Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction

Efficacy and Safety of Fluoroscopy-Guided Self-Expandable Metal Stent Placement for Treatment of Malignant Colorectal Obstruction

AIM

To investigate long-term outcomes after SEMS insertion in patients with malignant colorectal obstruction and to identify the risk factors for complications.

METHODS

The data of 119 patients with malignant colorectal obstruction who received SEMS insertion between March 2014 and February 2020 were retrospectively analyzed. Patients were divided into two groups according to the intent of treatment, i.e., stenting as "bridge to surgery" (surgical group) and stenting for palliation (palliative group). Technical and clinical success rates and incidence of complications were compared between the two groups.

RESULTS

The overall technical and clinical success rates were 97.5% and 96.6%, respectively. The technical and clinical success rates and complication rate were comparable between the two groups. In the palliative group, the mean stent patency time was 230 days. Patency rates were not significantly different between primary CRC and recurrent CRC. Incidence of complications was higher in the palliative group than in the surgical group. In multivariate analysis, chemotherapy before stent implantation may increase the risk of stent-related complications, whereas chemotherapy after stent implantation did not. Additionally, the factors independently associated with complications were female sex and preoperative chemotherapy.

CONCLUSIONS

SEMS under fluoroscopic guidance is a safe and effective treatment for malignant colorectal obstruction. For patients with resectable CRC, stent placement can serve as a bridge to elective surgery. It is worth noting that adjuvant chemotherapy between SEMS and surgery did not increase the complications. For patients with recurrent CRC, stent placement can relieve symptoms, alleviate pain, and improve quality of life.

Definition of large bowel obstruction by primary colorectal cancer: A systematic review

AIM

Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies.

METHOD

A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements.

RESULTS

A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07).

CONCLUSION

In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.

Endoscopic stenting in colorectal cancer

Acute malignant large bowel obstruction presents as one of the few emergencies of colorectal cancer (CRC). Management of this condition can either be by (I) upfront surgery or (II) the use of self-expanding metallic stent (SEMS) as a bridge to elective surgery. For patients with metastasis, the use of SEMS is reported to enable earlier commencement of chemotherapy. Although the use of SEMS in patients with acute malignant large bowel obstruction looks promising, it is plagued by its own set of complications and divided opinion over its long-term outcomes. Conflicting data are present, and definitive indication requires further evaluation and debate. This article will describe the typical presentation of patients with acute malignant large bowel obstruction. An introduction to the SEMS insertion procedural steps will be undertaken. Following which the article aims to review the safety profile of SEMS and the short- and long-term outcomes of SEMS in both the curative and palliative setting.

A Pediatric Nasogastroscope Facilitates Colorectal Endoscopic Stenting

PURPOSE

Endoscopic placement of self-expandable metal stents (SEMSs) to relieve malignant colorectal obstruction has been widely accepted in clinical practice. Despite increasing experience, early and late complications occur with an incidence ranging from 4% to 20%.

MATERIALS AND METHODS

We have adopted a modification in the technique. A pediatric nasogastroscope (4.8 mm in diameter) has been used to pass the obstruction. It is possible to have a direct vision of the anatomy and pathology, and to pass the guidewire above the obstruction, through the nasogastroscope, under direct vision. Fluoroscopy was also used to follow the course of the guidewire and deployment of the stent.

RESULTS

Early and late complications have been reduced with the new technique.

CONCLUSIONS

In the most recent experience of 64 patients, early and late complications have been reduced significantly. This new technique reduces radiation exposure by 70% for the patients and for the operators.

Endoscopic Stenting for Colorectal Cancer: Lessons Learned From a 15-Year Experience

GOAL

The aim of our prospective study was to analyze the results of endoscopic stenting to treat obstruction due to colorectal cancer and complications after colorectal resection for cancer.

BACKGROUND

Endoscopic stenting for obstructing colorectal cancer has become a common place in clinical practice. However, there is a 2% to 5% risk of bowel perforation, and a percentage of technical failure of 2% to 10%.

MATERIALS AND METHODS

In a 15-year period (August, 1999 to December, 2013), 153 patients with colorectal cancer had endoscopic placement of a self-expandable metal stent for treatment of an obstructing colorectal cancer (133 patients) or for treatment of complications after colorectal resection for cancer (20 patients). They were prospectively evaluated in a database and they form the basis of this report.

