1
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Chen KA, Kapadia MR. Large Bowel Obstruction: Etiologies, Diagnosis, and Management. Clin Colon Rectal Surg 2024; 37:376-380. [PMID: 39399137 PMCID: PMC11466520 DOI: 10.1055/s-0043-1777452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2024]
Abstract
Large bowel obstructions (LBOs) often require urgent surgical intervention. Diagnosis relies on astute history and physical examination, as well as imaging with computed tomography (CT) scan for stable patients. Because of the high mortality associated with colonic perforation in patients with LBOs, decisive surgical decision-making is needed for optimal outcomes. This review seeks to provide an overview of the etiologies of LBO, diagnosis, and general management principles, as well as specific management for the most common etiologies, including colorectal cancer and strictures.
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Affiliation(s)
- Kevin A. Chen
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Muneera R. Kapadia
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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2
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Walayat S, Johannes AJ, Benson M, Nelsen E, Akhter A, Kennedy G, Soni A, Reichelderfer M, Pfau P, Gopal D. Outcomes of colon self–expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature. World J Gastrointest Endosc 2023; 15:309-318. [PMID: 37138935 PMCID: PMC10150280 DOI: 10.4253/wjge.v15.i4.309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/09/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement.
AIM To review long- and short-term clinical success of SEMS use for colonic obstruction at our center.
METHODS We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded.
RESULTS Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS).
CONCLUSION Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53705, United States
| | - Andrew J Johannes
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53705, United States
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Eric Nelsen
- Gastroenterology, Park Nicollet Digestive and Endoscopy Center, Methodist Hospital, St. Louis Park, Minneapolis, MN 55426, United States
| | - Ahmed Akhter
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Gregory Kennedy
- Department of Surgery, University of Alabama-Birmingham School of Medicine, Brimingham, AL 35243, United States
| | - Anurag Soni
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Mark Reichelderfer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Patrick Pfau
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Abstract
CASE SUMMARY A 46-year-old man with no significant medical or surgical history presented to the emergency department with a 1-week history of worsening constipation, abdominal distension, nausea, and nonbloody, nonbilious emesis. Workup included a CT scan that was notable for a 5.3 × 3.9 cm "apple core-type" mass located within the sigmoid colon with proximal large-bowel dilation. Carcinoembryonic antigen was 1.4. No metastatic disease was seen on chest, abdominal, or pelvic CT scans. Flexible sigmoidoscopy identified a sigmoid colon mass 30 cm from the anal verge with near complete obstruction. Biopsies of the mass did not show evidence of dysplasia or malignancy. The Gastroenterology service declined to place a stent without a malignancy diagnosis. The patient subsequently underwent exploratory laparotomy, sigmoid colectomy, and end colostomy. Recovery was uneventful. Final pathology showed diverticulitis with abscess formation and no evidence of malignancy. A completion colonoscopy was unremarkable, and the patient underwent colostomy reversal 3 months later.
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Affiliation(s)
- Brian T Cain
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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4
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Abstract
Nearly one-quarter of bowel obstructions occur in the large bowel. As with all bowel obstructions, large bowel obstructions have three defining characteristics: partial or complete, intrinsic or extrinsic, benign or malignant. The work-up for a large bowel obstruction should focus on the etiology of the obstruction as well as severity. Management strategy is contingent on the previous characteristics and can include endoscopy, diversion, or resection. This chapter will discuss common and rare etiologies of large bowel obstructions as well as management strategies for clinical guidance.
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Affiliation(s)
- Wali R Johnson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T Hawkins
- Department of Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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5
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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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6
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Uncovered self-expandable metal stents for the treatment of refractory benign colorectal anastomotic stricture. Sci Rep 2020; 10:19841. [PMID: 33199742 PMCID: PMC7669833 DOI: 10.1038/s41598-020-76779-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/28/2020] [Indexed: 11/08/2022] Open
Abstract
Self-expandable metal stent (SEMS) placement has been suggested as a therapeutic modality for treating benign colorectal strictures. Covered stents are generally used, given the concerns regarding the efficacy and safety of uncovered stents. Hence, few studies have evaluated the efficacy and safety of uncovered SEMSs (UCSEMSs) in patients with refractory benign colorectal anastomotic strictures. In this study, 12 patients with postoperative benign symptomatic anastomotic strictures refractory to pneumatic dilation (range, 2–9) and transient indwelling-covered SEMSs were treated using UCSEMS. All enrolled patients were men (mean age, 61 years). Stent placement was successful in all 12 patients, and early clinical success was achieved in 11 (92%) patients. Four patients (25%) showed successful clinical outcomes without further intervention, but eight patients (75%) were clinically unsuccessful, and showed stricture recurrence or functional obstructive symptoms. Three patients underwent surgery, and the remaining five patients required repeat stent procedures. Despite the high reobstruction rate, the median follow-up period after UCSEMS placement was 16.7 months, demonstrating that UCSEMS may be able to achieve medium-term symptom relief without any complications. Therefore, UCSEMS may be an alternative option in exceptional circumstances in carefully selected patients, where invasive surgical treatments, such as stoma diversion, are not an option, thereby improving patients’ quality of life.
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7
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Venezia L, Michielan A, Condino G, Sinagra E, Stasi E, Galeazzi M, Fabbri C, Anderloni A. Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract. World J Gastrointest Endosc 2020; 12:60-71. [PMID: 32064031 PMCID: PMC6965004 DOI: 10.4253/wjge.v12.i2.60] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/08/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023] Open
Abstract
In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.
