Self-expanding metal stent insertion by colorectal surgeons in the management of obstructing colorectal cancers: a 6-year experience. Tech Coloproctol. 2014;18:453-458. [PMID: 24114608 DOI: 10.1007/s10151-013-1073-0]

Self-expanding metal stent insertion by colorectal surgeons using a two-person approach colonoscopy without fluoroscopic monitoring in the management of acute colorectal obstruction: a 14-year experience

BACKGROUND

Placement of a self-expanding metal stent (SEMS) in patients presenting with an acute colorectal obstruction (ACO) may obviate emergency surgery (ES), potentially effectively palliating incurable tumors, acting as a bridge to surgery (BTS) in patients with operable or potentially operable tumors and achieving effective decompression of other ACO. We present our experience with SEMS insertion by colorectal surgeons without fluoroscopic monitoring for ACO especially for acute malignant colorectal obstruction (AMCO) for nearly a 14-year period (2007-2020).

AIM

To explore the safety and effectiveness of SEMS insertion in the management of ACO by colorectal surgeons using a two-person approach colonoscopy without fluoroscopic monitoring.

METHODS

We reviewed the medical records of patients retrospectively to identify all patients presenting to our unit with ACO especially with AMCO who had stenting carried out to achieve colonic decompression. All 434 procedures were performed by colorectal surgeons using a two-person approach colonoscopy without fluoroscopic monitoring.

RESULTS

The overall technique success rate and clinic success rate by SEMS insertion were 428/434 (98.6%) and 412/434 (94.9%). The overall incidence of complications by SEMS insertion was 19/434 (4.4%). The complications included clinical perforation (6/434, 1.4%); stent migration (2/434, 0.5%), 1 of which re-stent; stent detachment (fell off) (3/434, 0.7%), none of them with re-stent; stool impaction (6/434, 1.4%), 1 of which re-stent; and abdominal or anal pain (2/434, 0.5%). There was no hemorrhage in any of the 434 patients.

CONCLUSIONS

SEMS insertion is a relatively safe and effective technique for colonic decompression in dealing with ACO as either a BTS or as a palliative measure. It is also a solution to other causes of ACO such as recurrent tumor, benign diseases, or extra-luminal compression. Therefore, ES was largely avoided.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection.

METHODS

A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival.

RESULTS

Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%.

CONCLUSION

Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.

Predictors of clinical outcome of colonic stents in patients with malignant large-bowel obstruction because of extracolonic malignancy

BACKGROUND AND AIMS

Colonic stent placement in patients with large-bowel obstruction (LBO) secondary to extracolonic malignancy (ECM) has been evaluated in small series with heterogeneous results. Our aim is to better characterize the technical and clinical success of colonic stent placement and to identify factors that affect this success in ECM patients.

METHODS

All patients at a single high-volume center who presented for colonic stent placement for LBO because of ECM between 2001 and 2012 were retrospectively identified. The outcomes of interest were technical success, clinical success, stent occlusion rate, and overall survival.

RESULTS

A total of 187 patients were identified. Mean age was 61.9 years (range, 23-89), and 150 (80.2%) were women. The most common malignancy type was urogynecologic (n = 104) and most common location sigmoid colon (n = 128). Overall, 142 patients (75.9%) achieved technical success and 102 patients (54.5%) clinical success. Radiographic presence of peritoneal carcinomatosis (P < .001) and multifocal disease (P < .001) were associated with both decreased technical and clinical success. Procedure-related adverse events were seen in 12 patients (6.4%). In patients with clinical success, the incidence of stent occlusion at 3 months was 14.7% (95% confidence interval, 7.8%-21.6%) and was higher in patients with prior radiation therapy (P = .011). The median overall survival for all patients from time of attempted stent placement was 3.3 months (95% confidence interval, 3.0-4.1).

CONCLUSIONS

This study represents the largest retrospective series of colonic stent placement for LBO in ECM patients in the literature. Our technical success rate of 75.9%, clinical success rate of 54.5%, and 3-month stent occlusion rate of 14.7% suggest that stent placement is a viable palliative option for patients with advanced disease because of ECM. Patients with peritoneal carcinomatosis and multifocal disease have reduced technical and clinical success. However, these factors should not dissuade an attempt at stent placement, if risk-to-benefit analysis is favorable.

Long-Term Oncological Outcomes of Endoscopic Stenting as a Bridge to Surgery Versus Emergency Surgery for Malignant Colorectal Obstruction: A Comparative Study

AIM

With consideration of the theoretical link between the stent insertion and the increased risk of tumor cells spillaged, which may lead to distant metastases, there is a concern about long-term clinical outcomes after the usage of self-expanding metallic stents (SEMS) as a "bridge to surgery" in the malignant colorectal obstruction (MCO) treatment. This cohort study aimed to compare the long-term oncological outcomes of SEMS as a bridge to surgery (SEMS group) with those of emergency surgery (ES group) for MCO.

