruction (MCO). However, their long-term efficacy and safety compared with those of stoma creation have not been well investigated. This study aimed to compare these long-term outcomes between these two techniques in patients with incurable MCO. METHODS This retrospective cohort included patients with incurable MCO with SEMS insertion (n = 105) and stoma creation (n = 97) between January 2009 and December 2019. The primary outcomes were patency after the procedure and 1-year re-intervention rates. RESULTS The patency of the SEMS group was lower than that of the stoma group (88.9 vs 93.2% at 6 months, 84.1 vs 90.5% at 12 months, and 65.8 vs 90.5% at 18 months; log-rank test, P = 0.024), but 1-year re-intervention rates were not different between the groups (10 vs 8%, P = 0.558). The median patency durations were 190 days for SEMS insertion and 231 days for stoma creation. Majority (84%) of SEMS patients did not require any re-intervention until death. The early complication rate did not differ between the groups (P = 0.377), but SEMS insertion had fewer late minor complications than stoma creation (5 vs 22%, P = 0.001). CONCLUSION SEMS insertion is a safe and effective treatment for patients with incurable MCO. Although SEMS insertion had a lower patency than stoma creation, especially after 1 year, the 1-year re-intervention rates were not different, and SEMS durability was sufficient in most patients.
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Affiliation(s)
- Sukit Pattarajierapan
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Chatiyaporn Manomayangoon
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Panat Tipsuwannakul
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine Chulalongkorn University Bangkok Thailand
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Fujisawa G, Niikura R, Kawahara T, Honda T, Hasatani K, Yoshida N, Nishida T, Sumiyoshi T, Kiyotoki S, Ikeya T, Arai M, Hayakawa Y, Kawai T, Fujishiro M. Effectiveness and safety of chemotherapy for patients with malignant gastrointestinal obstruction: A Japanese population-based cohort study. World J Clin Cases 2022; 10:5253-5265. [PMID: 35812690 PMCID: PMC9210883 DOI: 10.12998/wjcc.v10.i16.5253] [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: 12/30/2021] [Revised: 03/09/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The impacts of chemotherapy on patients with malignant gastrointestinal obstructions remain unclear, and multicenter evidence is lacking.
AIM To evaluate the effectiveness and safety of chemotherapy in patients with unresectable malignant gastrointestinal obstructions.
METHODS We conducted a multicenter retrospective cohort study that compared the chemotherapy group who received any chemotherapeutics after interventions, including palliative surgery or self-expandable metal stent placement, for unresectable malignant gastrointestinal obstruction vs the best supportive care (BSC) group between 2014 and 2019 in nine hospitals. The primary outcome was overall survival, and the secondary outcomes were patency duration and adverse events, including gastrointestinal perforation and gastrointestinal bleeding.
RESULTS In total, 470 patients in the chemotherapy group and 652 patients in the BSC group were analyzed. During the follow-up period of 54.1 mo, the median overall survival durations were 19.3 mo in the chemotherapy group and 5.4 mo in the BSC group (log-rank test, P < 0.01). The median patency durations were 9.7 mo [95% confidence interval (CI): 7.7-11.5 mo] in the chemotherapy group and 2.5 mo (95%CI: 2.0-2.9 mo) in the BSC group (log-rank test, P < 0.01). The perforation rate was 1.3% (6/470) in the chemotherapy group and 0.9% (6/652) in the BSC group (P = 0.567). The gastrointestinal bleeding rate was 1.5% (7/470) in the chemotherapy group and 0.5% (3/652) in the BSC group (P = 0.105).
CONCLUSION Chemotherapy after interventions for unresectable malignant gastrointestinal obstruction was associated with increased overall survival and patency duration.
