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Chen XQ, Xue CR, Hou P, Lin BQ, Zhang JR. Lymphocyte-to-monocyte ratio effectively predicts survival outcome of patients with obstructive colorectal cancer. World J Gastroenterol 2019; 25:4970-4984. [PMID: 31543687 PMCID: PMC6737316 DOI: 10.3748/wjg.v25.i33.4970] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/09/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obstructive colorectal cancer (OCC) is always accompanied by severe complications, and the optimal strategy for patients with OCC remains undetermined. Different from emergency surgery (ES), self-expandable metal stents (SEMS) as a bridge to surgery (BTS), could increase the likelihood of primary anastomosis. However, the stent failure and related complications might give rise to a high recurrence rate. Few studies have focused on the indications for either method, and the relationship between preoperative inflammation indexes and the prognosis of OCC is still underestimated.
AIM To explore the indications for ES and BTS in OCCs based on preoperative inflammation indexes.
METHODS One hundred and twenty-eight patients who underwent ES or BTS from 2008 to 2015 were enrolled. Receiver operating characteristic (ROC) curve analysis was used to define the optimal preoperative inflammation index and its cutoff point. Kaplan–Meier analyses and Cox proportional hazards models were applied to assess the association between the preoperative inflammation indexes and the survival outcomes [overall survival (OS) and disease-free survival (DFS)]. Stratification analysis was performed to identify the subgroups that would benefit from ES or BTS.
RESULTS OS and DFS were comparable between the ES and BTS groups (P > 0.05). ROC curve analysis showed derived neutrophil-to-lymphocyte ratio (dNLR) as the optimal biomarker for the prediction of DFS in ES (P < 0.05). Lymphocyte-to-monocyte ratio (LMR) was recommended for BTS with regard to OS and DFS (P < 0.05). dNLR was related to stoma construction (P = 0.001), pneumonia (P = 0.054), and DFS (P = 0.009) in ES. LMR was closely related to lymph node invasion (LVI) (P = 0.009), OS (P = 0.020), and DFS (P = 0.046) in the BTS group. dNLR was an independent risk factor for ES in both OS (P = 0.032) and DFS (P = 0.016). LMR affected OS (P = 0.053) and DFS (P = 0.052) in the BTS group. LMR could differentiate the OS between the ES and BTS groups (P < 0.05).
CONCLUSION Preoperative dNLR and LMR could predict OS and DFS in patients undergoing ES and BTS, respectively. For OCC, as the potential benefit group, patients with a low LMR might be preferred for BTS via SEMS insertion.
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Affiliation(s)
- Xian-Qiang Chen
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Chao-Rong Xue
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Ping Hou
- Immunotherapy Institute, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Bing-Qiang Lin
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jun-Rong Zhang
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
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Do Self-Expanding Metal Stents as a Bridge to Surgery Benefit All Patients with Obstructive Left-Side Colorectal Cancers? Gastroenterol Res Pract 2019; 2019:7418348. [PMID: 30863441 PMCID: PMC6377959 DOI: 10.1155/2019/7418348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/09/2018] [Indexed: 01/26/2023] Open
Abstract
Background Self-expanding metal stents (SEMS) have been increasingly used in patients with obstructive left-sided colorectal cancer (OLCC); however, stent-specific complications (e.g., perforations) might worsen the long-term survival outcome. Strict indication needed to be identified to confirm the benefit subgroups. This study was designed to explore the indication for emergency surgery (ES) and SEMS in patients with OLCC and to suggest optimal strategies for individuals. Methods After propensity score matching, 36 pairs were included. Perioperative and long-term survival outcomes (3-year overall survival (OS) and 3-year disease-free survival (DFS)) were compared between the ES and SEMS groups. Independent risk factors were evaluated among subgroups. Stratification survival analysis was performed to identify subgroups that would benefit from SEMS placement or ES. Results The perioperative outcomes were similar between the SEMS and ES groups. The 3-year OS was comparable between the SEMS (73.5%) and ES (60.0%) groups, and the 3-year DFS in the SEMS group (69.7%) was similar to that in the ES group (57.1%). The pT stage was an independent risk factor for 3-year DFS (p = 0.014) and 3-year OS (p = 0.010) in the SEMS group. The comorbidity status (p = 0.049) independently affected 3-year DFS in the ES group. The 3-year OS rate was influenced by the cM stage (p = 0.003). Patients with non-pT4 stages in the SEMS group showed obviously better 3-year OS (95.0%) than the other subgroups. The 3-year OS rate was 36.4% in the ES group when patients had a worse comorbidity status than their counterparts. Conclusion SEMS might be preferred for patients of obstructive left-sided colorectal cancer in the "high-operative risk group" with existing comorbidities or those without locally advanced invasion, such as the non-pT4-stage status.