RESULTS

There was no case of mortality or major morbidity. Overall technical success was 94.8%. After introducing the use of a pediatric nasogastroscope to pass the obstruction (71 patients), technical success was 100%. Complications in patients in whom the stent was left in place during the follow-up were frequent, requiring a close observation. We had 20 patients with fecal obstruction, 4 cases of stent dislodgment, and 8 cases of obstruction from ingrowth of the tumor. All patients were treated successfully endoscopically.

CONCLUSIONS

Placement of self-expandable metal stents represents a valid technique. A proper training is required.

Predictors of outcome for endoscopic colorectal stenting: a decade experience

PURPOSE

Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various factors on the short- and long-term results of colorectal stenting.

METHODS

A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome.

RESULTS

Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90 %) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22 % of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio [AOR] 0.2 [95 % confidence interval (CI) 0.1-0.8]; p = 0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 [95 % CI 1.4-10.3]; p = 0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 [95 % CI 1.0-10.0]; p = 0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 [95 % CI 1.5-11.7]; p = 0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 [95 % CI 2.6-71.2]; p = 0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 [95 % CI 1.3-16.2]; p = 0.017).

CONCLUSIONS

Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.

Safety and efficacy of palliative systemic chemotherapy combined with colorectal self-expandable metallic stents in advanced colorectal cancer: A multicenter study

PURPOSE

Self-expandable metallic stent (SEMS) placement is an accepted palliative therapy for management of acute malignant bowel obstruction in advanced colorectal cancer. Nevertheless, data are lacking on the effects of systemic chemotherapy combined with colorectal SEMS. The aim of this study was to investigate the safety and efficacy of palliative chemotherapy for advanced colorectal cancer combined with colorectal SEMS placement.

PATIENTS AND METHODS

This multicentre retrospective study included all consecutive advanced colorectal cancer patients who received first-line palliative chemotherapy combined with endoscopic stenting for colorectal cancer with obstruction. We analyzed the number of cycles and the type of combination used. The primary endpoint was overall survival. Secondary endpoints included progression-free survival, response rate, grade 3-4 toxicity and the outcomes of SEMS for malignant colorectal obstruction.

RESULTS

A total of 38 patients were included. Among them, 25 patients received oxaliplatin and 5-fluorouracil combination chemotherapy. Objective response and stabilization occurred in 38 and 24% of patients, respectively. The median overall survival and progression-free survival from the start of chemotherapy were 18 and 5months, respectively. The objective response rate and overall disease control rate were 38 and 62%, respectively. Toxicity was generally acceptable. Major complications related to stenting included perforation (8%), stent migration (5%), and reobstruction secondary to tumor ingrowths (13%).

CONCLUSIONS

Chemotherapy combined with colonic stenting as a first-line treatment seems to be a valid option in advanced colorectal cancer patients with malignant colorectal obstruction.

Stents for colorectal obstruction: Past, present, and future

Since the development of uncovered self-expanding metal stents (SEMS) in the 1990s, endoscopic stents have evolved dramatically. Application of new materials and new designs has expanded the indications for enteral SEMS. At present, enteral stents are considered the first-line modality for palliative care, and numerous types of enteral stents are under development for extended clinical usage, beyond a merely palliative purpose. Herein, we will discuss the current status and the future development of lower enteral stents.

Colonic strictures: dilation and stents

Colonic strictures, both benign and malignant, are commonly encountered in clinical practice. Benign strictures are most commonly treated by balloon dilation and less frequently with stents. Balloon dilation can help forestall or obviate surgery in some patients. Colonic strictures of malignant etiology generally need to be managed by stents and/or surgery. This article reviews endoscopic approaches to the management of colonic strictures.

Palliative self-expandable metal stents for acute malignant colorectal obstruction: clinical outcomes and risk factors for complications

OBJECTIVE

Self-expandable metal stents (SEMSs) have been used as palliative treatment or bridge to surgery for obstructions caused by colorectal cancer (CRC). We assessed the long-term outcomes of palliative SEMSs and evaluated the risk factors influencing complications.

MATERIALS AND METHODS

One hundred and seventy-five patients underwent SEMS placement for acute malignant colorectal obstruction. Of the 72 patients who underwent palliative treatment for primary CRC, 30 patients received chemotherapy (CT) for primary cancer (CT group) and 42 underwent best supportive treatment (BST) without CT (BST group).

RESULTS

There was a significant difference in late migration between the CT group and the BST group (20.0% in CT group, 2.4% in BST group, p = 0.018). Response to CT influenced the rate of late obstruction (0% in disease control, 35.7% in disease progression, p = 0.014). However, late obstruction was not associated with stent properties, such as diameter or type (≤22 mm vs. >22 mm, 13.5% vs. 14.3%, p = 1.00; uncovered stent vs. covered stent, 15.5% vs. 7.1%, p = 0.675) and migration (≤22 mm vs. >22 mm, 16.2% vs. 2.9%, p = 0.108; uncovered stent vs. covered stent, 8.6% vs. 14.3%, p = 0.615) in palliative SEMS.