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Affiliation(s)
- Gota Fujisawa
- Department of Gastroenterology, Graduate school of Medicine, The University of Tokyo, Tokyo 1138655, Japan
| | - Ryota Niikura
- Gastroenterological Endoscopy, Tokyo Medical University, Tokyo 1600023, Japan
| | - Takuya Kawahara
- Clinical Research Support Center, The University of Tokyo Hospital, Tokyo 1138655, Japan
| | - Tetsuro Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 8508555, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui 9108526, Japan
| | - Naohiro Yoshida
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Ishikawa 9208530, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka 5608565, Japan
| | - Tetsuya Sumiyoshi
- Department of Gastroenterology, Tonan Hospital, Hokkaido 0600004, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi 7420032, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo 1048560, Japan
| | - Masahiro Arai
- Department of Gastroenterology, Nerima Hikarigaoka Hospital, Tokyo 1790072, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, Graduate school of Medicine, The University of Tokyo, Tokyo 1138655, Japan
| | - Takashi Kawai
- Gastroenterological Endoscopy, Tokyo Medical University, Tokyo 1600023, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate school of Medicine, The University of Tokyo, Tokyo 1138655, Japan
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Ahmed O, Lee JH, Thompson CC, Faulx A. AGA Clinical Practice Update on the Optimal Management of the Malignant Alimentary Tract Obstruction: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1780-1788. [PMID: 33813072 DOI: 10.1016/j.cgh.2021.03.046] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The purpose of this expert review is to describe the current methodologies available to manage malignant alimentary tract obstructions as well the evidence behind the various methods (including their efficacy and safety), indications, and appropriate timing of interventions. METHODS This is not a formal systematic review but is based on a review of the literature to provide best practice advice statements. No formal rating of the quality of evidence or strength of recommendation is carried out. BEST PRACTICE ADVICE 1: For all patients with alimentary tract obstruction, the decision about specific interventions should be made in a multidisciplinary setting including oncologists, surgeons, and endoscopists and take into account the characteristics of the obstruction, patient's expectations, prognosis, expected subsequent therapies, and functional status. BEST PRACTICE ADVICE 2: For patients who present with esophageal obstruction from esophageal cancer and who are potential candidates for resection or chemoradiation, clinicians should not routinely insert a self-expanding metal stent (SEMS) without multidisciplinary review because of high rates of stent migration, higher morbidity and mortality, and potentially lower R0 (microscopically negative margins) resection rates. BEST PRACTICE ADVICE 3: For patients who present with esophageal obstruction from esophageal cancer who are potential candidates for resection and who have concerns of malnutrition, clinicians may consider the use of enteral feeding tubes (via nasogastric or percutaneous route). Clinicians should be aware of the potential risk of abdominal wall tumor seeding as well as making subsequent gastric conduit formation difficult with percutaneous endoscopic gastrostomy placement. BEST PRACTICE ADVICE 4: For patients who present with esophageal obstruction from esophageal cancer who are not candidates for resection, clinicians should consider either SEMS insertion or brachytherapy as sole therapy or in combination. Clinicians should not consider the use of laser therapy or photodynamic therapy because of the lack of evidence of better outcomes and superior alternatives. BEST PRACTICE ADVICE 5: For patients with malignant esophageal obstruction who are undergoing SEMS placement, clinicians should use a fully covered or partially covered SEMS and not an uncovered SEMS, with consideration of a stent-anchoring/fixation method. BEST PRACTICE ADVICE 6: For patients with gastric outlet obstruction who have a life expectancy greater than 2 months, have good functional status, and who are surgically fit, surgical gastrojejunostomy should be considered. BEST PRACTICE ADVICE 7: For patients with gastric outlet obstruction who are undergoing surgical gastrojejunostomy, a laparoscopic approach is favored over an open approach because of lower blood loss and shorter hospital stay. BEST PRACTICE ADVICE 8: For patients with gastric outlet obstruction who are not candidates for gastrojejunostomy (surgical or endoscopic ultrasound-guided), clinicians should consider the insertion of an enteral stent. BEST PRACTICE ADVICE 9: Enteral stents should not be used in patients with multiple luminal obstructions or severely impaired gastric motility because of the limited benefit in these scenarios. Clinicians can consider placement of a venting gastrostomy in these patients. BEST PRACTICE ADVICE 10: Depending on the experience of the endoscopist, endoscopic ultrasound-guided gastrojejunostomy is an acceptable alternative to surgical gastrojejunostomy and enteral stent placement. Clinicians should be aware that there are currently no dedicated Food and Drug Administration-approved devices for endoscopic ultrasound-guided gastrojejunostomy. BEST PRACTICE ADVICE 11: For patients with malignant colonic obstruction who are candidates for resection, insertion of SEMS is a reasonable choice as a "bridge to surgery" to allow for one-stage, elective resection. BEST PRACTICE ADVICE 12: For patients with malignant colonic obstruction who are not candidates for resection, either SEMS placement or a diverting colostomy are reasonable choices depending on the patient's goals and functional status. BEST PRACTICE ADVICE 13: SEMS is a reasonable option for patients with proximal (or right-sided) malignant obstructions, both as a "bridge to surgery" and in the palliative setting. BEST PRACTICE ADVICE 14: SEMS placement is a reasonable alternative for patients with extracolonic malignancy who are not candidates for surgery, although their placement is more technically challenging, clinical success rates are more variable, and complications (including stent migration) are more frequent.
