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Zhou XC, Ke FY, Dhamija G, Viroja RD, Huang CW. Application of metal stent implantation with endoscope and X-ray fluoroscopy combined laparoscopic surgery in the treatment of acute left hemicolon cancer obstruction. World J Surg Oncol 2023; 21:331. [PMID: 37865772 PMCID: PMC10589989 DOI: 10.1186/s12957-023-03228-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/14/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND This study aimed to conduct a case-control study of endoscopic and fluoroscopic metal stent placement combined with laparoscopic surgery versus conventional open Hartmann's procedure in treating acute left-sided colon cancer obstruction. Additionally, the study aims to discuss the application value of endoscopic and X-ray-guided metal stent placement combined with laparoscopic surgery in the treatment of acute left-sided colon cancer obstruction. METHODS From June 2011 to December 2019, 23 patients with acute left-sided colon cancer obstruction who underwent metal stent implantation combined with laparoscopic surgery under endoscopy and X-ray fluoroscopy in Wenzhou Central Hospital were collected, and 20 patients with acute left-sided colon cancer obstruction who underwent traditional emergency open Hartmann's surgery during the same period were selected as a control group. All patients were diagnosed with left colon obstruction by plain abdominal film and/or CT before the operation and colon adenocarcinoma by colonoscopic biopsy and/or postoperative pathology. The operation time, intraoperative blood loss, postoperative anal exhaust time, the success rate of one-stage anastomosis, postoperative hospital stay, and postoperative complications were compared between the two groups. RESULTS This study showed a significant difference in the therapeutic effect between the two groups. Compared with the traditional Hartmann's operation group, the success rate of one-stage anastomosis in endoscopic and X-ray-guided metal stent placement combined with the laparoscopic operation group was significantly higher than that in the Hartmann's operation group (P < 0.05). The overall incidence of postoperative complications and hospital stay were significantly lower in the observation group than in the Hartmann's group (P < 0.05). Further subgroup analysis of the overall postoperative complication rate of the two groups showed that the traditional Hartmann's operation group was more likely to have an incomplete intestinal obstruction (P < 0.05). This study also showed no significant differences between the two groups in operation time, intraoperative blood loss, number of harvested lymph nodes, and postoperative anal exhaust time (all P > 0.05). This study also found no significant differences between the two groups in overall survival rates or recurrence-free survival rates (all P > 0.05). CONCLUSIONS The comparison of the therapeutic effects of the two groups verified the feasibility of endoscopy combined with X-ray fluoroscopy metal stent placement in combination with laparoscopic surgery in the treatment of acute left-sided colon cancer obstruction. Compared with the traditional emergency open Hartmann's procedure, metal stent implantation under endoscopy and X-ray fluoroscopy combined with laparoscopic surgery is more minimally invasive, safe, and effective. It avoids the traditional second or even third surgical trauma to effectively improve the quality of life of patients, so that patients can recover quickly after surgery.
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Affiliation(s)
- Xiao-Cong Zhou
- Department of Colorectal Surgery, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou, Zhejiang People’s Republic of China
| | - Fei-Yue Ke
- Postgraduate Training Base Alliance of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou, Zhejiang People’s Republic of China
| | - Gaurav Dhamija
- School of International Studies, Wenzhou Medical University, Wenzhou, Zhejiang People’s Republic of China
| | - Ruchi D. Viroja
- School of International Studies, Wenzhou Medical University, Wenzhou, Zhejiang People’s Republic of China
| | - Chun-Wei Huang
- Department of Gastroenterology, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), No.252, Baili East Road, 325000 Wenzhou, Zhejiang People’s Republic of China
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Moutzoukis M, Argyriou K, Kapsoritakis A, Christodoulou D. Endoscopic luminal stenting: Current applications and future perspectives. World J Gastrointest Endosc 2023; 15:195-215. [PMID: 37138934 PMCID: PMC10150289 DOI: 10.4253/wjge.v15.i4.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/30/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
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.