CONCLUSION

The administration of CT increases the rate of stent migration, and disease control by CT can reduce the risk of obstruction by maintaining the luminal patency of palliative SEMSs.

Perforation in colorectal stenting: a meta-analysis and a search for risk factors

BACKGROUND

Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement.

OBJECTIVE

To identify risk factors for perforation from colonic stenting.

DESIGN

A meta-analysis of 86 studies published between 2005 and 2011.

SETTING

Multicenter review.

PATIENTS

All patients who underwent colorectal stent placement.

INTERVENTION

Colorectal stent placement.

MAIN OUTCOME MEASUREMENTS

The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab.

RESULTS

A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%).

LIMITATIONS

Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis.

CONCLUSIONS

The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.

Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome

AIM

UK cancer guidelines recommend patients with colonic obstruction due to suspected malignancy be considered for stenting with a self-expanding metal stent (SEMS). Considerable variation in practice exists due to a lack of expertise, technical difficulties and other, as yet ill-defined features. This retrospective multi-centre study aims to determine the outcome following colonic stenting for large bowel obstruction and identify factors associated with successful intervention.

METHOD

A regional programme of colonic stenting for large bowel obstruction, in five UK centres from 2005 to 2010 was evaluated for outcome including technical and clinical success, survival, complications and reoperation.

RESULTS

A SEMS was inserted in 334 patients, including 264 (79.0%) for palliation and 52 (15.6%) as a bridge to surgery. Technical success was achieved in 292 (87.4%) patients, with 46 (13.8%) experiencing a complication or technical failure. Reoperation was required in 39 (14.8%) patients stented for palliation of colorectal cancer of whom 16 (6.1%) subsequently required a colostomy. A one-stage primary anastomosis was achieved in 35 (67.3%) of the 52 patients undergoing stenting as a bridge to resection. Technical success did not vary by indication or site of obstruction (P = 0.60) but was higher for operators who had performed more than 10 procedures (OR 3.34, P = 0.001). ASA grade ≥3 predicted a worse clinical outcome (OR 0.43, P = 0.04). The through-the-scope (TTS) endoscopy technique was more successful than radiological placement alone (90.3% vs 74.8%, P < 0.001).

CONCLUSION

Experienced operators using a TTS technique achieved a better outcome for the emergency management of large bowel obstruction. Older, sicker patients and those with extracolonic and benign strictures fared less well.

Mmp-9 expression after metallic stent placement in patients with colorectal cancer: association with in-stent restenosis

PURPOSE

To verify the expression of matrix metalloproteinase (MMP)-9 in stent-induced hyperplastic tissue from patients with colorectal cancer who received colorectal stents as a bridge to surgery.

MATERIALS AND METHODS

This prospective study was institutional review board-approved, and informed consent was obtained from all patients. Eleven patients (nine men, two women; mean age, 67 years; age range, 53-82 years) with malignant colorectal obstructions who received a colorectal stent between May and December 2010 were included. Tissue specimens were analyzed for MMP-9 and MMP-2 expression. After resection, the tissue was segmented into three parts: tumor tissue, stent-induced tissue hyperplasia, and normal colon tissue. MMP-9 and MMP-2 expression were determined by using zymography, Western blot analysis, and real-time reverse-transcription (qRT) polymerase chain reaction (PCR). Significance of differences between groups was evaluated with Friedman analysis of variance test. Signed-rank test was used to determine differences between malignant tumor tissue and stent-induced hyperplastic tissue groups.

RESULTS

Stent placement was technically successful in all 11 patients. Stent-induced hyperplastic tissues were found in all patients. Zymography (P = .003) and Western blot analysis (P = .008) showed that expression of MMP-9 was higher in malignant tumor tissue and stent-induced hyperplastic tissue groups compared with normal colorectal tissue group, demonstrating significant differences between groups but no significant differences between malignant tumor and stent-induced hyperplastic tissues. As for results of qRT PCR analysis, the stent-induced hyperplastic tissue group showed increases in messenger RNA expression level of MMP-9 compared with the malignant tumor tissue group (50.42-fold ± 66.30 higher).

CONCLUSION

High expression of MMP-9 is closely associated with stent-induced colorectal tissue hyperplasia in patients with colorectal cancer.

