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Calicis R, Dubois A, Ritter C, Tinton N, Calicis B, Hoebeke Y, Lepore D, Da Rocha De Sousa F, Cambier E, Corbisier F. Predictive factors of surgery in metastatic colorectal cancer: a retrospective cohort study. Acta Chir Belg 2024; 124:170-177. [PMID: 37605980 DOI: 10.1080/00015458.2023.2231211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Current management of metastatic colorectal cancer is based on neoadjuvant chemotherapy. Few studies have reported on surgery procedures in patients with metastatic colorectal cancer. The objective of this study was to describe our institutional experience with emergency surgery performed in patients with metastatic colorectal cancer during chemotherapy. PATIENTS AND METHODS This was a retrospective cohort study including adult patients of ≤80 years with a metastatic colorectal cancer between 2017 and 2020 and undergoing surgery during chemotherapy. Statistical analyses were based on Kaplan-Meier's curve and Cox proportional hazard model. The surgery statistical risk during chemotherapy was studied through all tumor and patient's characteristics. Multivariable logistic regression models were used to identify predictive factors of emergency surgery in these patients. RESULTS Seventy-two cases were identified and 60% patients undergone an emergency surgery. By Kaplan-Meier's analyses, intestinal surgery was much more frequent and early in patients who have severe stenosis (either blocking or only permeable using a gastroscope) at the time of diagnosis. Patients with severe malignant stenosis presented a 6.28 time higher surgery risk (p < .0001). The median time between admission and surgery was 54 days in patients with severe stenosis who were operated. CONCLUSION The degree of colorectal tumor stenosis measured by endoscopy was a risk factor for emergency surgery in patients with metastatic colorectal cancer during neoadjuvant chemotherapy. In this group of patients presenting low survival outcomes, further studies are needed to define the place of preventive surgery, avoiding emergency surgery and morbidity in such fragile patients.
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Affiliation(s)
- Raffaele Calicis
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Antoine Dubois
- Abdominal Transplant Surgery & Transplant Coordination, University Hospitals Leuven & Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Department of Experimental Surgery and Transplantation (CHEX), University Hospital Saint-Luc, Brussels, Belgium
| | - Christian Ritter
- Statistical Methodology and Computing Service, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Nicolas Tinton
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Benjamin Calicis
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Yves Hoebeke
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - David Lepore
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
| | | | - Emmanuel Cambier
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Fabrice Corbisier
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Charleroi, Belgium
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Walayat S, Johannes AJ, Benson M, Nelsen E, Akhter A, Kennedy G, Soni A, Reichelderfer M, Pfau P, Gopal D. Outcomes of colon self–expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature. World J Gastrointest Endosc 2023; 15:309-318. [PMID: 37138935 PMCID: PMC10150280 DOI: 10.4253/wjge.v15.i4.309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/09/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement.
AIM To review long- and short-term clinical success of SEMS use for colonic obstruction at our center.
METHODS We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded.
RESULTS Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS).
CONCLUSION Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53705, United States
| | - Andrew J Johannes
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53705, United States
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Eric Nelsen
- Gastroenterology, Park Nicollet Digestive and Endoscopy Center, Methodist Hospital, St. Louis Park, Minneapolis, MN 55426, United States
| | - Ahmed Akhter
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Gregory Kennedy
- Department of Surgery, University of Alabama-Birmingham School of Medicine, Brimingham, AL 35243, United States
| | - Anurag Soni
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Mark Reichelderfer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Patrick Pfau
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Outcome of self-expandable metal stents placement for obstructive colorectal cancer: 7 years’ experience from a Swedish tertiary center. Surg Endosc 2022; 37:2653-2658. [PMID: 36401103 PMCID: PMC10082091 DOI: 10.1007/s00464-022-09761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
Abstract
Background and study aims
Self expandable metal stents (SEMS) is an alternative to emergency surgery to treat malignant large bowel obstruction. It can be used either for palliation or as a bridge to curative surgery. Our study aims to review the outcomes of SEMS treatment in a tertiary center and to find predictors for the clinical outcome.
Patient and methods
We retrospectively analyzed data from SEMS insertion at Sahlgrenska University Hospital, a referral center in Western Sweden (1.7 million inhabitants), between 2014 and 2020. Data collected were age, the intent of intervention, tumor localization, complication rate, technical and clinical success, 30- and 90-days mortality as well as long-term survival for the indication bridge to surgery.
Results
We identified 265 SEMS insertions (mean age 72, female 49.4%). Most SEMS were used for palliation (90.2%). The malign obstruction was most often located in the left colon (71.7%). Technical success was achieved in 259 (97.7%) cases and clinical success in 244 (92.1%) cases. Post-operative complications occurred in 11 cases (4.2%). The 30-days mortality rate was 11.7% and the 90-day was 31.7%. In our analysis the tumor site was not associated with adverse outcomes and bridge to surgery indication was a positive prognostic factor for the 90-day mortality.
Conclusions
We found that SEMS is an effective and safe treatment for patients with acute obstructive colorectal cancer.
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Bravington A, Obita G, Baddeley E, Johnson MJ, Murtagh FE, Currow DC, Boland EG, Nelson A, Seddon K, Oliver A, Noble SI, Boland JW. The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review. Palliat Med 2022; 36:1336-1350. [PMID: 36131489 PMCID: PMC10150264 DOI: 10.1177/02692163221122352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent. AIM To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set. DESIGN The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy. DATA SOURCES Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021. RESULTS A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life. CONCLUSIONS Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment 'success' that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population.
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Affiliation(s)
- Alison Bravington
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elaine G Boland
- Queen's Centre for Oncology and Haematology, Cottingham, Hull, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Alfred Oliver
- National Cancer Research Institute, Consumer Liaison Group, Trans-Humber Consumer Research Panel, London, UK
| | - Simon Ir Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
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5
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Kim GH, Shin JH, Zeng CH, Park JH. Recent Updates in Gastrointestinal Stent Placement from the Esophagus to the Colon: A Radiological Perspective. Cardiovasc Intervent Radiol 2022; 45:425-437. [PMID: 35166883 DOI: 10.1007/s00270-022-03067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/02/2022]
Abstract
Fluoroscopic-guided stent placement has become an advantageous treatment option for diverse gastrointestinal disorders. In addition to palliative stent placement in patients with inoperable cancers, stenting has gradually expanded to other conditions, including as a bridge to surgery, as well as in patients' benign lesions and anastomotic strictures or leaks. This narrative review describes the indications, efficacy and safety of stent placement from the esophagus to the colon, including current recommendations, recent updates, and novel stents.
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Affiliation(s)
- Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea.
| | - Chu Hui Zeng
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Jung Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
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Henbrey R. Stoma formation as a palliative procedure: the role of the clinical nurse specialist in maintaining quality of life. ACTA ACUST UNITED AC 2021; 30:S4-S10. [PMID: 33769878 DOI: 10.12968/bjon.2021.30.6.s4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
More than half of patients diagnosed with colon cancer present at an advanced stage, and palliative treatment may involve stoma formation. A literature review was undertaken to determine the potential effects of stoma formation as a palliative procedure on a patient's quality of life, and to examine the role of the clinical nurse specialist in this situation. Limited literature was found on this specific subject, so established evidence surrounding stoma formation and quality of life was examined in relation to palliative care. The clinical nurse specialist provides expert knowledge that can help to limit stoma complications and is also able to conduct assessments that identify holistic concerns affecting quality of life. However, access to a clinical nurse specialist may be limited, particularly when surgery is performed as an emergency. There is the potential for research surrounding patient experiences that may improve service provision for this client group.
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Affiliation(s)
- Rachel Henbrey
- Colorectal Clinical Nurse Specialist, University Hospitals Birmingham NHS Foundation Trust
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Trabulsi NH, Halawani HM, Alshahrani EA, Alamoudi RM, Jambi SK, Akeel NY, Farsi AH, Nassif MO, Samkari AA, Saleem AM, Malibary NH, Abbas MM, Gianotti L, Lamazza A, Yoon JY, Farsi NJ. Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis. Saudi J Gastroenterol 2021; 27:127-135. [PMID: 33976008 PMCID: PMC8265400 DOI: 10.4103/sjg.sjg_506_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients. METHODS We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates. RESULTS We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I2 = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I2 = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I2 = 79.3%, P < 0.001). CONCLUSION The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.
