Through-the-scope double colonic stenting in the management of inoperable proximal malignant colonic obstruction: a pilot study

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Clinical effect of double coaxial self-expandable metallic stent in management of malignant colon obstruction

PURPOSE

We aimed to evaluate the clinical effectiveness and safety of double coaxial self-expandable metallic stent (DCSEMS) in management of malignant colonic obstruction as a bridge to surgery or palliation for inoperable patients.

METHODS

Between April 2006 and December 2012, 49 patients (27 males and 22 females; median age, 68 years; age range, 38-91 years) were selected to receive decompressive therapy for malignant colonic obstruction by implanting a DCSEMS. Application of DCSEMS was attempted in 49 patients under fluoroscopic guidance. The obstruction was located in the transverse colon (n=2), descending colon (n=7), sigmoid colon (n=24), rectosigmoid junction (n=6), and the rectum (n=10). The intended use of DCSEMS was as a bridge to elective surgery in 23 patients and palliation in 26 patients.

RESULTS

Clinical success, defined as >50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 48 of 49 patients (98%). The stent was properly inserted in all patients. No immediate major procedure-related complications occurred. One patient in the bridge-to-surgery group had colon perforation three days after DCSEMS application. Four patients had late migrations of the double stent.

CONCLUSION

Application of DCSEMS is safe and effective in management of malignant colonic obstruction; it prevents stent migration and tumor ingrowth and lowers perforation rate during the stent application.

Radiologic Placement of Uncovered Stents for the Treatment of Malignant Colonic Obstruction Proximal to the Descending Colon

PURPOSE

To evaluate the safety, feasibility, and patency rates of radiologic placement of uncovered stents for the treatment of malignant colonic obstruction proximal to the descending colon.

MATERIALS AND METHODS

This was a retrospective, single-center study. From May 2003 to March 2015, 53 image-guided placements of uncovered stents (44 initial placements, 9 secondary placements) were attempted in 44 patients (male:female = 23:21; mean age, 71.8 years). The technical and clinical success, complication rates, and patency rates of the stents were also evaluated. Technical success was defined as the successful deployment of the stent under fluoroscopic guidance alone and clinical success was defined as the relief of obstructive symptoms or signs within 48 h of stent deployment.

RESULTS

In total, 12 (27.3 %) patients underwent preoperative decompression, while 32 (72.7 %) underwent decompression with palliative intent. The technical success rate was 93.2 % (41/44) for initial placement and 88.9 % (8/9) for secondary placement. Secondary stent placement in the palliative group was required in nine patients after successful initial stent placement due to stent obstruction from tumor ingrowth (n = 7) and stent migration (n = 2). The symptoms of obstruction were relieved in all successful cases (100 %). In the palliative group, the patency rates were 94.4 % at 1 month, 84.0 % at 3 months, 64.8 % at 6 months, and 48.6 % at 12 months.

CONCLUSIONS

The radiologic placement of uncovered stents for the treatment of malignant obstruction proximal to the descending colon is feasible and safe, and provides acceptable clinical results.

Development of Biliary and Enteral Stents by the Korean Gastrointestinal Endoscopists

Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.

Successful Palliation of a Malignant Cologastric Fistula with a Covered Self-Expanding Metal Stent

When patients present with malignant cologastric fistulas, the tumor stage is often advanced and management is only palliative. We report the case of a 75-year-old man with a symptomatic cologastric fistula arising from an advanced tumor in the transverse colon, previously stented owing to malignant obstruction. An 8-cm-long covered self-expanding metal stent (COMVI enteral colonic stent; Taewoong Medical) was placed inside the primary stent, which sealed the fistula and completely alleviated the symptoms. Considering the successful outcome, we propose that insertion of a covered stent be considered in the palliative management of patients with malignant cologastric fistulas.

Gastrointestinal stenting: Current status and imaging features

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.

[The results of endoscopic gastroduodenal, enteral and colorectal stenting for blastomatous stenosis: 8-year experience]

INTRODUCTION

Gastroduodenal, enteral and colorectal stenting of blastomatous stenosis is a reasonable alternative to operative treatment of unresectable tumors. Moreover in some cases it allows to gain time and to prepare the patient for radical surgery.