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Affiliation(s)
- Ludovica Venezia
- Gastroenterology Unit, AOU Città della Salute e della Scienza Turin, Turin 10100, Italy
| | - Andrea Michielan
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Santa Chiara, Trento 38122, Italy
| | - Giovanna Condino
- Gastroenterology Unit, Azienda Ospedaliera S.S. Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto Giuseppe Giglio, Contrada Pietra Pollastra Pisciotto, Cefalù 90015, Italy
- Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo 90100, Italy
| | - Elisa Stasi
- Gastroenterology Unit, Department of Medicine, “Vito Fazzi” Hospital, Lecce 73100, Italy
| | - Marianna Galeazzi
- University of Milano-Bicocca, School of Medicine and Surgery, Monza 20052, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena, Azienda U.S.L. Romagna, Ospedale G. Morgagni-L. Pierantoni, Cesena 200868, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan 20100, Italy
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8
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Søreide JA, Tholfsen T, Karlsen LN, Kvaløy JT, Kørner H. Palliative surgical outcome score (PSOS) in patients treated palliatively with self-expanding metal stent (SEMS) for malignant incurable colorectal obstruction. Surg Oncol 2019; 29:134-139. [PMID: 31196477 DOI: 10.1016/j.suronc.2019.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/07/2019] [Accepted: 04/28/2019] [Indexed: 12/11/2022]
Abstract
AIM The palliative surgical outcome score (PSOS) was proposed for evaluation of the effect of palliative surgical interventions. As a surrogate measure for successful symptom control, it is defined as the proportion of days outside the hospital of the remaining life time up to six months after a palliative intervention. In this study we evaluate the PSOS in patients treated palliatively with self-expanding metal stents (SEMSs) for incurable malignant colorectal obstruction. METHODS All eligible patients endoscopically treated with palliative intent with SEMSs were identified. Demographics and clinical characteristics, including complete follow-up, were recorded, and the PSOS was calculated. Non-parametric tests were used for comparisons, and survival was evaluated by univariable and multivariable analyses. RESULTS Between 2005 and 2013, 116 patients (median age 71.5 years; 53.4% women) were identified. Most obstructions were caused by primary colorectal cancers. Technical- and clinical success rates were 94.0% and 87.1%, respectively. Procedure-related complications occurred in 17 (14.7%) of the patients, and most were minor. A PSOS>70 (regarded as excellent palliation) was achieved in 79 (68.1%) patients. This goal was significantly more often achieved in patients who survived at least 6 months than in those with shorter survival (p < 0.001). No clinical variables at the time of the endoscopic palliative procedure could predict a PSOS>70. However, in patients who survived at least 6 months (n = 69), a PSOS>70 was independently associated with better survival in the multivariable Cox analysis. CONCLUSIONS PSOS could be used as a practical proxy or a pragmatic tool for the effectiveness of palliative interventions, when such interventions are compared. Clinical factors that could significantly add to the clinical decision-making and predict a PSOS>70 in an individual patient were not identified for this specific group of patients.
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Affiliation(s)
- Jon Arne Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tore Tholfsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Lars Normann Karlsen
- Department of Gastroenterology, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, Stavanger, Norway; Department of Mathematics and Physics, University of Stavanger, Norway
| | - Hartwig Kørner
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Regional Centre of Palliative Medicine in Western Norway, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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9
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Sarani B, Paspulati RM, Hambley J, Efron D, Martinez J, Perez A, Bowles-Cintron R, Yi F, Hill S, Meyer D, Maykel J, Attalla S, Kochman M, Steele S. A multidisciplinary approach to diagnosis and management of bowel obstruction. Curr Probl Surg 2018; 55:394-438. [PMID: 30526888 DOI: 10.1067/j.cpsurg.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/11/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Babak Sarani
- Center for Trauma and Critical Care, George Washington University School of Medicine, Washington, DC.
| | | | - Jana Hambley
- Department of Trauma and Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Efron
- Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jose Martinez
- Division of Minimally Invasive Surgery, Minimally Invasive Surgery/Flexible Endoscopy Fellowship Program, University of Miami Miller School of Medicine, Miami, FL
| | - Armando Perez
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Fia Yi
- Brooke Army Medical Center, San Antonio, TX
| | - Susanna Hill
- University of Massachusetts Medical Center, Worcester, MA
| | - David Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Sara Attalla
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael Kochman
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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10
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Abstract
Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.
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11
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Clarke L, Abbott H, Sharma P, Eglinton TW, Frizelle FA. Impact of restenting for recurrent colonic obstruction due to tumour ingrowth. BJS Open 2018; 1:202-206. [PMID: 29951623 PMCID: PMC5989957 DOI: 10.1002/bjs5.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/07/2017] [Indexed: 11/08/2022] Open
Abstract
Background Endoscopic stenting is used to palliate malignant large bowel obstruction. A proportion of patients will develop recurrent obstruction due to tumour ingrowth and require reintervention. This study aimed to assess the outcome (clinical success and complication rates) of endoscopic reintervention compared with surgical intervention in patients with stent obstruction due to tumour ingrowth. Methods This was an observational study using data from a database of patients who underwent palliative colonic stenting between January 1998 and March 2017 at Christchurch Public Hospital. Results A total of 190 patients underwent colonic stent insertion, for palliation in 182 cases. Reintervention was performed in 55 (30·2 per cent). Thirty-one patients (17·0 per cent) developed obstruction within the stent at a median of 4·6 (i.q.r. 2·3-7·7) months after the procedure. Of these, 21 had endoscopic restenting and ten underwent surgery. Restenting had technical and clinical success rates of 100 per cent, and involved a significantly shorter length of stay compared with surgery (median 2 (i.q.r. 1-4) versus 11 (6-19) days respectively; P = 0·006). Seven of the 21 patients in the restented group underwent a third palliative intervention. The overall stoma rate in the restented group was significantly lower than that in the surgical group (4 of 21 versus 10 of 10; P < 0·001). There was no difference in complications or survival between the two groups. Conclusion Among palliative patients who develop malignant stent obstruction, endoscopic restenting had a high chance of technical success. It resulted in a shorter hospital stay and lower stoma rate than those seen after surgery.
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Affiliation(s)
- L Clarke
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - H Abbott
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - P Sharma
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - T W Eglinton
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand.,Department of Surgery, University of Otago Christchurch New Zealand
| | - F A Frizelle
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand.,Department of Surgery, University of Otago Christchurch New Zealand
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12
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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: 13] [Impact Index Per Article: 2.2] [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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13
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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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14
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Sardiwalla Y, Sardiwalla I, Kumar N, Koto M, Balabyeki M. Right-sided malignant colonic obstruction the use of a self expanding metal stent to facilitate laparoscopic surgery: A case report. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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15
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Laparoscopic approaches to complicated diverticulitis. Langenbecks Arch Surg 2017; 403:11-22. [PMID: 28875302 DOI: 10.1007/s00423-017-1621-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. PURPOSE The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. CONCLUSIONS New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.