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Affiliation(s)
- Miltiadis Moutzoukis
- Department of Gastroenterology, University Hospital of Ioannina, Ioannina GR45333, Greece
| | - Konstantinos Argyriou
- Department of Gastroenterology, Medical School and University Hospital of Larissa, Larissa GR41334, Greece
| | - Andreas Kapsoritakis
- Department of Gastroenterology, Medical School and University Hospital of Larissa, Larissa GR41334, Greece
| | - Dimitrios Christodoulou
- Department of Gastroenterology, Medical School and University Hospital of Ioannina, Ioannina GR45500, Greece
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Hanaoka M, Ogo T, Kawamura Y, Miura T, Aburatani T, Sugimoto H, Hoshino N, Yauchi T, Nishioka Y, Kawano T. Self-expandable Metal Stent as a Bridge to Surgery for Colorectal Cancer: Safety and Oncological Outcomes. In Vivo 2020; 34:1325-1331. [PMID: 32354926 DOI: 10.21873/invivo.11909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/07/2020] [Accepted: 03/11/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIM Self-expandable metal stent (SEMS) as a bridge to surgery (BTS) for obstructive colorectal cancer (CRC) raises concerns regarding the short-term as well as oncological outcome. The present study aimed to investigate the safety of SEMS placement and risk factors of worse short-term and oncological outcomes as BTS. PATIENTS AND METHODS Twenty-four patients with obstructive CRC who underwent SEMS placement as BTS were included. Success rate of SEMS placement and 2-year relapse-free survival (RFS) rates in stage II/III BTS patients were assessed. RESULTS Technical and clinical success rates for SEMS placement were 100% and 87.5%, respectively. In Multivariate analyses, longer tumour length, longer interval to surgery, and angular positioning were risk factors related with the complication of stent placement. Two-year RFS rates were significantly higher in the no-complication than in the complication group (100% vs. 75%, log-rank test, p<0.01). CONCLUSION A long tumour length, long interval between SEMS insertion and surgery, and angular positioning of the SEMS were identified as risk factors for SEMS-related complications. Moreover, SEMS insertion and/or surgery complications were associated with worse oncological outcome in CRC patients.
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Affiliation(s)
- Marie Hanaoka
- Department of Surgery, Soka Municipal Hospital, Soka, Japan
| | - Taichi Ogo
- Department of Surgery, Soka Municipal Hospital, Soka, Japan
| | - Yudai Kawamura
- Department of Surgery, Soka Municipal Hospital, Soka, Japan
| | - Tomiyuki Miura
- Department of Surgery, Soka Municipal Hospital, Soka, Japan
| | | | | | - Naoaki Hoshino
- Department of Surgery, Soka Municipal Hospital, Soka, Japan
| | - Tsunehito Yauchi
- Department of Gastroenterology, Soka Municipal Hospital, Soka, Japan
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Stenting as a bridge to surgery for extra-colonic malignancy induced colorectal obstruction: preliminary experience. BMC Gastroenterol 2020; 20:117. [PMID: 32306900 PMCID: PMC7168826 DOI: 10.1186/s12876-020-01273-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 04/08/2020] [Indexed: 01/08/2023] Open
Abstract
Background The majority of colonic obstructions result from colorectal cancer. However, malignancies of extra-colonic origin can also disrupt colorectal patency, and the efficacy of self-expanding metal stents (SEMS) insertion as a bridge to surgery in these patients are still in debate. The aim of this study is to evaluate the efficacy of endoscopic stenting as a bridge to surgery (BTS) for extra-colonic malignancy (ECM)-induced colonic obstruction. Methods Thirty-three patients with colonic obstruction due to ECM who received self-expanding metal stents (SEMS) insertion at a single academic tertiary medical center between 2004 and 2015 were included. The purpose of SEMS insertion was determined based on whether the patient’s medical records indicated any surgical plans before SEMS insertion. Technical success was defined as a patent SEMS covering the entire length of the obstruction. Bridging success was defined as elective surgical procedures after the first SEMS insertion. Results Among the 33 patients who underwent SEMS insertion for colorectal obstruction due to ECM, nine underwent SEMS as a BTS. Technical success was achieved in 100% (9/9). Seven patients underwent elective surgery after successful decompression with the first SEMS, and the bridging success rate was 77.8% (7/9). Two patients needed secondary stent insertion before elective surgery. However, none of them required emergent surgery. No major complications occurred, including death related to colorectal endoscopic procedures, perforation, or bleeding. Conclusion SEMS insertion as a BTS is a good treatment option to avoid emergent surgery in patients with colonic obstruction caused by extra-colonic malignancy.
