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Ma B, Ren T, Cai C, Chen B, Zhang J. Palliative procedures for advanced obstructive colorectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2024; 39:148. [PMID: 39311995 PMCID: PMC11420309 DOI: 10.1007/s00384-024-04724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2024] [Indexed: 09/26/2024]
Abstract
PURPOSE Advanced obstructive colorectal cancer (AOCC) presents surgical challenges. Consideration must be given to alleviating symptoms and also quality of life and survival time. This study compared prognostic efficacies of palliative self-expanding metal stents (SEMSs) and surgery to provide insights into AOCC treatment. METHODS PubMed, Web of Science, MEDLINE, and Cochrane Library were searched for studies that met inclusion criteria. Using a meta-analysis approach, postoperative complications, survival rates, and other prognostic indicators were compared between patients treated with SEMSs and those treated surgically. Network meta-analysis was performed to compare prognoses between SEMS, primary tumor resection (PTR), and stoma/bypass (S/B). RESULTS Twenty-one studies were selected (1754 patients). The odds ratio (OR) of SEMS for clinical success compared with surgery was 0.32 (95% confidence interval [CI] 0.15, 0.65). The ORs for early and late complications were 0.34 (95% CI 0.19, 0.59) and 2.30 (95% CI 1.22, 4.36), respectively. The ORs for 30-day mortality and stoma formation were 0.65 (95% CI 0.42, 1.01) and 0.11 (95% CI 0.05, 0.22), respectively. Standardized mean difference in hospital stay was - 2.08 (95% CI - 3.56, 0.59). The hazard ratio for overall survival was 1.24 (95% CI 1.08, 1.42). Network meta-analysis revealed that SEMS had the lowest incidence of early complications and rate of stoma formation and the shortest hospital stay. PTR ranked first in clinical success rate and had the lowest late-complication rate. The S/B group exhibited the lowest 30-day mortality rate. CONCLUSION Among palliative treatments for AOCC, SEMSs had lower early complication, stoma formation, and 30-day mortality rates and shorter hospital stays. Surgery had higher clinical success and overall survival rates and lower incidence of late complications. Patient condition/preferences should be considered when selecting AOCC treatment.
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Affiliation(s)
- Bingqing Ma
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tianxing Ren
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chengjun Cai
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Biao Chen
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jinxiang Zhang
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Lin W, Chok AY, Seow-En I, Tan EKW. Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes. Surg Endosc 2024; 38:2632-2640. [PMID: 38503904 DOI: 10.1007/s00464-024-10780-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES). METHODS This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes. RESULTS Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed. Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence. Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55). Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence. CONCLUSIONS There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.
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Affiliation(s)
- Wenjie Lin
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Emile Kwong-Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
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Chok AY, Zhao Y, Lim HJ, Ng YYR, Tan EJKW. Stenting as a bridge to surgery in obstructing colon cancer: Long-term recurrence pattern and competing risk of mortality. World J Gastrointest Endosc 2023; 15:64-76. [PMID: 36925648 PMCID: PMC10011892 DOI: 10.4253/wjge.v15.i2.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/28/2022] [Accepted: 01/10/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Stenting as a bridge to curative surgery (SBTS) for obstructing colon cancer (OCC) has been associated with possibly worse oncological outcomes.
AIM To evaluate the recurrence patterns, survival outcomes, and colorectal cancer (CRC)-specific death in patients undergoing SBTS for OCC.
METHODS Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined. Primary outcomes were recurrence patterns, overall survival (OS), cancer-specific survival (CSS), and CRC-specific death. OS and CSS were estimated using the Kaplan-Meier curves. Competing risk analysis with cumulative incidence function (CIF) was used to estimate CRC-specific mortality with other cause-specific death as a competing event. Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death. Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated.
RESULTS 28 patients (45.2%) developed metastases after a median period of 16 mo. Among the 18 patients with single-site metastases: Four had lung-only metastases (14.3%), four had liver-only metastases (14.3%), and 10 had peritoneum-only metastases (35.7%), while 10 patients had two or more sites of metastatic disease (35.7%). The peritoneum was the most prevalent (60.7%) site of metastatic involvement (17/28). The median follow-up duration was 46 mo. 26 (41.9%) of the 62 patients died, of which 16 (61.5%) were CRC-specific deaths and 10 (38.5%) were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%; 1-, 3-, and 5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mo was liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictive of CRC-specific death.
CONCLUSION The peritoneum was the most common metastatic site among patients undergoing SBTS. Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors of CRC-specific death.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
- Department of Group Analytics, Singapore Health Services, Singapore 168582, Singapore
| | - Hui Jun Lim
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Yvonne Ying Ru Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
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Bravington A, Obita G, Baddeley E, Johnson MJ, Murtagh FE, Currow DC, Boland EG, Nelson A, Seddon K, Oliver A, Noble SI, Boland JW. The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review. Palliat Med 2022; 36:1336-1350. [PMID: 36131489 PMCID: PMC10150264 DOI: 10.1177/02692163221122352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent. AIM To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set. DESIGN The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy. DATA SOURCES Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021. RESULTS A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life. CONCLUSIONS Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment 'success' that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population.