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Affiliation(s)
- Nora H. Trabulsi
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Address for correspondence: Dr. Nora H. Trabulsi, Department of Surgery, Faculty of Medicine, King Abdulaziz University, PO Box 21589, Jeddah 80200, Saudi Arabia. E-mail:
| | - Hajar M. Halawani
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Rawan M. Alamoudi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sama K. Jambi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nouf Y. Akeel
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali H. Farsi
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed O. Nassif
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali A. Samkari
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdulaziz M. Saleem
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nadim H. Malibary
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad M. Abbas
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Luca Gianotti
- Department of Surgery, School of Medicine and Surgery, University of Milano-Bicocca, and San Gerardo Hospital, Monza, Italy
| | - Antonietta Lamazza
- Department Pietro Valdoni-Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Nada J. Farsi
- Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
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Kwaan MR, Ren Y, Wu Y, Xirasagar S. Colonic Stent Use by Indication and Patient Outcomes: A Nationwide Inpatient Sample Study. J Surg Res 2021; 265:168-179. [PMID: 33940240 DOI: 10.1016/j.jss.2021.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 02/14/2021] [Accepted: 03/22/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Colonic stent placement can avoid urgent surgery for large bowel obstruction in selected patients. Population-wide stent utilization patterns and outcomes are unknown. MATERIALS AND METHODS Using retrospective, population-based, Nationwide Inpatient Sample data, we studied patients with colonic stents discharged during 2010-2015. The primary outcome was ostomy creation during the same hospitalization. Other outcomes were perforation or peritonitis, and in-hospital death. Associations of outcomes with stent indication were investigated, adjusting for patient-, admission-, and hospital characteristics. We estimated annual population-wide stent use volumes. RESULTS Of 4257 patients with stent placement (52% male, mean age 64.6 years), 9.9% had non-metastatic colon cancer, 12.9% metastatic colon cancer, 37.8% extracolonic malignancy (ECM), and 39.3% had benign obstruction. In 8.1% of patients, ostomy creation surgery was performed. Perforation or peritonitis occurred in 16.7%, and in-hospital death in 4.5%. Relative to ECM, ostomy creation was several-fold more likely among nonmetastatic colon cancer (adjusted odds ratio (OR) 3.4; 95%CI, 2.1-5.5), metastatic colon cancer (adjusted OR 2.5; 95%CI, 1.7-3.7), and benign obstruction patients (adjusted OR 3.1; 95%CI, 2.1-4.7). Benign obstruction was associated with high risk of perforation/peritonitis (adjusted OR 3.1 relative to non-metastatic CC (95%CI, 2.1-4.5)). Perforation/peritonitis was highly associated with inpatient death (adjusted OR 6.8 (95%CI, 4.9-9.5)). Annually, about 3,580 patients underwent stent placement, with benign obstruction showing an increasing trend (P=0.0002). CONCLUSIONS Over 75% of stent placements were done for patients with benign disease and ECM obstruction. Subsequent ostomy creation during the hospitalization was least likely among ECM patients. Rates of perforation/peritonitis in benign obstructions were concerningly high. (22.2%).
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Affiliation(s)
- Mary R Kwaan
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Yang Ren
- University of South Carolina, Department of Computer Science and Engineering, Columbia, SC
| | - Yuqi Wu
- University of South Carolina, Department of Health Services Policy and Management, Columbia, SC
| | - Sudha Xirasagar
- University of South Carolina, Department of Health Services Policy and Management, Columbia, SC
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Veld JV, Beek KJ, Consten EC, ter Borg F, van Westreenen HL, Bemelman WA, van Hooft JE, Tanis PJ. Definition of large bowel obstruction by primary colorectal cancer: A systematic review. Colorectal Dis 2021; 23:787-804. [PMID: 33305454 PMCID: PMC8248390 DOI: 10.1111/codi.15479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/10/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
AIM Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies. METHOD A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements. RESULTS A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07). CONCLUSION In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.
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Affiliation(s)
- Joyce V. Veld
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kim J. Beek
- Department of Gastroenterology and HepatologyNWZ AlkmaarAlkmaarThe Netherlands
| | - Esther C.J. Consten
- Department of SurgeryMeander Medical CenterAmersfoortThe Netherlands,Department of SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and HepatologyDeventer HospitalDeventerThe Netherlands
| | | | - Wilhelmus A. Bemelman
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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10
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Seoane Urgorri A, Saperas E, O'Callaghan Castella E, Pera Román M, Raga Gil A, Riu Pons F, Barranco Priego L, Dedeu Cusco JM, Pantaleón Sánchez M, Bessa Caserras X, Álvarez-González MA. Colonic stent vs surgical resection of the primary tumor. Effect on survival from stage-IV obstructive colorectal cancer. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:694-700. [PMID: 32755149 DOI: 10.17235/reed.2020.5701/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES the impact of surgical primary tumor resection on survival of obstructive metastatic colorectal cancer remains controversial. The primary goal of this study was to analyze survival in patients with obstructive metastatic colorectal cancer after treatment with either resection surgery or a colonic stent. MATERIAL AND METHODS a prospective study was performed of all patients with stage-IV colorectal cancer and obstructive manifestations, diagnosed from 2005 to 2012 and managed with either resection surgery or a colonic stent. Cases with a perforation, abscess, right colon or distal rectal malignancy, multiple colorectal cancer or derivative surgery were excluded. RESULTS a total of 95 patients were included, 49 were managed with resection surgery and 46 with a colonic stent. The colonic stent group had a higher Charlson index (9.5 ± 2.1 vs 8.6 ± 1.5, p = 0.01), a shorter time to oral intake (0.9 ± 1.1 vs 16.4 ± 53.5 days, p = 0.05), a shorter hospital stay (4 ± 4.8 vs 16.7 ± 15.5 days, p = 0.0001), less need for stomata (11.1 % vs 32.7 %, p = 0.01), fewer early complications (4.3 % vs 46.9 %, p = 0.0001) and more late complications (33.3 % vs 6.4 %, p = 0.001). Undergoing chemotherapy (p = 0.008) was the only independent factor related to increased survival. In the subgroup of patients managed with chemotherapy, surgical primary tumor resection was an independent factor associated with increased survival. CONCLUSION both treatments are effective for resolving obstructive manifestations in patients diagnosed with stage-IV obstructive colorectal cancer. Resection surgery has no positive impact on survival and thus cannot be recommended as a therapy of choice.
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Affiliation(s)
| | | | | | | | | | - Faust Riu Pons
- Aparato Digestivo, Parc de Salut Mar. Hospital del Mar, España
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11
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Abstract
Endoscopic stenting of the colorectum has emerged as a viable alternative to surgical interventions in a selected group of patients. The main indication for stenting is bowel obstruction. As such stenting can be used to palliate patients with metastatic disease or bridge patients to surgical intervention. The main advantages of stenting in the emergency setting include lower morbidity and mortality, lower incidence of stoma formation, shorter hospitalization, and better quality of life. For patients with unresectable disease and short life expectancy, stenting can be considered. However, for patients with longer life expectancy, the potential long-term complications of a metal stent such as erosion, migration, or obstruction have engendered debate whether such patients are better served by operative intervention. Stenting as a bridge to surgery is an alternative to surgery in patients who are high risk for emergency surgery but concerns remain regarding its impact on oncologic outcome in potentially curable patients.
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Affiliation(s)
- Humaa Darr
- Department of Surgery - Surgical Oncology, Al Zahra Hospital, Dubai, United Arab Emirates
| | - Maher A Abbas
- Department of Surgery - Colorectal and Digestive Surgery, Al Zahra Hospital, Dubai, United Arab Emirates
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Miyasako Y, Kuwai T, Ishaq S, Tao K, Konishi H, Miura R, Sumida Y, Kuroki K, Tamaru Y, Kusunoki R, Yamaguchi A, Kouno H, Kohno H. Newly developed self-expandable Niti-S MD colonic metal stent for malignant colonic obstruction. World J Gastrointest Surg 2020; 12:138-148. [PMID: 32426093 PMCID: PMC7215972 DOI: 10.4240/wjgs.v12.i4.138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colonic stents are increasingly used to treat acute malignant colonic obstructions. The WallFlex and Niti-S D type stents are the commonly used self-expandable metallic stents available in Japan since 2012. WallFlex stent has a risk of stent-related perforation because of its axial force, while the Niti-S D type stent has a risk of obstructive colitis because of its weaker radial force. Niti-S MD type stents not only overcome these limitations but also permit delivery through highly flexible-tipped smaller-caliber colonoscopes.