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Crespí-Mir A, Romero-Marcos JM, de la Llave-Serralvo A, Dolz-Abadía C, Cifuentes-Ródenas JA. Impact on surgical and oncological results of the use of colonic stents as a bridge to surgery for potentially curable occlusive colorectal neoplasms. Cir Esp 2018; 96:419-428. [PMID: 29669684 DOI: 10.1016/j.ciresp.2018.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/08/2018] [Accepted: 03/12/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The outcomes of patients treated with colonic stents as a bridge to surgery (BTS) have recently been questioned in terms of safety and long-term oncologic outcomes. The aim of this study is to evaluate the effects on surgical and oncologic outcomes of colonic stents as a BTS for potentially resectable obstructive colorectal cancer. METHODS We conducted a retrospective analysis of patients operated on for potentially resectable obstructive colorectal cancer with or without distant disease between September 2002 and October 2015, comparing the patients treated with a colonic stent as a BTS (Stent group) with those directly operated on (Surgery group). RESULTS Twenty patients underwent urgent surgery, while stent placement as a BTS was attempted in 57 patients. The Stent group had more patients treated with a laparoscopic approach (64.9 vs. 5%, P<.001), higher primary anastomosis rate (91.2 vs. 55%, P=.001), less need for stomata (10.5 vs. 50%, P=.001) and shorter postoperative hospital stay (7 vs. 12 days, P=.014). Thirty-day morbidity was reduced in the Stent group, although not significantly (29.8 vs. 50%, P=.104). However, 30-day mortality was significantly lower (1.8 vs. 20%, P=.015). Regarding the long-term oncologic outcomes, no significant differences were found when comparing overall survival, disease-free survival, local recurrence-free survival, distant recurrence-free survival or progression-free survival. CONCLUSIONS Colonic stenting as a BTS for potentially resectable obstructive colorectal cancer seems to offer better surgical and equal long-term oncologic outcomes when compared to those of patients directly operated on.
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Affiliation(s)
- Antònia Crespí-Mir
- Servicio de Cirugía General, Hospital Son Llàtzer, Palma de Mallorca, España
| | | | | | - Carlos Dolz-Abadía
- Servicio de Gastroenterología, Hospital Son Llàtzer, Palma de Mallorca, España
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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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Abstract
Acute malignant colorectal obstruction (AMCO) is an emergency associated with colorectal cancer (CRC). Emergency surgery is standard therapy for AMCO, and 1-stage surgery without colostomy is preferable, but it is occasionally difficult in the emergency setting. A self-expandable metallic stent (SEMS) enables noninvasive colonic decompression and subsequent 1-stage surgery, which has been widely applied for CRC with AMCO. However, recent accumulation of high-quality evidence has highlighted some problems and the limited efficacy of SEMS for AMCO. In palliative settings, SEMS placement reduces hospital stay and short-term complication rates, whereas it increases the frequency of long-term complications, such as delayed perforation. SEMS placement does not seem compatible with recent standard chemotherapy including bevacizumab. As a bridge to surgery, while SEMS placement provides a lower clinical success rate than emergency surgery, it can facilitate primary anastomosis without stoma. However, evidence regarding long-term survival outcomes with SEMS in both palliative and bridge to surgery settings is lacking. The efficacy of transanal colorectal tube placement, another endoscopic treatment, has been reported, but its clinical evidence level is low due to the limited number of studies. This review article comprehensively summarizes the current knowledge about surgical and endoscopic management of CRC with AMCO.
