Role of colonic stents in the management of colorectal cancers

Technical and Clinical Outcomes After Colorectal Stenting in Malignant Large Bowel Obstruction: A Single-Center Experience

Purpose

Malignant large bowel obstruction is a surgical emergency that requires urgent decompression. Stents are increasingly being used, though reported outcomes are variable. We describe our multidisciplinary experience in using stents to manage malignant large bowel obstruction.

Methods

All patients undergoing colorectal stent insertion for acute large bowel obstruction in a teaching hospital were included. Outcomes, complications, and length of stay (LOS) were recorded.

Results

Over a 7-year period, 73 procedures were performed on 67 patients (37 male, mean age of 76 years). Interventional radiology was involved in all cases. Endoscopic guidance was required in 24 cases (32.9%). In 18 patients (26.9%), treatment intent was to bridge to elective surgery; 16 had successful stent placement; all had subsequent curative resection (laparoscopic resection, 8 of 18; primary anastomosis, 14 of 18). Overall LOS, including both index admission and elective admission, was 16.4 days. Treatment intent was palliative in 49 patients (73.1%). In this group, stents were successfully placed in 41 of 49 (83.7%). Complication rate within 30 days was 20%, including perforation (2 patients), per rectal bleeding (2), stent migration (1), and stent passage (5). Nineteen patients (38.8%) required subsequent stoma formation (6, during same admission; 13, during subsequent admission). Overall LOS was 16.9 days.

Conclusion

In our experience colorectal stents can be used effectively to manage malignant large bowel obstruction, with only selective endoscopic input. As a bridge to surgery, most patients can avoid emergency surgery and have a primary anastomosis. In the palliative setting, the complication rate is acceptable and two-thirds avoid a permanent stoma.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

[Standardization of surgical care for malignant colonic obstruction]

AIM

To standardize surgical care for malignant colonic obstruction.

MATERIAL AND METHODS

There were 572 patients with malignant colonic obstruction: 247 of them were hospitalized in 2011-2013 (I group); 325 - in 2014-2017 (group II). Forty-six patients underwent medication; 302 - acute resection; 141 - stoma construction; 83 - stent deployment. Elective surgery and radiation or chemotherapy was performed after 0.5-6 months in 110 patients of group II. Acute resection was more common in I group, elective resection - in group II. Early and long-term results including Kaplan-Meier 3-year overall survival were compared in both groups.

RESULTS

Complications occurred in 46.69% (group I) and 21% (group II). Postoperative mortality was significantly higher in group I compared with II group: 26.11 and 10.33%, respectively. Three-year overall survival was higher in group I compared with group II: 0.82 and 0.69, respectively.

CONCLUSION

Advisability of new two-stage surgical standard is confirmed for malignant colonic obstruction. Stoma formation and stenting may be a valid alternative in some patients with malignant colonic obstruction due to significantly lower postoperative mortality.

Tertiary stent-in-stent for obstructing colorectal cancer: A case report and literature review

BACKGROUND

Self-expandable metal stents (SEMSs) are frequently used in the setting of palliation for occluding, inoperable colorectal cancer (CRC). Among possible complications of SEMS positioning, re-obstruction is the most frequent. Its management is controversial, potentially involving secondary stent-in-stent placement, which has been poorly investigated. Moreover, the issue of secondary stent-in-stent re-obstruction and of more-than-two colonic stenting has never been assessed. We describe a case of tertiary SEMS-in-SEMS placement, and also discuss our practice based on available literature.

CASE SUMMARY

A 66-year-old male with occluding and metastatic CRC was initially treated by positioning of a SEMS, which had to be revised 6 mo later when a symptomatic intra-stent tumor ingrowth was treated by a SEMS-in-SEMS. We hereby describe an additional episode of intestinal occlusion due to recurrence of intra-stent tumor ingrowth. This patient, despite several negative prognostic factors (splenic flexure location of the tumor, carcinomatosis with ascites, subsequent chemotherapy that included bevacizumab and two previously positioned stents (1 SEMS and 1 SEMS-in-SEMS)) underwent successful management through the placement of a tertiary SEMS-in-SEMS, with immediate clinical benefit and no procedure-related adverse events after 150 d of post-procedural follow-up. This endoscopic management has permitted 27 mo of partial control of a metastatic disease without the need for chemotherapy discontinuation and, ultimately, a good quality of life until death.

CONCLUSION

Tertiary SEMS-in-SEMS is technically feasible, and appears to be a safe and effective option in the case of recurrent SEMS obstruction.