Evidence-based recommendations on colorectal stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Recently, placement of self-expandable metallic stents has been used for the treatment of colorectal obstruction. As domestic awareness of colorectal cancer has increased, the number of colorectal stenting procedures performed has also increased. We aimed to provide evidence-based recommendations for colorectal stenting to aid gastroenterologists in making informed decisions regarding the management of patients who present with colorectal obstruction. The working group consisted of eight gastroenterologists who actively practice and conduct research in the field of colorectal stenting and are the members of the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy. A literature search was conducted using the PubMed, Embase, KoreaMed, and the Cochrane Library databases to identify relevant articles published between January 2001 and June 2012. Based on the modified Delphi process, 10 recommendation statements regarding indications, usefulness, methodology and complications of colorectal stenting, and alternative treatments for malignant colorectal obstruction were determined. The contents will be widely distributed, and periodically revised to reflect the latest knowledge. These evidence-based recommendations for colorectal stenting will provide gastroenterologists and patients with appropriate and balanced information, and will improve the quality of care.

Colonic stenting: a practical update

Colonic stenting is part of the UK service provision guidelines for colorectal cancer. However, there are issues about availability and expertise within the UK, and controversies remain regarding various clinical and technical aspects of the technique. Based on the current evidence, this article will provide a practical update on the indications, the clinical and technical considerations and the remaining unanswered questions regarding colonic stenting.

Self-expandable metallic stents in patients with stage IV obstructing colorectal cancer

BACKGROUND

The aim of the present study was to analyze the results of our experience with elective placement of self-expandable metallic stents (SEMS) in patients with stage IV obstructing colorectal cancer. A systematic review of the literature was also carried out to analyze the factors influencing the results of SEMS placement and to determine if there has been any improvement in the more recent period.

MATERIALS AND METHODS

The results of a personal series of 100 patients were analyzed. There was no case of mortality or major morbidity. The systematic review included 27 articles published from April 2007 to December 2011.

RESULTS

In our experience the technical success rate was 96% and the clinical success rate was 92%. During the follow-up period a repeat colonoscopy was needed in 31% of the patients for recurrent symptoms of obstruction due to fecal impaction (19%), tumor growth (8%), or stent dislodgment (4%). Review of the literature showed similar results, with a significant improvement in the reports of the last 6 years; procedures performed on an emergency basis had poorer results.

CONCLUSIONS

Self-expandable metallic stent placement offers a valid alternative to surgery in patients with obstructing stage IV colorectal cancer, but careful follow-up is required.

A temporary self-expanding metallic stent for malignant colorectal obstruction

AIM: To investigate the clinical safety and efficacy of a temporary self-expanding metallic stent (SEMS) for malignant colorectal obstruction.

METHODS: From September 2007 to June 2012, 33 patients with malignant colorectal obstruction were treated with a temporary SEMS. The stent had a tubular configuration with a retrieval lasso attached inside the proximal end of the stent to facilitate its removal. The SEMS was removed one week after placement. Clinical examination, abdominal X-ray and a contrast study were prospectively performed and both initial and follow-up data before and at 1 d, 1 wk, and 1 mo, 3 mo, 6 mo and 12 mo after stent placement were obtained. Data collected on the technical and clinical success of the procedures, complications, need for reinsertion and survival were analyzed.

RESULTS: Stent placement and removal were technically successful in all patients with no procedure-related complications. Post-procedural complications included stent migration (n = 2) and anal pain (n = 2). Clinical success was achieved in 31 (93.9%) of 33 patients with resolution of bowel obstruction within 3 d of stent removal. Eleven of the 33 patients died 73.81 ± 23.66 d (range 42-121 d) after removal of the stent without colonic re-obstruction. Clinical success was achieved in another 8 patients without symptoms of obstruction during the follow-up period. Reinsertion of the stent was performed in the remaining 12 patients with re-obstruction after 84.33 ± 51.80 d of follow-up. The mean and median periods of relief of obstructive symptoms were 97.25 ± 9.56 d and 105 ± 17.43 d, respectively, using Kaplan-Meier analysis.

CONCLUSION: Temporary SEMS is a safe and effective approach in patients with malignant colorectal obstruction due to low complication rates and good medium-term outcomes.

A new technique for placement of a self-expanding metallic stent (SEMS) in patients with colon rectal obstruction: a prospective study of 43 patients

BACKGROUND

Self-expanding metallic stent (SEMS) placement is a valid form of therapy for patients with obstructing colon rectal cancer. The procedure is not feasible for a minority of patients with a very low risk of bowel perforation. This report analyzes the results of a technical detail used for SEMS placement.

