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Lin W, Chok AY, Seow-En I, Tan EKW. Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes. Surg Endosc 2024:10.1007/s00464-024-10780-4. [PMID: 38503904 DOI: 10.1007/s00464-024-10780-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES). METHODS This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes. RESULTS Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed. Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence. Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55). Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence. CONCLUSIONS There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.
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Affiliation(s)
- Wenjie Lin
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Emile Kwong-Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
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2
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Nakagawa K, Ishibe A, Ohya H, Ozawa M, Suwa Y, Watanabe J, Suwa H, Den K, Mori K, Momiyama M, Goto K, Endo I. Effects of neoadjuvant chemotherapy for patients with obstructive colon cancer: A multicenter propensity score-matched analysis (YCOG2101). Ann Gastroenterol Surg 2024; 8:262-272. [PMID: 38455492 PMCID: PMC10914701 DOI: 10.1002/ags3.12736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/25/2023] [Accepted: 08/10/2023] [Indexed: 03/09/2024] Open
Abstract
Aim Obstructive colon cancer is locally advanced colon cancer with poor prognosis. However, the effect of neoadjuvant chemotherapy (NAC) on obstructive colon cancer remains unclear. Therefore, this study aimed to investigate the safety and efficacy of NAC in patients with obstructive colon cancer. Methods From January 2012 to December 2017, we collected patient data for clinical stage II/III obstructive colon cancer at seven Yokohama Clinical Oncology Group (YCOG) institutions. The long-term outcomes of the NAC and non-NAC groups were analyzed retrospectively after adjusting for patients' background characteristics using propensity score matching. Results Among the 202 eligible patients, propensity score matching extracted 51 patients each for the NAC and non-NAC groups. After matching, the groups showed no marked differences in the background factors. All the patients in the NAC group underwent diverting stoma construction. Nineteen patients (37.3%) experienced grade 3-4 adverse events during NAC. The incidence of postoperative complications was similar between groups. The 5-year progression-free survival rates were 75.8% in the NAC group and 63.0% in the non-NAC group (p = 0.22, log-rank test). The 5-year overall survival rates were 88.5% in the NAC group and 78.8% in the non-NAC group (p = 0.09, log-rank test). Conclusion Although NAC was feasible for obstructive colon cancer after diverting stoma construction, its effects on long-term outcomes could not be proven.
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Affiliation(s)
- Kazuya Nakagawa
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Atsushi Ishibe
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Hiroki Ohya
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Mayumi Ozawa
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Yusuke Suwa
- Department of Surgery, Gastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Jun Watanabe
- Department of Surgery, Gastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Hirokazu Suwa
- Department of SurgeryYokosuka Kyousai HospitalYokosukaJapan
| | - Kanechika Den
- Department of SurgeryYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Koichi Mori
- Department of SurgeryFujisawa City HospitalFujisawaJapan
| | | | - Koki Goto
- Department of SurgeryYokohama Medical CenterYokohamaJapan
| | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
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Paniagua García-Señoráns M, Sánchez Santos R, Cano Valderrama Ó, Vigorita V, de Castro Parga ML, Cea Pereira S, Rodríguez Fernández L, Moncada Iribarren E. Stent as bridge to surgery decreases postoperative complications without worsening oncological outcomes: retrospective unicentric cohort study and stent placement protocol. Surg Endosc 2023:10.1007/s00464-023-10091-0. [PMID: 37198409 DOI: 10.1007/s00464-023-10091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/19/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Even if the use of stent as bridge to surgery (BTS) for obstructive colon cancer was described long ago, there is still much controversy on their use. Patient recovery before surgery and colonic desobstruction are just some of the reasons to defend this management that can be found in several available articles. METHODS This is a single-center, retrospective cohort study, including patients with obstructive colon cancer treated between 2010 and 2020. The primary aim of this study is to compare medium-term oncological outcomes (overall survival, disease-free survival) between stent as BTS and ES groups. The secondary aims are to compare perioperative results (in terms of approach, morbidity and mortality, and rate of anastomosis/stomas) between both groups and, within the BTS group, analyze whether there are any factors that may influence oncological outcomes. RESULTS A total of 251 patients were included. Patients belonging to the BTS cohort presented a higher rate of laparoscopic approach, required less intensive care management, less reintervention, and less permanent stoma rate, when comparing with patients who underwent urgent surgery (US). There were not significant differences in terms of disease-free survival and overall survival between the two groups. Lymphovascular invasion negatively affected oncological results but was not related with stent placement. CONCLUSION The stent as a bridge to surgery is a good alternative to urgent surgery, which leads to a decrease in postoperative morbidity and mortality without significantly worsening oncological outcomes.
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Affiliation(s)
- Marta Paniagua García-Señoráns
- Colorrectal Surgery Unit, Álvaro Cunqueiro Hospital, Vigo, Spain.
- Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36312, Vigo, Spain.
| | | | | | | | | | - Sonia Cea Pereira
- Interventional Radiology Service, Álvaro Cunqueiro Hospital, Vigo, Spain
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4
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Hadaya J, Verma A, Sanaiha Y, Mabeza RM, Chen F, Benharash P. Preoperative stents for the treatment of obstructing left-sided colon cancer: a national analysis. Surg Endosc 2023; 37:1771-1780. [PMID: 36220989 PMCID: PMC10017588 DOI: 10.1007/s00464-022-09650-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 09/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Given the risks associated with urgent colectomy for large bowel obstruction, preoperative colonic stenting has been utilized for decompression and optimization prior to surgery. This study examined national trends in the use of colonic stenting as a bridge to resection for malignant large bowel obstruction and evaluated outcomes relative to immediate colectomy. METHODS Adults undergoing colonic stenting or colectomy for malignant, left/sigmoid large bowel obstruction were identified in the 2010-2016 Nationwide Readmissions Database. Patients were classified as immediate resection (IR) or delayed resection (DR) if undergoing colonic stenting prior to colectomy. Generalized linear models were used to evaluate the impact of resection strategy on ostomy creation, in-hospital mortality, and complications. RESULTS Among 9,706 patients, 9.7% underwent colonic stenting, which increased from 7.7 to 16.4% from 2010 to 2016 (p < 0.001). Compared to IR, the DR group was younger (63.9 vs 65.9 years, p = 0.04), had fewer comorbidities (Elixhauser Index 3.5 vs 3.9, p = 0.001), and was more commonly managed at high-volume centers (89.4% vs 68.1%, p < 0.001). Laparoscopic resections were more frequent among the DR group (33.1% vs 13.0%, p < 0.001), while ostomy rates were significantly lower (21.5% vs 53.0%, p < 0.001). After risk adjustment, colonic stenting was associated with reduced odds of ostomy creation (0.34, 95% confidence interval 0.24-0.46), but similar odds of mortality and complications. CONCLUSION Colonic stenting is increasingly utilized for malignant, left-sided bowel obstructions, and associated with lower ostomy rates but comparable clinical outcomes. These findings suggest the relative safety of colonic stenting for malignant large bowel obstruction when clinically appropriate.
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Affiliation(s)
- Joseph Hadaya
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arjun Verma
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yas Sanaiha
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Russyan Mark Mabeza
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Formosa Chen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Surgery, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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5
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Chok AY, Zhao Y, Lim HJ, Ng YYR, Tan EJKW. Stenting as a bridge to surgery in obstructing colon cancer: Long-term recurrence pattern and competing risk of mortality. World J Gastrointest Endosc 2023; 15:64-76. [PMID: 36925648 PMCID: PMC10011892 DOI: 10.4253/wjge.v15.i2.64] [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: 11/29/2022] [Revised: 12/28/2022] [Accepted: 01/10/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Stenting as a bridge to curative surgery (SBTS) for obstructing colon cancer (OCC) has been associated with possibly worse oncological outcomes.
AIM To evaluate the recurrence patterns, survival outcomes, and colorectal cancer (CRC)-specific death in patients undergoing SBTS for OCC.
METHODS Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined. Primary outcomes were recurrence patterns, overall survival (OS), cancer-specific survival (CSS), and CRC-specific death. OS and CSS were estimated using the Kaplan-Meier curves. Competing risk analysis with cumulative incidence function (CIF) was used to estimate CRC-specific mortality with other cause-specific death as a competing event. Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death. Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated.
RESULTS 28 patients (45.2%) developed metastases after a median period of 16 mo. Among the 18 patients with single-site metastases: Four had lung-only metastases (14.3%), four had liver-only metastases (14.3%), and 10 had peritoneum-only metastases (35.7%), while 10 patients had two or more sites of metastatic disease (35.7%). The peritoneum was the most prevalent (60.7%) site of metastatic involvement (17/28). The median follow-up duration was 46 mo. 26 (41.9%) of the 62 patients died, of which 16 (61.5%) were CRC-specific deaths and 10 (38.5%) were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%; 1-, 3-, and 5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mo was liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictive of CRC-specific death.
CONCLUSION The peritoneum was the most common metastatic site among patients undergoing SBTS. Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors of CRC-specific death.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
- Department of Group Analytics, Singapore Health Services, Singapore 168582, Singapore
| | - Hui Jun Lim
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Yvonne Ying Ru Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
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Binetti M, Lauro A, Tonini V. Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020. World J Clin Oncol 2022; 13:957-966. [PMID: 36618078 PMCID: PMC9813834 DOI: 10.5306/wjco.v13.i12.957] [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: 09/17/2022] [Revised: 10/31/2022] [Accepted: 12/06/2022] [Indexed: 12/19/2022] Open
Abstract
It has been found that 8%-29% of colorectal cancers are obstructive. The use of “stent as bridge to surgery” is one of the most debated topics in obstructive left-sided colorectal cancer management. The endoscopic placement of a self-expanding metallic stent as bridge to surgery (BTS) could turn an emergency surgery to an elective one, increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one. However, in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted. Therefore, despite the useful short-term outcomes related to BTS, the recent literature has focused on long-term outcomes investigating the disease-free survival, the recurrence rate and the overall survival. Due to discordant data, international guidelines are still conflicting, and the debate is still open. There is not agreement about using self-expanding metallic stent for BTS as the gold standard.