AIM To compare the efficacy and safety of the newly developed Niti-S MD type colonic stents.
METHODS This single-center retrospective observational study included 110 patients with endoscopic self-expandable metallic stents placed between November 2011 and December 2018: WallFlex (Group W, n = 37), Niti-S D type (Group N, n = 53), and Niti-S MD type (Group MD, n = 20). The primary outcome was clinical success, defined as a resolution of obstructive colonic symptoms, confirmed by clinical and radiological assessment within 48 h. The secondary outcome was technical success, defined as accurate stent placement with adequate stricture coverage on the first attempt without complications.
RESULTS The technical success rate was 100% in Groups W, N, and MD, and the overall clinical success rate was 89.2% (33/37), 96.2% (51/53), and 100% (20/20) in Groups W, N, and MD, respectively. Early adverse events included pain (3/37, 8.1%), poor expansion (1/37, 2.7%), and fever (1/37, 2.6%) in Group W and perforation due to obstructive colitis (2/53, 3.8%) in Group N (likely due to poor expansion). Late adverse events (after 7 d) included stent-related perforations (4/36, 11.1%) and stent occlusion (1/36, 2.8%) in Group W and stent occlusion (2/51, 3.9%) in Group N. The stent-related perforation rate in Group W was significantly higher than that in Group N (P < 0.05). No adverse event was observed in Group MD.
CONCLUSION In our early and limited experience, the newly developed Niti-S MD type colonic stent was effective and safe for treating acute malignant colonic obstruction.
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Affiliation(s)
- Yuki Miyasako
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Sauid Ishaq
- Gastroenterology Department, Russells Hall Hospital, Birmingham City University, Birmingham B17 9BE, United Kingdom
- St George’s University, University Centre Grenada, West Indies, Grenada
| | - Kanae Tao
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Hirona Konishi
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Ryoichi Miura
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Yuki Sumida
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Kazutaka Kuroki
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Yuzuru Tamaru
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Ryusaku Kusunoki
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Atsushi Yamaguchi
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Hirotaka Kouno
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Hiroshi Kohno
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
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Abstract
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.
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Affiliation(s)
- Tian-Zhi Lim
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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14
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Saida Y. Current status of colonic stent for obstructive colorectal cancer in Japan; a review of the literature. JOURNAL OF THE ANUS RECTUM AND COLON 2019; 3:99-105. [PMID: 31583324 PMCID: PMC6774736 DOI: 10.23922/jarc.2019-009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023]
Abstract
Colorectal cancer is the most common cancer in Japan. Approximately 10%-20% of the patients with colorectal cancer present with large bowel obstruction, and those who present with malignant colonic obstruction (MCO) require urgent decompression because MCO can cause electrolytic fluid imbalance, colonic necrosis, bacterial translocation, and death. Placement of colonic stents (self-expandable metallic stents) for MCO is a major and standard endoscopic treatment that has been available since 2012 in Japan. This review presents the current conditions and future prospects of this procedure based on the literature. The current indication of colonic stent placement is malignant colorectal stenosis. One of the purposes of using stents is palliative treatment; further, its advantages over emergency surgery with colostomy include avoidance of colostomy, relief of obstruction, shorter hospitalization, and better quality of life. In addition, stent placement can also be used as a bridge to surgery since the duration of the hospitalization is shorter and postoperative complications, colostomy rates, and mortality rates are lower with elective than with emergency surgery. Although recent studies have reported low complication rates related to colonic stents, complications may still occur, highlighting the importance of good preparation, adequate staffing, backup systems, and informed consent. The current major problem related to colonic stents is the lack of evidence on patients' long-term prognoses for bridge to surgery purposes, awaiting the results of ongoing clinical research.
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Affiliation(s)
- Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
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15
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Miller D, Nevadunsky N. Palliative Care and Symptom Management for Women with Advanced Ovarian Cancer. Hematol Oncol Clin North Am 2018; 32:1087-1102. [DOI: 10.1016/j.hoc.2018.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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16
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Lim TZ, Chan DKH, Tan KK. Endoscopic stenting should be advocated in patients with stage IV colorectal cancer presenting with acute obstruction. J Gastrointest Oncol 2018; 9:785-790. [PMID: 30505576 DOI: 10.21037/jgo.2018.06.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background It remains contentious whether endoscopic stenting or upfront surgery is more optimal in patients with metastatic colorectal cancers presenting with large bowel obstruction. Methods A retrospective review of all patients with metastatic colorectal cancer who underwent either endoscopic stenting or emergency surgery for acute large bowel obstruction was performed. Results Between January 2007 and June 2014, 66 patients, median age, 64 (range, 25-96) years, presented with acute large bowel obstruction from metastatic colorectal cancer. Forty (60.6%) patients underwent endoscopic stenting whilst the rest received immediate upfront surgical intervention. Of the 40 patients, 29 (72.5%) were successfully stented. The remaining 11 (27.5%) patients who failed endoscopic stenting required immediate emergency surgery to relieve the obstruction. Patients who failed endoscopic stenting had worse complications than those patients who had their stents successfully inserted [odds ratio (OR), 23.3; 95% confidence interval (CI), 2.29-250.00, P=0.004]. Patients who underwent emergency surgery had a longer median length of stay than patients who had successful endoscopic stenting (P=0.003). The patients that underwent successful stenting had earlier commencement of chemotherapy compared to those who had upfront surgery (P=0.02). There was no difference in stoma creation rates between patients who had emergency surgery versus those who were successfully stented. Conclusions Stenting is a safe option in patients with stage IV colorectal cancer presenting with acute large bowel obstruction. Earlier commencement of chemotherapy occurs in patients who were successfully stented. Patients who failed stenting have equivalent outcomes to those who undergone upfront emergency surgery.
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Affiliation(s)
- Tian-Zhi Lim
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Dedrick Kok Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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17
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Clarke L, Abbott H, Sharma P, Eglinton TW, Frizelle FA. Impact of restenting for recurrent colonic obstruction due to tumour ingrowth. BJS Open 2018; 1:202-206. [PMID: 29951623 PMCID: PMC5989957 DOI: 10.1002/bjs5.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/07/2017] [Indexed: 11/08/2022] Open
Abstract
Background Endoscopic stenting is used to palliate malignant large bowel obstruction. A proportion of patients will develop recurrent obstruction due to tumour ingrowth and require reintervention. This study aimed to assess the outcome (clinical success and complication rates) of endoscopic reintervention compared with surgical intervention in patients with stent obstruction due to tumour ingrowth. Methods This was an observational study using data from a database of patients who underwent palliative colonic stenting between January 1998 and March 2017 at Christchurch Public Hospital. Results A total of 190 patients underwent colonic stent insertion, for palliation in 182 cases. Reintervention was performed in 55 (30·2 per cent). Thirty-one patients (17·0 per cent) developed obstruction within the stent at a median of 4·6 (i.q.r. 2·3-7·7) months after the procedure. Of these, 21 had endoscopic restenting and ten underwent surgery. Restenting had technical and clinical success rates of 100 per cent, and involved a significantly shorter length of stay compared with surgery (median 2 (i.q.r. 1-4) versus 11 (6-19) days respectively; P = 0·006). Seven of the 21 patients in the restented group underwent a third palliative intervention. The overall stoma rate in the restented group was significantly lower than that in the surgical group (4 of 21 versus 10 of 10; P < 0·001). There was no difference in complications or survival between the two groups. Conclusion Among palliative patients who develop malignant stent obstruction, endoscopic restenting had a high chance of technical success. It resulted in a shorter hospital stay and lower stoma rate than those seen after surgery.