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Donlon NE, Kelly ME, Narouz F, McCormick PH, Larkin JO, Mehigan BJ. Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes. Int J Colorectal Dis 2019; 34:613-619. [PMID: 30652215 DOI: 10.1007/s00384-019-03239-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection. METHODS A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival. RESULTS Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%. CONCLUSION Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.
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Affiliation(s)
- N E Donlon
- Department of Colorectal Surgery, St James Hospital, Dublin 8, Ireland.
| | - M E Kelly
- Department of Colorectal Surgery, St James Hospital, Dublin 8, Ireland
| | - F Narouz
- Department of Colorectal Surgery, St James Hospital, Dublin 8, Ireland
| | - P H McCormick
- Department of Colorectal Surgery, St James Hospital, Dublin 8, Ireland
| | - J O Larkin
- Department of Colorectal Surgery, St James Hospital, Dublin 8, Ireland
| | - B J Mehigan
- Department of Colorectal Surgery, St James Hospital, Dublin 8, Ireland
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Bayrak S, Tatar C, Kinaci E, Cakar E, Colak S, Sevinc MM, Bektas H. Stent experiences in emergency conditions in acute mechanical intestinal obstruction caused by colorectal cancer. Wideochir Inne Tech Maloinwazyjne 2019; 14:46-51. [PMID: 30766628 PMCID: PMC6372870 DOI: 10.5114/wiitm.2018.76072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/10/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Stent treatment can be applied to avoid surgery in surgically risky patients or to turn a high-risk emergency operation into a lower-risk elective operation and save time. AIM In this study, the techniques, clinical efficacy, safety and complications of endoscopic stents applied in emergency conditions were evaluated in patients with acute mechanical intestinal obstruction (AMIO) due to colorectal cancer. MATERIAL AND METHODS Between 2013 and 2015, 23 patients with an average age of 69.5 ±13.5 years who presented with AMIO and anastomosis stenosis secondarily to cancer to the emergency department were subjected to stent treatment under emergency conditions. RESULTS Thirteen (56.5%) patients were diagnosed with colon cancer, 5 (21.7%) with rectal cancer, and 5 (21.7%) with stenosis in the previous anastomosis line. Fourteen (60.9%) patients were diagnosed with stage 4 cancer, 7 (30.4%) with stage 3 cancer and 2 (8.7%) with stage 2 cancer. The stents were applied to the sigmoid colon in 10 (43.5%) patients, to the recto-sigmoid area in 9 (39.1%) patients and to the rectum area in 4 (17.4%) patients. While 14 (60.9%) patients had local or locally advanced disease, 9 (39.1%) patients had metastases in different parts of their bodies, particularly in their livers. CONCLUSIONS The study demonstrates that stents offer a favorable therapeutic alternative to emergency surgery and are associated with promising short-term outcomes as well as an acceptable safety profile for AMIO.
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Affiliation(s)
- Savas Bayrak
- Department of General Surgery, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Cihad Tatar
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Erdem Kinaci
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Ekrem Cakar
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Sukru Colak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Mert Mahsuni Sevinc
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Hasan Bektas
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
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Endoscopic stenting for palliation of intra-abdominal gastrointestinal malignant obstruction: predictive factors for clinical success. Eur J Gastroenterol Hepatol 2018; 30:1033-1040. [PMID: 29851864 DOI: 10.1097/meg.0000000000001178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic stenting proved to be a safe alternative to surgery for malignant intra-abdominal gastrointestinal obstruction. Although high technical success rates have been reported, some patients do not experience relief in symptoms. AIM This study aimed to analyse the factors predicting the effectiveness of stent placement in patients with gastrointestinal obstruction. PATIENTS AND METHODS A retrospective study was carried out including 160 patients who underwent palliative stenting for intra-abdominal obstruction in a tertiary centre from December 2012 to July 2017. Technical and clinical success, stent dysfunction and adverse events were analysed. RESULTS The rate of technical success was 98%. The rate of early clinical success was 69 and 81% in upper and lower gastrointestinal obstructions, respectively (P=0.107). In the upper tract, obstruction caused by carcinomatosis was the only independent factor predicting early and late clinical failure [odds ratio (OR): 9.7, 95% confidence interval (CI): 2.5-38.4, P=0.001 and OR: 7.6, 95% CI: 1.8-31.9, P=0.006, respectively]. In the colon, Eastern Cooperative Oncology Group score of at least 3 was an independent factor for early clinical failure (OR: 29.8, 95% CI: 1.9-464.9, P=0.002) and obstruction caused by carcinomatosis was an independent factor for late clinical failure (OR: 14.4, 95% CI: 1.7-119.6, P=0.013). Perforation occurred in 4 patients (2.5%) and stent dysfunction occurred in 15% of patients (4% stent migration; 9% restenosis). Carcinomatosis was a risk factor for perforation (P=0.039) and migration was higher with shorter 6 cm stents (P=0.044). CONCLUSION Stents are effective and safe for palliation of intra-abdominal obstruction. Carcinomatosis predicts an unfavourable clinical outcome. Palliative stenting as an option should be weighed carefully in these patients.
