Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

Upfront Surgery vs. Endoscopic Stenting Bridge to Minimally Invasive Surgery for Treatment of Obstructive Left Colon Cancer: Analysis of Surgical and Oncological Outcomes

BACKGROUND

Left colon cancer obstruction treatment is a debated topic in the literature. Stent placement is effective as a bridge-to-surgery strategy, but there are some concerns about the oncological safety for the reported higher risk of local and peritoneal recurrence. This study aims to compare the surgical and oncological outcomes of patients treated with stent followed by elective surgery with those treated with primary resection.

METHODS

This is a retrospective observational study. We included patients of both sexes, ≥18 years old, with a histological diagnosis of intestinal adenocarcinoma, and admitted to our hospital for left colon cancer obstruction demonstrated by CT scan without metastasis or perforation. They were treated through primary resection (PR) or stent placement followed by elective surgery (SR). The two groups were compared for general characteristics, surgical outcomes, and oncological outcomes (metastasis and local recurrence) at 30 days, 90 days, 1 year, and 3 years. Post-operative quality of life (QoL) was also investigated.

RESULTS

The SR group showed a shorter hospital stay, a lower post-operative mortality, a lower stoma rate at 1 year, and a higher number of minimally invasive procedures. Oncological outcomes were not different compared to the PR group. The SR group demonstrated better QoL in two out of six items on the EQ-5D-5L test.

CONCLUSIONS

Stent placement as a bridge-to-surgery strategy is feasible and provides better surgical outcomes in terms of post-operative complications, surgical approach, stoma rate, and QoL. Oncological outcomes were not reported differently, but further studies should be conducted to better evaluate this aspect.

The use of self-expanding metallic stents in the management of benign colonic obstruction: a systematic review and meta-analysis

INTRODUCTION

Patients presenting with large bowel obstruction (LBO) frequently undergo emergency surgery that is associated with significant morbidity. In malignant LBO, endoscopic approaches with placement is a self-expanding metal stent (SEMS), have been proposed to prevent emergency surgery and act as a bridge to an elective procedure-with the intention of avoiding a stoma and reducing morbidity. This systematic review aims to assess the quality and outcomes of data available on the use of SEMS in benign causes of colonic obstruction.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered on Prospero (ID: CRD42021239363). PUBMED, MEDLINE, HMIC, CINAHL, AMED, EMBASE, APA and Cochrane databases were searched. Studies were assessed for quality utilising the MINORS criteria. Pooled odds ratios with 95% confidence intervals (95% CI) were calculated using random effects models.

RESULTS

Sixteen studies were included for analysis. 300 patients were included with an average age of 68, and a male predominance of 57%. The quality of the papers included were at risk of bias. The pooled rate of technical success of procedure was 94.4% (95% CI 90.5-96.8%) The pooled rate of clinical success was 77.6% (95% CI: 66.6-85.7%). Adverse effects were low, with perforation 8.8% (4.5-16.6%), recurrence 26.5% (17.2-38.5%) and stent migration 22.5% (14.1-33.8%).

DISCUSSION

This systematic review demonstrated that SEMS for benign colonic obstruction can be a safe and successful procedure. The utilisation of SEMS in malignant disease as a bridge to surgery has been well documented. Whilst the limitations of the data interpreted are appreciated, we postulate that SEMS could be utilised to decompress patients acutely and allow pre-operative optimisation, leading to a more elective surgery with less subsequent morbidity.

Colon stenting as a bridge to surgery in obstructive colorectal cancer management

Colonic stent placement is a commonly used bridging strategy for surgery in patients with obstructive colorectal cancer. The procedure involves the placement of a self-expandable metallic stent (SEMS) across the obstructive lesion to restore intestinal patency and alleviate the symptoms of obstruction. By allowing patients to receive surgery in a planned and staged manner with time for preoperative optimization and bowel preparation, stent placement may reduce the need for emergency surgery, which is associated with higher complication rates and poorer outcomes. This review focuses on the role of colon stenting as a bridge to surgery in the management of obstructive colorectal cancer. SEMS as a bridge to surgery for left-sided colon cancer has been demonstrated to be particularly useful; however, further research is needed for its application in cases of right-sided colon cancer. Colon stent placement also has limitations and potential complications including stent migration, re-obstruction, and perforation. However, the timing of curative surgery after SEMS placement remains inconclusive. Considering the literature to date, performing surgery at an interval of approximately 2 weeks is considered appropriate. Therefore, colonic stent placement may be an effective strategy as a bridge to surgery in patients with obstructive colorectal cancer.

Colonic Resection, Stoma, or Self-expanding Metal Stents for Obstructive Left Colon Cancer: the CROSCO-1 study protocol

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes.

METHODS

CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC.

RESULTS

The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

CONCLUSIONS

The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

Influence of endoscopists' expertise level on clinical outcomes after bridge-to-surgery stenting in obstructive colorectal cancer

BACKGROUND AND AIM

This study aimed to investigate the effect of stenting-related factors, including endoscopists' expertise, on clinical outcomes after bridge-to-surgery (BTS) stenting for obstructive colorectal cancer (CRC).

METHODS

We analyzed BTS stenting-related factors, including stenting expertise and the interval between stenting and surgery, in 233 patients (63 [13] years, 137 male) who underwent BTS stenting for obstructive CRC. We evaluated the influence of these factors on post-BTS stenting clinical outcomes such as stent-related complications and cancer recurrence.

RESULTS

The interval between stenting and surgery was ≤ 7 days in 79 patients (33.9%) and > 7 days in 154 patients (66.1%). BTS stenting was performed by endoscopists with ≤ 50, 51-100, and > 100 prior stenting experiences in 94, 43, and, 96 patients, respectively. The clinical success rate of BTS stenting was 93.1%. Stent-related and postoperative complications developed in 19 (8.2%) and 20 (8.6%) patients, respectively. Cancer recurrence occurred in 76 patients (32.6%). Short BTS interval of ≤ 7 days increased the risk of postoperative complications (odds ratio [OR], 2.61 [1.03-6.75]; P = 0.043). Endoscopists' stenting experience > 100 showed greater clinical success of stenting (OR, 5.50 [1.45-28.39]; P = 0.021) and fewer stent-related complications (OR, 0.26 [0.07-0.80]; P = 0.028) compared with stenting experience ≤ 50. BTS stenting-related factors did not affect long-term oncological outcomes.