MATERIAL AND METHODS

For the period from 2007 to 2015 in endoscopic department of acad. B.V. Petrovskiy Russian Research Center for Surgery 76 patients with piloroduodenal, enteral and colic stenoses successfully underwent self-expanding metal stents installation. There were 21 patients with malignant stenosis of the stomach and pilorobulbar area, 17 with secondary duodenal stenosis, 17 after gastrectomy and distal gastric resection; 2 with stenosing colorectal cancer, 4 patients with rectal cancer involving rectosigmoid junction, 7 with rectosigmoid junction cancer and 8 with sigmoid cancer.

RESULTS

Ambulatory and hospital interventions were performed in 35.5% and 64.5% of cases respectively. Hospital-stay did not exceed 2 days. The total complication rate was 11.8% (9/76), 3 of 9 patients required surgical intervention. The attention is given to important technical aspects of intervention as well as to those clinical situations when stenting is inappropriate because of absence of favourable functional outcome.

CONCLUSION

Stenting should be more actively implemented in clinical practice, especially in emergency surgical hospitals. However it requires adequate technical support of hospitals with different endoprostheses, because it provides simultaneous diagnostic survey and remedial procedure.

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

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

A systematic review and meta-analysis of randomized trials and prospective studies comparing covered and bare self-expandable metal stents for the treatment of malignant obstruction in the digestive tract

BACKGROUND

Self-expandable metal stents (SEMS) are widely used for the palliative treatment of malignant gastrointestinal obstruction. Our aim was to evaluate the evidence comparing covered and bare SEMS in the digestive tract using meta-analytical techniques.

METHODS

A literature search was performed using PubMed, Cochrane Library, and Embase databases for comparative studies assessing the two types of stents. The primary outcomes of interest were stent patency and patient survival; second outcomes included technical success, clinical success, tumor ingrowth, tumor overgrowth, and stent migration. A random-effects model was conducted. Pooled analysis was done separately based on the different segments of the digestive tract.

RESULTS

Eleven studies (8 randomized controlled trials and 3 prospective cohort studies) including a total of 1376 patients were identified. Covered SEMS were equivalent to bare SEMS in terms of technical success, clinical success, stent patency (gastroduodenal obstruction: HR =0.87, 95% CI 0.53-1.42; colorectal obstruction: HR =0.89, 95% CI 0.18-4.45; biliary obstruction: HR =0.73, 95% CI 0.41-1.32) and survival rates (esophageal obstruction: HR =1.80, 95% CI 0.73-4.44; gastroduodenal obstruction: HR =0.83, 95% CI 0.55-1.26; biliary obstruction: HR =0.99, 95% CI 0.77-1.28), although bare stents were more prone to tumor ingrowth (esophageal obstruction: RR =0.10, 95% CI 0.01-0.77; gastroduodenal obstruction: RR =0.12, 95% CI 0.03-0.55; colorectal obstruction: RR =0.21, 95% CI 0.06-0.70; biliary obstruction: RR =0.21, 95% CI 0.06-0.69), whereas covered stents had the higher risk of stent migration (gastroduodenal obstruction: RR =5.01, 95% CI 1.53-16.43; colorectal obstruction: RR =11.70, 95% CI 2.84-48.27; biliary obstruction: RR =8.11, 95% CI 1.47-44.76) and tumor overgrowth (biliary obstruction: RR =2.03, 95% CI 1.08-3.78).

CONCLUSION

Both covered and bare SEMS are comparable in efficacy for the palliative treatment of malignant obstruction in the digestive tract. Each type of the stents has its own merit and demerit relatively.

Colonic stent and percutaneous ethanol injection as a treatment for colocutaneous fistula secondary to benign stricture

We report successful treatment of colocutanteous stulae at the site of a benign colonic anastomotic stricture using Self-Expandable Metal Stents (SEMS) and Percutaneous Ethanol Injection (PEI). The stricture and the secondary stulae developed after Hartmann's procedure for sigmoid diverticular abscess followed by reversal of the Hartmann's procedure with a de-functioning loop ileostomy. Although there have been previously reported cases of SEMS for closure of malignant colonic stula, there are limited reports of SEMS for closure of benign colonic stulae and none of SEMS combined with PEI for benign colonic fistula. We conclude that this patient's case exemplies the potential applications of SEMS combined with PEI as a feasible option of therapy for benign colorectal disease.

Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction

Background/Aims

There are limited data regarding the clinical outcomes of self-expandable metal stents in the treatment of proximal colon obstruction. We compared the clinical outcomes of stent placement in patients with malignant proximal to distal colon obstructions.

Methods

We reviewed medical records from 37 consecutive patients from three institutions (19 men; mean age, 72 years) who underwent endoscopic stent placement at a malignant obstruction of the proximal colon. We also examined the records from 99 patients (50 men; mean age, 65 years) who underwent endoscopic stent placement for a distal colon obstruction. Technical success, clinical improvements, complications and stent patency were compared between treatments.

Results

The technical success rate tended to be lower in stents inserted to treat proximal colon obstructions than in those used to treat distal colon obstructions (86% vs 97%, p=0.06). Clinical improvement was achieved in 78% of patients (29/37) with proximal colonic stenting and in 91% of patients (90/99) with distal colonic stenting (p=0.08). Complications (24% vs 27%), stent migration (8% vs 8%) and stent reocclusion rates (11% vs 17%) did not differ significantly between groups. Two cases of bowel perforation related to stenting (5%) occurred in patients with proximal colonic stenting.

Conclusions

The technical success and clinical improvement associated with self-expandable metal stents used to treat proximal colon obstruction tend to be lower than cases of distal colon obstruction. Technical failure is an important cause of poor clinical improvement in patients with proximal colon stenting. Complication rates and stent patency appear to be similar in both groups.

Severity of initial stent angulation predicts reintervention after successful palliative enteral stenting for malignant luminal obstruction

BACKGROUND AND AIM

Recurrent stent obstruction necessitating reintervention is problematic and incompletely understood. The aim of the present study was to identify factor(s) predisposing to reintervention.

METHODS

Retrospective review of patients (n = 117) referred to a single major endoscopic referral centre for palliative enteral stenting from 1999 to 2006. Twelve were excluded due to inadequate follow-up data (n = 7) or initial radiographic documentation (n = 5). A total of 105 patients (gastroduodenal n = 57, colonic n = 48) were therefore analyzed. The primary outcome of interest was recurrent obstruction necessitating reintervention. Kaplan-Meier analysis of potential factors predisposing to reintervention, including stent angulation (mild [<15°], moderate [15°-90°], severe [>90°]) was completed for 98 patients (technically successful enteral stenting).

RESULTS

Technical and clinical success were achieved in 98 of 105 (93.3%) and 92 of 98 (93.9%) cases, respectively. Post-stenting median survival was 97.5 days (range 3-1054). Eighteen patients (18.4%) required reintervention for stent obstruction at a median time to reintervention of 85 days (range 7-481). Increased stent angulation (severe vs mild hazard ratio 6.73 (95% confidence interval 1.59-27.59), P = 0.009) was the only statistically significant factor in multivariate analysis predicting reintervention.

CONCLUSIONS

Despite its limitation as a retrospective review, this study found that reintervention for stent obstruction is necessary in almost one in five cases, and increasing severity of stent angulation is the most important risk factor.

Placement of stents in proximal colonic obstructions using a percutaneous retroperitoneal colostomy

In cases of proximal colonic obstruction, the long distances and the tortuosity of the distal bowel make it difficult to advance and position the stent in the target lesion. We report 2 cases of stent placement for malignant obstruction of the proximal colon in which access was obtained through percutaneous retroperitoneal colostomy. In these cases, we initially tried to place a stent through the rectum under endoscopic guidance, but it was not possible to reach the lesion. We then decided to cross the lesion through percutaneous puncture of the retroperitoneum. The procedures were completed without complications and the patients' symptoms improved. A percutaneous retroperitoneal approach for the deployment of colonic stents has not been described earlier in the literature. We suggest that our technique provides an alternative means of colonic decompression in cases in which conventional retrograde methods fail to provide acceptable palliation in nonsurgical candidates.

