Short-term results of self-expanding metal stents for acute malignant large bowel obstruction

Outcome of self-expandable metal stents placement for obstructive colorectal cancer: 7 years’ experience from a Swedish tertiary center

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.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction

BACKGROUND

Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness.

METHODS

A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses.

RESULTS

Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of - $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time.

CONCLUSIONS

In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Comparison of Clinical Outcomes and Pathological Characteristics of Self-Expandable Stent Bridge to Surgery and Emergency Surgery in Obstructive Colon Cancer

Aim

Obstructive colon cancer can be treated by self-expanding metal stents (SEMS) prior to definitive surgery. However, the oncological outcome remains controversial, especially regarding whether stent placement or obstruction results in more perineural invasion (PNI) or lymphovascular invasion (LVI). This study aimed to compare clinical outcomes of emergency surgery (ES) and stent as bridge to surgery (SBTS) in patients with obstructive colon cancer. The pathological characteristics were also compared between obstructive and nonobstructive cancer.

Methods

This study included 880 patients (including 47 ES and 45 SBTS) admitted to Peking University Third Hospital from January 2010 to December 2018. Short-term and long-term outcomes were compared. The pathological differences between an equal number of obstructive and nonobstructive patients matched using propensity scores were investigated.

Results

SBTS patients had less intraoperative blood loss (P < 0.001), shorter ICU stay time (P = 0.007), lower incidence of colostomy (P < 0.001), and higher laparoscopic achievement (P < 0.001) than did ES patients. No pathological difference was found between the two groups. SBTS patients showed better overall survival (86.7% vs 68.1%, P = 0.029), but not disease-free survival (68.9% vs 59.6%, P = 0.211) than did ES patients. PNI was significantly higher in obstructive cancer than in nonobstructive cancer (29.3% vs 16.3%, P = 0.035).

Conclusion

SBTS had a lower incidence of short-term complications and did not affect long-term prognosis compared with that of ES, indicating that SBTS is a safe and effective treatment. Further, PNI may be associated with obstruction, but not with stent insertion.

Comparative outcomes between palliative ileostomy and colostomy in patients with malignant large bowel obstruction

Objectives: Palliative stoma creation should be considered in patients at high risk of colonic metallic stent failure. However, it is unclear whether ileostomy or colostomy is superior. This study compared short-term outcomes between palliative ileostomy and colostomy. Methods: We identified 82 patients with malignant large bowel obstruction, caused by various advanced cancers, between January 2005 and December 2016. We compared short-term outcomes between the ileostomy group (n = 33) and the colostomy group (n = 49). Results: For all 82 patients, clinical success was achieved. Three patients with ileostomy died within 30 days of ostomy formation. The ileostomy group had statistically significant differences in median operative time (113 vs. 129 minutes, p = 0.045) and blood loss (8 vs. 40 g, p = 0.037) in comparison with the colostomy group. No statistically significant differences were observed in the surgical complications (30.3 vs. 38.8%, p = 0.431), in the median period to oral intake (3 vs. 4 days, p = 0.335) and in the hospital stay after surgery (32 vs. 27 days, p = 0.509) between the two groups. Overall stoma-related complications occurred in 27 (32.9%) patients. Stoma-related complications occurred more frequently in the ileostomy group (16/33 vs. 11/49 patients, p = 0.014). High output stoma (6 patients) and irritation (5 patients) occurred more frequently in the ileostomy group. Conclusions: Palliative colostomy is superior to ileostomy due to fewer stoma-related complications. When ileostomy is required, aggressive interventions for high output stomas should be implemented.

Successful treatment of obstructing colonic cancer by combining self-expandable stent and neoadjuvant chemotherapy: A case report

BACKGROUND

Surgery 5-10 d after stent insertion was recommended by the European Society of Gastrointestinal Endoscopy for obstructing colonic cancer. For some obstructive patients, this may be not a good choice. Here, we report the successful treatment of obstructing colonic cancer by combining self-expandable stent and neoadjuvant chemotherapy.

CASE SUMMARY

The patient was a 72-year-old man who was admitted with a chief complaint of abdominal pain for more than 1 mo. Computed tomography (CT) scanning revealed that there was a mass in the descending colon, which led to intestinal obstruction. On admission, a series of therapeutic measures, such as fasting and water deprivation, gastrointestinal decompression, total parenteral nutrition, and octreotide acetate, were taken to improve the obstructive symptoms. At the same time, a self-expandable metal stent was successfully placed across the stenosis, and a biopsy was obtained and diagnosed as adenocarcinoma. CT scanning 14 d after insertion of the stent revealed that the intestine was swollen significantly. Systemic chemotherapy with modified FOLFOX6 (mFOLFOX6) was administered. After two courses of mFOLFOX6, CT scanning showed clearly that swelling of the intestine was improved. Subsequently, the patient underwent left hemi-colectomy without stoma placement. The postoperative course was uneventful, and he has been disease-free for 6 mo after surgery.

CONCLUSION

This modified treatment strategy may provide an alternative therapy for patients with obstructing colonic cancers.

Clinical outcomes and factors related to colonic perforations in patients receiving self-expandable metal stent insertion for malignant colorectal obstruction

BACKGROUND AND AIMS

Although colonic perforation is a dreadful adverse event associated with stent placement, data on this topic are sparse. We aimed to investigate the clinical outcomes of colonic perforation and factors related to its occurrence in patients who received self-expandable metal stents (SEMSs) for malignant colorectal obstruction.

METHODS

We retrospectively reviewed the data of 474 patients with malignant colorectal obstruction who received endoscopic SEMS insertion from April 2004 to May 2011 in Severance Hospital and Gangnam Severance Hospital. Early perforation, defined as perforation occurring within 2 weeks, was assessed in bridge-to-surgery (n = 164) and palliative stent placement patient groups (n = 310). Delayed perforation was analyzed using data from the palliative stent placement group alone.

RESULTS

The technical and clinical success rates were 90.5% and 81.0%, respectively. Early and delayed perforations occurred in 2.7% (13/474) and 2.7% (8/301) of patients, respectively. Among 21 patients with perforation, 14 (66.7%) received emergency surgery and 5 (23.8%) died within 30 days after perforation. Regarding the perforation-related factors, age ≥70 years (odds ratio, 3.276; 95% confidence interval [CI], 1.041-10.309) and sigmoid colonic location (odds ratio, 7.706; 95% CI, 1.681-35.317) were independently associated with occurrence of early perforation. Stent location in the flexure (hazard ratio, 17.573; 95% CI, 2.004-154.093) and absence of peritoneal carcinomatosis (hazard ratio, 6.139; 95% CI, 1.150-32.776) were significantly associated with delayed perforation.

CONCLUSIONS

The perforation-related 30-day mortality rate was 23.8%. Older age and sigmoid colonic location were significantly associated with occurrence of early perforation, whereas flexure location and absence of peritoneal carcinomatosis were related to delayed perforation.