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Affiliation(s)
- Margherita Binetti
- Department of Medical and Surgical Sciences, University of Bologna, Alma mater Studiorum, Bologna 40138, Italy
| | - Augusto Lauro
- Department of Medical and Surgical Sciences, Sapienza University, Roma 324-00161, Italy
| | - Valeria Tonini
- Department of Medical and Surgical Sciences, University of Bologna, Alma mater Studiorum, Bologna 40138, Italy
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7
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Plá Sánchez P, Muñoz Rodríguez J, Bennazar Nin R, López Monclús J, Caselles A. Cecal pneumatosis: Is it a contraindication for an endoscopic self expandable stent placement in patients with obstructive colorectal carcinoma? Cir Esp 2022:S2173-5077(22)00200-9. [PMID: 35728763 DOI: 10.1016/j.cireng.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Pau Plá Sánchez
- General and Digestive Surgery Department, Puerta de Hierro - Majadahonda University Hospital, Spain.
| | - Joaquín Muñoz Rodríguez
- General and Digestive Surgery Department, Puerta de Hierro - Majadahonda University Hospital, Spain
| | - Rosaura Bennazar Nin
- General and Digestive Surgery Department, Puerta de Hierro - Majadahonda University Hospital, Spain
| | - Javier López Monclús
- General and Digestive Surgery Department, Puerta de Hierro - Majadahonda University Hospital, Spain
| | - Artés Caselles
- General and Digestive Surgery Department, Puerta de Hierro - Majadahonda University Hospital, Spain
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Degett TH, Christensen J, Dalton SO, Bossen K, Frederiksen K, Iversen LH, Gögenur I. Prediction of the postoperative 90-day mortality after acute colorectal cancer surgery: development and temporal validation of the ACORCA model. Int J Colorectal Dis 2021; 36:1873-1883. [PMID: 33982139 DOI: 10.1007/s00384-021-03950-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to develop and validate a model to predict 90-day mortality after acute colorectal cancer surgery. METHODS The model was developed in all patients undergoing acute colorectal cancer surgery in 2014-2016 and validated in a patient group operated in 2017 in Denmark. The outcome was 90-day mortality. Tested predictor variables were age, sex, performance status, BMI, smoking, alcohol, education level, cohabitation status, tumour localization and primary surgical procedure. Variables were selected according to the smallest Akaike information criterion. The model was shrunken by bootstrapping. Discrimination was evaluated with a receiver operated characteristic curve, calibration with a calibration slope and the accuracy with a Brier score. RESULTS A total of 1450 patients were included for development of the model and 451 patients for validation. The 90-day mortality rate was 19% and 20%, respectively. Age, performance status, alcohol, smoking and primary surgical procedure were the final variables included in the model. Discrimination (AUC = 0.79), calibration (slope = 1.04, intercept = 0.04) and accuracy (brier score = 0.13) were good in the developed model. In the temporal validation, discrimination (AUC = 0.80) and accuracy (brier score = 0.13) were good, and calibration was acceptable (slope = 1.19, intercept = 0.52). CONCLUSION We developed prediction model for 90-day mortality after acute colorectal cancer surgery that may be a promising tool for surgeons to identify patients at risk of postoperative mortality.
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Affiliation(s)
- Thea Helene Degett
- Center for Surgical Science (CSS), Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600, Koge, Denmark. .,Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Jane Christensen
- Statistics and Data analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Naestved, Denmark
| | | | - Kirsten Frederiksen
- Statistics and Data analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Lene Hjerrild Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science (CSS), Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600, Koge, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
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Inoue H, Arita T, Kuriu Y, Shimizu H, Kiuchi J, Yamamoto Y, Konishi H, Morimura R, Shiozaki A, Ikoma H, Kubota T, Fujiwara H, Okamoto K, Otsuji E. Emergency Management of Obstructive Colorectal Cancer - A Retrospective Study of Efficacy and Safety in Self-expanding Metallic Stents and Trans-anal Tubes. In Vivo 2021; 35:2289-2296. [PMID: 34182508 DOI: 10.21873/invivo.12502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/13/2021] [Accepted: 05/20/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIM The self-expanding metallic stent (SEMS) has recently been used for obstructive colorectal cancer (OCRC), and reports of its use are increasing. However, the long-term results of OCRC after using SEMS remain unclear. This study investigated the characteristics of SEMS compared to trans-anal tube (TAT) and clarified the long-term results and efficacy of SEMS for OCRC. PATIENTS AND METHODS We analyzed 48 patients who required SEMS or TAT for emergent decompression of OCRC and underwent resection for OCRC between 2007 and 2019. The perioperative factors and long-term results in the two groups were evaluated. RESULTS Patients with OCRC were divided into the SEMS (n=23) and the TAT group (n=25). No significant differences were seen in background factors, complications and the 5-year overall survival after surgery (p=0.3500) between the two groups. The clinical success of decompression (p=0.0072), oral intake (p<0.0001) and change in serum albumin (p<0.0001) from decompression to surgery were significantly better in the SEMS compares to the TAT group. CONCLUSION The long-term outcomes in the SEMS group were not significantly different than in the TAT group, and nutritional status was better in patients with SEMS, suggesting that SEMS is very effective and may be the first-line treatment of OCRC.
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Affiliation(s)
- Hiroyuki Inoue
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomohiro Arita
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshiaki Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroki Shimizu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jun Kiuchi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Yamamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirotaka Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Atsushi Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuma Okamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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10
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Zeng WG, Liu MJ, Zhou ZX, Hu JJ, Wang ZJ. Stent as a bridge to surgery versus urgent surgery for malignant right colonic obstruction: A multicenter retrospective study. ANZ J Surg 2021; 91:E500-E506. [PMID: 34013626 DOI: 10.1111/ans.16942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/15/2021] [Accepted: 05/01/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The impact of self-expandable metal stent (SEMS) for malignant right colonic obstruction remains undefined. The aim of this study was to compare short-term postoperative and long-term oncologic outcomes of colonic stenting as a bridge to surgery (SBTS) and urgent colectomy for patients with malignant right-sided obstruction. METHODS A total of 98 consecutive patients who underwent SEMS placement during the period 2004-2015 from three hospitals were included. For comparative analyses, patients were matched (1:2) with 196 patients treated with emergency colectomy from our prospective database. RESULTS The two groups were comparable in terms of demographics and tumor characteristics. The proportion of patients who underwent laparoscopic colectomy was higher in SBTS group than urgent colectomy group (75.5% vs. 37.2%; p < 0.001). Patients treated with SBTS were less likely to have a temporary stoma constructed (3.1% vs. 10.7%; p = 0.024). SBTS was associated with significantly less median estimated blood loss (90 vs. 100 ml; p = 0.029), shorter length of hospital stay (11 vs. 12 days; p < 0.001), lower overall postoperative complication rate (18.4% vs. 31.3%; p = 0.018), and wound-related complication rate (5.1% vs. 14.3%; p = 0.019) compared with urgent surgery. Reoperation rate, 30-day mortality, and lymph nodes harvested were not significantly different between two groups. Disease-free survival rate and overall survival rate were similar between the two groups. CONCLUSIONS SEMS insertion is safe and feasible for treating malignant right-sided obstruction. SBTS is associated with better short-term outcomes and equivalent long-term oncologic results compared with urgent colectomy.
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Affiliation(s)
- Wei-Gen Zeng
- Department of General Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Meng-Jia Liu
- Department of Ultrasound, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhi-Xiang Zhou
- Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jun-Jie Hu
- Department of Gastrointestinal Surgery, Hubei Cancer Hospital, Wuhan, China
| | - Zhen-Jun Wang
- Department of General Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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11
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Ueki T, Miyake T, Kojima M, Kaida S, Iida H, Shimizu T, Tani M. Comparison of self-expandable metallic stent placement followed by laparoscopic resection and elective laparoscopic surgery without stent placement for left-sided colon cancer. Ann Gastroenterol Surg 2021; 5:338-344. [PMID: 34095724 PMCID: PMC8164467 DOI: 10.1002/ags3.12422] [Citation(s) in RCA: 1] [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: 10/01/2020] [Revised: 11/14/2020] [Accepted: 12/14/2020] [Indexed: 01/10/2023] Open
Abstract
AIM Self-expandable metallic stent (SEMS) placement for obstructive colon cancer is widely performed as a bridge to surgery (BTS) procedure before resection. This study aimed to investigate the surgical and oncological results of laparoscopic elective surgery with or without SEMS placement to assess the efficacy of SEMS placement as a BTS. METHODS We retrospectively analyzed consecutive patients with stage II, III, and IV left-sided colon cancer who underwent elective laparoscopic resection between 2013 and 2019. All patients were divided into two groups: with and without SEMS placement. RESULTS The SEMS group included 24 patients, whereas the non-SEMS group included 86 patients. The serum hemoglobin and albumin levels were lower (P = .049, P = .03), and the serum leukocyte and C-reactive protein levels were higher (P < .0001, P = .022) in the SEMS group. The tumor diameter and tumor circumferential rate were higher in the SEMS group (both P < .0001). No significant differences were observed in operation time, blood loss, postoperative complications, or postoperative hospital stay. After 1:1 propensity score matching, 15 patients in the SEMS group were compared with 15 patients in the non-SEMS group. The 3-year overall survival rates of the SEMS and non-SEMS groups were 87.5% and 88.9%, respectively (P = .97). The 3-year recurrence-free survival rates of the SEMS and non-SEMS groups were 58.2% and 81.7%, respectively (P = .233). No significant difference was found in the sites of recurrence. CONCLUSION The perioperative and long-term outcomes of SEMS placement as a BTS before laparoscopic resection could be acceptable compared with other elective laparoscopic operations without SEMS placement.