METHODS

Twenty-seven patients who underwent semielective curative resection after endoscopic SEMS insertion were included from October 2007 to December 2012 in the SEMS group were compared with 33 patients who underwent emergency curative surgery for MCO during the same period in the ES group. The clinical pathologic characteristics and the overall survival (OS) rate were compared between the two groups.

RESULTS

There were no significant differences in demographics, tumor stage, location, and histology between the SEMS and ES groups. The median OS times were 37 months for the SEMS group and 23 months for the ES group. The proportions of patients who received postoperative adjuvant chemotherapy were comparable (SEMS group versus ES group, 70.4% versus 45.5%; P = .138). There were no significant differences in terms of the long-term oncological outcome between two groups in the 3-year OS rate (55.6% versus 39.4%; P = .2119) and the 5-year OS rate (48.1% versus 36.4%; P = .3570).

CONCLUSIONS

Long-term oncological outcomes of the SEMS group were comparable to those of the ES group.

Self-Expandable Metal Stents for Colorectal Cancer: From Guidelines to Clinical Practice

INTRODUCTION

Colonic self-expandable metal stent placement is widely used for palliation of obstructive colorectal cancer. The European recommendations for stent placement as a bridge to elective surgery in obstructive colorectal cancer were recently reviewed. The aim of this study was to evaluate the efficacy and safety of stent placement in obstructive colorectal cancer and to discuss these recent guidelines.

MATERIALS AND METHODS

Demographic characteristics, procedure indications, complications and final outcome in patients with obstructive colorectal cancer who underwent endoscopic stent placement between January 2012 and June 2015 were retrospectively analyzed. Statistical analysis was performed with SPSS V22.

RESULTS

Thirty-six patients were included, 20 (56%) women, mean age 70.6 ± 10.9 years. Stent placement as a bridge to elective surgery was performed in 75% (n = 27) of patients and with palliation intent in 25% (n = 9). In 94% (n = 34) of procedures, technical and clinical success was achieved. A total of eleven (11%) complications were observed: 2 migrations and 9 perforations. No procedure related death was recorded. When stents were placed as a bridge to surgery, average time between endoscopic procedure and surgery was 11.7 ± 9.4 days (excluding three patients who underwent neoadjuvant chemotherapy). Six perforations were recorded in this group: one overt and five silent (three during surgery and two after histopathological examination of the resected specimen). Twenty-one patients underwent adjuvant chemotherapy. During the follow-up period of 14.7 ± 10.9 months recurrence was observed in five patients. None of the recurrence occurred in the group of patients with perforation.

CONCLUSIONS

In this study, stent placement was an effective procedure in obstructive colorectal cancer. It was mainly used as a bridge to elective surgery. However, a significant rate of silent perforation was observed, which may compromise the oncological outcome of these potentially curable patients. Prospective real life studies are warranted for a better definition of actual recommendations.

Value of endoscopic intestinal stent placement in treatment of colorectal cancer complicated with intestinal obstruction

AIM: To evaluate the safety, efficacy and value of endoscopic intestinal stent placement in the treatment of colorectal cancer complicated with acute intestinal obstruction.

METHODS: A total of 263 patients with colorectal cancer complicated with intestinal obstruction treated at our hospital from January 2010 to December 2014 were included. Stenting treatment was performed under endoscopy and (or) X-ray. The rate of success, the incidence of postoperative complications, the rate of symptom remission, the rate of surgical excision and other indicators were evaluated.

RESULTS: Stent implantation was successful in 258 (98.1%) cases. The rates of adverse events were: perforation, 1.1% (3 cases); hemorrhage, 3.8% (10 cases); fever, 4.6% (12 cases), and others such as stent dislocation and migration, 3.0% (8 cases). The rates of symptom remission were: abdominal pain, 97.3% (256 cases); abdominal distension, 97.3% (258 cases); and anal dysfunction, 98.1% (258 cases). The rates of surgical resection were: 60 cases for palliative treatment, 198 cases for surgical resection 5-13 d after stent implantation after intestinal preparation, and 143 cases for removal of the tumor by one-stage operation.

CONCLUSION: The symptoms of intestinal obstruction can be relieved by endoscopic intestinal stenting. Emergency endoscopic stenting can be used as a bridge treatment before operation, and it can turn emergency operation to elective surgery, turn two-stage operation to one-stage operation, reduce the difficulty and risk of operation for clinicians, reduce the incidence of postoperative complications, relieve pain, and improve survival quality.