METHODS

In 43 patients with colon rectal obstruction, the SEMS apparatus was introduced through a guidewire passed above the obstruction in the channel of a pediatric nasogastroscope (diameter, 4.9 mm). The pediatric nasogastroscope was passed into the obstruction and above, allowing the anatomy of the colorectal lesion and the passage of the guidewire to be visualized directly.

RESULTS

The SEMS was inserted successfully in all cases without complications. In a previous series of 82 patients who had passage of the guidewire through the obstruction blindly, four technical failures occurred (nonsignificant difference).

CONCLUSIONS

A pediatric nasogastroscope can be useful for passing the colon rectal obstruction and guiding the passage of the guidewire under direct vision.

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction

BACKGROUND

The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.

METHODS

Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.

RESULTS

Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %.

CONCLUSIONS

In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Duodenal and colonic stent placement with 0.025″ and 0.035″ guidewires is equally safe and effective

BACKGROUND

The overwhelming majority of reported duodenal and colonic SEMS placements in the literature have used the 0.035″ guidewire almost to the exclusion of guidewires of other diameters.

AIMS

The purpose of this study was to compare technical and clinical outcomes in patients undergoing duodenal or colonic SEMS placement with 0.025″ or 0.035″ guidewires.

METHODS

This was a retrospective study to compare technical and clinical outcomes and complications of patients receiving duodenal or colonic SEMS placement with a 0.035″ guidewire to those undergoing placement with a 0.025″ guidewire.

RESULTS

A total of 34 duodenal and 30 colonic stent placement procedures were performed in 59 patients. Technical success was achieved in all duodenal stent placement procedures. The difference in mean GOOSS score increase after stent placement was not statistically significant between the 0.035″ and 0.025″ guidewire groups (P = 0.49). Complications were not statistically significantly different between the two groups undergoing gastroduodenal stenting. Technical and clinical success was achieved in all colonic stent placement procedures. There were no statistically significant differences in complication rates between the two groups undergoing colonic stenting. Procedure times were not significantly different using either wire type.

CONCLUSIONS

Our study shows that both 0.035″ and 0.025″ guidewires were equally effective with regards to technical success, clinical success, and with regards to the development of complications.

Dual-design expandable colorectal stent for a malignant colorectal obstruction: preliminary prospective study using new 20-mm diameter stents

Objective

To evaluate the safety and effectiveness of a 20-mm diameter dual-design expandable colorectal stent for malignant colorectal obstruction.

Materials and Methods

The study series included 34 patients with malignant colorectal obstruction who underwent implantation of a 20-mm dual-design expandable colorectal stent in our department between March 2009 and June 2010. The 20-mm dual-design expandable colorectal stent was placed by using a 3.8-mm delivery system that had 28-mm diameter proximal and distal ends. Among the 34 patients, stent placement for palliation was performed in 20 patients, while stent placement for bridge to surgery was performed in 14 patients.

Results

A 97% (33 of 34) success rate was achieved for the stent placement. The perforation rate in the bridge to surgery group was 7% (1 of 14), compared to 0% (0 of 19) in palliative group. Migration occurred in one of 33 patients (3%) at 30 days after stent placement.

Conclusion

The placement of a 20-mm diameter dual-design stent appears to be clinically safe and effective for the management of colorectal obstruction, with low perforation and migration rates.

Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction

BACKGROUND

Although self-expandable metal stent (SEMS) insertion is widely used for relief of malignant colorectal obstructions, the immediate technical and clinical failure rates of SEMSs and the associated risk factors remain largely unknown.

OBJECTIVE

To identify rates and factors predictive of technical and clinical failure of SEMSs when their use is attempted for the decompression of malignant colorectal obstruction.

DESIGN

Retrospective chart review.

SETTING

A tertiary-care academic medical center in South Korea.

PATIENTS

This study involved a total of 412 patients with malignant colorectal obstruction in whom SEMS insertion was attempted.

INTERVENTION

Placement of colonic SEMSs.

MAIN OUTCOME MEASUREMENTS

Technical success and immediate and long-term clinical success rates.

RESULTS

Technical and clinical failures were found in 36 of 276 patients (13.0%) and 39 of 240 patients (16.3%) in the palliative group, respectively, and in 3 of 136 patients (2.2%) and 7 of 133 patients (5.3%) in the preoperative group, respectively. Factors associated with technical failure were extracolonic origin of tumor, the presence of carcinomatosis, and a proximal obstruction site. Factors associated with long-term clinical failure in the palliative group were combined dilation procedure, no additional chemotherapy, and extracolonic origin of the tumor. In the preoperative group, only older patients had both higher technical failure and clinical failure rates.