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Outcomes of stent insertion and mortality in obstructive stage IV colorectal cancer patients through 10 year duration. Surg Endosc 2018; 33:1225-1234. [PMID: 30167945 DOI: 10.1007/s00464-018-6399-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/20/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal stents are frequently used in patients with stage IV colorectal cancer with obstruction. However, there are only few studies on changes in outcomes of these patients and on the effect of stents on outcome over a long period of time with ongoing changes in therapeutic strategy, including chemotherapy. METHODS We retrospectively evaluated 353 patients with bowel obstruction in stage IV colorectal cancer who underwent colonic stenting between years 2005 and 2014. The study population was divided into three groups based on time periods: 2005-2008, 2009-2011, and 2012-2014. RESULTS The frequency of colorectal stent insertion procedure increased over the time periods (13.8%, 18.3%, and 20.8%, respectively). There were no changes in success rate and total complication rate. However, the early complication rate in the 3rd period was significantly lower than in the other periods (15.4% vs. 17.1% vs. 7.2%; P = 0.039). In the multivariate analysis, carcinomatosis (hazard ratio, 1.478; 95% confidence interval, 1.016-2.149; P = 0.041) and covered or partial-covered stent (hazard ratio, 1.733; 95% confidence interval, 1.144-2.624; P = 0.009; hazard ratio, 1.988; 95% confidence interval, 1.132-3.493; P = 0.017, respectively) were associated with increased complication rate. Stent-related perforation was an independent risk factor related with increased mortality. Although survival duration increased over time (P = 0.042), the mortality rate was unchanged across the three time periods. CONCLUSIONS Over 10 years, the targeted agent use and survival duration increased, and early complication rate was decreased, without change in late complication rate or mortality rate during the three time periods in patients with obstructive stage IV colorectal cancer and stent insertion.
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Kobborg M, Broholm M, Frostberg E, Jeppesen M, Gögenür I. Short-term results of self-expanding metal stents for acute malignant large bowel obstruction. Colorectal Dis 2017; 19:O365-O371. [PMID: 28892247 DOI: 10.1111/codi.13880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 08/01/2017] [Indexed: 12/24/2022]
Abstract
AIM Self-expanding metal stents (SEMSs) can be used as a palliative treatment or to initially decompress colon prior to definitive surgery (as a so-called 'bridge to surgery'). The purpose of this study was to investigate the efficacy and safety of SEMS used as palliation and bridge to surgery for malignant large bowel obstruction. METHOD A multicentre retrospective study was conducted from January 2010 to December 2013 to identify patients undergoing stent placement for acute large bowel obstruction. Patients were included from four Danish colorectal centres. Outcomes identified included clinical success, 30-day mortality, stent related complications and surgery related complications. Furthermore, we analysed for predictive factors for successful stenting. Clinical success was defined as relief of obstructive symptoms, without the need of other additional surgical interventions during the hospital stay. RESULTS SEMSs were inserted in 239 patients for whom the indication was as a bridge to surgery in 112 patients (47%) and as palliation in 127 (53%) patients. Clinical success was achieved in 90 patients (80.4%) in the bridge to surgery group and in 105 patients (82.8%) in the palliation group. The 30-day mortality rates in the two groups were 5.4% and 11.8% for bridge to surgery and palliation respectively. A total of 17.8% of the patients in the bridge to surgery group had a stent related complication and in the palliation group it was 20.4%. Multivariate analysis demonstrated that clinical failure is a predictive factor of 30-day mortality (OR 11.1, 95% CI: 4.1-30.0). CONCLUSION The use of a SEMS to relieve a malignant large bowel obstruction is generally an effective and safe method, but complications are seen in about 20% of patients. Further investigations are required to determine the role of SEMSs in the treatment of acute, malignant, large bowel obstruction.