CONCLUSION

Greater expertise of endoscopists was associated with better short-term outcomes, including high stenting success rate and low rate of stent-related complications after BTS stenting for obstructive CRC. An interval of > 7 days between BTS stenting and surgery was required to decrease postoperative complications.

Short-term Outcomes of Elective Surgery Following Self-Expandable Metallic Stent and Neoadjuvant Chemotherapy in Patients With Left-Sided Colon Cancer Obstruction

BACKGROUND

Colonic stenting reduces morbidity and stoma formation for left-sided colon cancer obstruction, and a prolonged interval between stenting and surgery with neoadjuvant chemotherapy administered might result in a lower stoma rate and tumor reduction.

OBJECTIVE

The study aimed to evaluate the short-term outcomes of elective surgery following colonic stenting compared with elective surgery following colonic stenting and neoadjuvant chemotherapy in patients with left-sided colon cancer obstruction.

DESIGN

This is a prospective multicenter cohort study.

SETTINGS

This study was conducted at 5 medical centers.

PATIENTS

Patients ( n = 100) with acute left-sided colon cancer obstruction undergoing colonic stenting between December 2015 and December 2019 were included.

INTERVENTIONS

Patients were assigned to the stenting-alone or chemotherapy group.

MAIN OUTCOME MEASURES

The primary outcomes measured were laparoscopic surgery and stoma rate.

RESULTS

Of the 100 patients who underwent colonic stenting, 52 were assigned to the stenting group and 48 were assigned to the chemotherapy group. No statistically significant differences were detected in stent-related complications. The adverse events associated with neoadjuvant chemotherapy were well tolerated. The level of hemoglobin (117.2 vs 107.6 g/L; p = 0.008), albumin (34.2 vs 31.5 g/L; p < 0.001), and prealbumin (0.19 vs 0.16 g/L; p = 0.001) was significantly increased, and the bowel wall thickness (1.09 vs 2.04 mm; p < 0.001) was significantly decreased preoperatively in the chemotherapy group compared with the stenting group. The number of mean harvested lymph nodes was greater in the chemotherapy group than in the stenting group (25.6 vs 21.8; p = 0.04). Laparoscopic surgery was performed more frequently (77.1% vs 40.4%; p < 0.001) and a stoma was created less frequently (10.4% vs 28.8%; p = 0.02) in the chemotherapy group than in the stenting group.

LIMITATIONS

This trial was limited by the nonrandomized design and a short follow-up period.

CONCLUSIONS

This study suggests that elective surgery following neoadjuvant chemotherapy and colonic stenting is a safe, effective, and well-tolerated treatment approach with a high laparoscopic resection rate and a low stoma rate. See Video Abstract at http://links.lww.com/DCR/B980 .

RESULTADOS A CORTO PLAZO DE LA CIRUGA ELECTIVA SEGUIDO DE STENT METLICO AUTOEXPANDIBLE Y QUIMIOTERAPIA NEOADYUVANTE EN PACIENTES CON OBSTRUCCIN POR CNCER DE COLON IZQUIERDO

ANTECEDENTES:La colocación de stents colónicos reduce la morbilidad y la formación de estomas por obstrucción por cáncer de colon izquierdo, y el intervalo prolongado entre la colocación de stents y la cirugía con quimioterapia neoadyuvante administrada podría resultar en una menor tasa de estomas y reducción del tumor.OBJETIVO:Evaluar los resultados a corto plazo de la cirugía electiva después de la colocación de stent en el colon en comparación con la cirugía electiva después de la colocación de stent en el colon y la quimioterapia neoadyuvante en pacientes con obstrucción por cáncer de colon izquierdo.DISEÑO:Estudio prospectivo de cohorte multicéntrico.ENTORNO CLINICO:Este estudio se realizó en 5 centros médicos.PACIENTES:Se incluyeron pacientes (n=100) con obstrucción aguda por cáncer de colon izquierdo que se sometieron a colocación de stent colónico entre diciembre de 2015 y diciembre de 2019.INTERVENCIONES:Los pacientes fueron asignados al grupo de stent solo o quimioterapia.MEDIDAS DE RESULTADO PRINCIPALES:Los resultados primarios medidos fueron la cirugía laparoscópica y la tasa de ostomía.RESULTADOS:De los 100 pacientes que se sometieron a la colocación de stent colónico, 52 fueron asignados al grupo de colocación de stent y 48 al grupo de quimioterapia. No se detectaron diferencias estadísticamente significativas en las complicaciones relacionadas con el stent. Los eventos adversos asociados con la quimioterapia neoadyuvante fueron bien tolerados. Hemoglobina (117,2 g/l vs. 107,6 g/l; p = 0,008), albúmina (34,2 g/l vs. 31,5 g/l; p < 0,001) y prealbúmina (0,19 g/l vs. 0,16 g/l; p = 0,001) aumentaron significativamente y el grosor de la pared intestinal (1,09 mm vs. 2,04 mm; p < 0,001) disminuyó significativamente antes de la operación en el grupo de quimioterapia en comparación con el grupo de colocación de stent. El número medio de ganglios linfáticos extraídos fue mayor en el grupo de quimioterapia que en el grupo de stent (25,6 vs. 21,8; p = 0,04). La cirugía laparoscópica se realizó con mayor frecuencia (77,1 % vs. 40,4 %; p < 0,001) y se creó un estoma con menos frecuencia (10,4 % vs. 28,8 % ; p = 0,02) en el grupo de quimioterapia que en el grupo de colocación de stent.LIMITACIONES:Este ensayo estuvo limitado por el diseño no aleatorio y el corto período de seguimiento.CONCLUSIONES:Este estudio sugiere que la cirugía electiva después de la quimioterapia neoadyuvante y la colocación de stent colónico es un tratamiento seguro, efectivo y bien tolerado, con una alta tasa de resección laparoscópica y una baja tasa de estoma. Consulte Video Resumen en http://links.lww.com/DCR/B980 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Colorectal cancer treatment guidelines and shared decision making quality and reporting assessment: Systematic review

INTRODUCTION

Physicians must share decisions and choose personalised treatments regarding patients´ beliefs and values.