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Affiliation(s)
- Tomoyuki Ueki
- Department of SurgeryShiga University of Medical ScienceShigaJapan
| | - Toru Miyake
- Department of SurgeryShiga University of Medical ScienceShigaJapan
| | - Masatsugu Kojima
- Department of SurgeryShiga University of Medical ScienceShigaJapan
| | - Sachiko Kaida
- Department of SurgeryShiga University of Medical ScienceShigaJapan
| | - Hiroya Iida
- Department of SurgeryShiga University of Medical ScienceShigaJapan
| | - Tomoharu Shimizu
- Department of SurgeryShiga University of Medical ScienceShigaJapan
| | - Masaji Tani
- Department of SurgeryShiga University of Medical ScienceShigaJapan
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Dolan PT, Abelson JS, Symer M, Nowels M, Sedrakyan A, Yeo HL. Colonic Stents as a Bridge to Surgery Compared with Immediate Resection in Patients with Malignant Large Bowel Obstruction in a NY State Database. J Gastrointest Surg 2021; 25:809-817. [PMID: 32939622 DOI: 10.1007/s11605-020-04790-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 09/06/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction. METHODS Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition. RESULTS A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups. DISCUSSION Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.
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Affiliation(s)
- Patrick T Dolan
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA
| | - Jonathan S Abelson
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA
| | - Matthew Symer
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA
| | - Molly Nowels
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY, USA
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY, USA
| | - Heather L Yeo
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA. .,Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY, USA.
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13
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Abstract
For the 8-29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation. More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used. Despite these attractive outcomes, the superiority of the BTS approach is not clearly established. Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis. For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches. This lack of consensus has spawned differing and sometimes discordant guidelines worldwide. In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic. We hope that these data will finally converge on a single set of recommendations supporting a management strategy with well-demonstrated superiority.
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14
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Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1439-1451. [PMID: 32572603 DOI: 10.1007/s00384-020-03664-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The placement of self-expandable metallic stents as a bridge to surgery in malignant colon obstruction is concerning due to the long-term oncological results reported in recent published studies. The aim of this study was to evaluate the oncological consequences of stent-related perforations in patients with malignant colon obstruction and potentially curable disease. METHODS MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed five meta-analyses to estimate the pooled effect sizes by using a random-effect model. The outcomes were global, locoregional and systemic recurrence rate and 3 and 5 year-survival rate depending on the presence or absence of stent-related perforation. RESULTS Thirteen studies (950 patients) were included. The overall rate of stent-related perforation was 8.9%. The global recurrence rate was significantly higher in stent-related perforation group (41.2 vs. 30.8%; OR 1.70; 95%CI: 1.02-2.84; p = 0.04). Locoregional recurrence rate was higher in the perforated group than in the non-perforated group (26.6 vs. 12.5%), with statistically significant differences (OR 2.41; 95% CI:1.33-4.34; p = 0.004). No significant differences were found in systemic recurrence rate (13.6 vs. 20.5%; OR 0.77; 95%CI: 0.35-1.7; p = 0.51); 3-year overall survival rate (65.4 vs. 74.8%; OR 0.63; 95% CI:0.29-1.39; p = 0.25) and 5-year overall survival rate (48.3 vs. 58.6%; OR 0.67; 95%CI: 0.27-1.65; p = 0.38). CONCLUSION Stent-related perforation is associated with an increased risk of global and locoregional recurrence. The successful placement of the stent as a bridge to surgery in the curative purpose of patients with obstructed colon cancer does not exclude the presence of underlying perforation, with the consequent danger of disease spread. PROSPERO registration number: CRD42020152817.
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15
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Niyozbekov BM, Rzaev TZ, Khalilov ZB, Chinikov MA. [Minimally invasive interventions in emergency large bowel surgery]. Khirurgiia (Mosk) 2020:109-113. [PMID: 32573541 DOI: 10.17116/hirurgia2020061109] [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: 11/17/2022]
Abstract
The current trends in the treatment of various surgical diseases of large bowel using minimally invasive operations are reviewed in the manuscript. It is shown that laparoscopy is currently possible in most cases for urgent large bowel diseases.
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Affiliation(s)
- B M Niyozbekov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - T Z Rzaev
- Peoples' Friendship University of Russia, Moscow, Russia
| | - Z B Khalilov
- Central Hospital of Baku, Baku, Republic of Azerbaijan
| | - M A Chinikov
- Peoples' Friendship University of Russia, Moscow, Russia
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16
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Fluoroscopic Stenting as a Bridge to Surgery versus Emergency Management for Malignant Obstruction of the Colon. Emerg Med Int 2020; 2020:4650780. [PMID: 32566301 PMCID: PMC7284933 DOI: 10.1155/2020/4650780] [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: 02/17/2020] [Revised: 04/18/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022] Open
Abstract
Aim To investigate the feasibility of a SEMS (self-expandable metallic stent) as a bridge to surgery for malignant colonic obstruction. Methods We retrospectively reviewed 83 patients that were in accordance with inclusion criteria; of these, 33 patients that underwent fluoroscopy-guided SEMS placement followed by elective curative resection were classified as a SEMS group and 50 patients, who received emergency surgery (ES), were classified as an ES group. The clinicopathological characteristics, surgery-related parameters, complications, and three-year survival rate were compared between the two groups. Results No significant differences between the two groups were observed in any of the clinicopathologic characteristics except for higher preoperative absolute neutrophil count in the ES group (P < 0.001). Compared to the ES group, the SEMS group has significantly more cases, which featured a laparoscopic approach (72.7% vs. 14.0%, P < 0.001), lower overall stoma rate (0% vs. 34.0%, P < 0.001), and lower overall postoperative morbidity (27.3% vs. 56.0%, P=0.010). The oncological outcomes did not differ significantly between the two groups in terms of three-year overall survival (P=0.125). The technical and clinical success rates of stent placement were 91.7% and 100%, respectively. Conclusion Patients treated with the stent-surgery approach had significant short-term superiorities and similar long-term outcomes, compared to patients who had emergency surgery alone. The SEMS is, therefore, safe and feasible as a bridge to surgery for malignant colonic obstruction.
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Han JG, Wang ZJ, Zeng WG, Wang YB, Wei GH, Zhai ZW, Zhao BC, Yi BQ. Efficacy and safety of self-expanding metallic stent placement followed by neoadjuvant chemotherapy and scheduled surgery for treatment of obstructing left-sided colonic cancer. BMC Cancer 2020; 20:57. [PMID: 31992260 PMCID: PMC6986080 DOI: 10.1186/s12885-020-6560-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/20/2020] [Indexed: 12/14/2022] Open
Abstract
Background This study aimed to evaluate the safety and feasibility of self-expanding metallic stent (SEMS) followed by neoadjuvant chemotherapy prior to elective surgery for obstructing left-sided colon cancer. Methods Eleven consecutive patients with obstructing left-sided colon cancer between May 2014 and November 2015 were included retrospectively. All patients received SEMS followed by neoadjuvant chemotherapy. The primary outcome measure was stoma and laparoscopic surgery. Results Chemotherapy was with two cycles of CAPOX (54.5%) or three cycles mFOLFOX6 (45.5%). Median serum albumin and hemoglobin levels before surgery were significantly higher than before neoadjuvant chemotherapy (p = 0.01 and p = 0.008 respectively) and before SEMS (p = 0.01 and p = 0.003 respectively). Median bowel wall thickness proximal to the upper edge of tumor was significantly more before neoadjuvant chemotherapy than before stent (p = 0.003), and significantly less before surgery than before neoadjuvant chemotherapy (p = 0.003). No patient underwent stoma creation. Laparoscopic surgery was performed in nine (81.8%) patients. No local recurrence or metastases developed over median cancer-specific follow-up of 44 months (range, 37–55 months). Conclusion SEMS followed by neoadjuvant chemotherapy prior to elective surgery appears to be safe and well tolerated in patients with obstructing left-sided colon cancer.
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Affiliation(s)
- Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Zhen Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Wei Gen Zeng
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Yan Bin Wang
- Department of Gastroenterology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Guang Hui Wei
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Zhi Wei Zhai
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Bao Cheng Zhao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Bing Qiang Yi
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 South Gongti Road, Chaoyang District, Beijing, 100020, People's Republic of China
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18
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Seo SY, Kim SW. Endoscopic Management of Malignant Colonic Obstruction. Clin Endosc 2020; 53:9-17. [PMID: 31906606 PMCID: PMC7003005 DOI: 10.5946/ce.2019.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.