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Affiliation(s)
- Osman Ahmed
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey H Lee
- Department of Gastroenterology, M. D. Anderson Cancer Center, Houston, Texas.
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ashley Faulx
- Department of Medicine, Case Western Reserve University, and University Hospitals, Cleveland Medical Center, Cleveland, Ohio
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Bleicher J, Lambert LA. A Palliative Approach to Management of Peritoneal Carcinomatosis and Malignant Ascites. Surg Oncol Clin N Am 2021; 30:475-490. [PMID: 34053663 DOI: 10.1016/j.soc.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In addition to severe, life-limiting complications such as malignant bowel obstruction, fistulae, and malignant ascites, peritoneal carcinomatosis frequently causes life-impacting symptoms such as pain, nausea, anorexia, cachexia, and fatigue. A variety of medical, interventional, and surgical therapies are now available for management of both complications and symptoms. Although surgery in this population is often associated with a relatively high risk of morbidity and mortality, operative intervention can offer effective palliative treatment in appropriately selected patients. Early involvement of palliative care specialists as part of a multidisciplinary team is essential to providing optimal, holistic care of patients with peritoneal carcinomatosis.
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Affiliation(s)
- Josh Bleicher
- Division of General Surgery, Huntsman Cancer Institute, University of Utah, 1950 Circle of Hope, Suite 6405, Salt Lake City, UT 84112, USA.
| | - Laura A Lambert
- Division of General Surgery, Huntsman Cancer Institute, University of Utah, 1950 Circle of Hope, Suite 6405, Salt Lake City, UT 84112, USA
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Takamizawa Y, Shida D, Boku N, Nakamura Y, Ahiko Y, Yoshida T, Tanabe T, Takashima A, Kanemitsu Y. Nutritional and inflammatory measures predict survival of patients with stage IV colorectal cancer. BMC Cancer 2020; 20:1092. [PMID: 33176752 PMCID: PMC7656744 DOI: 10.1186/s12885-020-07560-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background This study aimed to evaluate the prognostic impact of nutritional and inflammatory measures (controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and modified Glasgow prognostic score (mGPS)) on overall survival (OS) in patients with stage IV colorectal cancer (CRC). Methods Subjects were 996 patients with stage IV CRC who were referred to the National Cancer Center Hospital between 2001 and 2015. We retrospectively investigated correlations between OS and CONUT score, PNI, and mGPS. Multivariate analyses were performed using Cox proportional hazards regression models. Results After adjusting for known factors (age, gender, BMI, ECOG performance status, location of primary tumor, CEA levels, histological type, M category, and prior surgical treatment), all three measures were found to be independent prognostic factors for OS in patients with stage (CONUT score, p < 0.001; PNI, p < 0.001; mGPS, p < 0.001). Significant differences in OS were found between low CONUT score (0/1) (n = 614; 61%) and intermediate CONUT score (2/3) (n = 276; 28%) (hazard ratio (HR) = 1.20, 95% confidence interval (CI): 1.02–1.42, p = 0.032), and intermediate CONUT score and high CONUT score (≥4) (n = 106; 11%) (HR = 1.30, 95% CI: 1.01–1.67, p = 0.045). Significant differences in OS were found between mGPS = 0 (n = 633; 64%) and mGPS = 1 (n = 234; 23%) (HR = 1.84, 95% CI: 1.54–2.19, p < 0.001), but not between mGPS = 1 and mGPS = 2 (n = 129; 13%) (HR = 1.12, 95% CI: 0.88–1.41, p = 0.349). Patients with low PNI (< 48.0) (n = 443; 44%) showed a significantly lower OS rate than those with high PNI (≥48.0) (n = 553; 56%) (HR = 1.39, 95% CI: 1.19–1.62, p < 0.001). Conclusions CONUT score, PNI, and mGPS were found to be independent prognostic factors for OS in patients with stage IV CRC, suggesting that nutritional and inflammatory status is a useful host-related prognostic indicator in stage IV CRC.