OBJECTIVE

To analyse the quality of the recommendations about shared decision making (SDM) in colorectal (CRC) and anal cancer treatment clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Guidelines were systematically reviewed following prospective registration (Prospero: CRD42021286146) without language restrictions searching 15 databases and 59 professional society websites from January 2010 to November 2021. A validated 31-item SDM quality assessment tool was employed to extract data in duplicate.

RESULTS

We identified 134 guidelines. Only 46/134 (34.3 %) mentioned SDM. Fifteen (11.1 %) made clear, precise and actionable recommendations, while 9/134 (6.7 %) indicated the strength of the SDM-related recommendations. CPGs underpinned by systematic reviews reported SDM more often than those based on consensus or reviews (35.9 % vs 32.0 %; p = 0.031). Guidelines that reported following quality tools (i.e., AGREE II) more commonly commented about SDM than when it was not reported (75.0 % vs 32.0 %; p = 0.003).

CONCLUSION AND PRACTICE IMPLICATIONS

Most of the CRC and anal treatment guidelines did not mention SDM and it was superficial. Guidelines based on systematic reviews and those using quality tools demonstrated better reporting of SDM. Recommendations about SDM in these guidelines merit urgent improvement.

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis

BACKGROUND

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated.

OBJECTIVE

The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer.

DATA SOURCE

A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included.

INTERVENTION

Stent or emergency resection in right-sided obstructive colon cancer.

MAIN OUTCOME MEASURES

Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent.

RESULTS

A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016).

LIMITATION

No randomized controlled trials are available.

CONCLUSION

Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis

BACKGROUND

Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent.

METHODS

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed.

RESULTS

From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01).

CONCLUSIONS

Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

Stent as bridge to surgery decreases postoperative complications without worsening oncological outcomes: retrospective unicentric cohort study and stent placement protocol

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.

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.

Self-expandable metallic stents as a bridge to surgery in obstructive right- and left-sided colorectal cancer: a multicenter cohort study

The insertion of a self-expandable metal stent (SEMS) has been proposed as an alternative to emergent surgery (ES) for obstructive colorectal cancer (CRC). We aimed to evaluate the perioperative and oncologic outcomes of SEMS as a bridge to surgery in obstructive CRC, as compared with ES. We retrospectively reviewed the medical records of patients who underwent curative resection of obstructive CRC at four Hallym University-affiliated hospitals between January 2010 and December 2019. All patients were analyzed overall colon, then according to the side of obstruction (overall, right or left). Of 167 patients, 52 patients underwent ES and 115 underwent SEMS insertion and surgery (SEMS group). The postoperative hospital stay and time to soft diet were shorter in the SEMS group than in the ES group for overall and both sided cancer. The SEMS group had lower rates of stoma formation and severe complications for overall and for left-sided cancer. The 5-year overall survival (P = 0.682) and disease-free survival (P = 0.233) rates were similar in both groups. SEMS insertion as a bridge to surgery was associated with faster recovery, a lower rate of stoma formation with similar oncologic outcomes to those of ES.

Short- and long-term outcomes following bridge to surgery and emergency resection in acute malignant large bowel obstruction

AIM

Bridge to surgery (BtS) aims to decrease perioperative morbidity and mortality in emergency resection (ER) of the colon. Previous results are inconsistent, and long-term comparisons are scarce. The aim of this study was to compare the short- and long-term outcomes of BtS and ER.

METHOD

This retrospective study examined data from the Swedish Colorectal Cancer Registry for patients treated for acute malignant large bowel obstruction from 2007 to 2009. Patients were grouped by treatment strategy: BtS (using a self-expanding metallic stent or diverting stoma) or ER. Medical records were scrutinized for all patients in the BtS group. The primary endpoints were 5-year overall survival (OS) and 3-year recurrence-free survival (RFS). The secondary endpoints were postoperative mortality and morbidity rates and stoma permanence.

RESULTS

Overall, 143 patients were treated using BtS versus 1302 patients treated with ER. The 5-year OS was higher in the BtS group than in the ER group (53.8% vs. 37.4%; p < 0.05). No difference was noted in the 3-year RFS (75.7% vs. 75.0%; p = 0.38). The postoperative mortality rate was lower in the BtS group than in the ER group (0.7% vs. 7.3%; p < 0.05). Complications occurred in 46.9% of patients in the BtS group (both procedures) versus 35.9% of patients in the ER group (p < 0.05); the rate of severe complications was 23.1% and 16.9%, respectively (p = 0.07).

CONCLUSION

This retrospective population-based registry study showed higher long-term survival and lower postoperative mortality rates among patients treated with BtS versus ER for acute malignant large bowel obstruction.

Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: Current evidence and prospects

Approximately 7%-29% of patients with colorectal cancer present with colonic obstruction. The concept of self-expandable metal stent (SEMS) insertion as a bridge to surgery (BTS) is appealing. However, concerns on colonic stenting possibly impairing oncologic outcomes have been raised. This study aimed to review current evidence on the short- and long-term oncologic outcomes of SEMS insertion as BTS for left-sided malignant colonic obstruction. For short-term outcomes, colonic stenting facilitates a laparoscopic approach, increases the likelihood of primary anastomosis without a stoma, and may decrease postoperative morbidity. However, SEMS-related perforation also increases local recurrence and impairs overall survival. Moreover, colonic stenting may cause negative oncologic outcomes even without perforation. SEMS can induce shear forces on the tumor, leading to increased circulating cancer cells and aggressive pathological characteristics, including perineural and lymphovascular invasion. The conflicting evidence has led to discordant guidelines. Well-designed collaborative studies that integrate both oncologic outcomes and data on basic research (e.g., alteration of circulating tumors) are needed to clarify the actual benefit of colonic stenting as BTS.

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

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.