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Suárez J, Jimenez-Pérez J. Long-term outcomes after stenting as a “bridge to surgery” for the management of acute obstruction secondary to colorectal cancer. World J Gastrointest Oncol 2016; 8:105-112. [PMID: 26798441 PMCID: PMC4714139 DOI: 10.4251/wjgo.v8.i1.105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 11/04/2015] [Indexed: 02/05/2023] Open
Abstract
Obstructive symptoms are present in 8% of cases at the time of initial diagnosis in cases of colorectal cancer. Emergency surgery has been classically considered the treatment of choice in these patients. However, in the majority of studies, emergency colorectal surgery is burdened with higher morbidity and mortality rates than elective surgery, and many patients require temporal colostomy which deteriorates their quality of life and becomes permanent in 10%-40% of cases. The aim of stenting by-pass to surgery is to transform emergency surgery into elective surgery in order to improve surgical results, obtain an accurate tumoral staging and detection of synchronous lesions, stabilization of comorbidities and performance of laparoscopic surgery. Immediate results were more favourable in patients who were stented concerning primary anastomosis, permanent stoma, wound infection and overall morbidity, having the higher surgical risk patients the greater benefit. However, some findings laid out the possible implication of stenting in long-term results of oncologic treatment. Perforation after stenting is related to tumoral recurrence. In studies with perforation rates above 8%, higher recurrences rates in young patients and lower disease free survival have been shown. On the other hand, after stenting the number of removed lymph nodes in the surgical specimen is larger, patients can receive adjuvant chemotherapy earlier and in a greater percentage and the number of patients who can be surgically treated with laparoscopic surgery is larger. Finally, there are no consistent studies able to demonstrate that one strategy is superior to the other in terms of oncologic benefits. At present, it would seem wise to assume a higher initial complication rate in young patients without relevant comorbidities and to accept the risk of local recurrence in old patients (> 70 years) or with high surgical risk (ASA III/IV).
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Tanis PJ, Paulino Pereira NR, van Hooft JE, Consten ECJ, Bemelman WA. Resection of Obstructive Left-Sided Colon Cancer at a National Level: A Prospective Analysis of Short-Term Outcomes in 1,816 Patients. Dig Surg 2015; 32:317-24. [PMID: 26159388 DOI: 10.1159/000433561] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 05/20/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS The prematurely closed Stent-In II trial in patients with left-sided obstructive colon cancer may have influenced clinical decision making in The Netherlands. The aim of this study was to evaluate treatment of left-sided malignant colon obstruction at a population level since then. METHODS Short-term outcomes of all patients who underwent resection for left-sided obstructive colon cancer between 2009 and 2012 were assessed based on a prospective national registry. RESULTS In total, 1,816 evaluable patients were included; acute resection was performed in 1,485 (81.8%), and endoscopic stent or decompressing stoma followed by resection in 196 (10.8%) and 135 (7.4%), respectively. The use of endoscopic stenting significantly decreased from 18% (2009) to 6% (2012). Overall 30-day or in-hospital mortality rate was 6.9, 5.6, and 3.7%, respectively (p = 0.107). Mortality rate after acute resection was 2.9% in patients <70 [corrected] years, but mortality rates up to 32.2% were observed in high-risk elderly patients. CONCLUSION Acute resection as first choice treatment seems justified for patients <70 [corrected] years of age given a mortality rate of 3%. For the elderly frail patients, mortality rates over 30% after acute resection stress the need for alternative treatment strategies.