LIMITATIONS

This was a single-institution, retrospective analysis.

CONCLUSION

Although colorectal SEMS placement is generally safe and effective, it is associated with clinically important technical and clinical failure rates. The identification of risk factors for the failure of colorectal SEMSs found in this study might help physicians decide between surgical decompression and endoscopic stenting in patients with malignant colorectal obstruction.

Metallic stent placement in the palliative treatment of malignant colonic obstructions: primary colonic versus extracolonic malignancies

PURPOSE

To compare retrospectively clinical outcomes in patients who underwent metallic stent placement for colonic obstruction caused by colonic or extracolonic malignancies.

MATERIALS AND METHODS

Palliative stent placement was performed for inoperable malignant colonic obstruction in 108 patients, including 58 for primary colorectal cancer and 50 for extracolonic malignancies including gastric (n = 31), pancreatic (n = 8), ovarian (n = 4), bladder (n = 2), bile duct (n = 1), gallbladder (n = 1), breast (n = 1), esophageal (n = 1), and renal (n = 1) cancers.

RESULTS

Technical (84% vs 94%, P = .137) and clinical (98% vs 96%, P = .533) success rates of stent placement were similar in patients with primary colorectal cancer and patients with extracolonic malignancies. Rates of perforation, stent migration, tumor overgrowth, bleeding, and pain did not differ significantly between groups of patients with primary colorectal cancer and extracolonic malignancies. The median symptom-free survival periods were 4 months in patients with primary colorectal cancer and 3 months in patients with extracolonic malignancies (P = .072).

CONCLUSIONS

Metallic stent placement was clinically effective in the palliative treatment of colonic obstructions in patients with primary colorectal cancer and patients with extracolonic malignancies.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Collagen levels are normalized after decompression of experimentally obstructed colon

AIM

Our aim was to define the dynamics in collagen concentrations in the large bowel wall following decompression of experimental obstruction.

METHOD

Colonic obstruction was created in 28 male rats by the placement of a silicone ring around the distal colon. The ring was removed after 4 days to mimic endoscopical decompression by stent deployment. Colon circumference and collagen concentration were measured proximal to the obstructed segment immediately and at 3 and 10 days after decompression. The corresponding colonic sites of 23 sham-operated and eight nonoperated control animals were subjected to identical analyses.

RESULTS

Four days of obstruction resulted in a more than twofold increase in colonic circumference (20 vs 8 mm), with a concomitant 43% reduction (P = 0.001) in collagen concentration in the bowel wall proximal to the obstruction compared with sham animals. Three days after decompression, collagen concentrations remained reduced (P < 0.05), while there was no significant difference after 10 days with either sham-operated or nonoperated controls. Colonic circumference of the obstructed colon remained slightly distended (11 mm) on day 10 and tended to correlate (r(S) = 0.51, P = 0.053) with total matrix metalloproteinase activity.

CONCLUSION

The marked reduction in collagen concentration in an experimentally obstructed colon is normalized 10 days after decompression. These findings may have clinical implications for the timing of surgical resection.

Long-term success of colonic stent insertion is influenced by indication but not by length of stent or site of obstruction

INTRODUCTION

Stent insertion plays an important part in the management of acute colonic obstruction. There are limited data on factors influencing short- and long-term success.

AIMS AND METHODS

We investigated indications, technical and clinical success rates, complication rates and the factors influencing them. Patients were identified from our prospective colonic stent database (2000-2008).

RESULTS

One hundred and four stents were attempted in 96 patients (technical success rate, 83.3%). Clinical short-term success was observed in 74 (77.1%) patients. Follow-up data available for 57 patients showed clinical long-term success in 77% (44/57). Multiple logistic regression analysis showed a significant decline in technical success over the study period (p = 0.041). Patients with colonic malignancy had significantly higher long-term success rates (81%), compared to those with extra-colonic malignancies (43%) (p = 0.049). Length of stent and site of obstruction were not significant factors. Early complications occurred in 10%, and late complications, in 26.3% of cases.

CONCLUSION

Colonic stent insertion provides symptom relief in over 70% when used as a long-term solution. Complication rates are high, and a significant minority of patients requires re-intervention. Obstruction caused by extra-colonic malignancy is far less likely to be permanently palliated by a stent, in comparison to colonic malignancy.