Over-the-catheter endoscope replacement for stenting in patients with inaccessible malignant colonic obstruction with coexisting peritoneal carcinomatosis

Although a large-caliber endoscope (LCE) is indispensable for through-the-scope placement of a self-expandable metallic stent (SEMS) in patients with malignant colonic obstruction (MCO), inaccessibility of the target obstructing lesion (TOL) by the endoscope is a significant cause of unsuccessful procedures. We herein present a novel salvage procedure when the TOL is not directly accessible by an LCE in conditions such as coexisting peritoneal carcinomatosis involving the colon. The salvage procedure, termed over-the-catheter endoscope replacement (OCER), starts with an ultraslim endoscope suitable for deep insertion beyond a tortuous colon for traversing a guidewire through the TOL. The ultraslim endoscope is then withdrawn and replaced by an LCE through the following steps. An endoscopic retrograde cholangiopancreatography catheter is preloaded in the LCE, the catheter alone is passed over the guidewire already traversed through the TOL, and the LCE is navigated over the catheter as far as possible toward the TOL to deliver the SEMS delivery system in a standard through-the-scope manner or further in an over-the-wire manner even if LCE insertion is incomplete. Among the 165 patients with MCO who underwent stenting during our study period, OCER led to successful procedures in all nine patients whose TOLs were initially inaccessible because of colon-involving peritoneal carcinomatosis. By utilizing the functions of distinctive endoscopes in a unique and complementary way, OCER can be a practical salvage option for challenging cases of MCO that are highly prone to unsuccessful palliation by conventional SEMS placement.

Self-Expandable Metal Stent as a Bridge to Surgery for Left-Sided Acute Malignant Colorectal Obstruction: Optimal Timing for Elective Surgery

OBJECTIVES

This randomized, single-center, retrospective, comparative cohort study is aimed at investigating the optimal time interval from self-expandable metal stent (SEMS) placement to surgery and potential risk factors for complications in patients with acute malignant colorectal obstruction.

METHODS

A total of 64 patients with left-sided acute malignant colorectal obstruction treated with SEMS placement and subsequent surgery between January 2013 and September 2020 were enrolled and allocated to a case group (SEMS placing time ≤ 14 days; n = 19 patients) and a control group (SEMS placing time > 14 days; n = 45 patients). The primary outcome was the difference in baseline information, patients' conditions during surgery, and postoperative conditions between the two groups. The secondary outcome included potential risk factors of postoperative complications. The propensity score matching (PSM) and super learner (SL) methods were used to eliminate multiple confounding factors of baseline data. A cohort of 21 samples was used for external validation, comprising 6 cases and 15 controls.

RESULTS

A significant difference was observed between the two groups in intraoperative blood loss (P = 0.009), postoperative hospital stay (P = 0.002), postoperative complications (Clavien-Dindo grading ≥ II) (P < 0.001), stoma creation (P < 0.001), and primary anastomosis (P < 0.001). After a 1 : 3 PSM analysis, no statistically significant differences between eight confounding variables of the two groups were observed (P > 0.05). Caliper set as 0.2 multiple logistic regression analysis showed that the potential risk factor for postoperative complications was SEMS placing time (RR = 0.109, 95% confidence interval (CI) = 0.028-0.433; P = 0.002), indicating that SEMS placing time > 14 days was an independent risk factor for postoperative complications in bridge-to-surgery (BTS) setting. The area under the AUC curve was 76.7% and validated using the validation cohort.

CONCLUSIONS

Long duration of SEMS placement (>14 days) may not influence surgical difficulty but could increase the risk of postoperative complications.

Upfront surgery versus self-expanding metallic stent as bridge to surgery in left-sided colonic cancer obstruction: A multicenter observational study

BACKGROUND

Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction.

METHODS

This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence.

RESULTS

A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups.

CONCLUSION

Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.

MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer

PURPOSE

To provide evidence-based recommendations on the management of malignant bowel obstruction (MBO) for patients with advanced cancer.

METHODS

The Multinational Association for Supportive Care in Cancer (MASCC) MBO study group conducted a systematic review of databases (inception to March 2021) to identify studies about patients with advanced cancer and MBO that reported on the following outcomes: symptom management, bowel obstruction resolution, prognosis, overall survival, and quality of life. The review was restricted to studies published in English, but no restrictions were placed on publication year, country, and study type. As per the MASCC Guidelines Policy, the findings were synthesized to determine the levels of evidence to support each MBO intervention and, ultimately, the graded recommendations and suggestions.

RESULTS

The systematic review identified 17,656 published studies and 397 selected for the guidelines. The MASCC study group developed a total of 25 evidence-based suggestions and recommendations about the management of MBO-related nausea and vomiting, bowel movements, pain, inflammation, bowel decompression, and nutrition. Expert consensus-based guidance about advanced care planning and psychosocial support is also provided.

CONCLUSION

This MASCC Guideline provides comprehensive, evidence-based recommendations about MBO management for patients with advanced cancer.

Laparoscopic resection after self-expanding stent insertion for obstructive left-sided colorectal cancer: Clinicopathological features and outcomes

BACKGROUND AND OBJECTIVE

Laparoscopic resection for obstructive colon cancer (CC) after insertion of self-expanding metallic stents (SEMSs) is reportedly difficult. However, this has not yet been thoroughly investigated. Therefore, we investigated the influence of SEMS insertion on laparoscopic resection.

METHODS

This retrospective comparative study included 87 patients with obstructive left-sided CC (December 2011-December 2019). Patients were assigned to two groups based on elective laparoscopic surgery for (1) obstructive CC necessitating emergent decompression with SEMS insertion (SEMS group) and (2) obstructive CC without emergent decompression (control group).

RESULTS

The SEMS group had a longer operation time (283.3 ± 79.3 min vs 222.2 ± 79.4 min, P = 0.002) and greater blood loss (204.8 ± 417.6 mL vs 53.7 ± 166.1 mL, P = 0.029) on univariate analysis; however, in multiple linear regression analysis, SEMS was not an independent risk factor for both operation time (Δ operation time 25.5 min: P = 0.19) and blood loss (Δ blood loss 33.6 mL: P = 0.58). The complication rate based on Clavien-Dindo grade II did not differ significantly (17% vs 20%, P = 1.00), whereas the rates of conversion to laparotomy (17% vs 2%, P = 0.016) and stoma creation (26% vs 2%, P = 0.001) were higher in the SEMS group. In oncological outcomes, there was no intergroup difference in the 5-year disease-free survival (80.0% vs 72.2%, P = 0.76) and overall survival (100% vs 86.3%, P = 0.25).

CONCLUSIONS

Laparoscopic surgery after SEMS for left-sided CC is demanding due to higher conversion rates to open surgery. However, this study also revealed that it is as safe as laparoscopic surgery for cases without SEMS because of comparable complication rate and long-term outcomes.