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Affiliation(s)
- Yasuyuki Takamizawa
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Dai Shida
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan. .,Division of Frontier Surgery, The Institute of Medical Science, The University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo, 1088639, Japan.
| | - Narikazu Boku
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Yuya Nakamura
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Yuka Ahiko
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan.,Division of Frontier Surgery, The Institute of Medical Science, The University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo, 1088639, Japan
| | - Takefumi Yoshida
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Taro Tanabe
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Atsuo Takashima
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
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Self-expandable metal stent (SEMS) placement or emergency surgery as palliative treatment for obstructive colorectal cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2020; 155:103110. [DOI: 10.1016/j.critrevonc.2020.103110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
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Jaruvongvanich V, Chesta FNU, Baruah A, Oberoi M, Adamo D, Singh PG, Meyer A, Law RJ, Buttar N. Palliative treatment for malignant gastrointestinal obstruction with peritoneal carcinomatosis: enteral stenting versus surgery. Endosc Int Open 2020; 8:E1487-E1494. [PMID: 33043118 PMCID: PMC7541184 DOI: 10.1055/a-1237-3956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting ( P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.
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Affiliation(s)
| | - FNU Chesta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Anushka Baruah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Meher Oberoi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Daniel Adamo
- Division of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Prabh G. Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Alyssa Meyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Ryan J. Law
- University of Michigan, Gastroenterology and Hepatology, Ann Arbor, Michigan, United States
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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11
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Cao Y, Ke S, Gu J, Mao F, Yao S, Deng S, Yan L, Wu K, Liu L, Cai K. The Value of Haematological Parameters and Tumour Markers in the Prediction of Intestinal Obstruction in 1474 Chinese Colorectal Cancer Patients. DISEASE MARKERS 2020; 2020:8860328. [PMID: 32855747 PMCID: PMC7443225 DOI: 10.1155/2020/8860328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/30/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022]
Abstract
Intestinal obstruction, a life-threatening problem, often occurs in patients with advanced colorectal cancer (CRC). However, the cause of obstruction is still unknown. Very few prediction models for intestinal obstruction in CRC exist, and their results are unreliable. Therefore, we investigated whether preoperative serum tumour markers (STMs) combined with haematological and biochemical markers could be used as predictors. We retrospectively analysed 1474 patients with CRC who underwent radical resection after admission. Several clinical features, STMs, and serum biochemical and haematological indicators were analysed. Predictors of intestinal obstruction were analysed with univariate and multivariate logistic regression. The accuracy of the multivariate predictors of obstruction was measured by the area under the receiver operating characteristic (ROC) curve (AUC). The Kaplan-Meier method was used to create survival curves. Obstruction was found more in males (62.18%), never-smokers (73.95%), the left colon (54.20%), the tumour diameter > 4.5 cm (55.88%), high differentiation (89.50%), and negative nerve invasion (70.17%). The serum tumour markers (STMs) and peripheral blood routine indexes (PBRI) were significantly associated with obstructive status (p < 0.05). Multivariate analysis demonstrated that the neutrophil and lymphocyte counts, carcinoembryonic antigen, carbohydrate antigen 19-9, carbohydrate antigen 125, albumin, alkaline phosphatase, gamma-glutamyl transpeptidase, total protein, and neutrophil-to-lymphocyte ratio were predictors of intestinal obstruction (p < 0.05). The AUC for the curve with all the eight factors was 0.715 (95% confidence interval: 0.673-0.758). The STMs and PBRI were related to the obstruction status of the patients, and they could be used in combination with other clinical factors to significantly improve diagnosis and management of intestinal obstruction in CRC patients.