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Affiliation(s)
- Pieter J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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ARE POLICY DECISIONS ON SURGICAL PROCEDURES INFORMED BY ROBUST ECONOMIC EVIDENCE? A SYSTEMATIC REVIEW. Int J Technol Assess Health Care 2014; 30:381-93. [DOI: 10.1017/s0266462314000531] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives: The aim of this study was to examine the empirical and methodological cost-effectiveness evidence of surgical interventions for breast, colorectal, or prostate cancer.Methods: A systematic search of seven databases including MEDLINE, EMBASE, and NHSEED, research registers, the NICE Web site and conference proceedings was conducted in April 2012. Study quality was assessed in terms of meeting essential, preferred and UK NICE specific requirements for economic evaluations.Results: The seventeen (breast = 3, colorectal = 7, prostate = 7) included studies covered a broad range of settings (nine European; eight non-European) and six were published over 10 years ago. The populations, interventions and comparators were generally well defined. Very few studies were informed by literature reviews and few used synthesized clinical evidence. Although the interventions had potential differential effects on recurrence and mortality rates, some studies used relatively short time horizons. Univariate sensitivity analyses were reported in all studies but less than a third characterized all uncertainty with a probabilistic sensitivity analysis. Although a third of studies incorporated patients’ health-related quality of life data, only four studies used social tariff values.Conclusions: There is a dearth of recent robust evidence describing the cost-effectiveness of surgical interventions in the management of breast, colorectal and prostate cancers. Many of the recent publications did not satisfy essential methodological requirements such as using clinical evidence informed by a systematic review and synthesis. Given the ratio of potential benefit and harms associated with cancer surgery and the volume of resources consumed by these, there is an urgent need to increase economic evaluations of these technologies.
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van Hooft JE, van Halsema EE, Vanbiervliet G, Beets-Tan RGH, DeWitt JM, Donnellan F, Dumonceau JM, Glynne-Jones RGT, Hassan C, Jiménez-Perez J, Meisner S, Muthusamy VR, Parker MC, Regimbeau JM, Sabbagh C, Sagar J, Tanis PJ, Vandervoort J, Webster GJ, Manes G, Barthet MA, Repici A. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Gastrointest Endosc 2014; 80:747-61.e1-75. [PMID: 25436393 DOI: 10.1016/j.gie.2014.09.018] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Emo E van Halsema
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Fergal Donnellan
- UBC Division of Gastroenterology, Vancouver General Hospital, Vancouver, Canada
| | | | | | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Javier Jiménez-Perez
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Søren Meisner
- Endoscopy Unit, Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, Denmark
| | - V Raman Muthusamy
- Division of Gastroenterology and Hepatology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | | | - Jean-Marc Regimbeau
- Department of Digestive and Oncological Surgery, University Hospital of Amiens, France
| | - Charles Sabbagh
- Department of Digestive and Oncological Surgery, University Hospital of Amiens, France
| | - Jayesh Sagar
- Department of Colorectal Surgery, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jo Vandervoort
- Department of Gastroenterology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - George J Webster
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Gianpiero Manes
- Department of Gastroenterology and Endoscopy, Guido Salvini Hospital, Garbagnate Milanese/Rho, Milan, Italy
| | - Marc A Barthet
- Department of Gastroenterology, Hôpital Nord, Aix Marseille Université, Marseille, France
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Sloothaak DAM, van den Berg MW, Dijkgraaf MGW, Fockens P, Tanis PJ, van Hooft JE, Bemelman WA. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg 2014; 101:1751-7. [PMID: 25298250 DOI: 10.1002/bjs.9645] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/02/2014] [Accepted: 08/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Stent-In 2 trial randomized patients with malignant colonic obstruction to emergency surgery or stent placement as a bridge to elective surgery. The aim of this study was to compare the oncological outcomes. METHODS Disease recurrence, and disease-free, disease-specific and overall survival were evaluated, including a subgroup analysis of patients with a stent- or guidewire-related perforation. RESULTS Of 98 patients included in the original Stent-In 2 trial, patients with benign (16) or incurable (23) disease were excluded from this study, along with a patient who had withdrawn from the trial. Of the remaining 58 patients, 32 were randomized to emergency surgery (31 resection, 1 stoma only) and 26 to stenting. Unsuccessful stenting required emergency surgery in six patients owing to wire or stent perforation. Locoregional or distant disease recurrence developed in nine of 32 patients in the emergency surgery group and 13 of 26 in the stent group. Disease-free survival was worse in the subgroup with stent- or guidewire-related perforation. Five of six patients in this subgroup developed a recurrence, compared with nine of 32 in the emergency surgery group and eight of 20 who had unperforated stenting. CONCLUSION Stent placement for malignant colonic obstruction was associated with a risk of recurrence in this trial, but the numbers are small. There is not enough evidence to refute the approach strongly. REGISTRATION NUMBER ISRCTN46462267 ( http://www.controlled-trials.com).