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

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

Gastrointestinal and biliary stents

Advances in stent design have led to a substantial increase in the use of stents for a variety of malignant and benign strictures in the gastrointestinal tract and biliary system. Whereas early stents were mostly composed of plastic, the majority of contemporary stents are self-expanding metal stents that are composed of either nitinol or stainless steel. These stents are able to exert an adequate expansile force and, at the same time, are highly flexible and biocompatible. Covered stents have been introduced to minimize tumor ingrowth through the metal mesh but are associated with higher rates for spontaneous migration. This has led to the development of covered stents with uncovered ends and stents with both covered and uncovered layers. Drug-eluting and biodegradable stents are also likely to become available in the near future. Although stents appear to be the preferred form of palliation for some patients with advanced cancer, many patients will benefit from a multidisciplinary approach that usually includes surgeons and oncologists.

[Comparison of effects of preoperative stenting for obstructing colorectal cancers according to the location of the obstructing lesion]

BACKGROUND/AIMS

With the development of self-expanding metallic stents, colonic obstruction can be relieved without the need for surgery. The results of preoperative placement of stents for malignant colorectal obstruction might be different according to the obstructing lesion. The objective of this study was to compare clinical improvement rates and operative results after preoperative placement of stents for malignant colorectal obstruction according to the location of the obstructing lesion.

METHODS

This is a retrospective study including 57 patients who underwent self-expanding metallic stent insertion for obstructing resectable colorectal cancers. Patients were classified into three groups according to the location of the lesion as follows: proximal to the sigmoid colon (Group A), sigmoid colon (Group B), and rectum (Group C).

RESULTS

The number of patients in A, B, and C groups was 13, 22, and 22, respectively. No significant differences in age, gender, stent type, and accompanying diseases among the three groups were observed. There were no significant differences in stent-related complications, clinical improvement rates, and one-stage resection rates among the three groups. The postoperative complications, the requirement rate of ICU care, the period of ICU stay, postoperative hospital stay, and hospital mortality did not significantly differ among the three groups.

CONCLUSIONS

Clinical improvement rates and operative results after successful placement of stents for obstructing resectable colorectal cancers are not different according to the location of the obstructing lesion, suggesting that preoperative stenting for one-stage curative resection is useful, irrespective of the location of lesion.

Stents and stentability: treatment for malignant bowel obstruction

Colonic stents offer a palliative treatment for patients with malignant bowel obstruction otherwise requiring surgery and possible stoma, or as a bridge to surgery for potentially curative malignant disease. This article reviews the indications, risks and benefits of stent insertion.

Emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma: a comparative study of short-term clinical outcomes

BACKGROUND

The aim of the present study was to compare the clinical outcomes of emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma.

METHODS

Between July 2003 and July 2006, 43 consecutive patients with obstructing right-sided colonic carcinoma underwent emergency right hemicolectomy at our institution, 14 with the laparoscopic-assisted approach and 29 with the open approach. Clinical data were retrospectively recorded and compared between the two groups.

RESULTS

There were no significant differences between the two groups with respect to age, gender, co-morbidities, duration of obstructing symptoms, tumor length, and tumor staging. The laparoscopic-assisted group had longer operative time than the open group (187.5 min versus 145 min; p=0.034) but less blood loss (20 ml versus 100 ml; p=0.020). The median time to full ambulation was significantly shorter in the laparoscopic-assisted group (4 days versus 6 days; p=0.016), but the time to return of gastrointestinal function and the duration of hospital stay were similar between the two groups. More patients in the open group developed postoperative complications (55.2% versus 28.6%), but the difference was not statistically significant.

CONCLUSIONS

Emergency laparoscopic-assisted right hemicolectomy for obstructing right-sided colonic carcinoma is feasible and safe. In comparison with the open approach, the laparoscopic-assisted procedure is associated with less blood loss, earlier ambulation, and possibly lower morbidity rate.