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Predictors of outcome for endoscopic colorectal stenting: a decade experience. Int J Colorectal Dis 2017; 32:375-382. [PMID: 27817034 DOI: 10.1007/s00384-016-2696-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various factors on the short- and long-term results of colorectal stenting. METHODS A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome. RESULTS Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90 %) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22 % of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio [AOR] 0.2 [95 % confidence interval (CI) 0.1-0.8]; p = 0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 [95 % CI 1.4-10.3]; p = 0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 [95 % CI 1.0-10.0]; p = 0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 [95 % CI 1.5-11.7]; p = 0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 [95 % CI 2.6-71.2]; p = 0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 [95 % CI 1.3-16.2]; p = 0.017). CONCLUSIONS Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.
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Saeed KM, Zafar W, Masood MA, Khattak S, Syed AA, Yusuf MA. Self-Expanding Metallic Stents (SEMS) in Left-Sided Colonic Cancer--a Cancer Center Experience. J Gastrointest Cancer 2016; 47:69-74. [PMID: 26691172 DOI: 10.1007/s12029-015-9789-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS Self-Expanding Metallic Stents (SEMS) are a surgery-sparing option for malignant colonic obstruction. They can be inserted as a "bridge to surgery" (BTS) for potentially curable disease, or as a palliative measure, thereby avoiding the higher morbidity and mortality associated with surgery. The objective of this study was to report our local experience of left-sided colonic stents. METHODS Data on 49 patients was collected retrospectively from Oct 2008 to Nov 2014 at our cancer centre. This included demographics, baseline clinical characteristics, indications for SEMS placement (bridge to surgery/palliative), technical and clinical success, complications, and the mean patency of duration. Survival in both groups was also plotted on a Kaplan-Meier chart. RESULTS A total of 49 patients with colorectal carcinoma (CRC) of the left side were enrolled. The mean age was 50 years (range 18-86). Ninety percent of patients had disease involving the rectum, sigmoid colon, or both. Forty-seven percent (n = 23) of patients had stent insertion as a BTS, whereas 53% (n = 26) had the procedure with palliative intent. Technical and clinical success rates were 96 and 88%, respectively. The clinical success rate of the palliative arm was lower than that of the BTS arm (p = 0.024). 87.5% (n = 42) had no procedure-related complications. Technical failure, perforation, and stent migration/expulsion, were each observed in 4% of cases. Mean stent patency duration was 83.9 days. CONCLUSION SEMS insertion for left-sided malignant colonic obstruction is a safe and effective procedure when used either as a bridge to surgery or with palliative intent.
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Affiliation(s)
- Kamran Muddasar Saeed
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan.
| | - Waleed Zafar
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Muhammad Adnan Masood
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Shahid Khattak
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Aamir Ali Syed
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Muhammed Aasim Yusuf
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
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Does Stenting as a Bridge to Surgery in Left-Sided Colorectal Cancer Obstruction Really Worsen Oncological Outcomes? Dis Colon Rectum 2016; 59:725-32. [PMID: 27384090 DOI: 10.1097/dcr.0000000000000631] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although self-expandable metal stents are used as a bridge to surgery in patients with colorectal cancer obstruction, their long-term oncological outcomes are unclear. OBJECTIVE The aim of this study was to investigate long-term oncological outcomes of self-expandable metal stents as a bridge to surgery (stent group) compared with direct surgery (direct operation group) in patients with left-sided colorectal cancer obstruction. DESIGN This was a retrospective chart review. SETTINGS This study was conducted at a single tertiary academic center. PATIENTS Of 113 patients who underwent curative surgery for left-sided colorectal cancer obstruction at Asan Medical Center between 2005 and 2011, 42 underwent direct surgery and 71 underwent self-expandable metal stent insertion followed by elective surgery. After 1:1 propensity-score matching, 42 patients were enrolled in both groups, and their postsurgical outcomes were compared. MAIN OUTCOME MEASURES The primary outcomes of this study were long-term oncological outcomes, including overall survival and recurrence-free survival of patients in both groups. RESULTS Three- and 5-year overall survival rates were similar in the stent (87.0% and 71.0%) and direct operation (76.4% and 76.4%) groups (p = 0.931). Three- and 5-year recurrence-free survival rates were also similar in the stent (91.9% and 66.4%) and direct operation (81.2% and 71.2%) groups (p = 0.581), as were postsurgical complication rates (9.5% and 16.7%; p = 0.344). No patient in either group experienced a permanent stoma. LIMITATIONS This study was limited by its small patient numbers and retrospective nature. CONCLUSIONS The long-term oncological outcomes of self-expandable metal stents as a bridge to surgery may not be inferior to those of direct surgery for left-sided colorectal cancer obstruction.
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Jessamy K, Ozden N, Simon HM, Kobrossi S, Ubagharaji E. Self-Expanding Metal Stenting in the Management of a Benign Colonic Stricture. Case Rep Gastroenterol 2016; 10:127-31. [PMID: 27403114 PMCID: PMC4929371 DOI: 10.1159/000445185] [Citation(s) in RCA: 2] [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] [Received: 02/02/2016] [Accepted: 03/02/2016] [Indexed: 11/19/2022] Open
Abstract
Colonic postanastomotic strictures occur in 1.5–8% of patients following colorectal surgery. Traditionally, colonic strictures were treated by multiple modalities including endoscopic dilatation. Self-expanding metal stents (SEMS) have been indicated in the management of benign colonic strictures; however, there are limited available data with regard to their efficacy. We present the case of a 68-year-old male who had perforated sigmoid diverticulitis followed by Hartmann's procedure with eventual reanastomosis 6 months later. He subsequently developed benign colonic stricture, which was treated with a metal stent. SEMS are associated with a low mortality rate and are appropriate in treating acute colonic obstruction as a result of benign stricture in the setting of postanastomosis.