Stent experiences in emergency conditions in acute mechanical intestinal obstruction caused by colorectal cancer

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.

[The optimal terms of the second stage of treatment of patients with malignant colonic obstruction]

AIM

To determine the optimal terms of the second stage of treatment of patients with malignant colonic obstruction.

MATERIAL AND METHODS

There were 110 patients with colorectal cancer stage T_3-4N₀M₀ (groups I-III, n=69) and T_3-4N_0-2M_0-1 (group IV, n=41). Everybody has been previously treated for colonic obstruction 0,5-6 months ago: stoma in 62 cases, stenting - in 48 cases. Elective radical surgery and radiotherapy and/or chemotherapy were applied in 2 (I group, n=23), 3 (II, n=23), 4 (III, n=23) weeks or 4-6 months (IV, n=41) after colonic decompression. The optimal terms of radical surgery are determined depending on CT-data, histological examination.

RESULTS

Bowel wall thickness was significantly higher in I-II groups compared with III-IV groups: 3.7; 2.5; 1.9; 1.7, respectively (p≤0,5). The maximum number of tumor emboli was found in III-IV groups. Signs of focal colitis were absent in III-IV groups.

CONCLUSION

The expediency of the new surgical standard is confirmed. Bridging strategy (stenting and stoma) may be a valid alternative in some patients with malignant colonic obstruction due to reduced postoperative mortality. The optimal terms for resection in patients with local cancer is 4 weeks after colonic decompression, in locally advanced cancer - 4-6 months.

[Managerial and methodological aspects of emergency surgery for malignant colonic obstruction]

AIM

To determine the most feasible treatment strategy for malignant colonic obstruction.

MATERIAL AND METHODS

There were 427 patients with malignant colonic obstruction who were hospitalized for emergency indications. 30 of them were treated with medical therapy; 286 - underwent acute resection; 43 - stoma construction; 68 - stents deployment. 64 out of 427 patients underwent elective restorative/radical surgery and radio- or chemotherapy in 1-8 months. 3-year Kaplan-Meier survival was assessed.

RESULTS

Complications occurred in 58% after acute resection and in 32.6% and 8.8% after stoma and stent deployment, respectively. Postoperative mortality was significantly lower after palliative surgery (stent or stoma) compared with acute resection: 2.9%, 18.6%, 29.37%, respectively. 3-year survival was higher after elective resections compared with emergency resection group: 0,81 и 0,68 respectively.

CONCLUSION

Bridging strategy (stoma/stents) may be a valid alternative in some patients with malignant colonic obstruction due to significantly reduced postoperative mortality. Acute surgery for malignant colonic obstruction should only be carried out by appropriately trained surgeons at multi-field hospital.

Observational study of colonoscopy techniques used for acute colorectal obstruction: A single-center experience

The prevalence of acute colorectal obstruction at the hospital setting is high. There is need for improvement in the quality of colonoscopy for relieving obstruction. A retrospective, uncontrolled, open-label study was conducted, with the aim of documenting the causes of acute colorectal obstruction and the quality of colonoscopy practice in managing obstruction at a university hospital in China. A total of 61 adult patients with acute colorectal obstruction treated with urgent colonoscopy between February, 2011 and January, 2016 were identified at the Endoscopic Unit of Tongji Hospital (Wuhan, China). The technique success rate was the primary outcome. The etiology was mainly related to malignant diseases, including colorectal cancer in 53 patients (86.9%) and advanced peritoneal serous carcinoma leading to extrinsic colonic compression in 1 patient (1.6%). Benign causes of obstruction included foreign bodies in 3 patients (4.9%) and fecal impaction in 2 patients (3.3%); furthermore, anastomotic strictures were found in 2 patients (3.3%). The technique success rate was 98.4% (60/61). All colorectal cancer patients who underwent urgent colonoscopy were admitted to the Department of Surgery for placement of a self-expanding metallic stent; 1 patient who had an extracolonic malignancy underwent placement of a transanal colonoscopic decompression tube as palliative therapy and 2 patients with anastomotic strictures underwent endoscopic balloon dilation. Furthermore, colonoscopy was used for extracting the foreign body, as well as removing fecal stones in all the patients. In conclusion, urgent colonoscopy as a minimal invasive approach is associated with certain advantages for diagnosing and managing acute colorectal obstruction. Furthermore, experienced operators achieved a better outcome when managing colorectal obstruction.