Self-expanding metallic stent insertion in the proximal colon

OBJECTIVE

Colonic obstruction may be relieved by the insertion of a self-expanding metallic stent (SEMS), either for permanent palliative relief or as a bridge to surgery. Lesions proximal to the descending colon can be more difficult to intubate and stent [1]. SEMS placement in the more proximal colon lesions has been reported in only a few cases [2,4]. The aim of this study was to review the outcome of SEMS for obstruction at the splenic flexure and above.

METHOD

A study of all colonic stents inserted in one specialist unit was undertaken. Patients' demographics, site and aetiology of the underlying obstruction, success or other outcome of the procedures were collected. Thirty-day morbidity and mortality were documented.

RESULTS

Seven patients had proximal lesions: four in the transverse colon and three at the splenic flexure. Six patients had colorectal carcinoma and one had extrinsic compression from a gastric carcinoma. Six of the SEMS were inserted for permanent palliation, and one as a bridge to surgery. Stent placement was technically successful in six of the seven patients. In the seventh patient, there was a failure of expansion of the stent, after successful intubation of the lesion, which was in the distal transverse colon. One patient suffered from minor self-limiting abdominal pain in the first 24 h after the procedure. There was no other SEMS related morbidity or mortality. All of the successfully stented patients were discharged from the surgical ward within 3 days after the procedure. Median survival time was 4.3 months (range 3-12 months). Three patients are still alive.

CONCLUSION

The SEMS is a useful tool in managing acute bowel obstruction. Placement of colonic stents proximal to the descending colon is safe, feasible and effective.

Comparison of uncovered stent with covered stent for treatment of malignant colorectal obstruction

BACKGROUND

Insertion of self-expandable metallic stents (SEMS) can provide rapid relief of malignant colorectal obstruction and can be used as a palliative treatment or as a bridge to surgery. A SEMS can be classified as an uncovered or covered stent. Both types of stents have their own merits and demerits.

OBJECTIVE

The objectives of this study were to compare success rates, durability, and complication rates of uncovered and covered stent groups of malignant colorectal obstruction. DESIGNS AND SETTING: A nonrandomized prospective, single-center study.

METHODS

We studied 80 patients with malignant colorectal obstruction: colon cancer in 70 patients, metastatic lesion of advanced gastric cancer in 8 patients, and cervix cancer in 2 patients. Insertion of uncovered stents was attempted in 39 patients (before surgery in 20, palliative in 19), and covered stents were used in 41 (before surgery in 23, palliative in 18).

INTERVENTION

The stent was inserted into the obstructive sites for preoperative or palliative purposes by using the through-the-scope method. After stent insertion, the patients had regular follow-ups, either as clinical checkups or telephone interviews.

MAIN OUTCOME MEASUREMENT

Insertion success rate, durability, and complication rate according to stent type.

RESULTS

Technical and clinical success rates of uncovered and covered stents were not different (100%; 95.1%, P > .05, 100%; 97.4%, P > .05). The early stent migration rate was not different in both groups. The late stent migration was more common in the covered stent group than the uncovered stent group (0% vs 40%, respectively, P = .005). Loss of stent function during the long-term follow-up period was more frequent in the covered stent group than in the uncovered stent group (18.8% vs 60%, respectively, P = .018).

LIMITATION

This was a small-sized, nonrandomized, prospective, single-center study. Confirmation of large-scale, multicenter, randomized, prospective outcome is required.

CONCLUSIONS

Insertion of either an uncovered or covered stent is similarly an effective treatment modality of malignant colorectal obstruction for preoperative purposes. However, there are no advantages of covered stents over uncovered stents during the follow-up period in the palliative purpose.

Palliation of colorectal cancer

Patients with advanced incurable colorectal cancer (CRC) face a grim prognosis. The goal of palliative intervention is directed at alleviating disease-related symptoms and improving quality of life. The provision of optimal palliative care for these patients is a compound and demanding process. This dilemma becomes more challenging when patients with advanced metastatic colorectal disease present with an incurable and asymptomatic primary lesion. Treatment options are numerous and include a variety of surgical and nonsurgical interventions. Most data regarding the role of surgery in palliation of CRC are from retrospective, nonrandomized case series. Surgical resection may provide good palliation of symptoms and prevent future tumor-related complications. Metal stents are also able to provide good palliative relief of obstruction and should be used when appropriate. The best palliative care will often require a multidisciplinary approach that involves input from surgical and nonsurgical teams, where treatment plans will be made in accordance with the wishes of the patient and family with a goal of decreasing morbidity and a focus on quality of life.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

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.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

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.

