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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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Bonfante P, D'Ambra L, Berti S, Falco E, Cristoni MV, Briglia R. Managing acute colorectal obstruction by "bridge stenting" to laparoscopic surgery: Our experience. World J Gastrointest Surg 2012; 4:289-95. [PMID: 23493809 PMCID: PMC3596526 DOI: 10.4240/wjgs.v4.i12.289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 10/01/2012] [Accepted: 12/01/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To verify the clinical results of the endoscopic stenting procedure for colorectal obstructions followed by laparoscopic colorectal resection with “one stage anastomosis”.
METHODS: From March 2003 to March 2009 in our surgical department, 48 patients underwent endoscopic stenting for colorectal occlusive lesion: 30 males (62.5%) and 18 females (37.5%) with an age range from 40 years to 92 years (median age 69.5). All patients enrolled in our study were diagnosed with an intestinal obstruction originating from the colorectal tract without bowel perforation signs. Obstruction was primitive colorectal cancer in 45 cases (93.7%) and benign anastomotic stricture in 3 cases (6.3%).
RESULTS: Surgical resection was totally laparoscopic in 69% of cases (24 patients) while 17% (6 patients) of cases were video-assisted due to the local extension of cancer with infiltrations of surrounding structures (urinary bladder in 2 cases, ileus and iliac vessels in the others). In 14% of cases (5 patients), resection was performed by open surgery due to the high American Society of Anesthesiologists score and the elderly age of patients (median age of 89 years). We performed a terminal stomy in only 7 patients out of 35, 6 colostomies and one ileostomy (in a total colectomy). In the other 28 cases (80%), we performed bowel anastomosis at the same time as resection, employing a temporary ileostomy only in 5 cases.
CONCLUSION: Colorectal stenting transforms an emergency operation in to an elective operation performable in a totally laparoscopic manner, limiting the confection of colostomy with its correlated complications.
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Affiliation(s)
- Pierfrancesco Bonfante
- Pierfrancesco Bonfante, Luigi D'Ambra, Stefano Berti, Emilio Falco, Department of Surgery, S.Andrea Hospital of La Spezia, 19100 La Spezia, 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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Faragher IG, Chaitowitz IM, Stupart DA. Long-term results of palliative stenting or surgery for incurable obstructing colon cancer. Colorectal Dis 2008; 10:668-72. [PMID: 18266885 DOI: 10.1111/j.1463-1318.2007.01446.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Self-expanding metal stents are an effective means of relieving left-sided malignant colonic obstruction, and in the setting of incurable disease may provide palliation while allowing the patients to avoid surgery altogether. With modern chemotherapy regimes, patients may have a long-life expectancy, even in the presence of metastases. The purpose of this study was to investigate the long-term results of palliative stent placement, compared with patients undergoing palliative surgery. METHOD This is a retrospective study of 55 consecutive patients who underwent colonic stenting or palliative surgery for incurable, obstructing adenocarcinoma of the left colon. RESULTS Twenty-nine patients underwent colonic stenting, and 26 had surgery during the study period. Survival was similar in the two groups (14 months in the stent group, 11 months in the surgery group). Median hospital stay was shorter in the stent group (4 vs 13.5 days), and fewer patients in the stent group had complications (2 vs 14). Only four patients in the stent group went on to require later surgery. The median time to failure of the stents was 14 months. CONCLUSION Colonic stenting provides effective and durable palliation for patients with incurable, obstructing adenocarcinomas of the left colon. It can be performed with less morbidity than palliative surgery, and offers similar long-term survival.
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Affiliation(s)
- I G Faragher
- Western Hospital, Footscray, Melbourne, Australia
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Fregonese D, Naspetti R, Ferrer S, Gallego J, Costamagna G, Dumas R, Campaioli M, Morante AL, Mambrini P, Meisner S, Repici A, Andreo L, Masci E, Mingo A, Barcenilla J, Petruzziello L. Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction. Gastrointest Endosc 2008; 67:68-73. [PMID: 18028916 DOI: 10.1016/j.gie.2007.05.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2007] [Accepted: 05/09/2007] [Indexed: 01/12/2023]
Abstract
BACKGROUND Emergency surgery for malignant colon obstruction entails relatively high morbidity and mortality rates and typically necessitates a 2-step resection. These problems might be potentially mitigated by placement of a self-expanding metal stent (SEMS) as a bridge to surgery. A nitinol colorectal SEMS may offer several advantages, but available evidence on the utility of this SEMS type remains highly limited. OBJECTIVE Our purpose was to evaluate the effectiveness and safety as a bridge to surgery of a nitinol SEMS designed for colorectal use. DESIGN Prospective and retrospective multicenter clinical study. SETTING Sixteen European study centers. PATIENTS Thirty-six patients with malignant colonic obstruction. INTERVENTIONS Nitinol colorectal SEMS placement. MAIN OUTCOME MEASURES Technical success in accurate SEMS placement with coverage of the entire stricture length, clinical success in alleviating colonic obstructive symptoms, and bridging to elective surgery. RESULTS Technical success was achieved in 97% of patients with a 95% CI of 85% to 100% and clinical success in 81% (95% CI, 64%-92%). Elective surgery was performed in 94% (95% CI, 81%-99%) of patients at a median of 11 days (95% CI, 7-15 days) after SEMS placement. SEMS-related perforation occurred in 3 patients. LIMITATIONS No control group was included in this nonrandomized cohort study. CONCLUSIONS In this first comparatively large clinical study of a nitinol colorectal SEMS as a bridge to surgery, a high proportion of patients successfully proceeded to elective surgery after prior decompression by SEMS placement.