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Affiliation(s)
- L Clarke
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - H Abbott
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - P Sharma
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand
| | - T W Eglinton
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand.,Department of Surgery, University of Otago Christchurch New Zealand
| | - F A Frizelle
- Colorectal Unit, Christchurch Hospital Christchurch New Zealand.,Department of Surgery, University of Otago Christchurch New Zealand
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Malignant Bowel Obstruction in Advanced Gynecologic Cancers: An Updated Review from a Multidisciplinary Perspective. Obstet Gynecol Int 2018; 2018:1867238. [PMID: 29887891 PMCID: PMC5985138 DOI: 10.1155/2018/1867238] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/26/2018] [Indexed: 12/22/2022] Open
Abstract
Malignant bowel obstruction (MBO) is a major complication in women with advanced gynecologic cancers which imposes a significant burden on patients, caregivers, and healthcare systems. Symptoms of MBO are challenging to palliate and result in progressive decompensation of already vulnerable patients with limited therapeutic options and a short prognosis. However, there is a paucity of guidelines or innovative approaches to improve the care of women who develop MBO. MBO is a complex clinical situation that requires a multidisciplinary approach to ensure the appropriate treatment modality and interprofessional care to optimally manage these patients. This review summarizes the current literature on the different approaches targeting MBO management including surgical intervention, chemotherapy, total parenteral nutrition, and pharmacological treatment. In addition, the impact of MBO management on patients' quality of life (QOL) is examined. This article focuses on the challenges in developing evidence-based treatment guidelines for MBO and barriers in clinical trial design for MBO and proposes strategies to advance the MBO management. Collaboration is essential to design studies that may improve the overall care and quality of life for these patients. Prospective data are needed to inform clinical practice, establish a new benchmark for evidence-based MBO management, and better understand the biology of MBO.
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Abstract
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.
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20
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Sousa M, Pinho R, Proença L, Silva J, Ponte A, Rodrigues J, Carvalho J. Predictors of Complications and Mortality in Patients with Self-Expanding Metallic Stents for the Palliation of Malignant Colonic Obstruction. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:122-128. [PMID: 28848796 DOI: 10.1159/000452697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/11/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Self-expanding metallic stents (SEMS) for palliative purposes in malignant colonic obstruction are an alternative to surgery that has gained popularity over time. METHODS We performed a retrospective study of patients submitted to SEMS for palliation of obstructing malignant colorectal cancer from 2005 to 2015 to evaluate predictive clinical factors for complications and mortality. RESULTS Forty-five patients with high rates of technical and clinical success were included (97.8 and 95.6%, respectively), with complications occurring in 17.8% (8.9% perforations, 4.4% obstructions, and 4.4% migrations). The length of the stenosis was superior in patients with complications (p = 0.01); 11.1% of patients had a re-intervention (2.2% surgery and 8.9% placement of another SEMS). Relief of obstruction without intervention was maintained until death in 77.8% of patients and in 81.4% of patients who had immediate clinical success. The mortality rate was 37.2% at 30 days, 56.5% at 60 days, and 87.5% at 1 year. There were no predictors of survival identified, including age, sex, tumor stage, metastasis, or complications of the procedure. DISCUSSION AND CONCLUSIONS In this study, SEMS placement was associated with a high rate of technical and clinical success and a low rate of complications, being an option to palliate patients with obstructive neoplasia. The length of the stenosis was associated with a greater risk of complications. The majority of stent-related complications can be managed successfully without surgery.
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Affiliation(s)
- Mafalda Sousa
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Rolando Pinho
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Luísa Proença
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Joana Silva
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Ana Ponte
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Jaime Rodrigues
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - João Carvalho
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
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Safety and efficacy of palliative colorectal stent placement using a nasal endoscope technique. Surg Laparosc Endosc Percutan Tech 2016; 25:262-5. [PMID: 26018052 PMCID: PMC4454541 DOI: 10.1097/sle.0000000000000159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to evaluate the safety and efficacy of palliative self-expanding metallic stent (SEMS) placement using a nasal endoscope technique in the context of colorectal malignant obstruction. Eighteen patients with malignant colorectal obstruction who underwent palliative SEMS insertion using a nasal endoscope technique at the Toyonaka Municipal Hospital from August 2005 to August 2011 were enrolled and retrospectively analyzed. In all cases, a guidewire could be inserted on the oral side of the tumor. The placement success rate was 94.4% (17/18), and the complication rate was 23.5% (4 cases). The stent migrated in 3 cases, and perforation occurred in 1 case following bevacizumab chemotherapy. These outcomes indicate that stenting is useful for terminal patients and that nasal endoscopy is useful in cases of difficult guidewire placement.
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Pires S, Pimentel-Nunes P. To Stent or Not to Stent in Colorectal Cancer: That is Still the Question in Gastroenterology! GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:59-60. [PMID: 28868434 PMCID: PMC5580099 DOI: 10.1016/j.jpge.2016.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Sara Pires
- Gastroenterology Department, Hospital Espírito Santo de Évora, Évora, Portugal
- Corresponding author.
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
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Takahashi H, Okabayashi K, Tsuruta M, Hasegawa H, Yahagi M, Kitagawa Y. Self-Expanding Metallic Stents Versus Surgical Intervention as Palliative Therapy for Obstructive Colorectal Cancer: A Meta-analysis. World J Surg 2016; 39:2037-44. [PMID: 25894403 DOI: 10.1007/s00268-015-3068-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although self-expanding metallic stents (SEMS) are useful tools for relieving large bowel obstructions in patients with colorectal cancer (CRC), their efficacy in a palliative setting has not been validated. This meta-analysis aimed to evaluate the feasibility of SEMS as a palliation for unresectable CRC patients with bowel obstructions and to determine their contribution to the prognosis of CRC, compared with surgical intervention. METHODS We conducted a literature search of the PubMed and Cochrane Library databases. We selected all controlled trials that compared SEMS with surgical interventions as palliative treatments in unresectable obstructive CRC patients. The primary outcome was early complications, and the secondary outcomes were mortality, other morbidities, and long-term survival rates. RESULTS Ten studies met our inclusion criteria. SEMS significantly reduced the risk of early complications (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.20-0.58%; P<0.01), mortality (OR 0.31; 95% CI 0.15%-0.64%; P<0.01), and stoma creation (OR 0.19; 95% CI 0.12-0.28%; P<0.01). Although SEMS placement was significantly associated with a higher risk of perforation of the large bowel (OR 5.25 95% CI 2.00-13.78%; P<0.01) and late complications (OR 1.94; 95% CI 0.90-4.19%; P=0.03), it also contributed significantly to better long-term survival (hazard ratio 0.46; 95% CI 0.31-0.68%; P<0.01). CONCLUSIONS Compared with surgical intervention, SEMS could provide feasible palliation for patients with bowel obstructions and unresectable CRC, because of their acceptable morbidity rates and better patient prognoses.
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Affiliation(s)
- Hidena Takahashi
- Department of Surgery, Keio University School of Medicine, 35 Shinanotmachi, Shinjuku-ku, Tokyo, Japan,
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Atukorale YN, Church JL, Hoggan BL, Lambert RS, Gurgacz SL, Goodall S, Maddern GJ. Self-Expanding Metallic Stents for the Management of Emergency Malignant Large Bowel Obstruction: a Systematic Review. J Gastrointest Surg 2016; 20:455-62. [PMID: 26501483 DOI: 10.1007/s11605-015-2997-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 10/14/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This paper evaluates the safety and effectiveness of self-expanding metallic stents (SEMS) for the management of emergency malignant colorectal obstruction in patients otherwise requiring multi-stage surgery. No systematic review has been conducted comparing SEMS to only multi-stage surgery. METHODS Bibliographic databases, including Cochrane, PubMed, EMBASE, and CINAHL, were searched in September 2011 and repeated in November 2013. A pre-determined protocol outlined the study inclusion and appraisal. RESULTS Forty articles were included, seven compared SEMS to multi-stage surgery. Included studies were of low to moderate quality. Bowel perforation was the most severe stent-related complication, while tumor- and stent-related events occurred most frequently. No significant differences in rates of obstruction relief were reported between treatments, and results regarding relative quality of life were inconclusive. SEMS recipients progressed to elective surgery sooner and required shorter post-procedural hospital stays, but commonly required re-intervention. SEMS provided enduring palliative relief of obstruction, with comparable survival longevity between treatments. Conclusion: SEMS placement is a viable alternative to multi-stage surgery, providing patients with benefits as a bridge-to-surgery and relief of obstruction in a palliative context, with minimal differences in clinical success and safety compared to multi-stage surgery.