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Affiliation(s)
- Kegan Jessamy
- Department of Medicine, SUNY Upstate Medical University, Syracuse, N.Y., USA
| | - Nuri Ozden
- Gastroenterology Division, Department of Medicine, SUNY Upstate Medical University, Syracuse, N.Y., USA
| | - Howard M Simon
- Department of Surgery, SUNY Upstate Medical University, Syracuse, N.Y., USA
| | - Semaan Kobrossi
- Department of Medicine, SUNY Upstate Medical University, Syracuse, N.Y., USA
| | - Ezinnaya Ubagharaji
- Department of Medicine, SUNY Upstate Medical University, Syracuse, N.Y., USA
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Padwick RT, Chauhan V, Newman M, Francombe J, Osborne MJ. Endoscopic stenting of acutely obstructing colorectal cancer: a 10-year review from a tertiary referral centre. ANZ J Surg 2016; 86:778-781. [DOI: 10.1111/ans.13614] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/23/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Robert T. Padwick
- Department of Colorectal Surgery, Shrewsbury and Telford Hospitals NHS Trust; Shrewsbury UK
| | - Vishnusai Chauhan
- Department of Colorectal Surgery, South Warwickshire Hospitals NHS Foundation Trust; Warwick UK
| | - Matthew Newman
- Department of Clinical Sciences, Warwick Medical School; Coventry UK
| | - James Francombe
- Department of Colorectal Surgery, South Warwickshire Hospitals NHS Foundation Trust; Warwick UK
| | - Martin J. Osborne
- Department of Colorectal Surgery, South Warwickshire Hospitals NHS Foundation Trust; Warwick UK
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Takahashi H, Okabayashi K, Tsuruta M, Hasegawa H, Yahagi M, Kitagawa Y. Self-Expanding Metallic Stents Versus Surgical Intervention as Palliative Therapy for Obstructive Colorectal Cancer: A Meta-analysis. World J Surg 2016; 39:2037-44. [PMID: 25894403 DOI: 10.1007/s00268-015-3068-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although self-expanding metallic stents (SEMS) are useful tools for relieving large bowel obstructions in patients with colorectal cancer (CRC), their efficacy in a palliative setting has not been validated. This meta-analysis aimed to evaluate the feasibility of SEMS as a palliation for unresectable CRC patients with bowel obstructions and to determine their contribution to the prognosis of CRC, compared with surgical intervention. METHODS We conducted a literature search of the PubMed and Cochrane Library databases. We selected all controlled trials that compared SEMS with surgical interventions as palliative treatments in unresectable obstructive CRC patients. The primary outcome was early complications, and the secondary outcomes were mortality, other morbidities, and long-term survival rates. RESULTS Ten studies met our inclusion criteria. SEMS significantly reduced the risk of early complications (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.20-0.58%; P<0.01), mortality (OR 0.31; 95% CI 0.15%-0.64%; P<0.01), and stoma creation (OR 0.19; 95% CI 0.12-0.28%; P<0.01). Although SEMS placement was significantly associated with a higher risk of perforation of the large bowel (OR 5.25 95% CI 2.00-13.78%; P<0.01) and late complications (OR 1.94; 95% CI 0.90-4.19%; P=0.03), it also contributed significantly to better long-term survival (hazard ratio 0.46; 95% CI 0.31-0.68%; P<0.01). CONCLUSIONS Compared with surgical intervention, SEMS could provide feasible palliation for patients with bowel obstructions and unresectable CRC, because of their acceptable morbidity rates and better patient prognoses.
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Affiliation(s)
- Hidena Takahashi
- Department of Surgery, Keio University School of Medicine, 35 Shinanotmachi, Shinjuku-ku, Tokyo, Japan,
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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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Kim JH, Kwon KA, Lee JJ, Lee WS, Baek JH, Kim YJ, Chung JW, Kim KO, Park DK, Kim JH. Surgical failure after colonic stenting as a bridge to surgery. World J Gastroenterol 2014; 20:11826-11834. [PMID: 25206288 PMCID: PMC4155374 DOI: 10.3748/wjg.v20.i33.11826] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/26/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify risk factors for surgical failure after colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction.
METHODS: The medical records of patients who underwent stent insertion for malignant colonic obstruction between February 2004 and August 2012 were retrospectively reviewed. Patients with malignant colonic obstruction had overt clinical symptoms and signs of obstruction. Malignant colonic obstruction was diagnosed by computed tomography and colonoscopy. A total of 181 patients underwent stent insertion during the study period; of these, 68 consecutive patients were included in our study when they had undergone stent placement as a bridge to surgery in acute left-sided malignant colonic obstruction due to primary colon cancer.
RESULTS: Out of 68 patients, forty-eight (70.6%) were male, and the mean age was 64.9 (range, 38-89) years. The technical and clinical success rates were 97.1% (66/68) and 88.2% (60/68), respectively. Overall, 85.3% (58/68) of patients underwent primary tumor resection and primary anastomosis. Surgically successful preoperative colonic stenting was achieved in 77.9% (53/68). The mean duration, defined as the time between the SEMS attempt and surgery, was 11.3 d (range, 0-26 d). The mean hospital stay after surgery was 12.5 d (range, 6-55 d). On multivariate analysis, the use of multiple self-expanding metal stents (OR = 28.872; 95%CI: 1.939-429.956, P = 0.015) was a significant independent risk factor for surgical failure of preoperative stenting as a bridge to surgery. Morbidity and mortality rates in surgery after stent insertion were 4.4% (3/68) and 1.5% (1/68), respectively.
CONCLUSION: The use of multiple self-expanding metal stents appears to be a risk factor for surgical failure.
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Shigeta K, Baba H, Yamafuji K, Kaneda H, Katsura H, Kubochi K. Outcomes for patients with obstructing colorectal cancers treated with one-stage surgery using transanal drainage tubes. J Gastrointest Surg 2014; 18:1507-13. [PMID: 24871080 DOI: 10.1007/s11605-014-2541-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/13/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute colorectal obstruction requires immediate surgical treatment. Although one-stage surgery with transanal drainage tubes (TDT) is reportedly safe and feasible, the long-term outcome of this procedure remains unclear. AIM To assess the outcome of one-stage surgery using TDT in the acute left colon or rectal obstructions due to colorectal carcinomas. METHODS Clinicopathological data were recorded from patients with colorectal cancer with acute obstructions between 2006 and 2013. RESULTS A total of 43 patients were enrolled including 29 males and 14 females. Among 39 patients, TDT was successful in 33 (84 %) and was incomplete in 6. Thus, 33 patients received one-stage surgery with TDT decompression, and 9 patients, including 6 with incomplete decompression, received one-stage surgery with no decompression. No significant differences in clinicopathological factors were observed between decompression and non-decompression groups. Adjusted analyses revealed that decompression using TDT was significantly associated with OS (hazard ratio 0.24; 95 % confidence interval, 0.08-0.72; p = 0.01). Furthermore, OS in the TDT decompression group was significantly longer than that in the non-decompression group (p = 0.01). CONCLUSIONS One-stage surgery with decompression using TDT may be effective to avoid stomas and to improve overall survival in patients with obstructing colorectal cancers.