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Affiliation(s)
- Seung Young Seo
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital and Medical School, Jeonju, Korea
| | - Sang Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital and Medical School, Jeonju, Korea
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Scomparin RC, Martins BC, Lenz L, Bento LH, Sparapam Marques C, Safatle-Ribeiro A, Ribeiro U, Nahas SC, Maluf-Filho F. Long-term survival analysis after endoscopic stenting as a bridge to surgery for malignant colorectal obstruction: comparison with emergency diverting colostomy. Clinics (Sao Paulo) 2020; 75:e2046. [PMID: 33206763 PMCID: PMC7603286 DOI: 10.6061/clinics/2020/e2046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The use of colorectal self-expanding metal stents (SEMS) as bridge therapy for malignant colorectal obstruction was first reported more than 20 years ago. However, its use remains controversial. In this study, we aimed to compare the long-term survival of patients with potentially resectable malignant colorectal obstruction who had undergone colorectal SEMS placement and emergency surgery. METHODS This study was a retrospective analyses. Patients who received treatment between 2009 and 2017 were included. According to the eligibility criteria, 21 patients were included in the SEMS group and 67 patients were included in the surgical group.. RESULTS The majority of the patients in the SEMS group were female (57.1%), whereas the majority of those in the surgical group were male (53.7%). The median follow-up time was 60 months for both groups with the same interquartile range of 60 months. There was no difference in the overall survival rate (log rank p=0.873) and disease-free survival rate (log rank p=0.2821) in the five-year analysis. There was no difference in local recurrence rates (38.1% vs. 22.4%, p=0.14) or distant recurrence rates (33.3% vs. 50.7%, p=0.16) in the SEMS and the surgical groups. Technical and clinical success rates of endoscopic stenting were 95.3% and 85.7%, respectively. There were no immediate adverse events (AEs). Severe AEs included perforation (14.3%), silent perforation (4.7%), reobstruction (14.3%), and bleeding (14.3%). Mild AEs included pain (42.8%), tenesmus (9.5%), and incontinence (4.76%). The limitations of this study was retrospective and was conducted at a single center. CONCLUSIONS No differences in disease-free and overall survival rates were observed in the five-year analysis of patients with resectable colorectal cancer who had undergone SEMS placement or colostomy for the treatment of malignant colorectal obstruction. Patients in the SEMS group had a higher rate of primary anastomosis and a lower rate of temporary colostomy than did those in the surgery group.
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Affiliation(s)
- Rodrigo Corsato Scomparin
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Bruno Costa Martins
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Luciano Lenz
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Luiza Haendchen Bento
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Carlos Sparapam Marques
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Adriana Safatle-Ribeiro
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Ulysses Ribeiro
- Divisao de Cirurgia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Sergio Carlos Nahas
- Divisao de Cirurgia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
| | - Fauze Maluf-Filho
- Divisao de Endoscopia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Universidade de Sao Paulo, SP, BR
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Ballestero Pérez A, García Pérez JC, Muriel A, Die Trill J, Lobo E. The long-term recurrence rate and survival of obstructive left-sided colon cancer patients: a stent as a bridge to surgery. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:718-725. [PMID: 30071736 DOI: 10.17235/reed.2018.5077/2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND a colonic stent as a bridge to elective surgery for left-sided malignant colonic obstruction is an alternative to the classical treatment. The aim of our study was to evaluate the recurrence rate as well as the morbidity and mortality of this treatment. PATIENTS AND METHODS patients admitted to the Emergency Department with left-sided malignant colonic obstruction between June 2006 and January 2014 were analyzed in a retrospective observational study. Patients who underwent self-expanding metallic stent placement via endoscopy as a bridge to surgery were included. The observation period was performed until May 2017. RESULTS fifty-three patients were treated with a colonic stent as a bridge to surgery; nine patients died during the postoperative period. The deceased patients were more frequently male (100% in the deceased vs 62% in the non-deceased, p = 0.02), with a more advanced age (81.4 ± 5.1 vs 71.6 ± 10.8, p < 0.001), lower hemoglobin levels on admission (12.9 vs 13.6 p < 0.001), a greater number of leukocytes (12,918 vs 9,437, p < 0.001) and greater coagulopathy (INR 1.6 vs 1, p < 0.001). Eight patients had a distant relapse with a median disease-free survival of 19.1 months. The variables were compared according to the appearance of distant disease and the mean age was lower in patients with a recurrence (65.9 ± 11.3 vs 74.9 ± 9.9, p < 0.001). CONCLUSIONS the results of the use of a stent as a bridge to curative surgery in patients with obstructive left colon cancer in our hospital is comparable to previous studies.
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Affiliation(s)
| | | | - Alfonso Muriel
- Servicio de Bioestadística Clínica, Hospital Universitario Ramón y Cajal
| | - Javier Die Trill
- Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, España
| | - Eduardo Lobo
- Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal
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21
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Ribeiro IB, de Moura DTH, Thompson CC, de Moura EGH. Acute abdominal obstruction: Colon stent or emergency surgery? An evidence-based review. World J Gastrointest Endosc 2019; 11:193-208. [PMID: 30918585 PMCID: PMC6425283 DOI: 10.4253/wjge.v11.i3.193] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/29/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
According to the American Cancer Society and Colorectal Cancer Statistics 2017, colorectal cancer (CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018. Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction (MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990s, self-expanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.
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Affiliation(s)
- Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
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Liu JJ, Ma TH, Qin QY, Wang L. Stent placement followed by preoperative chemotherapy and elective surgery for acute malignant colorectal obstruction: Six cases of report. World J Gastrointest Oncol 2019; 11:264-269. [PMID: 30918598 PMCID: PMC6425326 DOI: 10.4251/wjgo.v11.i3.264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/18/2018] [Accepted: 01/09/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The self-expandable metal stent is used as a bridge to surgery in the treatment of acute malignant colorectal obstruction (AMCO). However, recent studies have shown inferior long-term outcomes and increased risk of tumor dissemination after stent placement. In addition, the optimal interval between stent placement and surgery is not clear. The aim of the current study was to present a new strategy for AMCO: stent placement followed by preoperative chemotherapy and elective surgery.
CASE SUMMARY Six patients were diagnosed as acute obstruction. There was one patient with descending cancer, four with sigmoid cancers and one with rectal cancer. The obstructive symptoms of these six patients were relieved within 3 d after stent placement. After receiving two cycles of preoperative chemotherapy, consisting of modified infusional fluorouracil, leucovorin and oxaliplatin [modified FOLFOX6 (mFOLFOX6)], they underwent elective surgery of primary tumor resection. None of the 6 patients received colostomy or colonic lavage during surgery. There was no complication of anastomotic leak, ileus or surgical site infection after surgery. In addition, the patients had low operation time and blood loss, adequate lymph nodes harvest and fast postoperative recovery.
CONCLUSION The two-cycle mFOLFOX6 preoperative chemotherapy and elective surgery after stent placement is a safe and feasible strategy in the management of AMCO.
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Affiliation(s)
- Jun-Jie Liu
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Teng-Hui Ma
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Qi-Yuan Qin
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Lei Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
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Sato R, Oikawa M, Kakita T, Okada T, Oyama A, Abe T, Yazawa T, Tsuchiya H, Akazawa N, Ohira T, Harada Y, Tanaka M, Okano H, Ito K, Tsuchiya T. Comparison of the long-term outcomes of the self-expandable metallic stent and transanal decompression tube for obstructive colorectal cancer. Ann Gastroenterol Surg 2019; 3:209-216. [PMID: 30923791 PMCID: PMC6422834 DOI: 10.1002/ags3.12235] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/25/2018] [Accepted: 01/07/2019] [Indexed: 02/07/2023] Open
Abstract
AIM Endoscopic decompression using the self-expandable metallic colonic stent (SEMS) or transanal decompression tube (TDT) can convert emergency surgery into elective one-stage surgery for obstructive colorectal cancer (OCRC). The aim of the present study was to clarify the effect of SEMS and TDT on long-term oncological outcomes. METHODS We retrospectively analyzed 76 consecutive pathological stage II and III OCRC patients who were inserted with SEMS or TDT as a bridge to curative surgery between 2009 and 2018. RESULTS There were 53 SEMS cases and 23 TDT cases. The tumor was located in the left colon in 58 cases and in the right colon in 18 cases. The interval between the decompression and the surgery was 16.5 days in the SEMS group and 13.0 days in the TDT group (P = 0.09). Technical and clinical success rates were 100% and 100% for SEMS, and 95% and 91% for TDT, respectively. Stoma was created in four patients in the SEMS group, and in five in the TDT group (P = 0.08). Three-year overall survival rates of the SEMS and TDT groups were 82% and 86% (P = 0.94), and disease-free survival rates were 68% and 62% (P = 0.79), respectively. The recurrence pattern was not significantly different. CONCLUSION This study found no statistically significant differences between the effects of SEMS and TDT for OCRC as a bridge to surgery on long-term outcomes.