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Fernandes D, Domingues S, Gonçalves BM, Bastos P, Ferreira A, Rodrigues A, Gonçalves R, Lopes L, Rolanda C. Acute Treatment of Malignant Colorectal Occlusion: Real Life Practice. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:66-75. [PMID: 28868436 PMCID: PMC5580112 DOI: 10.1016/j.jpge.2015.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/02/2015] [Indexed: 12/27/2022]
Abstract
Introduction Colorectal cancer presents itself as acute bowel occlusion in 10–40% of patients. There are two main therapeutic approaches: urgent surgery and endoluminal placement self-expandable metallic stents (SEMS). Aims and Methods This study intended to better clarify the risk/benefit ratio of the above-mentioned approaches. We conducted a retrospective longitudinal multicenter study, including 189 patients with acute malignant colorectal occlusion, diagnosed between January 2005 and March 2013. Results Globally (85 patients – 35 bridge-to-surgery and 50 palliative), SEMS's technical success was of 94%. Palliative SEMS had limited clinical success (60%) and were associated with 40% of complications. SEMS occlusion (19%) was the most frequent complication, followed by migration (9%) and bowel perforation (7%). Elective surgery after stenting was associated with a higher frequency of primary anastomosis (94% vs. 76%; p = 0.038), and a lower rate of colostomy (26% vs. 55%; p = 0.004) and overall mortality (31% vs. 57%; p = 0.02). However, no significant differences were identified concerning postoperative complications. Regarding palliative treatment, no difference was found in the complications rate and overall mortality between SEMS and decompressive colostomy/ileostomy. In this SEMS subgroup, we found a higher rate of reinterventions (40% vs. 5%; p = 0.004) and a longer hospital stay (14, nine vs. seven, three days; p = 0.004). Conclusion SEMS placement as a bridge-to-surgery should be considered in the acute treatment of colorectal malignant occlusion, since it displays advantages regarding primary anastomosis, colostomy rate and overall mortality. In contrast, in this study, palliative SEMS did not appear to present significant advantages when compared to decompressive colostomy.
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Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion. Dis Colon Rectum 2015; 58:838-49. [PMID: 26252845 DOI: 10.1097/dcr.0000000000000431] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery remains the dominant treatment for large-bowel obstruction, with emerging data on self-expanding metallic stents. OBJECTIVE The aim of this study was to assess whether stent insertion improves quality of life and survival in comparison with surgical decompression. DESIGN This study reports on a randomized control trial (registry number ACTRN012606000199516). SETTING This study was conducted at Royal Prince Alfred Hospital, Sydney, and Western Hospital, Melbourne. PATIENTS AND INTERVENTION Patients with malignant incurable large-bowel obstruction were randomly assigned to surgical decompression or stent insertion. MAIN OUTCOME MEASURES The primary end point was differences in EuroQOL EQ-5D quality of life. Secondary end points included overall survival, 30-day mortality, stoma rates, postoperative recovery, complications, and readmissions. RESULTS Fifty-two patients of 58 needed to reach the calculated sample size were evaluated. Stent insertion was successful in 19 of 26 (73%) patients. The remaining 7 patients required a stoma compared with 24 of 26 (92%) surgery group patients (p < 0.001). There were no stent-related perforations or deaths. The surgery group had significantly reduced quality of life compared with the stent group from baseline to 1 and 2 weeks (p = 0.001 and p = 0.012), and from baseline to 12 months (p = 0.01) in favor of the stent group, whereas both reported reduced quality of life. The stent group had an 8% 30-day mortality compared with 15% for the surgery group (p = 0.668). Median survival was 5.2 and 5.5 months for the groups (p = 0.613). The stent group had significantly reduced procedure time (p = 0.014), postprocedure stay (p = 0.027), days nothing by mouth (p = 0.002), and days before free access to solids (p = 0.022). LIMITATIONS This study was limited by the lack of an EQ-5D Australian-based population set. CONCLUSIONS Stent use in patients with incurable large-bowel obstruction has a number of advantages with faster return to diet, decreased stoma rates, reduced postprocedure stay, and some quality-of-life benefits.
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Imbulgoda A, MacLean A, Heine J, Drolet S, Vickers MM. Colonic perforation with intraluminal stents and bevacizumab in advanced colorectal cancer: retrospective case series and literature review. Can J Surg 2015; 58:167-71. [PMID: 25799132 DOI: 10.1503/cjs.013014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Self-expanding metal stents (SEMS) are increasingly used in the treatment of malignant large bowel obstruction in the setting of inoperable colorectal cancer. Perforation is a well-known complication associated with these devices. The addition of the vascular endothelial growth factor inhibitor bevacizumab is suspected to increase the rate, but the extent of the increase is not known. METHODS We retrospectively reviewed the records of patients receiving SEMS in tertiary hospitals in Calgary, Alta., between October 2001 and January 2012. RESULTS We reviewed the records of 87 patients with inoperable colorectal cancer who received SEMS during our study period. Nine perforations occurred in total: 4 of 30 (13%) patients who received no chemotherapy, 3 of 47 (6%) who received chemotherapy but no bevacizumab, and 2 of 10 (20%) who received chemotherapy and bevacizumab. These two patients received bevacizumab with FOLFIRI after SEMS placement, and they had peritoneal disease. CONCLUSION Our case series and other studies suggest that bevacizumab may increase the risk of colonic perforation in the setting of SEMS. Caution should be used when combining these therapies.
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Affiliation(s)
- Amal Imbulgoda
- The Department of Oncology, University of Calgary, Calgary, Alta
| | - Anthony MacLean
- The Department of Surgery, University of Calgary, Calgary, Alta
| | - John Heine
- The Department of Surgery, University of Calgary, Calgary, Alta
| | | | - Michael M Vickers
- The Department of Medicine, Division of Medical Oncology, University of Ottawa, Ottawa, Ont
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Mangiavillano B, Pagano N, Arena M, Miraglia S, Consolo P, Iabichino G, Virgilio C, Luigiano C. Role of stenting in gastrointestinal benign and malignant diseases. World J Gastrointest Endosc 2015; 7:460-480. [PMID: 25992186 PMCID: PMC4436915 DOI: 10.4253/wjge.v7.i5.460] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 12/10/2014] [Accepted: 02/02/2015] [Indexed: 02/05/2023] Open
Abstract
Advances in stents design have led to a substantial increase in the use of stents for a variety of digestive diseases. Initially developed as a non-surgical treatment for palliation of esophageal cancer, the stents now have an emerging role in the management of malignant and benign conditions as well as in all segments of the gastrointestinal tract. In this review, relevant literature search and expert opinions have been used to evaluate the key-role of stenting in gastrointestinal benign and malignant diseases.
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Malgras B, Lo Dico R, Pautrat K, Dohan A, Boudiaf M, Pocard M, Soyer P. Gastrointestinal stenting: Current status and imaging features. Diagn Interv Imaging 2015; 96:593-606. [PMID: 25953525 DOI: 10.1016/j.diii.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 12/13/2022]
Abstract
The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.
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Affiliation(s)
- B Malgras
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France.
| | - R Lo Dico
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - K Pautrat
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - A Dohan
- Department of Abdominal and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Sorbonne Paris Cité, université Diderot - Paris 7, 10, avenue de Verdun, 75010 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - M Boudiaf
- Department of Abdominal and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - M Pocard
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Sorbonne Paris Cité, université Diderot - Paris 7, 10, avenue de Verdun, 75010 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - P Soyer
- Department of Abdominal and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Sorbonne Paris Cité, université Diderot - Paris 7, 10, avenue de Verdun, 75010 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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30
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Yoshida S, Isayama H, Koike K. Palliative self-expandable metallic stent placement for colorectal obstruction caused by an extracolonic malignancy. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Sahebally SM, Sarwar A, Cooke F. Short-term outcomes following the use of self-expanding metallic stents in acute malignant colonic obstruction--a single centre experience. Int J Surg 2014; 12:1198-202. [PMID: 25300737 DOI: 10.1016/j.ijsu.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/10/2014] [Accepted: 09/19/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term outcomes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution over a 3-year period. METHODS A prospectively maintained database was reviewed to identify all patients who presented to our institution with AMCO between August 2010 and 2013 and who were treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews and operation notes. RESULTS Sixteen patients (12 males, 4 females) each had a single stent inserted during the study period, either palliatively (n = 11) or as a BTS (n = 5). The technical and clinical success rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and required emergency surgery while five patients with curable disease proceeded to elective resections. There was no procedure-related mortality or stent-related perforations. The mean (standard deviation) length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All patients in the BTS group were stoma-free post-operatively, while both patients who had emergency surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary to migration. CONCLUSIONS Although limited by a small sample size, the study shows that SEMS have favourable short-term outcomes. Further adequately powered trials are needed to confirm those findings.
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Affiliation(s)
- Shaheel M Sahebally
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Azhar Sarwar
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Fiachra Cooke
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland.