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Affiliation(s)
- M Kobborg
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark
| | - M Broholm
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege and Roskilde Hospital, Koege and Roskilde, Denmark
| | - E Frostberg
- Department of Surgery, Vejle Hospital, Vejle, Denmark
| | - M Jeppesen
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege and Roskilde Hospital, Koege and Roskilde, Denmark
| | - I Gögenür
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege and Roskilde Hospital, Koege and Roskilde, Denmark
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Phothong N, Swangsri J, Akaraviputh T, Chinswangwatanakul V, Trakarnsanga A. Colonic stenting for malignant colonic obstruction with pneumatosis intestinalis: A case report. Int J Surg Case Rep 2016; 26:38-41. [PMID: 27448227 PMCID: PMC4957606 DOI: 10.1016/j.ijscr.2016.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/24/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023] Open
Abstract
Pneumatosis intestinalis is characterized by the presence of air localizing in the submucosa and subserosa layers of the bowel wall. Because of its risk of impending perforation, emergency surgery is generally required to be a definite treatment. Colonic stenting can be used as a safe alternative procedure in the selected patient.
Introduction Pneumatosis intestinalis is one of serious conditions following mechanical bowel obstruction. Emergency surgery is generally required to be a definite treatment in these patients of pneumatosis intestinalis, because of its risk of bowel ischemia and perforation. Since the operation in unprepared colon usually resulted in unfavorable outcome, the use of colonic stent is considered one of potential options as a bridge to definitive surgery. Presently, there is no widely published report of using colonic stent in these patients, particularly for stepping to curative surgery. Therefore, we herein report a case of obstructing sigmoid cancer with pneumatosis intestinalis who underwent successfully emergency metallic stent placement to convert from emergency to elective surgery. Presentation of case A 50-year-old woman presented with 3-day history of abdominal pain and obstipation. Abdominal computed tomography demonstrated a short segment of circumferential luminal narrowing at sigmoid colon, the presence of pneumatosis intestinalis at cecum, including ascending colon, and no extraluminal air. We performed colonoscopy and placed the metallic stent. The patient was then improved. After 1 week, the patient underwent elective hand-assisted laparoscopic sigmoidectomy and was discharged 5 days later. Pathological report showed stage IIa sigmoid cancer. The patient had no local recurrence or distant metastasis in 1 year follow up. Conclusion In obstructing colonic patient with pneumatosis intestinalis, nonsurgical treatment by colonic stenting can be used in selected patient as a bridge to definitive surgery. This will result in decreased morbidity and mortality and lower rate of stoma formation.
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Affiliation(s)
- Natthawut Phothong
- Minimally Invasive Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, 10700, Thailand; Department of Surgery, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Pak Kret, Nonthaburi, 11120, Thailand
| | - Jirawat Swangsri
- Minimally Invasive Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, 10700, Thailand
| | - Thawatchai Akaraviputh
- Minimally Invasive Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, 10700, Thailand
| | - Vitoon Chinswangwatanakul
- Minimally Invasive Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, 10700, Thailand
| | - Atthaphorn Trakarnsanga
- Minimally Invasive Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, 10700, Thailand.