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Affiliation(s)
- Ryuichiro Sato
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Masaya Oikawa
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Tetsuya Kakita
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Takaho Okada
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Atsushi Oyama
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Tomoya Abe
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Takashi Yazawa
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Haruyuki Tsuchiya
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Naoya Akazawa
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Tetsuya Ohira
- Department of GastroenterologySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Yoshihiro Harada
- Department of GastroenterologySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Megumi Tanaka
- Department of GastroenterologySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Haruka Okano
- Department of GastroenterologySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Kei Ito
- Department of GastroenterologySendai City Medical Center Sendai Open HospitalSendaiJapan
| | - Takashi Tsuchiya
- Department of Gastroenterological SurgerySendai City Medical Center Sendai Open HospitalSendaiJapan
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Urgent Management of Obstructing Colorectal Cancer: Divert, Stent, or Resect? J Gastrointest Surg 2019; 23:425-432. [PMID: 30284201 DOI: 10.1007/s11605-018-3990-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Abstract
Despite the availability of effective colorectal cancer (CRC) screening strategies, up to 10% of CRC patients present with obstructive symptoms as the first sign of disease. For patients with acute or subacute malignant obstruction that requires urgent intervention, treatment options include endoscopic stenting as a bridge to surgery, one-stage surgical resection and anastomosis, or diverting ostomy which may or may not be followed by later tumor resection and stoma closure. However, to date, there is no consensus guideline for the optimal approach to manage malignant colorectal obstruction. This article aims to illustrate clinical scenarios in palliative, curative, and potentially curative settings, and delineate the key factors to be considered when making an individualized decision in order to determine the optimal treatment.
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25
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Is bridge to surgery stenting a safe alternative to emergency surgery in malignant colonic obstruction: a meta-analysis of randomized control trials. Surg Endosc 2019; 33:293-302. [PMID: 30341649 DOI: 10.1007/s00464-018-6487-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, remains a concern. AIM The aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS). METHODS Randomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to Sep 2018, were retrieved from the Pubmed, Embase database, clinical trials registry of U. S. National Library of Medicine and BMJ and Google Search. RESULTS There were seven eligible RCTs, involving a total of 448 patients. Compared to EmS, BTS stent had a significantly lower risk of overall complications (RR = 0.605; 95% CI 0.382-0.958; p = 0.032). However, the overall recurrence rate was higher in the BTS stent group (37.0% vs. 25.9%; RR = 1.425; 95% CI 1.002-2.028; p = 0.049). BTS stent significantly increased the risk of systemic recurrence (RR = 1.627; 95% CI 1.009-2.621; p = 0.046). This did not translate into a significant difference in terms of 3-year disease-free survival or 3-year overall survival. CONCLUSION BTS stent is associated with a lower rate of overall morbidities than EmS. However, BTS stent was associated with a greater chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor treatments for patients suffering from left-sided obstructing cancer of the colon.
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26
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Critical appraisal of oncological safety of stent as bridge to surgery in left-sided obstructing colon cancer; a systematic review and meta-analysis. Crit Rev Oncol Hematol 2018; 131:66-75. [DOI: 10.1016/j.critrevonc.2018.08.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 07/23/2018] [Accepted: 08/22/2018] [Indexed: 02/06/2023] Open
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27
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Management of Colorectal Cancer Patients Undergoing a Colonic Stenting: A Multidisciplinary Team Approach. Gastroenterol Nurs 2018; 40:342-349. [PMID: 28957966 DOI: 10.1097/sga.0000000000000255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Colonic stent procedure is one of the best therapeutic medical interventions for managing a colorectal cancer patient with large bowel obstruction. This is a retrospective study that evaluated data from the past 10 years; it examined the epidemiological and clinical data of patients with colorectal cancer undergoing a colonic stent procedure. In addition, this study prospectively evaluated the nurse's roles during a colonic stent procedure, and at the same time, it explored the patient's satisfaction with the procedure at the Hospital Universitario Central de Asturias (Spain). The results revealed that for the last 10 years, a total of 102 patients underwent a colonic stent procedure. Male patients outnumbered female patients by 2:1. The palliative group consisted of patients with multiple cancer metastases, elderly patients, and patients with other comorbidities, whereas the preoperative group comprised those patients with fewer comorbidities and no multiple cancer metastases. Survival time in the palliative group was 3 months without any aggressive treatment, whereas patients with a favorable condition and fit for surgery after a colonic stent procedure had a survival time of 28 months. In the prospective study, nurses implemented care in terms of a multidisciplinary team approach of safety culture that included patient safety, equipment safety, and environment and procedure safety. Therefore, the level of patient satisfaction was high. In conclusion, management of a colorectal cancer patient undergoing colonic stenting performed at the Hospital Universitario Central de Asturias has high technical and clinical success, and it is a quality procedure that includes a multidisciplinary team approach.
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28
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Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, Agresta F, Allievi N, Bellanova G, Coccolini F, Coy C, Fugazzola P, Martinez CA, Montori G, Paolillo C, Penachim TJ, Pereira B, Reis T, Restivo A, Rezende-Neto J, Sartelli M, Valentino M, Abu-Zidan FM, Ashkenazi I, Bala M, Chiara O, De' Angelis N, Deidda S, De Simone B, Di Saverio S, Finotti E, Kenji I, Moore E, Wexner S, Biffl W, Coimbra R, Guttadauro A, Leppäniemi A, Maier R, Magnone S, Mefire AC, Peitzmann A, Sakakushev B, Sugrue M, Viale P, Weber D, Kashuk J, Fraga GP, Kluger I, Catena F, Ansaloni L. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018; 13:36. [PMID: 30123315 PMCID: PMC6090779 DOI: 10.1186/s13017-018-0192-3] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023] Open
Abstract
ᅟ Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.
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Affiliation(s)
- Michele Pisano
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Luigi Zorcolo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Cecilia Merli
- Unit of Emergency Medicine Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | | | - Elia Poiasina
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Marco Ceresoli
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | | | - Niccolò Allievi
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | - Federico Coccolini
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | - Claudio Coy
- 9Colorectal Unit, Campinas State University, Campinas, SP Brazil
| | - Paola Fugazzola
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | | | - Ciro Paolillo
- Emergency Department Udine Healthcare and University Integrated Trust, Udine, Italy
| | | | - Bruno Pereira
- 14Department of Surgery, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Oncology Surgery and Intensive Care, Oswaldo Cruz Hospital, Recife, Brazil
| | - Angelo Restivo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Joao Rezende-Neto
- 16Department of Surgery Division of General Surgery, University of Toronto, Toronto, Canada
| | | | - Massimo Valentino
- 18Radiology Unit Emergency Department, S. Antonio Abate Hospital, Tolmezzo, UD Italy
| | - Fikri M Abu-Zidan
- 19Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Miklosh Bala
- 21Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | | | - Nicola De' Angelis
- 22Unit of Digestive Surgery, HPB Surgery and Liver Transplant Henri Mondor Hospital, Créteil, France
| | - Simona Deidda
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Belinda De Simone
- Department of General and Emergency Surgery Cannes' Hospital Cannes, Cedex, Cannes, France
| | | | - Elena Finotti
- Department of General Surgery ULSS5 del Veneto, Adria, (RO) Italy
| | - Inaba Kenji
- 25Division of Trauma & Critical Care University of Southern California, Los Angeles, USA
| | - Ernest Moore
- 26Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Steven Wexner
- Digestive Disease Center, Department of Colorectal Surgery Cleveland Clinic Florida, Tallahassee, USA
| | - Walter Biffl
- 28Acute Care Surgery The Queen's Medical Center, Honolulu, HI USA
| | - Raul Coimbra
- 29Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Sciences, San Diego, USA
| | - Angelo Guttadauro
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | - Ari Leppäniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Stefano Magnone
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Alain Chicom Mefire
- 32Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Andrew Peitzmann
- 33Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- 34General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Dieter Weber
- 37Trauma and General Surgeon, Royal Perth Hospital, Perth, Australia
| | - Jeffry Kashuk
- 38Surgery and Critical Care Assuta Medical Centers, Tel Aviv, Israel
| | - Gustavo P Fraga
- 39Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ioran Kluger
- 40Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
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29
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Tomita M, Saito S, Makimoto S, Yoshida S, Isayama H, Yamada T, Matsuzawa T, Enomoto T, Kyo R, Kuwai T, Hirata N, Shimada M, Hirakawa T, Koizumi K, Saida Y. Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction: pooled analysis of 426 patients from two prospective multicenter series. Surg Endosc 2018; 33:499-509. [PMID: 30006840 PMCID: PMC6342866 DOI: 10.1007/s00464-018-6324-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/06/2018] [Indexed: 12/15/2022]
Abstract
Background Self-expandable metallic stenting (SEMS) for malignant colorectal obstruction (MCO) as a bridge to elective surgery (BTS) is a widely used procedure. The aim of this study was to assess short-term outcomes of SEMS for MCO as BTS. Methods This study analyzed pooled data from BTS patients who were enrolled in two multicenter prospective single-arm observational clinical studies that used different stent types. Both studies were conducted by the Japan Colonic Stent Safe Procedure Research Group (JCSSPRG). The first study evaluated the WallFlex™ colonic stent for BTS or palliative treatment (PAL) from May 2012 to October 2013 and the second evaluated the Niti-S™ colonic stent from October 2013 to May 2014. Fifty-three facilities in Japan participated in the studies. Before each study started, the procedure had been shared with the participating institutions by posting details of the standard methods of SEMS placement on the JCSSPRG website. Patients were followed until discharged after surgery. Results A total of 723 consecutive patients were enrolled in the two studies. After excluding nine patients, the remaining 714 patients were evaluated as a per-protocol cohort. SEMS placement was performed in 426 patients (312 WallFlex and 114 Niti-S) as BTS and in 288 as PAL. In the 426 BTS patients, the technical success rate was 98.1% (418/426). The clinical success rate was 93.8% (392/418). SEMS-related preoperative complications occurred in 8.5% of patients (36/426), perforations in 1.9% (8/426), and stent migration in 1.2% (5/426). Primary anastomosis was possible in 91.8% of patients (391/426), 3.8% of whom (15/393) had anastomosis leakage. The overall stoma creation rate was 10.6% (45/426). The postoperative complication rate was 16.9% (72/426) and mortality rate was 0.5% (2/426). Conclusions SEMS placement for MCO as BTS is safe and effective with respect to peri-procedural outcomes. Further investigations are needed to confirm long-term oncological outcomes. Electronic supplementary material The online version of this article (10.1007/s00464-018-6324-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Masafumi Tomita
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1 Kamori-cho, Kishiwada-shi, Osaka, 596-8522, Japan.