Transanal decompression tube is superior to self-expandable metallic colonic stent for malignant colorectal obstruction: a retrospective study

BACKGROUND

The surgical management of left-sided malignant large bowel obstruction (MLBO) is associated with high morbidity and mortality. Recently, self-expandable metallic colonic stent (SEMS) and transanal decompression tube (TDT) used as a 'bridge to surgery' (BTS) have been widely used. This study aims to compare the clinical outcomes and oncological safety of SEMS and TDT as BTS to transform MLBO into elective surgery.

METHODS

Between February 2013 and March 2019, 62 patients with MLBO received SEMS (n = 32) or TDT (n = 30), and elective one-stage surgery later. We evaluated decompression efficiency and oncological safety in selective operation in TDT and SEMS groups, including preoperative preparation time, surgical approach, number of lymphatic dissection and vascular invasion, ulcer formation and histopathological findings of resected specimens.

RESULTS

The preoperative preparation time in the SEMS group was shorter than that of the TDT group (P < 0.05). However, there was no significant difference between the groups in postoperative length of hospital stay (P > 0.05). The number of vascular invasions in the TDT group was less than that in the SEMS group (P < 0.05). Furthermore, the risk of wound abscess and ulcer formation in the TDT group was significantly lower than that in the SEMS group (P < 0.05).

CONCLUSION

Our findings suggest that SEMS is associated with a relatively poor oncological outcome and the placement of TDT as BTS in MLBO patients may be a better alternation.

Is stent insertion for obstructing colon cancer a good prognostic factor in long-term oncologic outcomes in symptomatic obstructive colon cancer?

Although obstructive colon cancer can often be treated with first-stage resection with primary anastomosis, the results of the oncological outcome of using stenting as a bridge of surgery in the literature are still controversial. Stent insertion for obstructed cancer provides an opportunity for bowel preparation and makes preoperative work-up and clinical staging possible. However, although stenting is becoming a more frequent treatment modality, studies with a significant number of patients acting as a bridge between surgery are still lacking. In this issue of Journal of Minimally Invasive Surgery, the study by Kim et al. highlights the efficacy of stent insertion as the initial treatment and analyzed the prognostic factors in symptomatic obstructive colon cancer. The study demonstrated that emergent surgery, vascular invasion, and omitting adjuvant chemotherapy were independent poor prognostic factors in long-term oncologic outcomes suggested that stent insertion should be considered an initial treatment for symptomatic obstructive colon cancer.

Considerations in the Management of Malignant Bowel Obstruction

Malignant bowel obstruction is a challenging clinical problem encountered in patients with advanced abdominal and pelvic malignancies. Although medical therapies form the foundation of management, some patients may be suitable candidates for surgical and procedural interventions. The literature is composed primarily of retrospective single-institution experiences and the results of prospective trials are pending. Given the high symptom burden and limited life expectancy of these patients, management may be best informed by multidisciplinary teams with relevant expertise.

Emergency Management of Obstructive Colorectal Cancer - A Retrospective Study of Efficacy and Safety in Self-expanding Metallic Stents and Trans-anal Tubes

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.

Ultrathin colonoscopy can improve complete preoperative colonoscopy for stenotic colorectal cancer: Prospective observational study

OBJECTIVES

Preoperative colonoscopy is often incomplete for stenotic colorectal cancers (CRC). This prospective observational study aimed to evaluate the ability of an ultrathin colonoscope (UTC) to inspect the whole colon by passing through the stenotic CRC.

METHODS

All patients who underwent preoperative colonoscopy for stenotic CRCs at Shizuoka Cancer Center were examined for eligibility. If a standard colonoscope (PCF-H290ZI) could not pass because of a stenosis, the patients were recruited. All of the eligible patients were prospectively enrolled when informed consent could be obtained, and complete colonoscopy was attempted again using an UTC (PCF-PQ260L). Patients with stent placement and those requiring right hemicolectomy were not recruited. Primary endpoints were pass-through and cecal intubation rates. The detected synchronous neoplasias (adenomas and cancers) and their pathological findings after resection were evaluated.

RESULTS

A total of 100 patients were enrolled between September 2017 and February 2019. The mean age was 65.6 ± 10.8 years, and 59% were male. The pass-through and cecal intubation rates were 67% (67/100) and 58% (58/100), respectively. Synchronous lesions located proximal to the stenoses were detected in 65.5% (38/58) of the complete colonoscopies, with a total of 86 lesions, including 18 advanced neoplasias with three invasive cancers.

CONCLUSION

When standard colonoscopy cannot pass through stenotic CRC, ultrathin colonoscopy can be considered as an option to inspect the whole colon proximal to the stenosis because treatment strategy can potentially be changed by detecting synchronous neoplasias proximal to the stenosis before surgery. (UMIN000028505).

Long-term survival after self-expanding metallic stent or stoma decompression as bridge to surgery in acute malignant large bowel obstruction

Aim

Self-expanding metallic stents (SEMS) as bridge to surgery have been questioned due to the fear of perforation and tumour spread. This study aimed to compare SEMS and stoma as bridge to surgery in acute malignant large bowel obstruction in the Swedish population.

Method

Medical records of patients identified via the Swedish Colorectal Cancer Register 2007–2009 were collected and scrutinized. The inclusion criterion was decompression intended as bridge to surgery due to acute malignant large bowel obstruction. Patients who underwent decompression for other causes or had bowel perforation were excluded. Primary endpoints were 5-year overall survival and 3-year disease-free survival. Secondary endpoints were 30-day morbidity and mortality rates.

Results

A total of 196 patients fulfilled the inclusion criterion (SEMS, 71, and stoma, 125 patients). There was no significant difference in sex, age, ASA score, TNM stage and adjuvant chemotherapy between the SEMS and stoma groups. No patient was treated with biological agents. Five-year overall survival was comparable in SEMS, 56 per cent (40 patients), and stoma groups, 48 per cent (60 patients), P = 0.260. Likewise, 3-year disease-free survival did not differ statistically significant, SEMS 73 per cent (43 of 59 patients), stoma 65 per cent (62 of 95 patients), P = 0.32. In the SEMS group, 1.4 per cent (one patient) did not fulfil resection surgery compared to 8.8 per cent (11 patients) in the stoma group (P = 0.040). Postoperative complication and 30-day postoperative mortality rates did not differ, whereas the duration of hospital stay and proportion of permanent stoma were lower in the SEMS group.