Complications of colonic stenting: a pictorial review

Surgical resection of colorectal carcinoma is the only curative treatment currently available. In the elective setting peri-operative mortality is low and refinements in surgical technique and peri-operative care have resulted in high primary anastamosis rates and progressively reduced postoperative morbidity. In those presenting with large bowel obstruction the mortality and morbidity remains high. Many of those undergoing surgery will have incurable disease and a short life expectancy. Increasingly self-expanding metal stents are being deployed as either a 'bridge to surgery' or for palliation. This review covers the imaging appearances, detection and management of complications of colonic stenting.

Metal stents for malignant colorectal obstruction

Malignant obstruction of the colon occurs in 7-25% of patients with colorectal cancer. As emergency laparotomy is reported to have relatively high morbidity and mortality rate, there is a need for alternative procedures with reduced complication rates. Over the last decade colorectal stenting has been reported as an alternative endoscopic method to relieve acute colonic obstruction. With the availability of more sophisticated stents and stent delivery systems, this approach has been used as a palliative method and as a pre-operative bridge to facilitate one-stage surgical resection of primary colonic tumors. Technical and clinical successes have been reported in 80-100% of treated patients. Distal lesions are more common and theoretically easier to stent although lesions within the ascending colon have been successfully managed. Minor complications include transient anorectal pain, tenesmus and rectal bleeding. However, stent migration and colonic perforation are also well recognized. Despite the fact that no randomized controlled studies have yet been performed, literature data show that colonic stenting is a safe and effective procedure and can reduce costs, avoiding the need for colostomy and improving the quality of life of patients with advanced disease.

Acute colonic obstruction

Acute colonic obstruction is a medical emergency because of the potential for bowel ischemia, perforation, and sepsis with peritonitis if not rapidly and appropriately treated. There are numerous causes of acute colonic obstruction, which must be differentiated from colonic pseudo-obstruction, which also is considered a medical emergency. Management options include medical therapy, surgical therapy, endoscopic therapy, and interventional radiologic therapy. Self-expandable metal stents (SEMS) have gained acceptance for alleviating acute malignant colonic obstruction and in some situations for preoperative relief of acute benign colonic obstruction. This article reviews the approach to the patient who has acute colonic obstruction.

Assistance of colorectal stent insertion by sphincterotome

PURPOSE

Palliation of patients with unresectable colorectal carcinoma is an effective treatment and technical failure is undesirable. Insertion of colorectal stent using a combined radiologic and colonoscopic technique may be technically limited by the ability to negotiate tortuous bends, particularly if the bowel is fixed.

METHODS

We used a through scope sphincterotome, which improved the ability to traverse difficult strictures.

RESULTS

We have used the technique in four cases as a last resort. This resulted in a technical success in all four cases (100 percent).

CONCLUSIONS

Sphincterotome is a useful adjunct in stenting difficult colorectal tumor strictures.

Repeated coaxial colonic stenting in the palliative management of benign colonic obstruction

In inflammatory bowel disease, strictures of the colon, causing bowel obstruction, is not uncommon. Usually an operative procedure can deal with these strictures. We describe a case of an unfit patient with pulmonary malignancy having a Crohn's stricture of the recto-sigmoid junction in which repeated coaxial placement of self-expanding metallic stents eliminated the need to perform an operation. This is the first report of multiple coaxial colonic stenting. It shows that there is a place for stents in selected cases of inflammatory bowel disease with a limited life expectancy and that repeated colonic stenting makes colonic stenting possible also in patients requiring stents for longer time periods.

Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction

BACKGROUND

In patients with colorectal cancer, a preoperative colonoscopy is recommended to exclude synchronous lesions. Unfortunately, between 7% and 29% of patients with colorectal cancer present with acute colonic obstruction, making complete colonoscopy impossible.