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van Halsema EE, van Hooft JE, Small AJ, Baron TH, García-Cano J, Cheon JH, Lee MS, Kwon SH, Mucci-Hennekinne S, Fockens P, Dijkgraaf MGW, Repici A. Perforation in colorectal stenting: a meta-analysis and a search for risk factors. Gastrointest Endosc 2014; 79:970-82.e7; quiz 983.e2, 983.e5. [PMID: 24650852 DOI: 10.1016/j.gie.2013.11.038] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 11/25/2013] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Emo E van Halsema
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Aaron J Small
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd H Baron
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jesús García-Cano
- Department of Gastroenterology, Hospital Virgen de la Luz, Cuenca, Spain
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Sung Lee
- Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, Bucheon, Korea
| | - Se Hwan Kwon
- Department of Radiology, Kyung Hee University Medical Center, Seoul, Korea
| | | | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Alessandro Repici
- Department of Digestive Endoscopy, Istituto Clinico Humanitas, Milan, Italy
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Currie A, Christmas C, Aldean H, Mobasheri M, Bloom ITM. Systematic review of self-expanding stents in the management of benign colorectal obstruction. Colorectal Dis 2014; 16:239-45. [PMID: 24033989 DOI: 10.1111/codi.12389] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 05/21/2013] [Indexed: 12/20/2022]
Abstract
AIM Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction. METHOD A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population. RESULTS The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis. CONCLUSION Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction.
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Affiliation(s)
- A Currie
- Department of Colorectal Surgery, Kingston Hospital, Kingston-upon-Thames, Surrey, UK
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Lamazza A, Fiori E, Sterpetti AV, Schillaci A, Scoglio D, Lezoche E. Self-expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer. Colorectal Dis 2014; 16:O150-3. [PMID: 24206040 DOI: 10.1111/codi.12488] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 07/29/2013] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the use of self-expandable metallic stents to treat patients with symptomatic benign anastomotic stricture after colorectal resection. METHOD Ten patients with a benign symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent. RESULTS The stent was placed successfully in all 10 patients without any major morbidity. At a mean follow-up of 18 months the stenosis was resolved successfully in 7 out 10 patients (70%). The remaining three patients were subsequently treated successfully with balloon dilatation. CONCLUSION Self-expandable metal stents represent a valid alternative to balloon dilatation to treat patients with benign symptomatic anastomotic stricture after colorectal resection for cancer.
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Affiliation(s)
- A Lamazza
- Istituto Pietro Valdoni-Istituto Paride Stefanini, University of Rome La Sapienza, Rome, Italy
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35
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Di Mitri R, Mocciaro F, Traina M, Montalbano LM, Familiari L, D'Amore F, Raimondo D, Virgilio C, Tarantino I, Barresi L, Giunta M, Borina E, Borruto A, Marino A. Self-expandable metal stents for malignant colonic obstruction: data from a retrospective regional SIED-AIGO study. Dig Liver Dis 2014; 46:279-82. [PMID: 24326063 DOI: 10.1016/j.dld.2013.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 10/17/2013] [Accepted: 11/02/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expandable metal stents are a non-surgical option for the treatment of symptomatic malignant colorectal obstruction as palliative treatment or as a bridge to surgery. AIMS To report data from a regional study on self-expandable metal stent (SEMS) placement for malignant colorectal obstruction. METHODS Two hundred and four patients (male 54.9%, mean age of 69.5 ± 14.2) were retrospectively evaluated and data on technical and clinical success, and complications, were analyzed. RESULTS Technical and clinical success rates were 99% and 94.6% respectively, with 36.7% treated on an emergency basis and 63.3% electively. Palliative treatment was administered to 70.1%, and as a bridge to surgery for 29.9%. Complications were 17 neoplastic ingrowths, 10 stent migrations, and 4 perforations. Palliative treatment was associated with a higher risk of stent ingrowth (p=0.003), and chemotherapy with a lower risk of stent ingrowth (p=0.009). CONCLUSION This regional study, although it has certain limitations, confirms the positive role of self-expandable metal stents in the treatment of symptomatic malignant colorectal obstruction, and that chemotherapy decreases the risk of ingrowth.
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Affiliation(s)
- Roberto Di Mitri
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Palermo, Italy.
| | - Filippo Mocciaro
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Medicine, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | | | - Luigi Familiari
- UOD Digestive Endoscopy, University of Messina, Messina, Italy
| | | | - Dario Raimondo
- Gastroenterology and Digestive Endoscopy Unit, San Raffaele-Giglio Hospital, Cefalù (PA), Italy
| | - Clara Virgilio
- Gastroenterology Unit, ARNAS Garibaldi Hospital, Catania, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Medicine, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Medicine, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Marco Giunta
- UOD Digestive Endoscopy, University of Messina, Messina, Italy
| | - Eleonora Borina
- Gastroenterology Unit, S. Vincenzo Hospital, Taormina (ME), Italy
| | - Antonino Borruto
- Gastroenterology Unit, S. Vincenzo Hospital, Taormina (ME), Italy
| | - Antonino Marino
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Palermo, Italy
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Cheung DY, Lee YK, Yang CH. Status and literature review of self-expandable metallic stents for malignant colorectal obstruction. Clin Endosc 2014; 47:65-73. [PMID: 24570885 PMCID: PMC3928494 DOI: 10.5946/ce.2014.47.1.65] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 12/14/2022] Open
Abstract
Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.
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Affiliation(s)
- Dae Young Cheung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong Kook Lee
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Chang Heon Yang
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
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Lamazza A, Fiori E, Schillaci A, Sterpetti AV, Lezoche E. Treatment of anastomotic stenosis and leakage after colorectal resection for cancer with self-expandable metal stents. Am J Surg 2014; 208:465-9. [PMID: 24560186 DOI: 10.1016/j.amjsurg.2013.09.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 09/03/2013] [Accepted: 09/09/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Self-expandable metallic stents can be used to treat patients with symptomatic anastomotic complications after colorectal resection. METHODS Twenty patients with symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent. Ten patients had "simple" anastomotic stricture. In the remaining 10 patients, a leak was associated with the stricture. RESULTS The anastomotic leakage healed without evidence of residual stricture or major fecal incontinence in 8 of 10 patients. Overall, the anastomotic stricture was resolved in 14 of the 20 patients. CONCLUSIONS Self-expandable metal stents represent a valid adjunctive to treat patients with symptomatic anastomotic complications after colorectal resection for cancer. They have a complementary role to balloon dilatation in case of simple anastomotic stricture, and they improve the rate of healing when the stricture is associated with a leak.
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Affiliation(s)
- Antonietta Lamazza
- Department "Pietro Valdoni", Department "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Enrico Fiori
- Department "Pietro Valdoni", Department "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Alberto Schillaci
- Department "Pietro Valdoni", Department "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Antonio V Sterpetti
- Department "Pietro Valdoni", Department "Paride Stefanini", Sapienza University of Rome, Rome, Italy.
| | - Emanuele Lezoche
- Department "Pietro Valdoni", Department "Paride Stefanini", Sapienza University of Rome, Rome, Italy
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The new nitinol conformable self-expandable metal stents for malignant colonic obstruction: a pilot experience as bridge to surgery treatment. ScientificWorldJournal 2014; 2014:651765. [PMID: 24526914 PMCID: PMC3910280 DOI: 10.1155/2014/651765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/15/2013] [Indexed: 01/23/2023] Open
Abstract
Introduction. Self-expandable metal stents (SEMS) are a nonsurgical option for treatment of malignant colorectal obstruction also as a bridge to surgery approach. The new nitinol conformable stent has improved clinical outcomes in these kinds of patients. We report a pilot experience with nitinol conformable SEMS placement as bridge to surgery treatment in patients with colorectal obstruction. Materials and Methods. Between April and August 2012, we collected data on colonic nitinol conformable SEMS placement in a cohort of consecutive symptomatic patients, with malignant colorectal obstruction, who were treated as a bridge to surgery. Technical success, clinical success, and adverse events were recorded. Results. Ten patients (7 male (70%)), with a mean age of 69.2 ± 10.1, were evaluated. The mean length of the stenosis was 3.6 ± 0.6 cm. Five patients (50%) were treated on an emergency basis. The median time from stent placement to surgery was 16 days (interquartile range 7–21). Technical and clinical success was achieved in all patients with a significant early improvement of symptoms. No adverse events due to the SEMS placement were observed. Conclusion. This pilot study confirmed the important role of nitinol conformable SEMS as a bridge to surgery option in the treatment of symptomatic malignant colorectal obstruction.