Conclusion

This nationwide registry-based study showed that long-term survival in patients with either SEMS or stoma as bridge to surgery in acute malignant large bowel obstruction were comparable. SEMS were associated with a lower rate of permanent stoma, higher rate of resection surgery and shorter duration of hospital stay.

Endoscopic Management of Bowel Obstruction

The traditional morbidity and mortality associated with traditional management has stimulated exploration of endoscopic approaches. Success depends on patient selection, the location and etiology of obstruction, patient status, and the capability of the endoscopist. This article discusses techniques of intralumenal dilation and stent placement and results from systematic reviews.

Appraisal of the Current Guidelines for Management of Malignant Left-Sided Colonic Obstruction Using the Appraisal of Guidelines Research and Evaluation II Instrument

INTRODUCTION

Colorectal cancer (CRC) is the fourth leading cause of death with 1.4 million new cases occurring annually worldwide. High-quality clinical practice guidelines are needed to tailor high-quality individualized treatment. The aim of the present study was to evaluate the methodological quality of the current guidelines for the management of acute malignant left-sided colonic bowel obstruction.

METHODS

A systematic search of the literature was carried out using electronic databases. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess the quality of each guideline.

RESULTS

Search results returned a total of 14 guidelines appropriate for assessment. Both domain I (scope and purpose) and domain VI (editorial independence) were assessed with the same median score of 83%. The lowest scoring domain was domain V (applicability), scoring only 43%. The 2 guidelines that had the highest score were the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN), each scoring 100%. However, there were significant variations in terms of quality. The NICE and New Zealand guidelines were voted unanimously for use unchanged, whilst 8 other guidelines were voted for use with modifications.

CONCLUSION

Variation in guideline quality in CRC is a concern despite some clearly excellent published guidelines. All guidelines score poorly when it comes to describing how the guidelines could be applied. Lack of patient participation in guideline development is also a shortcoming that requires urgent redress.

Bridge to Surgery for Obstructing Colonic Cancer: A Comparison between Right- and Left-sided Lesions

Objectives:

Few studies have compared management and outcomes of bridge to surgery (BTS) for obstructive colonic cancer according to the location of the tumor. Additional information is needed about this procedure's characteristics and short-term and long-term outcomes. We aimed to compare patient and tumor characteristics, and outcomes of BTS for obstructive right-sided versus left-sided colonic cancers.

Methods:

This was a retrospective, single center, cohort study. The study cohort comprised 149 patients, including 48 with right-sided and 101 with left-sided obstructive colonic cancers, who were treated with BTS between January 2007 and December 2017. Data on medical history, investigations, treatments, and prognosis were collected from an electronic database of a single hospital. The primary end points were overall (OS) and disease-free (DFS) survival and short-term surgical outcomes.

Results:

Significantly more patients with right-sided cancers had postoperative complications (29.2% vs. 14.9%, p = 0.039). Additionally, postoperative chemotherapy was administered to a marginally significantly greater proportion of patients with left-sided cancers (29.2% vs 45.5%, p = 0.057). The long-term outcomes were comparable between the two groups (the 5-year OS rates were 67.6% and 80.9% [p = 0.117] and the 5-year DFS rates were 62.2% and 58.6% [p = 0.671]). Multivariate analyses using all studied variables showed that lymphovascular invasion, advanced T stage, and adjuvant chemotherapy were independent poor prognostic factors.

Conclusions:

The long-term outcome was not different between the right- and left-sided groups. In a BTS setting, postoperative complications may reduce the compliance of adjuvant chemotherapy in right-sided cancers and affect long-term outcomes.

Early surgery after bridge-to-surgery stenting for malignant bowel obstruction is associated with better oncological outcomes

BACKGROUND

Placement of self-expanding metal stents has been increasingly adopted as a bridge to surgery in patients presenting with obstructed left-sided colorectal cancers. The optimal bridging time has yet to be widely established, hence this retrospective study aims to determine the optimal bridging time to elective surgery post endoluminal stenting.

PATIENTS AND METHODS

All patients who underwent colorectal stenting for large bowel obstruction in a single, tertiary hospital in Singapore between January 2003 and December 2017 were retrospectively identified. Patients' baseline demographics, tumour characteristics, stent-related complications, intra-operative details, post-operative complications and oncological outcomes were analysed.

RESULTS

Of the 53 patients who successfully underwent colonic stenting for malignant left sided obstruction, 33.96% of patients underwent surgery within two weeks of stent placement while 66.04% of patients underwent surgery after 2 weeks of stent placement. Univariate analysis between both groups did not demonstrate significant differences in postoperative complications and stoma formation. Significant differences were observed between both groups for stent complications (38.89% vs 8.57%, p = 0.022), on-table decompression (38.89% vs 2.86%, p = 0.001) and systemic recurrence (11.11% vs 40.00%, p = 0.030). Increased bridging interval to surgery (OR 13.16, CI 1.37-126.96, p = 0.026) was a significant risk factor for systemic recurrence on multivariate analysis.

CONCLUSIONS

Patients undergoing definitive surgery within 2 weeks of colonic stenting may have better oncological outcomes without compromising on postoperative outcomes. Further prospective studies are required to compare outcomes between emergency surgery and different bridging intervals.

Long-term Oncologic Results After Stenting as a Bridge to Surgery Versus Emergency Surgery for Malignant Left-sided Colonic Obstruction: A Multicenter Randomized Controlled Trial (ESCO Trial)

OBJECTIVE

To assess overall (OS), time to progression (TTP), and disease-free survival (DFS) at 3 years after treatment, comparing stenting as bridge-to-surgery (SBTS) versus emergency surgery (ES) in neoplastic left colon obstruction, secondary endpoints of the previously published randomized controlled trial.

BACKGROUND

While SBTS in neoplastic colon obstruction may reduce morbidity and need for a stoma compared with ES, concern has been raised, about long-term survival.

METHODS

Individuals affected by left-sided malignant large-bowel obstruction were enrolled from 5 European hospitals and randomly assigned (1:1 ratio) to receive SBTS or ES. The computer-generated randomization sequence was stratified by center on cT and concealed by the use of a web-based application. Investigators and participants were unmasked to treatment assignment. The secondary outcomes analyzed here were OS, TTP, and DFS. Analysis was by intention to treat. This study is registered, ID-code NCT00591695.