| | - Shuji Saito
- Division of Surgery, Gastrointestinal Center, Yokohama Shin-Midori General Hospital, Yokohama, Japan
| | - Shinichiro Makimoto
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1 Kamori-cho, Kishiwada-shi, Osaka, 596-8522, Japan
| | - Shuntaro Yoshida
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Tomonori Yamada
- Department of Gastroenterology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Takeaki Matsuzawa
- Department of Digestive and General Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Toshiyuki Enomoto
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Rika Kyo
- Department of Gastroenterology, Saiseikai Yokohamashi-Nanbu Hospital, Yokohama, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Nobuto Hirata
- Department of Gastroenterology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Mamoru Shimada
- Department of Surgery, Toyonaka Midorigaoka Hospital, Osaka, Japan
| | - Tomio Hirakawa
- Department of Gastroenterology, Toyonaka Midorigaoka Hospital, Osaka, Japan
| | - Koichi Koizumi
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
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30
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Verstockt B, Van Driessche A, De Man M, van der Spek P, Hendrickx K, Casneuf V, Dobbels P, Van Molhem Y, Vandervoort J. Ten-year survival after endoscopic stent placement as a bridge to surgery in obstructing colon cancer. Gastrointest Endosc 2018; 87:705-713.e2. [PMID: 28579348 DOI: 10.1016/j.gie.2017.05.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Self-expandable metal stents are used increasingly in the treatment of obstructing colorectal cancer (CRC). Although endoscopic colon stenting is widely accepted in palliation, disagreement exists about its role in a curative setting. This study aims to describe long-term survival data in a large patient group treated with colon stenting as a bridge to surgery for CRC. METHODS This prospective study included 97 patients who presented in a Belgian hospital between 1998 and 2013 with obstructing, although potentially curable, CRC. All patients underwent endoscopic stenting as a bridge to surgery. Procedure-related adverse events and long-term follow-up data were retrospectively collected and compared with the CRC mortality in Belgium in the same time span. RESULTS Overall survival in this observational cohort did not differ significantly from survival in all Belgian patients with CRC in the same period (P = .14). One-year, 5-year, and 10-year survival rates were similar in both groups (95.9% vs 79.0%; 54.7% vs 51.2%; 41.0% vs 35.6%, respectively). The technical success rate was 94.8%. Seventy-three patients did not experience any adverse event. Stent migration occurred in 9 patients, whereas micro-perforations and macro-perforations were observed in 14 patients, without influence on survival. Incidence rates of peritoneal metastases did not differ between patients with and without any type of perforation (22.2% vs 15.2%, respectively; P = .47). The type of stent influenced the overall adverse event risk, mainly driven by a significant increase in stent migration in case of Wallstent enteral (Boston Scientific Corporation, Natick, Mass). CONCLUSIONS Colon stenting before surgery is effective and did not worsen the survival outcome in patients with obstructing CRC who were treated with curative intent, which affirms the role for stenting as a bridge to surgery.
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Affiliation(s)
- Bram Verstockt
- Translational Research in Gastrointestinal Disorders (TARGID), Catholic University Leuven (KUL), Leuven, Belgium; Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Department of Gastroenterology, OLV Hospitals Aalst/Asse/Ninove, Belgium
| | - Annelien Van Driessche
- Department of Gastroenterology, OLV Hospitals Aalst/Asse/Ninove, Belgium; Department of Gastroenterology, UZ Gent, Belgium; Department of Gastroenterology, AZ Glorieux, Ronse, Belgium
| | - Marc De Man
- Department of Gastroenterology, UZ Gent, Belgium
| | | | - Koen Hendrickx
- Department of Gastroenterology, OLV Hospitals Aalst/Asse/Ninove, Belgium
| | - Veerle Casneuf
- Department of Gastroenterology, OLV Hospitals Aalst/Asse/Ninove, Belgium; Department of Gastroenterology, UZ Gent, Belgium
| | - Pieter Dobbels
- Department of Gastroenterology, OLV Hospitals Aalst/Asse/Ninove, Belgium
| | - Yves Van Molhem
- Department of Abdominal Surgery, OLV Hospitals Aalst/Asse/Ninove, Belgium
| | - Jo Vandervoort
- Department of Gastroenterology, OLV Hospitals Aalst/Asse/Ninove, Belgium
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31
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Kobborg M, Broholm M, Frostberg E, Jeppesen M, Gögenür I. Short-term results of self-expanding metal stents for acute malignant large bowel obstruction. Colorectal Dis 2017; 19:O365-O371. [PMID: 28892247 DOI: 10.1111/codi.13880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 08/01/2017] [Indexed: 12/24/2022]
Abstract
AIM Self-expanding metal stents (SEMSs) can be used as a palliative treatment or to initially decompress colon prior to definitive surgery (as a so-called 'bridge to surgery'). The purpose of this study was to investigate the efficacy and safety of SEMS used as palliation and bridge to surgery for malignant large bowel obstruction. METHOD A multicentre retrospective study was conducted from January 2010 to December 2013 to identify patients undergoing stent placement for acute large bowel obstruction. Patients were included from four Danish colorectal centres. Outcomes identified included clinical success, 30-day mortality, stent related complications and surgery related complications. Furthermore, we analysed for predictive factors for successful stenting. Clinical success was defined as relief of obstructive symptoms, without the need of other additional surgical interventions during the hospital stay. RESULTS SEMSs were inserted in 239 patients for whom the indication was as a bridge to surgery in 112 patients (47%) and as palliation in 127 (53%) patients. Clinical success was achieved in 90 patients (80.4%) in the bridge to surgery group and in 105 patients (82.8%) in the palliation group. The 30-day mortality rates in the two groups were 5.4% and 11.8% for bridge to surgery and palliation respectively. A total of 17.8% of the patients in the bridge to surgery group had a stent related complication and in the palliation group it was 20.4%. Multivariate analysis demonstrated that clinical failure is a predictive factor of 30-day mortality (OR 11.1, 95% CI: 4.1-30.0). CONCLUSION The use of a SEMS to relieve a malignant large bowel obstruction is generally an effective and safe method, but complications are seen in about 20% of patients. Further investigations are required to determine the role of SEMSs in the treatment of acute, malignant, large bowel obstruction.
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Affiliation(s)
- M Kobborg
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark
| | - M Broholm
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege and Roskilde Hospital, Koege and Roskilde, Denmark
| | - E Frostberg
- Department of Surgery, Vejle Hospital, Vejle, Denmark
| | - M Jeppesen
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege and Roskilde Hospital, Koege and Roskilde, Denmark
| | - I Gögenür
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege and Roskilde Hospital, Koege and Roskilde, Denmark
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32
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Arezzo A, Passera R, Lo Secco G, Verra M, Bonino MA, Targarona E, Morino M. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc 2017; 86:416-426. [PMID: 28392363 DOI: 10.1016/j.gie.2017.03.1542] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Twenty years after the first description of the technique, the debate is still open on the role of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery for symptomatic left-sided malignant colonic obstruction. The aim was to compare morbidity rates after colonic stenting bridge to surgery (SBTS) versus emergency surgery (ES) for left-sided malignant obstruction. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) on SBTS or ES for acute symptomatic malignant left-sided large bowel obstruction. The primary outcome was overall morbidity within 60 days after surgery. RESULTS The meta-analysis included 8 RCTs and 497 patients. Overall mortality within 60 days after surgery was 9.6% in SBTS-treated patients and 9.9% in ES-treated patients (relative risk [RR], 0.99; P = .97). Overall morbidity within 60 days after surgery was 33.9% in SBTS-treated patients and 51.2% in ES-treated patients (RR, 0.59; P = .023). The temporary stoma rate was 33.9% after SBTS and 51.4% after ES (RR, 0.67; P < .001). The permanent stoma rate was 22.2% after SBTS and 35.2% after ES (RR, 0.66; P = .003). Primary anastomosis was successful in 70.0% of SBTS-treated patients and 54.1% of ES-treated patients (RR, 1.29; P = .043). CONCLUSIONS SBTS was associated with lower short-term overall morbidity and lower rates of temporary and permanent stoma. Depending on multiple factors such as local expertise, clinical status including level of obstruction, and level of certainty of diagnosis, SBTS does offer some advantages with less risk than ES for left-sided malignant colonic obstruction in the short term.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
| | - Giacomo Lo Secco
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Mauro Verra
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | | | | | - Mario Morino
- Department of Surgical Sciences, University of Torino, Turin, Italy
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Newton K, Hill J. Colonic cancer: The current role of stent insertion. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Katherine Newton
- Department of General Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James Hill
- Department of General Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Allievi N, Ceresoli M, Fugazzola P, Montori G, Coccolini F, Ansaloni L. Endoscopic Stenting as Bridge to Surgery versus Emergency Resection for Left-Sided Malignant Colorectal Obstruction: An Updated Meta-Analysis. Int J Surg Oncol 2017; 2017:2863272. [PMID: 28761765 PMCID: PMC5516723 DOI: 10.1155/2017/2863272] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 05/24/2017] [Accepted: 05/31/2017] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Emergency resection represents the traditional treatment for left-sided malignant obstruction. However, the placement of self-expanding metallic stents and delayed surgery has been proposed as an alternative approach. The aim of the current meta-analysis was to review the available evidence, with particular interest for the short-term outcomes, including a recent multicentre RCT. METHODS We considered randomized controlled trials comparing stenting as a bridge to surgery and emergency surgery for the management of left-sided malignant large bowel obstruction, performing a systematic review in MEDLINE, PubMed database, and the Cochrane libraries. RESULTS We initially identified a total of 2543 studies. After the elimination of duplicates and the screening of titles and abstracts, seven studies, for a total of 448 patients, were considered. The current meta-analysis revealed no difference in the mortality rate between the stent group and the emergency surgery group; the postoperative complication rate (37.84% versus 54.87%, P = 0.02), the stoma rate (28.8% versus 46.02%, P < 0.0001), and the incidence of wound infection (8.11% versus 15.49%, P = 0.01) were reduced after stent as a bridge to surgery. CONCLUSION Colonic stenting as a bridge to surgery appears to be a safe approach to malignant large bowel obstruction. Possible advantages of this treatment can be identified in a reduced incidence of postoperative complications and a lower stoma rate. Further RCTs considering long-term outcomes and cost-effectiveness analysis are needed.