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Affiliation(s)
- Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Songqing Ke
- Department of Epidemiology and Biostatistics, The Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Fuwei Mao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Shuang Yao
- Department of Epidemiology and Biostatistics, The Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Lizhao Yan
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Li Liu
- Department of Epidemiology and Biostatistics, The Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
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Seoane Urgorri A, Saperas E, O'Callaghan Castella E, Pera Román M, Raga Gil A, Riu Pons F, Barranco Priego L, Dedeu Cusco JM, Pantaleón Sánchez M, Bessa Caserras X, Álvarez-González MA. Colonic stent vs surgical resection of the primary tumor. Effect on survival from stage-IV obstructive colorectal cancer. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:694-700. [PMID: 32755149 DOI: 10.17235/reed.2020.5701/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES the impact of surgical primary tumor resection on survival of obstructive metastatic colorectal cancer remains controversial. The primary goal of this study was to analyze survival in patients with obstructive metastatic colorectal cancer after treatment with either resection surgery or a colonic stent. MATERIAL AND METHODS a prospective study was performed of all patients with stage-IV colorectal cancer and obstructive manifestations, diagnosed from 2005 to 2012 and managed with either resection surgery or a colonic stent. Cases with a perforation, abscess, right colon or distal rectal malignancy, multiple colorectal cancer or derivative surgery were excluded. RESULTS a total of 95 patients were included, 49 were managed with resection surgery and 46 with a colonic stent. The colonic stent group had a higher Charlson index (9.5 ± 2.1 vs 8.6 ± 1.5, p = 0.01), a shorter time to oral intake (0.9 ± 1.1 vs 16.4 ± 53.5 days, p = 0.05), a shorter hospital stay (4 ± 4.8 vs 16.7 ± 15.5 days, p = 0.0001), less need for stomata (11.1 % vs 32.7 %, p = 0.01), fewer early complications (4.3 % vs 46.9 %, p = 0.0001) and more late complications (33.3 % vs 6.4 %, p = 0.001). Undergoing chemotherapy (p = 0.008) was the only independent factor related to increased survival. In the subgroup of patients managed with chemotherapy, surgical primary tumor resection was an independent factor associated with increased survival. CONCLUSION both treatments are effective for resolving obstructive manifestations in patients diagnosed with stage-IV obstructive colorectal cancer. Resection surgery has no positive impact on survival and thus cannot be recommended as a therapy of choice.
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Affiliation(s)
| | | | | | | | | | - Faust Riu Pons
- Aparato Digestivo, Parc de Salut Mar. Hospital del Mar, España
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13
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Chok AY, Lim HJ, Lye WK, Samarakoon LB, Guo J, Tang CL, Mathew R. Stenting as a bridge to surgery for obstructed stage IV colorectal cancers - long-term outcomes of a 10-year study. Asian J Endosc Surg 2020; 13:343-350. [PMID: 31436381 DOI: 10.1111/ases.12747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/22/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Successful stenting of an obstructing colorectal tumor can avert upfront emergency surgery in malnourished obstructed patients with metastatic disease and poor physiological condition. This study aims to evaluate the outcomes of stenting followed by primary colorectal tumor resection among patients with obstructed stage IV colorectal cancer at presentation, over a 10-year period. METHODS From 2007 to 2016, a cohort comprising 25 consecutive patients were retrospectively reviewed from a prospectively collected database. The durability of palliation of bowel obstruction, oncological outcomes and factors influencing overall survival were analyzed. RESULTS No re-interventions were required for bowel obstruction during the study period. The overall perioperative morbidity rate was 16%, with no postoperative 90-day mortality. Laparoscopic resection rate was 52% and stoma formation rate was 8%. The median overall survival was 24 months for the entire cohort, and the 1-, 3- and 5-year survival rates were 80%, 35% and 23.33% respectively. More than one site of distant metastases, peritoneal involvement, and elevated carcinoembryonic antigen levels were significantly associated with poorer survival outcomes. Patients with peritoneal-only metastasis had worse outcomes, with a median survival of 7 months and no patients surviving beyond 18 months. CONCLUSION Stenting followed by resection of the primary obstructing colorectal cancer provides durable palliation among patients with stage IV disease, with low perioperative morbidity and stoma formation rates. Superior survival was observed among patients with single-site, non-peritoneal distant metastases.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hui Jun Lim
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Weng Kit Lye
- Center for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Lasitha B Samarakoon
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jiwei Guo
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Choong Leong Tang
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ronnie Mathew
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
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14
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Quinn PL, Arjani S, Ahlawat SK, Chokshi RJ. Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction. Surg Endosc 2020; 35:2240-2247. [PMID: 32430522 DOI: 10.1007/s00464-020-07637-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 05/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness. METHODS A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses. RESULTS Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of - $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time. CONCLUSIONS In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.