RESULTS

Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 115 (SBTS n = 56, ES n = 59) were eligible for analysis, while 20 participants were excluded for a benign disease, 1 for unavailability of the endoscopist while 8 withdrew from the trial. With a median follow-up of 37 months (range 1-62), no difference was observed in the SBTS group compared with ES in terms of OS (HR 0.93 (95% CI 0.49-1.76), P = 0.822), TTP (HR 0.81 (95% CI 0.42-1.54), P = 0.512), and DFS (HR 1.01 (95% CI 0.56-1.81), P = 0.972). Planned subgroup analysis showed no difference in respect to age, sex, American Society for Anesthesiology score, body mass index, and pT between SBTS and ES groups. Those participants randomized for the SBTS group whose obstruction was located in the descending colon had a better TTP compared with ES group (HR 0.44 (95% CI 0.20-0.97), P = 0.042), but no difference was observed in terms of OS (HR 0.73 (95% CI 0.33-1.63), P = 0.442) and DFS (HR 0.68 (95% CI 0.34-1.34), P = 0.261) in the same individuals.

CONCLUSIONS

This randomized controlled trial shows that, although not powered for these seconday outcomes, OS, TTP, and DFS did not differ between groups at a minimum follow-up of 36 months.

Long-term outcomes of colonic stent as a "bridge to surgery"for left-sided malignant large-bowel obstruction

BACKGROUND

The role of self-expandable metallic stents (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction is still debated. Here we assess the morbidity, mortality and long-term oncological outcomes as a bridge to surgery for patients with left-sided malignant colonic obstruction.

METHOD

Prospective observational study with retrospective analysis of patients with left-sided malignant colonic obstruction undergoing stenting. April 2006-April 2018. We assessed all patients with intent-to treat and per protocol analyses and long-term follow-up variables.

RESULTS

Colonic stent was performed in 117 patients. Technical and clinical success of SEMS placement: 94.4% (111/117), only 4.3% perforation. Elective surgery resection following the strategy of SEMS was performed in 83.8% (98/117). A laparoscopic approach was: 25.6% (30/117); 76.9% in the last two years. Primary anastomosis rate: 92.8% (91/98), without protective stoma in any patients. Anastomotic leakage rate: 8.2% (8/97). Median follow-up: 44.5 months (range 0-109). The intent-to-treat analysis showed overall and disease-free survival rates of 63.3% (74/117) and 58.1% (68/117), and local and distant recurrence rates: 9.4% (11/117) and 58.1% (68/117). In the per protocol analysis, overall and disease-free survival rates: 63.2% (62/98) and 60.2% (58/98), and local and distant recurrence rates: 10.2% (10/98) and 36.7% (36/98). Disease progression was predominantly observed during the first 5 years' follow-up as disease recurrence; after five years' follow-up, 60% of the patients were disease-free.

CONCLUSIONS

According to the results of the study SEMS as a bridge to surgery achieves perioperative results comparable to non-occlusive colonic cancer surgery and does not adversely affect long-term oncological outcomes. Further investigations are needed.

Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?

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.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: A systematic review and meta-analysis of high quality prospective and randomised controlled trials

Self-expanding metallic stent placement as a bridge to surgery has been reported as an alternative to emergency surgery for acute malignant colorectal obstruction. However, results from clinical trials and previous meta-analyses are conflicting. We carried out a meta-analysis to compare the surgical and oncological outcomes between emergency surgery and self-expanding metallic stents for malignant large bowel obstruction. Pubmed, Embase, CINAHL, Web of Science and Cochrane were searched for prospective and randomised controlled trials. The outcomes of focus included 3- and 5-year overall and disease-free survival, overall tumour recurrence, overall complication and 30-day mortality rate, length of hospital and ICU stay, overall blood loss, number of patients requiring transfusion, total number of lymph nodes harvested, stoma and primary anastomosis rate. Twenty-seven studies were included with a total of 3894 patients. There was no significant difference in terms of 3-year and 5-year disease-free and overall survival. Stenting resulted in less blood loss (mean difference -234.72, P < 0.00001) and higher primary anastomosis rate (RR 1.25, P < 0.00001). For curative cases, bridge to surgery groups had lower 30-day mortality rate (RR 0.65, P = 0.01), lower overall complication rate (RR 0.65, P < 0.0001), more lymph nodes harvested (mean difference 2.51, P = 0.005), shorter ICU stay (mean difference -2.27, P = 0.02) and hospital stay (mean difference -7.24, 95% P < 0.0001). Compared to emergency surgery, self-expanding metallic stent interventions improve short-term surgical outcomes, especially in the curative setting, but have similar long-term oncological and survival outcomes.

Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis

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.

Enhanced Recovery After Emergency Surgery: Utopia or Reality?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

Obstructive left side colon cancer: time for a tailored operative approach?

BACKGROUND

Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases.

METHODS

Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety.

RESULTS

One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH.

CONCLUSIONS

The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.

Stent Placement for Palliative Treatment of Malignant Colorectal Obstruction: Extracolonic Malignancy Versus Primary Colorectal Cancer

OBJECTIVE. The purpose of this study is to compare the clinical outcomes of stent placement for the palliative treatment of colorectal obstruction in patients with extracolonic malignancy (ECM) versus those with primary colorectal cancer (CRC) and to identify the risk factors for stent failure. MATERIALS AND METHODS. Between January 2005 and December 2017, a total of 85 patients underwent stent placement for the palliative treatment of inoperable malignant colorectal obstructions caused by ECM (n = 56) or CRC (n = 29). Technical and clinical success, reintervention rates, and stent patency were compared between the two groups. Predictive factors associated with stent failure were identified. RESULTS. Stent placement was technically successful in 54 patients with ECM (96.4%) and 27 patients with CRC (93.1%) (p = 0.60). The proportion of patients with ECM who required reintervention was greater than that of patients with CRC (20.4% vs 3.7%, respectively; p = 0.04); however, they had a marginally lower clinical success rate (88.9% vs 100.0%, respectively; p = 0.07). The 6- and 12-month stent patency rates were 64.2% and 22.0%, respectively, in patients with ECM and 68.4% and 31.3%, respectively, in patients with CRC (p = 0.89). Long obstructions (hazard ratio, 1.40) and multiple obstructions (hazard ratio, 4.03) were independent factors associated with stent failure. CONCLUSION. Stent placement for the palliative treatment of colorectal obstruction is less effective and more frequently requires reintervention in patients with ECM than in patients with CRC. Long obstructions and multiple obstructions were associated with stent failure.