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Affiliation(s)
- Kohei Shigeta
- Department of Surgery, Saitama City Hospital, 2460 Mimuro, Midori-ku, Saitama-shi, Saitama, 336-8522, Japan,
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Uncovered Self-Expanding Metal Stent (SEMS) Four Years After Placement for Long-Term Treatment of a Benign Colonic Obstruction. ACG Case Rep J 2014; 1:206-8. [PMID: 26157878 PMCID: PMC4435329 DOI: 10.14309/crj.2014.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 03/21/2014] [Indexed: 12/29/2022] Open
Abstract
Self-expanding metal stents (SEMS) have emerged as an alternative to surgery in the treatment of malignant colorectal obstructions. There is limited data about their use for benign colonic obstructions, especially in regards to safety and long-term patency. We present a case in which long-term SEMS placement proved to be a durable option for over 4 years in a patient with a benign colonic stricture.
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Jovani M, Genco C, Bravatà I, Repici A. Stents in the management of benign colorectal strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Rickles AS, Fleming FJ. Non-operative treatment of anastomotic leaks: Current and investigational therapies. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Currie A, Christmas C, Aldean H, Mobasheri M, Bloom ITM. Systematic review of self-expanding stents in the management of benign colorectal obstruction. Colorectal Dis 2014; 16:239-45. [PMID: 24033989 DOI: 10.1111/codi.12389] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 05/21/2013] [Indexed: 12/20/2022]
Abstract
AIM Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction. METHOD A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population. RESULTS The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis. CONCLUSION Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction.
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Affiliation(s)
- A Currie
- Department of Colorectal Surgery, Kingston Hospital, Kingston-upon-Thames, Surrey, UK
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Huang X, Lv B, Zhang S, Meng L. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg 2014; 18:584-91. [PMID: 24170606 DOI: 10.1007/s11605-013-2344-9] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 08/26/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this paper is to evaluate the efficacy and safety of colonic stenting as a bridge to surgery versus emergency surgery for acute left-sided malignant colonic obstruction. METHODS Randomized clinical trials (RCT) that compared the efficacy or safety of preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction were searched in medical databases, including PubMed, OVID, EMBASE, and the Cochrane Library. Statistical heterogeneity between trials was evaluated by Revman 5.1 and was considered to exist at I(2) > 50%. RESULTS Seven RCTs were identified. There was a total of 382 patients, 195 who received a colonic stent and 187 who received emergency surgery. Compared with the emergency surgery group, the colonic stent group achieved significantly more favorable rates of permanent stoma, primary anastomosis, wound infection, and overall complications. There was no significant difference between the two groups in anastomotic leakage, mortality, or intra-abdominal infection. Inspection of funnel plots for all outcome measures did not reveal evidence of publication bias. CONCLUSIONS Self-expanding metal stents serve as a safe and effective bridge to subsequent surgery in patients with obstructing left-sided colon cancer. They can significantly improve one-stage surgery rates, and decrease the rates of permanent stoma and wound infection.
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Affiliation(s)
- Xuan Huang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, 54 Youdian Road, Shangcheng District, Hangzhou City, 310006, Zhejiang Province, China
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Wong RF, Bhutani MS. Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies. Expert Rev Anticancer Ther 2014; 5:705-18. [PMID: 16111470 DOI: 10.1586/14737140.5.4.705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.
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Affiliation(s)
- Robert F Wong
- Division of Gastroenterology, Department of Internal Medicine, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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Abbott S, Eglinton TW, Ma Y, Stevenson C, Robertson GM, Frizelle FA. Predictors of outcome in palliative colonic stent placement for malignant obstruction. Br J Surg 2013; 101:121-6. [PMID: 24301218 DOI: 10.1002/bjs.9340] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment. METHODS Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment. RESULTS Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful. CONCLUSION SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.
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Affiliation(s)
- S Abbott
- Colorectal Unit, Christchurch Hospital, Christchurch, New Zealand
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Manta R, Magno L, Conigliaro R, Caruso A, Bertani H, Manno M, Zullo A, Frazzoni M, Bassotti G, Galloro G. Endoscopic repair of post-surgical gastrointestinal complications. Dig Liver Dis 2013; 45:879-85. [PMID: 23623147 DOI: 10.1016/j.dld.2013.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/28/2013] [Accepted: 03/09/2013] [Indexed: 12/11/2022]
Abstract
Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.
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Affiliation(s)
- Raffaele Manta
- Gastroenterology and Endoscopy Unit, New S. Agostino Hospital, Modena, Italy.
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Lujan HJ, Barbosa G, Zeichen MS, Mata WN, Maciel V, Plasencia G, Hartmann RF, Viamonte M, Fogel R. Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction. JSLS 2013; 17:204-11. [PMID: 23925013 PMCID: PMC3771786 DOI: 10.4293/108680813x13654754534990] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Self-expanding metallic stents are effective for the palliation of malignant obstruction. This study indicates that stents for bowel obstruction may allow for minimally invasive surgical intervention with a shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Background and Objectives: Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group's experience. Methods: We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up. Results: The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications. Discussion: The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.
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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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Choi JH, Lee YJ, Kim ES, Choi JH, Cho KB, Park KS, Jang BK, Chung WJ, Hwang JS. Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction. Surg Endosc 2013; 27:3220-7. [PMID: 23494513 DOI: 10.1007/s00464-013-2897-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 02/15/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications. METHODS Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy. RESULTS A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100% and the clinical success rate 94.1%. Overall complications were observed in 49 patients (32.2%) during the follow-up period (median, 98 days; interquartile range, 19-302 days). Obstruction (17.1%), migration (7.9%), perforation (5.2%), bleeding (1.3%), and tenesmus (0.7%) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan-Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group. CONCLUSIONS Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.