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Maitra RK, Maxwell-Armstrong CA. Surgical management of obstructed and perforated colorectal cancer: still debating and unresolved issues. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
SUMMARY Emergency surgery for obstruction and perforation from colorectal cancer (CRC) predicts poorer outcomes compared with elective surgery. For obstructed cancers, the evidence suggests significantly poorer outcomes with multistaged procedures compared with single-stage procedures in this group. Stenting remains an attractive option as a ‘bridge-to-surgery’, with multiple single-center studies demonstrating excellent short-term outcomes. However, contradictory evidence from three randomized trials casts doubts on stenting as the preferred modality for initial management of all curative obstructed CRCs. Results from a UK multicenter randomized controlled trial are still awaited. Palliative stenting shows predominantly positive results and is a valuable option for nonresectable or incurable CRCs. All authors agree on emergency surgery as the primary modality of treatment for perforated malignancies. Short-term outcomes are markedly poorer than the elective surgery group and correlate with the degree of peritoneal contamination. Long-term outcomes are comparable to elective surgery when perioperative deaths are excluded.
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Affiliation(s)
- Rudra K Maitra
- Department of Digestive Diseases & Thoracics Directorate, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, E Floor, West Block, NG7 2UH, UK
| | - Charles A Maxwell-Armstrong
- Department of Digestive Diseases & Thoracics Directorate, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, E Floor, West Block, NG7 2UH, UK
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Zhao XD, Cai BB, Cao RS, Shi RH. Palliative treatment for incurable malignant colorectal obstructions: A meta-analysis. World J Gastroenterol 2013; 19:5565-5574. [PMID: 24023502 PMCID: PMC3761112 DOI: 10.3748/wjg.v19.i33.5565] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.
METHODS: The databases of Medline, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies (prospective, retrospective, randomized controlled trials, and case-control trials) designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by self-expanding metallic stents (SEMS) or palliative surgery. No language restrictions were imposed. The main outcome measures were hospital stay, intensive care unit admission, clinical success rate, 30-d mortality, stoma formation, complications, and overall survival time. The data extraction was conducted by two investigators working independently and using a standardized form. The Mantel-Haenszel χ2 method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model; when statistical heterogeneity existed in the pooled data (as evaluated by Q test and I2 statistics, where P < 0.10 and I2 < 25% indicated heterogeneity), a random-effects model was used.
RESULTS: Thirteen relevant articles, representing 837 patients (SEMS group, n = 404; surgery group, n = 433), were selected for analysis. Compared to the surgery group, the SEMS group showed lower clinical success (99.8% vs 93.1%, P = 0.0009) but shorter durations of hospital stay (18.84 d vs 9.55 d, P < 0.00001) and time to initiation of chemotherapy (33.36 d vs 15.53 d, P < 0.00001), and lower rate of stoma formation (54.0% vs 12.7%, P < 0.00001). Additionally, the SEMS group experienced a significantly lower rate of 30-d mortality (4.2% vs 10.5%, P = 0.01). Stent-related complications were not uncommon and included perforation (10.1%), migration (9.2%), and occlusion (18.3%). Surgery-related complications were slightly less common and included wound infection (5.0%) and anastomotic leak (4.7%). The rate of total complications was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the surgery-related complications occurred earlier than stent-related complications (rate of early complications: 33.7% vs 13.7%, P = 0.03; rate of late complications: 32.3% vs 12.7%, P < 0.0001). The overall survival time of SEMS- and surgery-treated patients was not significantly different (7.64 mo vs 7.88 mo).
CONCLUSION: SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions, but is associated with a shorter time to chemotherapy and lower 30-d mortality.
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Sarkar S, Geraghty J, Rooney P. Colonic stenting: a practical update. Frontline Gastroenterol 2013; 4:219-226. [PMID: 28839728 PMCID: PMC5369802 DOI: 10.1136/flgastro-2012-100286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 01/31/2013] [Accepted: 02/07/2013] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Sanchoy Sarkar
- Department of Gastroenterology and Hepatology, Royal Liverpool University Hospital, Liverpool, UK,Department of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Joe Geraghty
- Department of Gastroenterology and Hepatology, Royal Liverpool University Hospital, Liverpool, UK,Department of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Paul Rooney
- Department of Surgery, Royal Liverpool University Hospital, Liverpool, UK
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Cennamo V, Luigiano C, Coccolini F, Fabbri C, Bassi M, De Caro G, Ceroni L, Maimone A, Ravelli P, Ansaloni L. Meta-analysis of randomized trials comparing endoscopic stenting and surgical decompression for colorectal cancer obstruction. Int J Colorectal Dis 2013; 28:855-63. [PMID: 23151813 DOI: 10.1007/s00384-012-1599-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Surgical decompression is the traditional treatment for acute colorectal cancer obstruction. In recent years, colorectal stenting has been used to relieve the obstruction. This study used meta-analytic techniques to compare colonic stenting versus surgical decompression for colorectal cancer obstruction. METHODS A comprehensive search of several databases was conducted. The search identified 321 potential abstracts and titles of which eight randomized trials involving 353 patients were retrieved in full text. A meta-analysis of the studies included was carried out to identify the differences in outcomes between the two procedures. RESULTS The pooled analysis showed no significant differences for mortality (odds ratio (OR) 0.91) and morbidity (OR 2.05) rates between the two strategies while the permanent stoma creation rate was significantly higher in the surgical group as compared to the stent group (OR 3.12). By comparing surgery and colonic stenting in studies which analyzed the use of stenting as a "bridge to surgery," the pooled analysis showed that primary anastomosis was more frequent in the stent group as compared to the surgical group (OR 0.42), and the stoma creation was more frequent in the surgical group as compared to the stent group (OR 2.36). CONCLUSION Our study suggested that, in patients with acute colorectal cancer obstruction, stent placement improved several outcomes, such as primary anastomosis, stoma formation, and permanent stoma, while it failed to show an improvement in mortality and morbidity risk.
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Affiliation(s)
- Vincenzo Cennamo
- Unit of Digestive Endoscopy, Department of Surgery, AUSL Bologna Bellaria Hospital, Via Altura, 40139, Bologna, Italy.
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Self-expandable metallic stents in patients with stage IV obstructing colorectal cancer. World J Surg 2013; 36:2931-6. [PMID: 22960673 DOI: 10.1007/s00268-012-1767-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Yoshida S, Watabe H, Isayama H, Kogure H, Nakai Y, Yamamoto N, Sasaki T, Kawakubo K, Hamada T, Ito Y, Yashima Y, Sasahira N, Hirano K, Yamaji Y, Tada M, Omata M, Koike K. Feasibility of a new self-expandable metallic stent for patients with malignant colorectal obstruction. Dig Endosc 2013; 25:160-6. [PMID: 23362948 DOI: 10.1111/j.1443-1661.2012.01353.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/01/2012] [Indexed: 12/16/2022]
Abstract
AIM Stent migration due to peristalsis of the colon is one of the unresolved complications of colonic self-expandable metallic stent (SEMS) placement. Axial force (AF), a recovery force of the stent to a straight position after bending, has been considered a factor influencing the conformability of the digestive tract. An uncovered SEMS (Niti-S Enteral Colonic Uncovered Stent, D-type; Taewoong, Inc., Gimpo, South Korea) with improved conformability is considered to decrease migration. METHODS Thirty three consecutive patients with symptomatic colorectal obstruction between March 2006 and December 2011 underwent endoscopic stent placement for palliation to estimate the efficacy and safety of Niti-S stents prospectively in four tertiary referral centers. RESULTS Technical and clinical success rates were 100% and 97%, respectively. Seventeen patients had the following complications: ingrowth (n = 6), overgrowth (n = 1), collapse of the SEMS (n = 1), stool impaction (n = 2), migration (n = 1), bleeding (n = 3), and tenesmus (n = 3). The patient with migration had no recurrent symptoms until death. Of these 17 patients, 10 required re-interventions. Seven patients underwent an additional SEMS implantation. One patient underwent surgery for stoma creation. Two patients had stool impaction, and they underwent endoscopic cleaning. The median duration of patency was 347.0 ± 65.5 days. The mean survival time after stent insertion was 240.1 ± 39.9 days. CONCLUSION The new SEMS effectively relieves malignant colorectal obstruction. Good conformability, according to the very low AF, may contribute to the low incidence of migration.