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Affiliation(s)
- Patrick L Quinn
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Simran Arjani
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Sushil K Ahlawat
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA. .,Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, 205 South Orange Ave, F1222, Newark, NJ, 07103, USA.
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15
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Cao Y, Yang M, Yan L, Deng S, Gu J, Mao F, Wu K, Liu L, Cai K. Colon metal stents as a bridge to surgery had no significant effects on the perineural invasion: a retrospective study. World J Surg Oncol 2020; 18:77. [PMID: 32321517 PMCID: PMC7178988 DOI: 10.1186/s12957-020-01845-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/25/2020] [Indexed: 02/08/2023] Open
Abstract
Purpose The long-term oncological effects of self-expandable metallic stent (SEMS) as a “bridge to surgery” are contradictory, and perineural invasion was supposed to be enhanced by the stenting. In this retrospective study, we compared the perineural invasion and the oncological outcomes between the stent as a bridge to surgery (SBTS)- and emergency surgery (ES)-treated patients to evaluate the results of stenting on the perineural invasion. Methods The clinical data of patients with acute intestinal obstruction caused by colorectal cancer from January 2013 to January 2017 were retrospectively collected. Forty-three patients underwent semi-elective curative resection after endoscopic SEMS insertion, and sixty-three underwent ES. The adverse events and long-term follow-up outcomes were assessed. The clinicopathological characteristics, perineural invasion rates, and survival rates were compared between the two patient groups. Results Stent insertion resulted in significantly lower stoma rate (32.6% vs 46%; P = 0.03), post-operative overall complication rate (11.6% vs 28.6%, P = 0.038), and total hospital stay (17.07 ± 5.544 days vs 20.48 ± 7.372 days, P = 0.042). Compared with the ES group, there was no significant increase in the incidence of peripheral invasion in the SBTS group (39.5% vs 47.6%, P = 0.411). No significant difference was noted in the survival rate and long-term prognosis between the SEMS and ES groups (P = 0.964). The technical success rate was 95.6%, and the clinical success rate was 97.7%. Conclusions Preoperative colon stenting was an effective transitional method for colorectal cancer patients with complete obstruction. Short-term stent implantation had no significant effect on perineural invasion in patients with CRC.
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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
| | - Ming Yang
- Department of Pathology, Union Hospital, Tongji Medical, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Lizhao Yan
- 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
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Fuwei Mao
- 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
| | - Li Liu
- Department of Epidemiology and Biostatistics, The Ministry of Education Key Lab of Environment and Health, School of Public Health, 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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An increase in the peripheral lymphocyte-to-monocyte ratio after primary site resection is associated with a prolonged survival in unresectable colorectal carcinoma. Surg Today 2019; 50:604-614. [PMID: 31786682 DOI: 10.1007/s00595-019-01927-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/18/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The prognostic benefits of primary tumor resection in patients with unresectable distant metastatic colorectal cancer remain unclear. A high pre-treatment lymphocyte-to-monocyte ratio (LMR) was previously shown to be associated with a better prognosis. We assessed whether or not primary tumor resection was associated with an improved survival if the peripheral lymphocyte-to-monocyte ratio increased after primary site resection. METHODS The survival in 64 and 59 patients with and without primary tumor resection, respectively, was retrospectively compared. After resection, the survival in 39 patients with a postoperatively increased LMR (LMR-increase) and 25 patients with a decreased LMR (LMR-decrease) was compared. RESULTS Primary tumor resection prolonged the median survival more frequently in cases of non-differentiated adenocarcinoma, obstructive symptoms, high serum albumin levels, and no lymph-node metastasis than in others. Cox regression showed that the potential independent prognostic variable was non-resection of the primary lesion. After resection, the median survival in the LMR-increase vs. LMR-decrease groups was significantly different (27.3 vs. 20.8 months). There were no marked differences in patient background characteristics between the groups, except for in the number of pre-operative peripheral blood lymphocytes. The resected specimens showed significantly lower CD8+:CD163+ invading leukocyte ratios in the LMR-increase group than in the LMR-decrease group. CONCLUSIONS Primary tumor resection in patients with unresectable metastatic colorectal cancer may be associated with an improved survival, especially when the LMR is increased after primary tumor resection.