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Affiliation(s)
- Jae Hyuk Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, 194 Dong San-dong, Jung-gu, Daegu 700-712, South Korea
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Yoshida S, Watabe H, Isayama H, Kogure H, Nakai Y, Yamamoto N, Sasaki T, Kawakubo K, Hamada T, Ito Y, Yashima Y, Sasahira N, Hirano K, Yamaji Y, Tada M, Omata M, Koike K. Feasibility of a new self-expandable metallic stent for patients with malignant colorectal obstruction. Dig Endosc 2013; 25:160-6. [PMID: 23362948 DOI: 10.1111/j.1443-1661.2012.01353.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/01/2012] [Indexed: 12/16/2022]
Abstract
AIM Stent migration due to peristalsis of the colon is one of the unresolved complications of colonic self-expandable metallic stent (SEMS) placement. Axial force (AF), a recovery force of the stent to a straight position after bending, has been considered a factor influencing the conformability of the digestive tract. An uncovered SEMS (Niti-S Enteral Colonic Uncovered Stent, D-type; Taewoong, Inc., Gimpo, South Korea) with improved conformability is considered to decrease migration. METHODS Thirty three consecutive patients with symptomatic colorectal obstruction between March 2006 and December 2011 underwent endoscopic stent placement for palliation to estimate the efficacy and safety of Niti-S stents prospectively in four tertiary referral centers. RESULTS Technical and clinical success rates were 100% and 97%, respectively. Seventeen patients had the following complications: ingrowth (n = 6), overgrowth (n = 1), collapse of the SEMS (n = 1), stool impaction (n = 2), migration (n = 1), bleeding (n = 3), and tenesmus (n = 3). The patient with migration had no recurrent symptoms until death. Of these 17 patients, 10 required re-interventions. Seven patients underwent an additional SEMS implantation. One patient underwent surgery for stoma creation. Two patients had stool impaction, and they underwent endoscopic cleaning. The median duration of patency was 347.0 ± 65.5 days. The mean survival time after stent insertion was 240.1 ± 39.9 days. CONCLUSION The new SEMS effectively relieves malignant colorectal obstruction. Good conformability, according to the very low AF, may contribute to the low incidence of migration.
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Affiliation(s)
- Shuntaro Yoshida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
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Bonfante P, D'Ambra L, Berti S, Falco E, Cristoni MV, Briglia R. Managing acute colorectal obstruction by "bridge stenting" to laparoscopic surgery: Our experience. World J Gastrointest Surg 2012; 4:289-95. [PMID: 23493809 PMCID: PMC3596526 DOI: 10.4240/wjgs.v4.i12.289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 10/01/2012] [Accepted: 12/01/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To verify the clinical results of the endoscopic stenting procedure for colorectal obstructions followed by laparoscopic colorectal resection with “one stage anastomosis”.
METHODS: From March 2003 to March 2009 in our surgical department, 48 patients underwent endoscopic stenting for colorectal occlusive lesion: 30 males (62.5%) and 18 females (37.5%) with an age range from 40 years to 92 years (median age 69.5). All patients enrolled in our study were diagnosed with an intestinal obstruction originating from the colorectal tract without bowel perforation signs. Obstruction was primitive colorectal cancer in 45 cases (93.7%) and benign anastomotic stricture in 3 cases (6.3%).
RESULTS: Surgical resection was totally laparoscopic in 69% of cases (24 patients) while 17% (6 patients) of cases were video-assisted due to the local extension of cancer with infiltrations of surrounding structures (urinary bladder in 2 cases, ileus and iliac vessels in the others). In 14% of cases (5 patients), resection was performed by open surgery due to the high American Society of Anesthesiologists score and the elderly age of patients (median age of 89 years). We performed a terminal stomy in only 7 patients out of 35, 6 colostomies and one ileostomy (in a total colectomy). In the other 28 cases (80%), we performed bowel anastomosis at the same time as resection, employing a temporary ileostomy only in 5 cases.
CONCLUSION: Colorectal stenting transforms an emergency operation in to an elective operation performable in a totally laparoscopic manner, limiting the confection of colostomy with its correlated complications.
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Affiliation(s)
- Pierfrancesco Bonfante
- Pierfrancesco Bonfante, Luigi D'Ambra, Stefano Berti, Emilio Falco, Department of Surgery, S.Andrea Hospital of La Spezia, 19100 La Spezia, Italy
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Horiuchi A, Nakayama Y, Kajiyama M, Kamijima T, Kato N, Ichise Y, Tanaka N. Endoscopic decompression of benign large bowel obstruction using a transanal drainage tube. Colorectal Dis 2012; 14:623-7. [PMID: 21689313 DOI: 10.1111/j.1463-1318.2011.02624.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM Endoscopic decompression of malignant colorectal obstruction is often dealt with using expandable metallic stents. Endoscopic decompression of benign large bowel obstruction is more difficult. We report the technique and outcome of transanal endoscopic decompression for benign large bowel obstruction. METHOD From January 2001 to June 2010, endoscopic decompression using a transanal drainage tube placement was attempted in consecutive patients with benign large bowel obstruction. The clinical features, technical success, complications, treatment after the tube placement and clinical success were retrospectively evaluated. RESULTS There were 13 patients (seven males, age 47-87, mean 69 years). The sites of obstruction were transverse colon [5 (38%)], sigmoid colon [3 (23%)], ileocecal valve [2 (15%)], splenic flexure [1 (8%)], descending colon [1 (8%)] and rectum [1 (8%)]. The most common cause of obstruction was anastomotic stricture [9 (69%)]. In 12 (92%) patients transanal decompression was technically successful with one perforation. An overtube, the reinsertion of colonoscope along the decompression tube, or the use of a small-diameter endoscope was required for the tube placement in seven (54%). In seven (54%) patients tube placement alone resulted in relief of bowel obstruction without operation. CONCLUSION Endoscopic decompression using a transanal drainage tube is effective for the management of benign large bowel obstruction.
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Affiliation(s)
- A Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan.
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Stenting for colorectal cancer obstruction compared to surgery--a study of consecutive patients in a single institution. Int J Colorectal Dis 2012; 27:665-70. [PMID: 22124678 DOI: 10.1007/s00384-011-1374-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Colonic obstruction is a common complication to colorectal cancer and surgical treatment is associated with high morbidity and mortality. Stenting has emerged as an alternative to surgery. The aim of this study was to compare short-term morbidity, mortality and hospital stay between treatment with self-expandable metallic stent and emergency surgery performed at our department during a 5-year period in a non-randomized setting. METHODS Patients with colonic obstruction due to rectal or colon cancer referred to the Endoscopic Unit or Surgical Department for insertion of a colonic stent between 1 August 2003 and 1 August 2008 were prospectively registered and followed (n = 112). A control group was identified using the hospital records of operations with the International Classification Code-10 (ICD-10) for bowel obstruction and colorectal cancer (n = 60). Age, gender, indication, preoperative investigations, surgical procedure, complications and procedure-related mortality were registered. Patients were followed in accordance with local guidelines. RESULTS The complication rate was similar in the two groups, although there was a trend toward a higher number of severe complications in the surgical group. The hospital stay was significantly lower in the stent group, median of 4 vs. 9 days (p < 0.0001). The procedure-related mortality was lower in the stent group; 7% vs. 20% (p < 0.05). CONCLUSIONS Stenting can be safely performed with lower or similar complication rate and lower mortality rate compared to surgery and results in significantly shorter hospital stay. The results support stenting as the treatment of choice in patients with acute colonic obstruction, especially in disseminated disease.