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Affiliation(s)
- D A M Sloothaak
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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van de Velde CJH, Boelens PG, Tanis PJ, Espin E, Mroczkowski P, Naredi P, Pahlman L, Ortiz H, Rutten HJ, Breugom AJ, Smith JJ, Wibe A, Wiggers T, Valentini V. Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery. Eur J Surg Oncol 2013; 40:454-68. [PMID: 24268926 DOI: 10.1016/j.ejso.2013.10.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/23/2013] [Indexed: 12/12/2022] Open
Abstract
The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?
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Affiliation(s)
- C J H van de Velde
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - P G Boelens
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - P J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E Espin
- Colorectal Surgery Unit, Hospital Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - P Mroczkowski
- Department of General, Visceral and Vascular Surgery/An-Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke University of Magdeburg, Germany
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Pahlman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - H Ortiz
- Department of Surgery, Public University of Navarra, Spain
| | - H J Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - A J Breugom
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - J J Smith
- Department of Colorectal Surgery, West Middlesex University Hospital, Isleworth, UK
| | - A Wibe
- Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - T Wiggers
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - V Valentini
- Unviersita Cattolica S. Cuore, Radioterapia 1, Largo A. Gemelli, 8, 00168 Rome, Italy
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Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: A systematic review and meta-analysis. Surg Oncol 2013. [DOI: 10.1016/j.suronc.2012.10.003] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
<b><i>Hintergrund: </i></b>Die Implantation von selbstexpandierenden Metallstents (SEMS) in das Kolorektum – insbesondere als «bridge to surgery» – hat sich zunehmend etabliert, obwohl die Charakteristika des Kolons eine Prothesenimplantation erschweren und bisher noch keine optimalen Stents für diese Lokalisation verfügbar sind. Mit einem Stent lässt sich beim Kolonileus sehr patientenschonend eine sofortige Dekompression des Darms herbeiführen und die sonst notwendige Notfalloperation mit hoher Letalität und Komplikationsrate vermeiden. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Trotz zahlreicher positiver Studienergebnisse («... Stenting ist sehr effektiv, sicher und komplikationsarm im Vergleich zur Operation ...») ergibt eine kritische Analyse der Publikationen aufgrund vieler Faktoren (Patientenselektion, Stenttyp, Implantationsmethode usw.) jedoch eine hohe Heterogenität. <b><i>Schlussfolgerungen: </i></b>Um gute Resultate zu erzielen, sollte eine Stentimplantation ins Kolon nur nach strenger Indikationsstellung von einem erfahrenen Endoskopiker durchgeführt werden. Dabei ist auch die mögliche Alternative einer endoskopisch eingelegten Dekompressionssonde zu prüfen; ebenso sind onkologische Gesichtspunkte (chirurgische Resektion als einziger kurativer Ansatz) zu beachten.