Colonic stents: the modern treatment of colonic obstruction

Colonic stents traditionally have been used for the management of colorectal cancer, either as a palliative treatment or as a bridge to surgery. More recently, colonic stents have also been advocated as part of the therapy of benign strictures. A number of colonic stents are available worldwide, four of which are made in the USA. These stents are classified as covered or uncovered, with similar clinical applications. Technical and clinical success rates are similar among these different stents, as well as the rate of complications, which mainly consist of obstruction and migration. The deployment systems utilize fluoroscopy, endoscopy, or both. More recently, stents became available that are deployed "through the scope" (TTS) making the procedure faster. However, this advance does not exclude the use of fluoroscopy, particularly in those cases where the direct visualization of the proximal end of the stricture is absent. The increasing experience in the management of colorectal cancer with colonic stents decreases the morbidity and mortality, as well as cost, in comparison with surgical intervention for acute colonic obstruction. Management with colonic stents can also rule out proximal synchronous lesions after initial decompression prior to definitive surgery. Benign conditions may also be treated with stents. A multidisciplinary approach for the use of colonic stents during assessment and management of acute colonic obstruction is necessary in order to achieve a satisfactory outcome, whether that be better quality of life or improved survival.

Colonic perforation after stent placement for malignant colorectal obstruction--causes and contributing factors

Self-expanding metal stents (SEMS) are used to manage malignant colorectal obstruction. Colonic perforation is the most worrisome complication from colonic stenting. We reviewed causes and contributing factors of perforation with colonic stent placement in patients with malignant colorectal obstruction. Articles from both English and foreign language publications were identified from Medline. Data were collected on causes, timing, treatment and mortality related to perforation. A total of 2287 patients from 82 articles were included in this analysis, which showed an overall perforation rate of 4.9%. Perforation rates for palliation and bridge to surgery (BTS) were not significantly different (4.8% vs. 5.4%, p = 0.66); over 80% occurred within 30 days of stent placement (half during or within one day of the procedure). The mortality rate related to perforation was 0.8% per stented patient, but the mortality of patients experiencing perforation was 16.2%. There was no significant difference (p = 0.78) in the mortality rates between the palliation and the BTS group and concomitant chemotherapy, steroids, and radiotherapy are risk factors of perforation. The overall perforation related mortality is far less than that of patients undergoing emergency surgery for bowel obstruction.

Update on the indications and use of colonic stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

Techniques and Outcomes of Endoscopic Decompression Using Transanal Drainage Tube Placement for Acute Left-sided Colorectal Obstruction

BACKGROUND

If it is possible, endoscopic decompression for acute left-sided colorectal obstruction will be effective in critically ill patients. This study was to evaluate the techniques and outcomes of transanal drainage tube placement following urgent colonoscopy in management of acute left-sided colorectal obstruction.

METHODS

From January 2000 to December 2009, 69 consecutive patients (36 males, age 38 to 94, mean = 71) were hospitalized because of acute left-sided colorectal obstruction. Urgent colonoscopy was performed within 12 hours of entry for diagnosis and treatment (mean time, 6.5 hours). Endoscopic decompression using a transanal drainage tube was attempted. Clinical success, methods used, and complications were retrospectively evaluated.

RESULTS

The cause of obstruction was colorectal carcinoma in 66 patients (96%). The site of obstruction was sigmoid colon in 37 (54%), rectum in 20 (29%), and descending colon in 12 (17%). Out of 69 patients, endoscopic decompression using the transanal drainage tube was successful in 66 (96%). The use of combination of transanal drainage tube and the equipped guidewire enabled endoscopic decompression was successful in 45 patients (65%), though a small-diameter upper endoscope was used in 2 patients to introduce the guidewire beyond the obstruction. Perforation during the placement developed in 2 patients and one patient was unsuccessful.

CONCLUSIONS

Transanal drainage tube placement following urgent colonoscopy was effective in the management of acute left-sided colorectal obstruction. In the majority of patients, the materials and methods used for the transanal drainage tube placement were simple and easy.

Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors

BACKGROUND

Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively.

OBJECTIVE

Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction.

DESIGN

Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008.

SETTING

Tertiary-care center.

PATIENTS

This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a "bridge to surgery."

INTERVENTION

Colonic SEMS placement.

MAIN OUTCOME MEASUREMENTS

Stricture location, stent-induced complications, time to adverse events, need for reintervention.

RESULTS

Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter < or = 22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation.

LIMITATIONS

Retrospective analysis, single institution.

CONCLUSION

Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.

Does stent placement for advanced colon cancer increase the risk of perforation during bevacizumab-based therapy?