Quasi-elective left colectomy after endoscopic colon stenting for obstructive cancer yields comparable oncologic outcome to full-elective operation

PURPOSE

Whether deferring surgery after endoscopic self-expandable metal stent (SEMS) placement for neoplastic stricture, and operating patients in a quasi-elective situation, may result in similar oncologic outcomes to elective operations is unclear. This study aimed to evaluate the disease-free survival (DFS) rates of patients who underwent an interval colon resection after SEMS placement or an elective operation with comparable cancer stages.

METHODS

From a prospective dataset, we retrospectively selected patients with the following characteristics: (1) left-sided colon cancer and (2) cancer stage I to III. Exclusion criteria were as follows: (1) palliative surgery and (2) emergency operation. Then we stratified patients into two groups: (A) full-elective left colon resection and (B) quasi-elective left colon resection, defined as surgery performed after SEMS placement for obstructive colon cancer. DFS function was studied by the Kaplan-Meier method.

RESULTS

After 1:2 matching based on cancer stage, 106 patients of the group A were compared with 53 patients of group B. In each group, there were 9.4% of stage I, 39.4% of stage II, and 50.9% of stage III patients. The rate of technical failure in SEMS placement was 3.8%. After a mean follow-up of 54 months, 16 (15.1%) patients in the full-elective groups and 10 (18.9%) in the quasi-elective group experience cancer recurrence (log rank = 0.588). DFS curve did not reach the median value.

CONCLUSIONS

SEMS placement with interval colon resection for obstructive neoplastic strictures seems to provide similar long-term oncologic outcomes to operations performed in an elective setting when a low rate of technical failure is achieved.

Surgical Risk and Pathological Results of Emergency Resection in the Treatment of Acutely Obstructing Colorectal Cancers: A Retrospective Cohort Study

Purpose

The treatment of acutely obstructing colorectal cancers is still a matter of debate. The prevailing opinion is that an immediate resection should be performed whenever possible. This study sought to determine whether immediate resection is safe and oncologically valid.

Methods

We completed a retrospective 2-center cohort study using the medical records of patients admitted for acutely obstructing colorectal cancer under the care of the Colorectal Team, Noble’s Hospital, Isle of Man, and the Emergency Surgery Unit, Umberto I University Hospital, Rome, from March 2013 to May 2017. The primary endpoints were 90-day mortality and morbidity, reoperation rate, and length of stay. The secondary endpoints were status of margins, number of lymph nodes retrieved, and the rate of adequate nodal harvest.

Results

Sixty-three patients were retrospectively enrolled in the study. Mortality was associated with age > 80 years and Dukes B tumors. The length of hospital stay was shorter in patients who had their resection less than 24 hours from their admission, in those who had laparoscopic resection and in those with distal tumors. The number of lymph nodes retrieved and rate of R0 resections were similar to those reported in elective colorectal surgery and were greater in laparoscopic resections and in patients operated on within 24 hours, respectively.

Conclusion

Immediate resection is a safe and reliable option in patients with acutely obstructing colorectal cancer.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.

Laparoscopic two-stage operation for rectal cancer with refractory obstructive colitis after kidney transplantation: a case report

Background

Although obstructive colitis with colon cancer is not a rare disease, most cases can be improved with conservative therapy. We report a case of a patient who underwent a laparoscopic two-stage operation for rectal cancer with refractory obstructive colitis after kidney transplantation.

Case presentation

The patient was a 71-year-old man taking immunosuppressants who had previously undergone right living kidney transplantation for chronic nephritis. He presented to hospital complaining of abdominal pain and was diagnosed as having rectal cancer with obstructive colitis. Although conservative therapy by fasting was continued for 5 weeks, his obstructive colitis did not improve. Therefore, we decided to perform a two-stage operation. First, we performed a laparoscopic Hartmann’s operation. It took 6 months for his obstructive colitis to improve after this operation, and then we performed a laparoscopic colorectal anastomosis. There were no postoperative complications in either operation.

Conclusion

A laparoscopic two-stage operation could be one of the operative options to reduce postoperative complications in patients with comorbidities such as taking immunosuppressants.

Efficacy and safety of self-expanding metallic stent placement followed by neoadjuvant chemotherapy and scheduled surgery for treatment of obstructing left-sided colonic cancer

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.

Long-term survival analysis after endoscopic stenting as a bridge to surgery for malignant colorectal obstruction: comparison with emergency diverting colostomy

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.

Endoscopic Management of Benign Colonic Obstruction and Pseudo-Obstruction

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

Outcomes following colonic stenting for malignant left-sided bowel obstruction: a systematic review of randomised controlled trials

PURPOSE

Malignant bowel obstruction is a common presentation and is associated with high morbidity and mortality. Emergency resection is the traditional treatment modality. In recent years, colonic stenting as a bridge to surgery has become more prevalent. However, there is considerable debate surrounding its use. The aim of this review was to examine the technical and clinical success of self-expanding metal stent (SEMS) as a bridge to surgery for obstructing colorectal tumours.

METHODS

We systematically reviewed randomised controlled trials using PubMed, Cochrane and SCOPUS databases. Included studies must have compared outcomes in SEMS as a bridge to surgery with those proceeding straight to emergency resection.

RESULTS

A total of 1245 studies were identified. After removal of duplicates and non-relevant studies, we identified seven articles which met the predefined criteria. This review observed that 81% of SEMS were technically successful, with 76% of patients having restoration of gastrointestinal function. Iatrogenic perforation rate was 5%. One-fifth of patients required emergency surgery following stent placement, and permanent stoma rate was 8.7%.

CONCLUSION

This study observed that SEMS as a bridge to surgery is associated with good technical and clinical success, with low rates of perforation and permanent stoma. SEMS should be part of the treatment armamentarium for obstructing colorectal neoplasms, but careful patient selection and institutional expertise are important factors for success.