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Affiliation(s)
- Diego Fregonese
- Camposampiero, Firenze, Rome, Prato, Torino, Milan, Italy, Valencia, Madrid, Burgos, Alicante, Palencia, Spain, Nice, Ajaccio, France, Copenhagen, Denmark
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Repici A, De Caro G, Luigiano C, Fabbri C, Pagano N, Preatoni P, Danese S, Fuccio L, Consolo P, Malesci A, D'Imperio N, Cennamo V, Cennamo V. WallFlex colonic stent placement for management of malignant colonic obstruction: a prospective study at two centers. Gastrointest Endosc 2008; 67:77-84. [PMID: 18155427 DOI: 10.1016/j.gie.2007.08.019] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Accepted: 08/09/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expanding metal stents (SEMSs) can alleviate malignant colonic obstruction and avoid emergency decompressive surgery. The use of colonic larger-diameter SEMSs may improve bowel function and reduce migration risk. OBJECTIVE To evaluate the effectiveness and safety of a novel large-diameter SEMS (WallFlex) designed for delivery through the endoscope in treating malignant colonic obstruction. DESIGN Prospective clinical cohort study. SETTING Two Italian study centers. PATIENTS Forty-two consecutive patients with malignant colonic obstruction: 23 requiring palliation and 19 bridging to surgery. INTERVENTIONS Colorectal SEMS placement. MAIN OUTCOME MEASUREMENTS Technical success, defined as accurate SEMS deployment across the stricture on the first attempt; clinical success, ie, complete relief of bowel obstruction without complications; and bridging to surgery, denoting the performance of elective one-stage surgery. RESULTS The rate of technical success was 93% (95% CI, 81%-99%) and of initial clinical success was 95% (95% CI, 84%-99%). In 58% (95% CI, 40%-84%) of the palliation group, clinical success was maintained after 6 months. All 19 patients with operable tumors were successfully bridged to one-stage elective surgery within a median of 5 days. One perforation and one stent migration occurred. All complications could be resolved nonsurgically. LIMITATIONS No control group was included. CONCLUSIONS In a prospective study of through-the-scope WallFlex stent placement for malignant colonic obstruction, high rates of technical and initial clinical success, and bridging to surgery were achieved. Complications could be readily managed.
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Abstract
OBJECTIVE To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature. SUMMARY BACKGROUND DATA Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers. METHODS A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review. RESULTS Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates. CONCLUSIONS Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.
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Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 2007; 246:24-30. [PMID: 17592286 PMCID: PMC1899207 DOI: 10.1097/01.sla.0000261124.72687.72] [Citation(s) in RCA: 254] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature. SUMMARY BACKGROUND DATA Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers. METHODS A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review. RESULTS Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates. CONCLUSIONS Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.
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Affiliation(s)
- Amber M Watt
- ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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Bhasin DK, Rana SS. Malignant colorectal obstruction: looking for synchronous lesions with the scope through a metal stent...! Gastrointest Endosc 2006; 63:820-3. [PMID: 16650545 DOI: 10.1016/j.gie.2006.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 02/05/2006] [Indexed: 01/08/2023]
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Targownik LE, Spiegel BM, Sack J, Hines OJ, Dulai GS, Gralnek IM, Farrell JJ. Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004; 60:865-74. [PMID: 15604999 DOI: 10.1016/s0016-5107(04)02225-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction. METHODS Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures. RESULTS Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941). CONCLUSIONS Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.
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Affiliation(s)
- Laura E Targownik
- Division of Digestive Diseases, School of Medicine, UCLA Center for the Health Sciences, University of California-Los Angeles, Los Angeles, CA 90095, USA
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Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004; 99:2051-7. [PMID: 15447772 DOI: 10.1111/j.1572-0241.2004.40017.x] [Citation(s) in RCA: 478] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expanding metal stents have been used in the management of colorectal obstruction as an alternative to emergency surgery. Our aim was to systematically review the efficacy and safety of these stents in the setting of malignant colorectal obstruction. METHODS Both English and foreign language reports were identified from Medline, Embase, Cancerlit, Science Citation Index, Cochrane Library, and proceedings of relevant meetings. Data were collected on technical success, clinical success, and safety parameters. RESULTS Fifty-four studies reported the use of stents in a total of 1,198 patients. The median technical and clinical success rates were 94% (i.q.r. 90-100) and 91% (i.q.r. 84-94), respectively. The clinical success when used as a bridge to surgery was 71.7%. Major complications related to stent placement included perforation (3.76%), stent migration (11.81%), and reobstruction (7.34%). Factors related to an increased complication risk were identified. Stent-related mortality was 0.58%. Limited available data suggest that this approach may be cost effective in the preoperative setting. CONCLUSION Placement of self-expanding metal stents is an effective and safe definitive procedure in the palliation of malignant colorectal obstruction. In operable patients, it provides a useful option to avoid colostomy, by facilitating safer single-stage surgery.
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Affiliation(s)
- Shaji Sebastian
- Department of Gastroenterology, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland
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Tratamiento mínimamente invasivo de la neoplasia oclusiva del colon izquierdo: prótesis endoluminal autoexpandible y colectomía laparoscópica. Resultados preliminares. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72209-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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