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Affiliation(s)
- Niccolò Allievi
- 1st Surgical Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Marco Ceresoli
- 1st Surgical Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paola Fugazzola
- 1st Surgical Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giulia Montori
- 1st Surgical Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Luca Ansaloni
- 1st Surgical Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Fugazza A, Galtieri PA, Repici A. Using stents in the management of malignant bowel obstruction: the current situation and future progress. Expert Rev Gastroenterol Hepatol 2017; 11:633-641. [PMID: 28325090 DOI: 10.1080/17474124.2017.1309283] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The use of self-expanding metal stents (SEMS) has been considered an effective and safe alternative to emergency surgery as bridge to surgery or for palliation in advanced colorectal cancer even though more recent data have raised concerns on both early and long-term outcomes when patients are treated with bridge to surgery indications. Areas covered: A comprehensive literature review of articles on endoscopic management of malignant bowel obstruction was performed. Indication, technique, outcomes, benefits and risks of these treatments in acute malignant colonic obstruction were reviewed. The clinical effectiveness and safety of SEMS in obstructive colorectal cancer, as bridge to surgery or for palliation compared to surgery, is discussed. Expert commentary: SEMS placement, when performed in tertiary level center with appropriate expertise in colorectal stenting, may have several advantages over surgery avoiding the potential for surgical morbidity in a typically frail group of patients even though these advantages are to be carefully balanced over the risk of life-threatening, stent-related complications.
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Affiliation(s)
- Alessandro Fugazza
- a Digestive Endoscopy Unit, Division of Gastroenterology , Humanitas Research Hospital , Rozzano , Italy
| | - Piera Alessia Galtieri
- a Digestive Endoscopy Unit, Division of Gastroenterology , Humanitas Research Hospital , Rozzano , Italy
| | - Alessandro Repici
- a Digestive Endoscopy Unit, Division of Gastroenterology , Humanitas Research Hospital , Rozzano , Italy.,b Academic Department of Bioscience , Humanitas University , Rozzano , Italy
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Arezzo A. Malignant colonic obstruction: To stent or not to stent? Cir Esp 2017; 95:121-122. [PMID: 28400026 DOI: 10.1016/j.ciresp.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/05/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy.
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Methodological overview of systematic reviews to establish the evidence base for emergency general surgery. Br J Surg 2017; 104:513-524. [PMID: 28295254 PMCID: PMC5363346 DOI: 10.1002/bjs.10476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/23/2016] [Accepted: 11/30/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions. METHODS Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist. RESULTS The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias. CONCLUSION This overview of reviews highlights the need for more and better research in this field.
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De Simone B, Catena F, Coccolini F, Di Saverio S, Sartelli M, Heyer A, De Angelis N, De Angelis GL, Ansaloni L. Preoperative colonic stents vs emergency surgery for acute left-sided malignant colonic obstruction: Meta-analysis with systematic review of the literature. World J Meta-Anal 2017; 5:1-13. [DOI: 10.13105/wjma.v5.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/15/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate by meta-analytic study and systematic review, advantages of colonic stent placement in comparison with emergency surgery.
METHODS We conducted an extensive literature search by PubMed, Google Scholar, Embase and the Cochrane Libraries. We searched for all the papers in English published till February 2016, by applying combinations of the following terms: Obstructive colon cancer, colon cancer in emergency, colorectal stenting, emergency surgery for colorectal cancer, guidelines for obstructive colorectal cancer, stenting vs emergency surgery in the treatment of obstructive colorectal cancer, self-expanding metallic stents, stenting as bridge to surgery. The study was designed following the Prisma Statement. By our search, we identified 452 studies, and 57 potentially relevant studies in full-text were reviewed by 2 investigators; ultimately, 9 randomized controlled trials were considered for meta-analysis and all the others were considered for systematic review.
RESULTS In the meta-analysis, by comparing colonic stenting (CS) as bridge to surgery and emergency surgery, the pooled analysis showed no significant difference between the two techniques in terms of mortality [odds ratio (OR) = 0.91], morbidity (OR = 2.38) or permanent stoma rate (OR = 1.67); primary anastomosis was more frequent in the stent group (OR = 0.45; P = 0.004) and stoma creation was more frequent in the emergency surgery group (OR = 2.36; P = 0.002). No statistical difference was found in disease-free survival and overall survival. The pooled analysis showed a significant difference between the colonic stent and emergency surgery groups (OR = 0.37), with a significantly higher 1-year recurrence rate in the stent group (P = 0.007).
CONCLUSION CS improves primary anastomosis rate with significantly high 1-year follow-up recurrence and no statistical difference in terms of disease-free survival and overall survival.
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Arezzo A, Balague C, Targarona E, Borghi F, Giraudo G, Ghezzo L, Arroyo A, Sola-Vera J, De Paolis P, Bossotti M, Bannone E, Forcignanò E, Bonino MA, Passera R, Morino M. Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial). Surg Endosc 2016; 31:3297-3305. [PMID: 27924392 DOI: 10.1007/s00464-016-5362-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction. METHODS This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery. RESULTS Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far. CONCLUSIONS Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy.
| | | | | | | | | | | | | | | | | | | | - Elisa Bannone
- Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy
| | - Edoardo Forcignanò
- Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy
| | - Marco Augusto Bonino
- Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy
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Endoscopic stenting as bridge-to-surgery (BTS) in left-sided obstructing colorectal cancer: Experience with conformable stents. Clin Res Hepatol Gastroenterol 2016; 40:638-644. [PMID: 27156171 DOI: 10.1016/j.clinre.2016.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 03/08/2016] [Accepted: 03/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Compared to emergency surgery, self-expandable metallic stents are effective and safe when used as bridge-to-surgery (BTS) in operable patients with acute colorectal cancer obstruction. In this study, we report data on the new conformable colonic stents. OBJECTIVES To evaluate clinical effectiveness of conformable stents as BTS in patients with acute colorectal cancer obstruction. DESIGN This was a retrospective study. SETTINGS The study was conducted at six Italian Endoscopic Units. PATIENTS Data about patients with acute malignant colorectal obstruction were collected between 2007 and 2012. MAIN OUTCOME MEASURES All patients were treated with conformable stents as BTS. Technical success, clinical success, rate of primary anastomosis and colostomy, early and late complications were evaluated. RESULTS Data about 88 patients (62 males) were reviewed in this study. Conformable SEMS were correctly deployed in 86 out of 88 patients, with resolution of obstruction in all treated patients. Tumor resection with primary anastomosis was possible in all patients. A temporary colostomy was performed in 40. Early complications did not occur. Late complications occurred in 11 patients. Stent migration was significantly higher in patients treated with partially-covered stents compared to the uncovered group (35% vs. 0%, P<0.001). Endoscopical re-intervention was required in 12% of patients. One patient with rectal cancer had an anastomotic dehiscence after surgery and he was successfully treated with endoscopic clipping. One year after surgery, all patients were alive and local recurrence have not been documented. LIMITATIONS This was a retrospective and uncontrolled study. CONCLUSIONS Preliminary data from this large case series are encouraging, with a high rate of technical and clinical success and low rate of clinically relevant complications. Partially-covered SEMS should be avoided in order to reduce the risk of endoscopic re-intervention.
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Costa Santos MP, Palmela C, Ferreira R, Barjas E, Santos AA, Maio R, Cravo M. Self-Expandable Metal Stents for Colorectal Cancer: From Guidelines to Clinical Practice. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:293-299. [PMID: 28868482 PMCID: PMC5580185 DOI: 10.1016/j.jpge.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Colonic self-expandable metal stent placement is widely used for palliation of obstructive colorectal cancer. The European recommendations for stent placement as a bridge to elective surgery in obstructive colorectal cancer were recently reviewed. The aim of this study was to evaluate the efficacy and safety of stent placement in obstructive colorectal cancer and to discuss these recent guidelines. MATERIALS AND METHODS Demographic characteristics, procedure indications, complications and final outcome in patients with obstructive colorectal cancer who underwent endoscopic stent placement between January 2012 and June 2015 were retrospectively analyzed. Statistical analysis was performed with SPSS V22. RESULTS Thirty-six patients were included, 20 (56%) women, mean age 70.6 ± 10.9 years. Stent placement as a bridge to elective surgery was performed in 75% (n = 27) of patients and with palliation intent in 25% (n = 9). In 94% (n = 34) of procedures, technical and clinical success was achieved. A total of eleven (11%) complications were observed: 2 migrations and 9 perforations. No procedure related death was recorded. When stents were placed as a bridge to surgery, average time between endoscopic procedure and surgery was 11.7 ± 9.4 days (excluding three patients who underwent neoadjuvant chemotherapy). Six perforations were recorded in this group: one overt and five silent (three during surgery and two after histopathological examination of the resected specimen). Twenty-one patients underwent adjuvant chemotherapy. During the follow-up period of 14.7 ± 10.9 months recurrence was observed in five patients. None of the recurrence occurred in the group of patients with perforation. CONCLUSIONS In this study, stent placement was an effective procedure in obstructive colorectal cancer. It was mainly used as a bridge to elective surgery. However, a significant rate of silent perforation was observed, which may compromise the oncological outcome of these potentially curable patients. Prospective real life studies are warranted for a better definition of actual recommendations.