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17
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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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Cao Y, Deng S, Gu J, Li J, Wu K, Zheng H, Cheng P, Zhang J, Zhao G, Tao K, Wang G, Cai K. Clinical Effectiveness of Endoscopic Stent Placement in Treatment of Acute Intestinal Obstruction Caused by Colorectal Cancer. Med Sci Monit 2019; 25:5350-5355. [PMID: 31322139 PMCID: PMC6660806 DOI: 10.12659/msm.914623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Emergency endoscopic intestinal stenting has been applied with increasing frequency in colorectal cancer patients with acute intestinal obstruction. However, its clinical effectiveness as compared to emergency surgery remains controversial. Material/Methods The clinical data of 96 patients with acute intestinal obstruction caused by colorectal cancer from April 2012 to April 2018 were retrospectively collected. Statistical technique success rate, clinical success rate, operative time, average indwelling time of stent, complications, transition time to second-stage surgery, postoperative hospital stay, sputum rate, and postoperative infection rate were studied. Results Endoscopic colonoscopy was successfully performed in 94 patients. The success rate of stent placement was 97.9%, and the average operative time was 35 minutes (range, 25–85 minutes). Forty-two patients underwent stage I colectomy after relief of the obstruction. The average stent retention time was 7 days (range, 5–15 days). Two patients suffered from anastomotic infection. Their intestinal preparation time, hospital stay, fistula rate, and infection rate were lower than those of patients undergoing emergency operation for colon cancer intestinal obstruction. A total of 52 patients with colon cancer underwent palliative stent placement. Three patients had complications, including 1 case of stent displacement in the palliative care group and 2 cases with perforation in the bridge surgery group. Conclusions Emergency endoscopic placement of an intestinal stent is safe and effective in the treatment of patients with acute intestinal obstruction caused by colorectal cancer. It is also a safe and simple procedure for patients receiving advanced palliative treatment, which greatly improves their quality of life and is easy for patients’ families to accept.
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Affiliation(s)
- Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Jiang Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Hai Zheng
- Department of Emergency and Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Ping Cheng
- Department of Emergency and Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Jinxiang Zhang
- Department of Emergency and Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Gang Zhao
- Department of Emergency and Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Guobing Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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To resect or not to resect: The hamletic dilemma of primary tumor resection in patients with asymptomatic stage IV colorectal cancer. Crit Rev Oncol Hematol 2018; 132:154-160. [PMID: 30447921 DOI: 10.1016/j.critrevonc.2018.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/05/2018] [Indexed: 02/07/2023] Open
Abstract
Primary tumor resection (PTR) in advanced asymptomatic colorectal cancer (CRC) has been a matter of intense debate for long time. With the advances in systemic treatments, this practice has decreased over the years, although it remains still pervasive. Although the removal of primary tumor has been extensively interrogated both in retrospective and prospective studies, it still remains a clinical conundrum. There are many arguments for and against PTR in CRC both from the preclinical and the clinical point of view. Two scoring models have been published aiming at identifying patients who are suitable candidate for PTR, but they deserve further investigations in larger datasets. While awaiting the results of ongoing randomized clinical trials (RCTs) on this controversial topic, both upfront systemic treatment and PTR followed by chemotherapy should be considered valid options in patients with asymptomatic mCRC. Clinical selection and a shared-decision making approach are the keys to success.