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Varadarajulu S, Roy A, Lopes T, Drelichman ER, Kim M. Endoscopic stenting versus surgical colostomy for the management of malignant colonic obstruction: comparison of hospital costs and clinical outcomes. Surg Endosc 2011; 25:2203-9. [PMID: 21293882 PMCID: PMC3116133 DOI: 10.1007/s00464-010-1523-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Accepted: 11/27/2010] [Indexed: 01/20/2023]
Abstract
Background Although stent placement is increasingly performed, colostomy still is considered the gold standard for emergent relief of malignant colonic obstruction (MCO). This study aimed to compare hospital costs and clinical outcomes between patients undergoing colostomy and those undergoing stenting for the management of MCO. Methods A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) data set was conducted to identify inpatient hospitalizations for colostomy or stent placement for the treatment of colon cancer (2007–2008). The outcomes evaluated using MedPAR compared the total length of hospital stay (LOS) and the costs associated with both techniques. Because MedPAR is a claims data set that does not provide outcomes at a patient level, a single-institution retrospective case–control study was conducted in which each stent placement patient was matched with two colostomy patients during the same period. Outcome measures (institutional data) were used to compare rates of treatment success, postprocedure LOS, and reinterventions between the two cohorts. Results The MedPAR data evaluated 778 stent placements and 5,868 colostomy hospitalizations. There were no differences in gender, age distribution, or comorbidity between the two groups. Compared with colostomy, the median LOS (8 vs. 12 days; p < 0.0001) and the median cost ($15,071 vs. $24,695; p < 0.001) per claim were significantly less for stent placement. Stent placement was more commonly performed at urban versus rural hospitals (84% vs. 16%; p < 0.0001), teaching versus nonteaching hospitals (56% vs. 44%; p = 0.0058) and larger versus smaller institutions (mean bed capacity, 331 vs. 227; p < 0.0001). The institution data included 12 patients who underwent stent placement and 24 who underwent colostomy. Although both methods were technically successful, the median postprocedure LOS (2.17 vs. 10.58 days; p = 0.0004) and the rate of readmissions for complications (0% vs. 25%; p = 0.01) were significantly lower for stent placement. Conclusion Although the technical and clinical outcomes for colostomy and stent placement appear comparable, stent placement is less costly and associated with shorter LOS and fewer complications. Dissemination of stent placement beyond large teaching hospitals located in urban areas as a treatment for MCO is important given its implications for patient care and resource use. Electronic supplementary material The online version of this article (doi:10.1007/s00464-010-1523-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shyam Varadarajulu
- Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, JT 664, 1530-3rd Avenue S, Birmingham, AL 35294-0012, USA.
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Stenting of the Lower Gastrointestinal Tract: Current Status. Cardiovasc Intervent Radiol 2010; 34:462-73. [DOI: 10.1007/s00270-010-0005-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 09/13/2010] [Indexed: 02/07/2023]
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Harrison ME, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Cash BD, Fanelli RD, Fisher L, Fukami N, Gan SI, Ikenberry SO, Jain R, Khan K, Krinsky ML, Maple JT, Shen B, Van Guilder T, Baron TH, Dominitz JA. The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction. Gastrointest Endosc 2010; 71:669-79. [PMID: 20363408 DOI: 10.1016/j.gie.2009.11.027] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 11/13/2009] [Indexed: 02/06/2023]
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Aloia TA, Fahy BN. A decision analysis model predicts the optimal treatment pathway for patients with colorectal cancer and resectable synchronous liver metastases. Clin Colorectal Cancer 2008; 7:197-201. [PMID: 18621638 DOI: 10.3816/ccc.2008.n.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The estimated 2400 Americans who annually present with colorectal cancer and simultaneous resectable liver metastases encounter a wide array of surgical and medical treatment options. Because of the large number of possible treatment sequences and the absence of clinical trials comparing these various pathways, there is no consensus on the optimal therapeutic strategy. MATERIALS AND METHODS To address this issue, a decision-making model was developed incorporating all possible combinations of the following treatments: colorectal resection, hepatic resection, simultaneous colohepatic resection, and systemic chemotherapy. Transition probabilities associated with each treatment were determined by systematic review of the literature. Variations in complication rates based on the extent of hepatectomy (minor: 1-2 segments vs. major: > 2 segments) were factored into the model. Sensitivity analyses were performed to identify threshold values for study variables that altered the optimal treatment pathway. RESULTS After 10,000 simulated patient trials with no bias toward any one initial treatment (ie, current practice conditions), the global calculated 5-year survival rate was 21%. For simulated patients with moderate hepatic tumor burden, only treatment sequences that placed systemic therapy before major hepatectomy resulted in improved 5-year survival projections (38% vs. 29%; P = .001; odds ratio, 1.82). Initial treatment with simultaneous colohepatic resection was only favored when the operative mortality rate was adjusted to < 0.5%. CONCLUSION This detailed decision-making analysis predicts that the optimal treatment pathway for most patients with colorectal cancer and simultaneous resectable liver metastases is preoperative systemic therapy followed by colohepatectomy or 2-stage resection. In the era of improved systemic therapies, major hepatic resection should be deferred until local and systemic disease can been addressed.
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Affiliation(s)
- Thomas A Aloia
- Department of Surgery, The Methodist Hospital, Houston, TX 77030, USA.
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