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Affiliation(s)
| | - Carolina Palmela
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Rosa Ferreira
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Elídio Barjas
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Rui Maio
- General Surgery Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marília Cravo
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
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Radiologic Placement of Uncovered Stents for the Treatment of Malignant Colonic Obstruction Proximal to the Descending Colon. Cardiovasc Intervent Radiol 2016; 40:99-105. [PMID: 27671155 DOI: 10.1007/s00270-016-1474-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/19/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the safety, feasibility, and patency rates of radiologic placement of uncovered stents for the treatment of malignant colonic obstruction proximal to the descending colon. MATERIALS AND METHODS This was a retrospective, single-center study. From May 2003 to March 2015, 53 image-guided placements of uncovered stents (44 initial placements, 9 secondary placements) were attempted in 44 patients (male:female = 23:21; mean age, 71.8 years). The technical and clinical success, complication rates, and patency rates of the stents were also evaluated. Technical success was defined as the successful deployment of the stent under fluoroscopic guidance alone and clinical success was defined as the relief of obstructive symptoms or signs within 48 h of stent deployment. RESULTS In total, 12 (27.3 %) patients underwent preoperative decompression, while 32 (72.7 %) underwent decompression with palliative intent. The technical success rate was 93.2 % (41/44) for initial placement and 88.9 % (8/9) for secondary placement. Secondary stent placement in the palliative group was required in nine patients after successful initial stent placement due to stent obstruction from tumor ingrowth (n = 7) and stent migration (n = 2). The symptoms of obstruction were relieved in all successful cases (100 %). In the palliative group, the patency rates were 94.4 % at 1 month, 84.0 % at 3 months, 64.8 % at 6 months, and 48.6 % at 12 months. CONCLUSIONS The radiologic placement of uncovered stents for the treatment of malignant obstruction proximal to the descending colon is feasible and safe, and provides acceptable clinical results.
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Managing Malignant Colorectal Obstruction with Self-Expanding Stents. A Closer Look at Bowel Perforations and Failed Procedures. J Gastrointest Surg 2016; 20:1643-9. [PMID: 27342437 DOI: 10.1007/s11605-016-3186-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/07/2016] [Indexed: 01/31/2023]
Abstract
Stent treatment of large bowel obstruction is still controversial. There are concerns regarding complications, particularly bowel perforation, as well as long-term outcome in curable patients. Through a 10-year retrospective study, we have evaluated efficacy, complications, delay in surgical interventions and stent patency in cases of palliative treatment. We treated 183 patients, 85 as bridge to surgery and 98 as definitive, palliative treatment. At presentation, 58 % of patients had advanced local or metastatic disease. Seventeen patients required more than one stent insertion. The total number of procedures was 213. We recorded technical and clinical success or failure, complications, necessity of restenting or surgical intervention, mortality and stent patency in the palliation group. Stenting was clinically successful in 89 % of the bridge to surgery group and 86 % of the palliative group. Complications occurred in 7 %, including 12 perforations. Six patients suffered an early perforation, of which two died. Half of the six late perforations were silent. Procedure related mortality was 1 %. The clinical success rate was high in both the palliative and bridge to surgery setting. The complication rate was low, and the sum of early and late perforations was 5.6 %. Procedure related mortality was low.
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Mangano A, Motson RW. Evidence-based analysis of self-expanding metallic stent as a bridge to surgery versus emergency surgery for colon cancer. Future Oncol 2016; 12:1957-60. [DOI: 10.2217/fon-2015-0047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Alberto Mangano
- The ICENI Centre & Colchester Hospital University, NHS Foundation Trust, Essex, UK
| | - Roger W Motson
- The ICENI Centre & Colchester Hospital University, NHS Foundation Trust, Essex, UK
- Anglia Ruskin University, Chelmsford, Essex, 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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Current status of laparoscopic colorectal surgery in the emergency setting. Updates Surg 2016; 68:47-52. [DOI: 10.1007/s13304-016-0356-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/28/2016] [Indexed: 12/15/2022]
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Sagar J. Role of colonic stents in the management of colorectal cancers. World J Gastrointest Endosc 2016; 8:198-204. [PMID: 26962401 PMCID: PMC4766252 DOI: 10.4253/wjge.v8.i4.198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/14/2015] [Accepted: 12/21/2015] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer is one of the commonly encountered cancers across the Western World. In United Kingdom, this constitutes third most common ranked cancer and second most common ranked cause of cancer related deaths. Its acute presentation as a malignant colonic obstruction imposes challenges in its management. Colonic stent has been used for many years to alleviate acute obstruction in such cases allowing optimisation of patient’s physiological status and adequate staging of cancer. In this review, current literature evidence regarding use of colonic stent in acute malignant colonic obstruction is critically appraised and recommendations on the use of colonic stent are advocated.
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Examination of Physicians' Perception of the Indications of Colorectal Stents in the Management of Malignant Large Bowel Obstruction: A Provincial Survey. Can J Gastroenterol Hepatol 2016; 2016:4629710. [PMID: 27725925 PMCID: PMC5048041 DOI: 10.1155/2016/4629710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/25/2016] [Indexed: 01/25/2023] Open
Abstract
Introduction. Data are conflicting when assessing indications for colorectal self-expandable metallic stents (SEMS) in managing acute malignant large bowel obstruction (MLO). In November 2014, European and American Societies published guidelines to aid in understanding which patients might benefit from colorectal stenting. Yet, there remain marked disparities in clinical practice. Methods. A web-based survey was sent to Gastroenterologists and Surgical Specialists across Quebec to assess physicians' knowledge and adherence to the indications for colonic SEMS placement in the management of MLO using eight clinical scenarios. Results. Out of 112 respondents, 74% preferred surgical intervention in young, healthy individuals with MLO. Advanced age and comorbidities motivated 56.3% (95% CI 47.1-65.5%) of participants to opt for SEMS placement. In palliative settings of patients undergoing chemotherapy including bevacizumab, a minority of respondents followed guidelines, 12.5% (95% CI 6.4-18.6%) for young patients and 25.0% for elderly patients (95% CI 17.0-33.0%). The pooled overall adherence to guidelines was 50.4% (95% CI 40.7-59.3%). Conclusion. This survey suggests that guidelines recommendations are not being implemented by at least half of specialists involved in the care of patients with MLO. Future studies should attempt to identify possible barriers responsible for this impaired knowledge translation and tailored educational initiatives planned accordingly.
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Zhang CD, Wang JN, Sui BQ, Zeng YJ, Chen JQ, Dai DQ. Prognostic and Predictive Model for Stage II Colon Cancer Patients With Nonemergent Surgery: Who Should Receive Adjuvant Chemotherapy? Medicine (Baltimore) 2016; 95:e2190. [PMID: 26735527 PMCID: PMC4706247 DOI: 10.1097/md.0000000000002190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
No ideal prognostic model has been applied to clearly identify which suitable high-risk stage II colon cancer patients with negative margins undergoing nonemergent surgery should receive adjuvant chemotherapy routinely. Clinicopathologic and prognostic data of 333 stage II colon cancer patients who underwent D2 or D3 lymphadenectomy during nonemergent surgery were retrospectively analyzed. Four pathologically determined factors, including adjacent organ involvement (RR 2.831, P = 0.001), histologic differentiation (RR 2.151, P = 0.009), lymphovascular invasion (RR 4.043, P < 0.001), and number of lymph nodes retrieved (RR 2.161, P = 0.011), were identified as independent prognostic factors on multivariate analysis. Importantly, a simple cumulative scoring system clearly categorizing prognostic risk groups was generated: risk score = ∑ coefficient' × status (AOI + histological differentiated + lymphovascular invasion + LNs retrieved). Our new prognostic model may provide valuable information on the impact of lymphovascular invasion, as well as powerfully and reliably predicting prognosis and recurrence for this particular cohort of patients. This model may identify suitable patients with an R0 resection who should receive routine postoperative adjuvant therapy and may help clinicians to facilitate individualized treatment. In this study, we aim to provide an ideal and quantifiable method for clinical decision making in the nonemergent surgical treatment of stage II colon cancer. Our prognostic and predictive model should be applied in multicenter, prospective studies with large sample sizes, in order to obtain a more reliable clinical recommendation.
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Affiliation(s)
- Chun-Dong Zhang
- From the Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang (C-DZ, B-QS, Y-JZ, D-QD); Department of General Surgery, Dalian Friendship Hospital, Dalian (J-NW); Cancer Center, the Fourth Affiliated Hospital of China Medical University (D-QD); and Cancer Research Institute, China Medical University, Shenyang, PR China (D-QD, J-QC)
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