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Affiliation(s)
- Shuntaro Yoshida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
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Lamazza A, Fiori E, Schillaci A, Sterpetti AV. A new technique for placement of a self-expanding metallic stent (SEMS) in patients with colon rectal obstruction: a prospective study of 43 patients. Surg Endosc 2012; 27:1045-8. [PMID: 23052503 DOI: 10.1007/s00464-012-2522-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 07/31/2012] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Antonietta Lamazza
- Departement Pietro Valdoni-Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, Rome 00167, Italy.
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Favorable long-term clinical outcome of uncovered D-weave stent placement as definitive palliative treatment for malignant colorectal obstruction. Dis Colon Rectum 2012; 55:983-9. [PMID: 22874606 DOI: 10.1097/dcr.0b013e31825c484d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most self-expandable metallic stents for colorectal placement are uncovered because of the high migration rate of covered stents. However, the optimal stent design for colorectal use remains unclear. OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of a double-wire woven uncovered stent for definitive palliative treatment of malignant colorectal obstruction. DESIGN This study was a prospective, single-arm, observational clinical study of patients enrolled between December 2005 and September 2010. SETTINGS This study was conducted at a referral hospital in Japan. PATIENTS Twenty-four consecutive patients with malignant colorectal obstruction were included in the study. INTERVENTIONS A double-wire woven uncovered stent was placed by use of a standard through-the-scope endoscopic placement technique. MAIN OUTCOME MEASURES Technical, initial clinical, and long-term clinical success were measured. Long-term clinical success was defined as sustained relief of obstructive symptoms without reintervention until the patient's death. RESULTS The Karnofsky performance status score before stent placement was 60 (median, interquartile range, 42.5-67.5). Twenty of 24 patients had primary colorectal cancer, and 4 had extracolorectal malignancies. The site of obstruction was the ascending colon in 10 patients, descending colon in 4 patients, sigmoid colon in 7 patients, and rectum in 3 patients. Technical, initial, and long-term clinical success rates were 100%, 100%, and 83%. Median stent patency time was 149 days (interquartile range, 45-198 days). Median survival time after stent placement was 155 days (interquartile range, 68-231 days). Four patients (17%) had negative outcomes including stent occlusion by tumor ingrowth (8%) and stent migration (8%). The highest Karnofsky performance status score after stent placement was 70 (median; interquartile range, 50-70). The Karnofsky performance status score improved after stent placement (p = 0.002). LIMITATIONS This study was limited because it was a single-arm, single-center study, and it had a small sample size. CONCLUSIONS Endoscopic placement of double-wire woven uncovered stents is effective and safe as definitive palliative treatment for patients with malignant colorectal obstruction.
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Self-Expanding Metal Stenting for Palliation of Patients with Malignant Colonic Obstruction: Effectiveness and Efficacy on 255 Patients with 12-Month's Follow-up. Gastroenterol Res Pract 2012; 2012:296347. [PMID: 22761609 PMCID: PMC3384950 DOI: 10.1155/2012/296347] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 04/08/2012] [Indexed: 12/16/2022] Open
Abstract
Background. Self-expanding metal stents can alleviate malignant colonic obstruction in incurable patients and avoid palliative stoma surgery. Objective. Evaluate stent effectiveness and safety on palliation of patients with malignant colorectal strictures. Design. Two prospective, one Spanish and one global, multicenter studies. Settings. 39 centers (22 academic, 17 community hospitals) from 13 countries. Patients. A total of 257 patients were enrolled, and 255 patients were treated with a WallFlex uncovered enteral colonic stent. Follow-up was up to 12 months or until death or retreatment. Interventions(s). Self-expanding metal stent placement. Main Outcome Measures. Procedural success, clinical success, and safety. Results. Procedural success was 98.4% (251). Clinical success rates were 87.8% at 30 days, 89.7% at 3 months, 92.8% at 6 months, and 96% at 12 months. Overall perforation rate was 5.1%. Overall migration rate was 5.5%. Overall death rate during follow-up was 48.6% (124), with 67.7% of deaths related to the patient's colorectal cancer, unrelated in 32.3%. Only 2 deaths were related to the stent or procedure. Limitations. No control group. Conclusions. The primary palliative option for patients with malignant colonic obstruction should be self-expanding metal stent placement due to high rates of technical success and efficacy in symptom palliation and few complications.
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Lee JH, Yoon JY, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. The learning curve for colorectal stent insertion for the treatment of malignant colorectal obstruction. Gut Liver 2012; 6:328-33. [PMID: 22844560 PMCID: PMC3404169 DOI: 10.5009/gnl.2012.6.3.328] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 11/28/2011] [Accepted: 12/02/2011] [Indexed: 12/12/2022] Open
Abstract
Background/Aims We aimed to assess the effectiveness of self-expanding metal stent (SEMS) insertion by evaluating the learning curve in relation to the experience of an endoscopist. Methods We retrospectively analyzed the outcomes of 120 SEMS insertion procedures performed by one endoscopist in patients with malignant colorectal obstruction. We compared the technical and clinical success rates, complication rates, and duration of the procedures by quartiles. Results The mean age of the patients (76 men and 44 women) was 64.6 years. The overall technical success rate was 95.0% (114/120), and the clinical success rate was 90.0% (108/120). The median procedure duration was 16.2 minutes (range, 3.4 to 96.5 minutes). From the first to the last quartile, the technical success rates were 90.0%, 96.7%, 96.7%, and 96.7% (p=0.263), and the clinical success rates were 90.0%, 90.0%, 96.7%, and 83.3% (p=0.588), respectively. Procedure-related complications were observed in 28 patients (23.3%). The complication rates for SEMS insertion when patients were divided by quartiles were 26.7%, 23.3%, 10.0%, and 33.3% (p=0.184), respectively. Moreover, the number of stents per procedure was 1.13, 1.03, 1.00, and 1.00 (p=0.029), respectively. The median duration of SEMS insertion decreased significantly, 20.9 to 14.8 minutes after the first 30 procedures (p=0.005). Conclusions An experienced endoscopist was able to perform the SEMS insertion procedure easily and effectively after performing 30 SEMS insertions.
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Affiliation(s)
- Ji Hoon Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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49
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Fiori E, Lamazza A, Schillaci A, Femia S, Demasi E, Decesare A, Sterpetti AV. Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial. Am J Surg 2012; 204:321-6. [PMID: 22575396 DOI: 10.1016/j.amjsurg.2011.11.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 11/02/2011] [Accepted: 11/02/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. METHODS In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. RESULTS There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125-612 days) in patients who had stents and 280 days (range, 135-591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. CONCLUSIONS Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.
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Affiliation(s)
- Enrico Fiori
- I Clinica Chirurgica Pietro Valdoni, University of Rome La Sapienza, Rome, Italy
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Chouhan H, Wong CX, Maharaj P, Lawrence MJ, Hunter A, Moore JW. Colorectal stenting for malignant obstruction: an 8-year clinical experience. ANZ J Surg 2012; 82:408-11. [PMID: 22548742 DOI: 10.1111/j.1445-2197.2012.06086.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A substantial percentage of patients with colorectal cancer present with obstructive symptoms. In such patients, surgery is often required and is associated with significant morbidity and mortality. Colorectal stenting is an increasingly commonplace alternative with potentially fewer risks than open surgery. We present our clinical experience over an 8-year period with colorectal stenting in a major tertiary Australian hospital. METHODS From 2000 to 2008, patients undergoing colorectal stenting were identified via medical records. Clinical data collected included patient demographics, tumour type, extent of metastatic disease, stent characteristics, technical and clinical success, acute and chronic complications, and long-term follow-up status. RESULTS Thirty-five patients (69 ± 13 years, 25 male) received a total of 39 stents. Technical success was achieved in 37 (95%), and clinical relief of obstruction was achieved in 34 (89%). One case was complicated by perforation at the time of procedure and three cases experienced delayed perforation. Reintervention was required in 17% of patients, all of whom had less than 50% hepatic volume replacement by metastatic disease. CONCLUSIONS Colorectal stenting is a feasible and safe alternative for patients presenting with obstructive symptoms but the benefit may be restricted to patients with a short expected survival.
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Affiliation(s)
- Hanumant Chouhan
- Colorectal Surgical Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
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