BACKGROUND & AIMS

Data on the safety of bevacizumab-based therapies for patients carrying a self-expandable metallic stent (SEMS) for occlusive colon cancer are lacking. We report 2 cases of colon perforation observed in our case series of patients with SEMS for occlusive colon cancer.

METHODS

Patients with occlusive symptoms caused by colon cancer received a colonic stent under endoscopic and radiologic guidance.

RESULTS

Over a 10-month period, 28 patients with occlusive colon cancer were treated with stent placement. The stent was placed as a bridge to surgery in 12 patients who were treated surgically within 4 to 78 days after the endoscopic procedures, without any stent-related complications. Seven patients did not receive any other antitumor treatment as a result of concomitant comorbidities. Nine patients with both primary tumor and metastatic lesions were treated with medical therapy. Over a median follow-up period of 131 days colonic perforation occurred in the 2 patients treated with a combination of capecitabine and oxaliplatin plus bevacizumab.

CONCLUSIONS

Further studies are needed to clarify whether SEMS placement increases the risk of perforation caused by bevacizumab-based therapies.

Dual-design expandable colorectal stent for malignant colorectal obstruction: comparison of flared ends and bent ends

OBJECTIVE

The purpose of this study was to compare, focusing on colonic perforation and stent migration, the clinical safety and efficacy of dual-design expandable colorectal stents with flared ends with those of stents with bent ends in the treatment of patients with malignant colorectal obstruction.

SUBJECTS AND METHODS

A total of 122 patients with malignant colorectal obstruction underwent implantation of dual-design stents with flared (n = 69) or bent (n = 53) ends.

RESULTS

Stent placement was technically successful in 116 of 122 patients (95.1%), 65 of 69 patients (94.2%) with flared-end stents and 51 of 53 patients (96.2%) with bent-end stents (p > 0.05). Clinical success was achieved within 2 days in 61 of 65 patients (93.8%) with bent-end stents and in 46 of 51 patients (90.2%) with flared-end stents (p > 0.05). Complications included seven cases of colonic perforation (6%), seven cases of stent migration (6%), three cases of tumor overgrowth (2.6%), four cases of severe rectal pain (3.4%), and four cases of bleeding (3.4%). There were no significant differences between the rates of colonic perforation and stent migration in the two groups (6.2% vs 5.9%), and the overall complication rates were similar (p > 0.05).

CONCLUSION

Dual-design expandable colorectal stents with flared ends and those with bent ends are equally safe and effective, having similar perforation and migration rates.

Side-viewing endoscope for colonic self-expandable metal stenting in patients with malignant colonic obstruction

Malignant colon obstruction is a medical emergency and endoscopic decompression, achieved by self-expandable metal stent placement, has been broadly used for both palliation in patients with advanced, nonresectable carcinoma and as a bridge to surgery in those patients with resectable disease. We propose stent insertion assisted by a side-viewing endoscope, in sharply angulated and remarkably stenotic lesions located at the distal sigmoid. Endoscopists should consider, at least for lesions situated in the distal colon, the insertion of a side-viewing endoscope for stenting of technically difficult cases of malignant intestinal obstruction.

Management of acute malignant colorectal obstruction with a novel self-expanding metallic stent as a bridge to surgery

PURPOSE

To prospectively evaluate the safety and clinical efficacy of a newly designed self-expandable metallic stent (SEMS) in the treatment of patients with acute malignant colorectal obstruction.

METHODS

Between April 2001 and October 2007, 52 patients with acute malignant colorectal obstruction were treated with a new designed SEMS as an investigational bridge to surgery. Patients were prospectively followed and relevant data collection was collected, including details regarding technique, clinical symptoms, complications, need for elective surgery, and overall survival.

RESULTS

Stent placement was technically successful in all but two patients (due to complete obstruction) with no procedure-related complications. Complications included stent migration (n=4), anal pain (n=2) and stool impaction (n=1). Clinical success was achieved in 49 (98%) of 50 patients with resolution of bowel obstruction within 2 days of stent placement. In one patient with stool impaction 2 days after stent placement, endoscopic disimpaction was successfully performed. An elective one-stage surgical procedure was performed in all 50 patients who successfully received a SEMS as a bridge to surgery within a mean of 8+/-2 days (range: 4-11 days) after stent placement. Mean follow-up time was 36+/-12 months (range 3-70 months), and all patients remained alive at the time of this report.

CONCLUSION

The newly designed SEMS placement as a bridge to surgery was a safe and effective intervention for colonic decompression in patients with acute malignant colorectal obstruction and allowed a high proportion of patients to be successfully proceeded to elective surgery.