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Chun YJ, Yoon NR, Park JM, Lim CH, Cho YK, Lee IS, Kim SW, Choi MG, Choi KY, Chung IS. Prospective assessment of risk of bacteremia following colorectal stent placement. Dig Dis Sci 2012; 57:1045-9. [PMID: 22057286 DOI: 10.1007/s10620-011-1962-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 10/20/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colorectal stent insertion is an invasive endoscopic procedure. However, there are no reports regarding the incidence of bacteremia with colorectal stent. OBJECTIVE This study was to evaluate the risk of bacteremia and infectious complications after stent insertion for colorectal obstruction. METHODS Patients who underwent colorectal stent insertion were enrolled consecutively. Blood cultures were obtained before colorectal stent insertion and at 30 min after the procedure. Patients were monitored for 48 h after colorectal stent insertion to detect the development of infectious complications. Procedural data collected included location of obstruction, degree of bowel preparation, obstructive symptoms, and the time required for the procedure. RESULTS Of 64 patients undergoing colorectal stent, four (6.3%) had a positive post-stent blood culture. All patients, including those with positive cultures, remained asymptomatic during the 48 h after the procedure. Site of obstruction, degree of bowel preparation, age, and underlying disease were not different between the two groups. Development of bacteremia was associated with long procedure time (p < 0.05). CONCLUSIONS Colorectal stent insertion does not induce significant bacteremia in patients with colorectal obstruction. These findings suggest that the routine use of prophylactic antibiotics may not be necessary in colorectal stent insertion.
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Affiliation(s)
- Yeon Joo Chun
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, #505, Banpo-dong, Seocho-gu, Seoul 137-701, Korea
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Qandeel H, Abudeeb H, Hammad A, Murch C, Mukherjee A. Colonic stent and percutaneous ethanol injection as a treatment for colocutaneous fistula secondary to benign stricture. J Surg Case Rep 2012; 2012:2. [PMID: 24960819 PMCID: PMC3649521 DOI: 10.1093/jscr/2012.4.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We report successful treatment of colocutanteous stulae at the site of a benign colonic anastomotic stricture using Self-Expandable Metal Stents (SEMS) and Percutaneous Ethanol Injection (PEI). The stricture and the secondary stulae developed after Hartmann's procedure for sigmoid diverticular abscess followed by reversal of the Hartmann's procedure with a de-functioning loop ileostomy. Although there have been previously reported cases of SEMS for closure of malignant colonic stula, there are limited reports of SEMS for closure of benign colonic stulae and none of SEMS combined with PEI for benign colonic fistula. We conclude that this patient's case exemplies the potential applications of SEMS combined with PEI as a feasible option of therapy for benign colorectal disease.
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Affiliation(s)
| | | | | | - C Murch
- Hairmyres Hospital, Glasgow, UK
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Levine RA, Wasvary H, Kadro O. Endoprosthetic management of refractory ileocolonic anastomotic strictures after resection for Crohn's disease: report of nine-year follow-up and review of the literature. Inflamm Bowel Dis 2012; 18:506-12. [PMID: 21542067 DOI: 10.1002/ibd.21739] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 03/21/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of endoluminal stenting in benign obstruction, especially for Crohn's disease (CD), is controversial, with limited data and widely disparate outcomes. The purpose of this study was to determine the long-term efficacy and safety of this technology in the treatment of fibrostenotic CD and to review the existing literature on this topic. METHODS We undertook a retrospective review of all patients undergoing endoluminal stenting for CD strictures at our institution from 2001 to 2010. Outcome measures included technical success, clinical improvement, duration of stent and luminal patency, and need for re-intervention. RESULTS Five patients underwent this procedure with a 100% rate of technical and an 80% rate of clinical success. Mean follow-up was 28 months (range 3 weeks to 109 months) and mean long-term luminal patency was 34.8 months (range 4.5-109 months). There was one complication involving reobstruction which required surgical intervention and no mortalities. CONCLUSIONS Endoluminal stenting of CD strictures is a safe and effective alternative to surgery which can provide lasting benefit in select patients. Further studies are necessary to clarify the full impact of this technology on long-term management of this complex disease.
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Affiliation(s)
- Rebecca A Levine
- Department of Colon & Rectal Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA.
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Kim SK, Lee CH, Lee MR, Kim JH. Multivariate Analysis of the Survival Rate for Treatment Modalities in Incurable Stage IV Colorectal Cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:35-41. [PMID: 22413080 PMCID: PMC3296940 DOI: 10.3393/jksc.2012.28.1.35] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 08/03/2011] [Accepted: 09/15/2011] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to compare survival in patients that underwent palliative resection treatment versus non-resection for incurable colorectal cancer (ICRC). METHODS The case records of 201 patients with ICRC between January 2000 and December 2009 were reviewed. Demographics, American Society of Anesthesiologists (ASA) score, carcinoembryonic antigen (CEA) level, the location of the colon cancer, histology, metastasis, treatment options and median survival were analyzed retrospectively. We divided the patients into four groups according to the treatment modalities: resection alone, resection with post-operative chemotherapy, non-resection treatment by chemotherapy alone, and stent or bypass. Median survival times were compared according to each treatment option, and the survival rates were analyzed. RESULTS 105 patients underwent palliative resection whereas 96 were treated with non-resection modalities. A palliative resection was performed in 44 cases for resection alone and in 61 cases for resection with post-operative chemotherapy. In patients treated with non-resection of the primary tumor, chemotherapy alone was done in 65 cases and stent or bypass in 31 cases. Multivariate analysis showed a median survival of 14 months in patients with palliative resections with post-operative chemotherapy, which was significantly higher than those for chemotherapy alone (8 months), primary tumor resection alone (5 months), and stent or bypass (5 months). Gender, age, ASA score, CEA level, the location of colon cancer, histology and the presence of multiple metastases were not independent factors in association with the median survival rate. CONCLUSION In the treatment of ICRC, palliative resection followed by post-operative chemotherapy shows the most favorable median survival compared to other treatment options.