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Okafor PN, Stobaugh DJ, Wong Kee Song LM, Limburg PJ, Talwalkar JA. Socioeconomic Inequalities in the Utilization of Colorectal Stents for the Treatment of Malignant Bowel Obstruction. Dig Dis Sci 2016; 61:1669-76. [PMID: 26738737 DOI: 10.1007/s10620-015-4019-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 12/20/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Colorectal stents are increasingly employed as a bridge to surgery or for palliative relief of malignant large bowel obstruction. AIM To explore determinants of inpatient colorectal stent utilization (CRSU). METHODS An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, 9th revision, codes were used to identify discharges associated with CRSU and patient/hospital factors for inclusion in a logistic regression model. RESULTS We identified 217,055 inpatient colonoscopies, approximating 1.1 million inpatient colonoscopies nationwide. Colorectal stents were placed in 1.4 % of all procedures. Across all racial groups, Medicare was the most common payer. Patients with commercial insurance had lower CRSU compared with Medicare patients [adjusted odds ratio (OR) 0.83, 95 % confidence interval (CI) 0.75-0.92]. No gender disparities were identified (OR 0.96, 95 % CI 0.89-1.03). In addition, no racial differences in CRSU existed between Caucasians versus African-Americans (OR 0.94, 95 % CI 0.83-1.06) and Caucasians versus Hispanics (OR 0.96, 95 % CI 0.83-1.1). Compared with patients living in less affluent neighborhoods, those residing in more affluent areas had higher CRSU (OR 1.65, 95 % CI 1.46-1.86). This displayed a linear relationship with the odds of CRSU increasing as household income increased. Less affluent patients also had the highest total charges and longest wait time to CRSU. CRSU was highest among patients treated in larger medical centers (OR 1.7, 95 % CI 1.51-1.93) and teaching hospitals (OR 3.9, 95 % CI 3.2-4.8). CONCLUSION Individuals from less affluent neighborhoods have lower colorectal stent utilization. This disparity is independent of race and likely related to poorer access to healthcare resources.
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Affiliation(s)
- Philip N Okafor
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derrick J Stobaugh
- North Shore University Health System, 4901 Searle Pkwy, Skokie, IL, 60077, USA
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Paul J Limburg
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jayant A Talwalkar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Abstract
Acute malignant colorectal obstruction (AMCO) is an emergency associated with colorectal cancer (CRC). Emergency surgery is standard therapy for AMCO, and 1-stage surgery without colostomy is preferable, but it is occasionally difficult in the emergency setting. A self-expandable metallic stent (SEMS) enables noninvasive colonic decompression and subsequent 1-stage surgery, which has been widely applied for CRC with AMCO. However, recent accumulation of high-quality evidence has highlighted some problems and the limited efficacy of SEMS for AMCO. In palliative settings, SEMS placement reduces hospital stay and short-term complication rates, whereas it increases the frequency of long-term complications, such as delayed perforation. SEMS placement does not seem compatible with recent standard chemotherapy including bevacizumab. As a bridge to surgery, while SEMS placement provides a lower clinical success rate than emergency surgery, it can facilitate primary anastomosis without stoma. However, evidence regarding long-term survival outcomes with SEMS in both palliative and bridge to surgery settings is lacking. The efficacy of transanal colorectal tube placement, another endoscopic treatment, has been reported, but its clinical evidence level is low due to the limited number of studies. This review article comprehensively summarizes the current knowledge about surgical and endoscopic management of CRC with AMCO.
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Ahn HJ, Kim SW, Lee SW, Lee SW, Lim CH, Kim JS, Cho YK, Park JM, Lee IS, Choi MG. Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery. Surg Endosc 2016; 30:4765-4775. [PMID: 26895922 DOI: 10.1007/s00464-016-4804-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with unresectable colorectal cancer (CRC) obstruction, choosing whether to perform self-expandable metal stent (SEMS) or palliative surgery is challenging, especially in those with good performance status. We aimed to compare the long-term outcomes of SEMS with those of palliative surgery in patients with unresectable CRC obstruction. METHODS This retrospective study comprised 114 patients with unresectable CRC obstruction who underwent SEMS placement (n = 73) or palliative surgery (n = 41). The main outcome measurements were success rate, adverse events, patency, and survival duration. RESULTS Early clinical success rates did not differ between SEMS and surgery. However, the rate of late adverse events was significantly higher in the SEMS group (27.4 vs. 9.8 %; P = .005). Patency duration was shorter after SEMS than after surgery (163 vs. 349 days; P < .001), even after additional intervention (202 vs. 349 days; P < .001). The median survival was significantly shorter after SEMS than after surgery (209 vs. 349 days; P = .005). Survival differed between treatments in patients with Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (P = .016) but not in those with ECOG 2 or 3 (P = .487), and this was confirmed by multivariate analysis, which showed that surgery was a significant favorable predictor of survival for patients with ECOG 0 or 1 (hazard ratio .442; 95 % confidence interval .234-.835; P = .016). CONCLUSIONS Surgery may be preferable to SEMS for the palliation of unresectable CRC obstruction in patients with good performance status, especially ECOG 0 or 1.
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Affiliation(s)
- Hyo Jun Ahn
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Woo Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Sung Won Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soon Wook Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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