OBJECTIVE

The aim of our study was to evaluate the feasibility of a preoperative colonoscopy after effective stent placement in patients with acute neoplastic obstruction.

DESIGN

Single-center prospective study.

SETTING

All examinations were carried out at a tertiary referral center with 24-hour emergency endoscopy service.

PATIENTS

Fifty-seven patients with acute neoplastic colon obstruction.

INTERVENTIONS

Patients who recovered from an acute colon obstruction by an effective stent placement and who had a resectable cancer underwent a preoperative colonoscopy.

MAIN OUTCOME MEASUREMENTS

Patients with a resectable cancer, complete preoperative colonoscopies, and synchronous lesions rates.

RESULTS

Self-expandable metallic stents (SEMS) were placed in 50 of 57 patients (87.8%). Thirty-one of 50 patients had a resectable cancer (62%), and a complete preoperative colonoscopy was possible in 29 of 31 patients (93.4%). A synchronous cancer was detected in 3 patients (9.6%), changing the surgical plan.

LIMITATIONS

Seven patients in whom the SEMS placement (12.2%) was unsuccessful underwent an urgent surgical intervention. Nineteen of 50 patients who had stent placement were not eligible for our study because of unresectable cancer.

CONCLUSIONS

Our study indicates that it is feasible in a majority of patients to perform full preoperative colonoscopy after relief of acute colonic obstruction with SEMS before surgical resection.

Colonic stenting: technique, technology, and outcomes for malignant and benign disease

Self-expandable metal stents (SEMS) have gained acceptance for use in the gastrointestinal tract to relieve malignant lumenal obstruction. In the colon, SEMS are used to avoid permanent or temporary colostomy during palliation and as a bridge to surgery for left-sided colonic obstruction. Limited data exist on their use for benign disease. This article reviews the latest in stent technology and the outcomes after their placement for benign and malignant disease.

The advancing art and science of endoscopy

Flexible endoscopy continues to advance encompassing treatment of a variety of diseases traditionally managed surgically. This review describes and evaluates many of these new endoscopic approaches with an eye toward the future. Gastroesophageal reflux disease is now treated with several endoscopic, non-operative techniques. A procedure using radiofrequency energy delivered by a peroral catheter with small needles inserted into the wall of the esophagus causes collagen deposition and ablates transient lower esophageal sphincter relaxation, both of which reduce reflux. With this treatment, >80% of patients will reduce or stop their medication for reflux. Trials involving new injectable materials show promise with a 75-80% improvement in heartburn-related quality-of-life scores and reduced medication use. Endoscopic suture and stapling devices restore the antireflux barrier with sutures that create a pleat or plication at the gastroesophageal junction. Early results indicated that 62-74% of patients had significant improvement. Long-term results are not available for any of these new techniques and there seems to be a drop off in effectiveness over time. Gastrointestinal bleeding has been more effectively managed with the recent introduction of small clips and detachable snares to control bleeding vessels. Banding and sclerotherapy for variceal bleeding has all but eliminated urgent operation for that diagnosis. In the biliary-pancreas realm, endoscopic management of pancreatic pseudocysts, stenting of pancreatic or biliary strictures and fistulae have reduced operative indications in those disease processes. Pseudocyst drainage involves creation of a transenteric communication between the pseudocyst and the stomach or duodenum. Complete cyst resolution without recurrence can be expected in 85% of patients. While endoscopic palliation of malignant biliary strictures has been accepted for years, experience with endoscopic management of iatrogenic strictures indicates that it may serve as an alternative option without surgery in many patients. Enteric stenting using metallic self-expanding stents in the esophagus, duodenum, and colon allows alleviation of obstruction without surgery for palliantation and in the colon may relieve obstruction to avoid colostomy prior to an elective resection. On the horizon stands the flexible endoscopic route to the abdominal cavity via the transgastric route and the promise of combined endoscopic-laparoscopic approaches to complex abdominal problems. General surgeons should rekindle their interest in flexible endoscopy or risk losing entire categories of disease to other specialties or to a small specialized group of endoscopic surgeons.