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Endoscopic stenting for palliation of intra-abdominal gastrointestinal malignant obstruction: predictive factors for clinical success. Eur J Gastroenterol Hepatol 2018; 30:1033-1040. [PMID: 29851864 DOI: 10.1097/meg.0000000000001178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic stenting proved to be a safe alternative to surgery for malignant intra-abdominal gastrointestinal obstruction. Although high technical success rates have been reported, some patients do not experience relief in symptoms. AIM This study aimed to analyse the factors predicting the effectiveness of stent placement in patients with gastrointestinal obstruction. PATIENTS AND METHODS A retrospective study was carried out including 160 patients who underwent palliative stenting for intra-abdominal obstruction in a tertiary centre from December 2012 to July 2017. Technical and clinical success, stent dysfunction and adverse events were analysed. RESULTS The rate of technical success was 98%. The rate of early clinical success was 69 and 81% in upper and lower gastrointestinal obstructions, respectively (P=0.107). In the upper tract, obstruction caused by carcinomatosis was the only independent factor predicting early and late clinical failure [odds ratio (OR): 9.7, 95% confidence interval (CI): 2.5-38.4, P=0.001 and OR: 7.6, 95% CI: 1.8-31.9, P=0.006, respectively]. In the colon, Eastern Cooperative Oncology Group score of at least 3 was an independent factor for early clinical failure (OR: 29.8, 95% CI: 1.9-464.9, P=0.002) and obstruction caused by carcinomatosis was an independent factor for late clinical failure (OR: 14.4, 95% CI: 1.7-119.6, P=0.013). Perforation occurred in 4 patients (2.5%) and stent dysfunction occurred in 15% of patients (4% stent migration; 9% restenosis). Carcinomatosis was a risk factor for perforation (P=0.039) and migration was higher with shorter 6 cm stents (P=0.044). CONCLUSION Stents are effective and safe for palliation of intra-abdominal obstruction. Carcinomatosis predicts an unfavourable clinical outcome. Palliative stenting as an option should be weighed carefully in these patients.
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Kong X, Li J, Cai Y, Tian Y, Chi S, Tong D, Hu Y, Yang Q, Li J, Poston G, Yuan Y, Ding K. A modified TNM staging system for non-metastatic colorectal cancer based on nomogram analysis of SEER database. BMC Cancer 2018; 18:50. [PMID: 29310604 PMCID: PMC5759792 DOI: 10.1186/s12885-017-3796-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background To revise the American Joint Committee on Cancer TNM staging system for colorectal cancer (CRC) based on a nomogram analysis of Surveillance, Epidemiology, and End Results (SEER) database, and to prove the rationality of enhancing T stage’s weighting in our previously proposed T-plus staging system. Methods Total 115,377 non-metastatic CRC patients from SEER were randomly grouped as training and testing set by ratio 1:1. The Nomo-staging system was established via three nomograms based on 1-year, 2-year and 3-year disease specific survival (DSS) Logistic regression analysis of the training set. The predictive value of Nomo-staging system for the testing set was evaluated by concordance index (c-index), likelihood ratio (L.R.) and Akaike information criteria (AIC) for 1-year, 2-year, 3-year overall survival (OS) and DSS. Kaplan–Meier survival curve was used to valuate discrimination and gradient monotonicity. And an external validation was performed on database from the Second Affiliated Hospital of Zhejiang University (SAHZU). Results Patients with T1-2 N1 and T1N2a were classified into stage II while T4 N0 patients were classified into stage III in Nomo-staging system. Kaplan–Meier survival curves of OS and DSS in testing set showed Nomo-staging system performed better in discrimination and gradient monotonicity, and the external validation in SAHZU database also showed distinctly better discrimination. The Nomo-staging system showed higher value in L.R. and c-index, and lower value in AIC when predicting OS and DSS in testing set. Conclusion The Nomo-staging system showed better performance in prognosis prediction and the weight of lymph nodes status in prognosis prediction should be cautiously reconsidered. Electronic supplementary material The online version of this article (10.1186/s12885-017-3796-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiangxing Kong
- Department of surgical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China
| | - Jun Li
- Department of surgical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China
| | - Yibo Cai
- Department of surgical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China
| | - Yu Tian
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, 310009, China
| | - Shengqiang Chi
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, 310009, China
| | - Danyang Tong
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, 310009, China
| | - Yeting Hu
- Department of surgical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China
| | - Qi Yang
- Department of surgical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China
| | - Jingsong Li
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, 310009, China
| | - Graeme Poston
- Department of Surgery, School of Translational Studies, University of Liverpool, Aintree University Hospital, Liverpool, L9 7AL, UK
| | - Ying Yuan
- Department of medical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China
| | - Kefeng Ding
- Department of surgical oncology, and The Key Laboratory of Cancer Prevention and Intervention, Second Affiliated Hospital, China National Ministry of Education, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang Province, 310009, China.
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