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Affiliation(s)
- Sung Kang Kim
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Chang Ho Lee
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Min Ro Lee
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Jong Hun Kim
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
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Chou SQH, Song HY, Kim JH, Park JH, Fan Y, Lee H, Yoon YS, Kim JC. Dual-design expandable colorectal stent for a malignant colorectal obstruction: preliminary prospective study using new 20-mm diameter stents. Korean J Radiol 2011; 13:66-72. [PMID: 22247638 PMCID: PMC3253405 DOI: 10.3348/kjr.2012.13.1.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 09/01/2011] [Indexed: 12/30/2022] Open
Abstract
Objective To evaluate the safety and effectiveness of a 20-mm diameter dual-design expandable colorectal stent for malignant colorectal obstruction. Materials and Methods The study series included 34 patients with malignant colorectal obstruction who underwent implantation of a 20-mm dual-design expandable colorectal stent in our department between March 2009 and June 2010. The 20-mm dual-design expandable colorectal stent was placed by using a 3.8-mm delivery system that had 28-mm diameter proximal and distal ends. Among the 34 patients, stent placement for palliation was performed in 20 patients, while stent placement for bridge to surgery was performed in 14 patients. Results A 97% (33 of 34) success rate was achieved for the stent placement. The perforation rate in the bridge to surgery group was 7% (1 of 14), compared to 0% (0 of 19) in palliative group. Migration occurred in one of 33 patients (3%) at 30 days after stent placement. Conclusion The placement of a 20-mm diameter dual-design stent appears to be clinically safe and effective for the management of colorectal obstruction, with low perforation and migration rates.
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Affiliation(s)
- Sandas Qi Hua Chou
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
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West M, Kiff R. Stenting of the colon in patients with malignant large bowel obstruction: a local experience. J Gastrointest Cancer 2011; 42:155-9. [PMID: 20596900 DOI: 10.1007/s12029-010-9178-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE There is an increasing evidence base to support the use of self-expanding metallic gastrointestinal stents. In patients with colorectal cancer, they are used as a bridge to surgery and for palliation. The purposes of this study are to assess technical success, clinical outcome, complication rate and patency following colonic stent insertion in patients with colonic cancer at a local level and to compare our results with the current evidence base. METHODS A retrospective, two-centre study was conducted. Twenty-seven patients were included over a 5-year period. Six patients had undergone stent insertion as a bridge to surgery, and 21 had the procedure for palliation. RESULTS Initial technical success was achieved in 26 of 27 patients (96%). Of these 26 patients, clinical success was achieved in 24 patients (92%). Five patients (21%) suffered from stent re-occlusion, and one patient (4%) suffered from stent migration. There was one case (4%) of procedure-related perforation. Of the 19 palliative patients in whom clinical success was achieved, 17 (89%) were alive at 30 days, 13 (68%) at 90 (53%) days and 10 at 180 days. Average stent patency was 195 days. CONCLUSION WallFlex® self-expanding metallic gastrointestinal stents are a safe and effective means of alleviating obstructive symptoms in patients with colonic cancer requiring palliative treatment or as a bridge to surgery. Our data suggest that although a small percentage of patients are affected by stent re-occlusion, this does not contribute to premature mortality. They improve quality of life in palliative care patients as well as reducing premature morbidity and mortality caused by emergency surgery.
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Affiliation(s)
- Malcolm West
- Department of General Surgery, St. Helens and Knowsley Teaching Hospitals, Whiston Hospital NHS Trust, Warrington Rd, Whiston, Prescot L35 5DR, UK.
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Guo MG, Feng Y, Zheng Q, Di JZ, Wang Y, Fan YB, Huang XY. Comparison of self-expanding metal stents and urgent surgery for left-sided malignant colonic obstruction in elderly patients. Dig Dis Sci 2011; 56:2706-10. [PMID: 21442324 DOI: 10.1007/s10620-011-1648-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 02/14/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute left-sided malignant colonic obstruction is common in elderly patients and multiple treatment options exist. To date, the use of self-expanding metallic stents (SEMS) in elderly patients has not been adequately described. AIMS The purpose of this study was to compare mortality, avoidance of stoma, and short-term survival in elderly patients with malignant bowel obstruction treated with either colonic stenting or surgery. METHODS In this retrospective review, elderly patients with acute left-sided colonic obstruction cancer underwent either insertion of a SEMS (n = 34) or primary surgery (n = 58). The two groups were compared for clinic variables, surgical procedures and outcome, acute mortality, and complications. RESULTS Both groups were similar in terms of age, sex, tumor distribution, ASA grade, and comorbidities. The SEMS were successful placed in 91% of patients,and surgery was effective in relieving obstruction in 100% of the patients. Primary anastomosis was 79% in the SEMS group compared to 47% in the primary surgery group (P = 0.002). Secondary reanastomosis was 31% in the primary surgery group but only 3% in the SEMS surgery group (P = 0.001). Patients in the SEMS group had less 30-day mortality compared to the primary surgery group (3% vs. 19%, P = 0.03). Postoperative complications were similar. CONCLUSIONS In elderly patients with acute left-sided colonic obstruction cancer due to colorectal cancer, SEMS provide an effective and safe therapeutic option compared to emergent surgery.
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Affiliation(s)
- Ming-Gao Guo
- Department of Surgery, The Six People Hospital of Shanghai, Shanghai Jiaotong University, 200233 Shanghai, China
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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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Lepsenyi M, Santen S, Syk I, Nielsen J, Nemeth A, Toth E, Thorlacius H. Self-expanding metal stents in malignant colonic obstruction: experiences from Sweden. BMC Res Notes 2011; 4:274. [PMID: 21801447 PMCID: PMC3163214 DOI: 10.1186/1756-0500-4-274] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 07/30/2011] [Indexed: 01/17/2023] Open
Affiliation(s)
- Mattias Lepsenyi
- Department of Surgery, Skane University Hospital Malmö, Lund University, S-20502 Malmö, Sweden.
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