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Affiliation(s)
- Alison Bravington
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elaine G Boland
- Queen's Centre for Oncology and Haematology, Cottingham, Hull, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Alfred Oliver
- National Cancer Research Institute, Consumer Liaison Group, Trans-Humber Consumer Research Panel, London, UK
| | - Simon Ir Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
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Short-term efficacy, safety and survival of laparoscopic radical resection for colorectal cancer patients with bowel obstruction. Med Eng Phys 2022; 107:103867. [DOI: 10.1016/j.medengphy.2022.103867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/20/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022]
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Pattarajierapan S, Manomayangoon C, Tipsuwannakul P, Khomvilai S. Comparison of colonic stenting and stoma creation as palliative treatment for incurable malignant colonic obstruction. JGH Open 2022; 6:630-636. [PMID: 36091319 PMCID: PMC9446394 DOI: 10.1002/jgh3.12800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Self-expandable metal stent (SEMS) is a favorable therapeutic option for patients with incurable malignant colonic obstruction (MCO). However, their long-term efficacy and safety compared with those of stoma creation have not been well investigated. This study aimed to compare these long-term outcomes between these two techniques in patients with incurable MCO. METHODS This retrospective cohort included patients with incurable MCO with SEMS insertion (n = 105) and stoma creation (n = 97) between January 2009 and December 2019. The primary outcomes were patency after the procedure and 1-year re-intervention rates. RESULTS The patency of the SEMS group was lower than that of the stoma group (88.9 vs 93.2% at 6 months, 84.1 vs 90.5% at 12 months, and 65.8 vs 90.5% at 18 months; log-rank test, P = 0.024), but 1-year re-intervention rates were not different between the groups (10 vs 8%, P = 0.558). The median patency durations were 190 days for SEMS insertion and 231 days for stoma creation. Majority (84%) of SEMS patients did not require any re-intervention until death. The early complication rate did not differ between the groups (P = 0.377), but SEMS insertion had fewer late minor complications than stoma creation (5 vs 22%, P = 0.001). CONCLUSION SEMS insertion is a safe and effective treatment for patients with incurable MCO. Although SEMS insertion had a lower patency than stoma creation, especially after 1 year, the 1-year re-intervention rates were not different, and SEMS durability was sufficient in most patients.
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Affiliation(s)
- Sukit Pattarajierapan
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Chatiyaporn Manomayangoon
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Panat Tipsuwannakul
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of MedicineChulalongkorn UniversityBangkokThailand
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Veld JV, Beek KJ, Consten EC, ter Borg F, van Westreenen HL, Bemelman WA, van Hooft JE, Tanis PJ. Definition of large bowel obstruction by primary colorectal cancer: A systematic review. Colorectal Dis 2021; 23:787-804. [PMID: 33305454 PMCID: PMC8248390 DOI: 10.1111/codi.15479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/10/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
AIM Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies. METHOD A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements. RESULTS A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07). CONCLUSION In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.
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Affiliation(s)
- Joyce V. Veld
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kim J. Beek
- Department of Gastroenterology and HepatologyNWZ AlkmaarAlkmaarThe Netherlands
| | - Esther C.J. Consten
- Department of SurgeryMeander Medical CenterAmersfoortThe Netherlands,Department of SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and HepatologyDeventer HospitalDeventerThe Netherlands
| | | | - Wilhelmus A. Bemelman
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Self-expandable metal stent (SEMS) placement or emergency surgery as palliative treatment for obstructive colorectal cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2020; 155:103110. [DOI: 10.1016/j.critrevonc.2020.103110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
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Seoane Urgorri A, Saperas E, O'Callaghan Castella E, Pera Román M, Raga Gil A, Riu Pons F, Barranco Priego L, Dedeu Cusco JM, Pantaleón Sánchez M, Bessa Caserras X, Álvarez-González MA. Colonic stent vs surgical resection of the primary tumor. Effect on survival from stage-IV obstructive colorectal cancer. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:694-700. [PMID: 32755149 DOI: 10.17235/reed.2020.5701/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES the impact of surgical primary tumor resection on survival of obstructive metastatic colorectal cancer remains controversial. The primary goal of this study was to analyze survival in patients with obstructive metastatic colorectal cancer after treatment with either resection surgery or a colonic stent. MATERIAL AND METHODS a prospective study was performed of all patients with stage-IV colorectal cancer and obstructive manifestations, diagnosed from 2005 to 2012 and managed with either resection surgery or a colonic stent. Cases with a perforation, abscess, right colon or distal rectal malignancy, multiple colorectal cancer or derivative surgery were excluded. RESULTS a total of 95 patients were included, 49 were managed with resection surgery and 46 with a colonic stent. The colonic stent group had a higher Charlson index (9.5 ± 2.1 vs 8.6 ± 1.5, p = 0.01), a shorter time to oral intake (0.9 ± 1.1 vs 16.4 ± 53.5 days, p = 0.05), a shorter hospital stay (4 ± 4.8 vs 16.7 ± 15.5 days, p = 0.0001), less need for stomata (11.1 % vs 32.7 %, p = 0.01), fewer early complications (4.3 % vs 46.9 %, p = 0.0001) and more late complications (33.3 % vs 6.4 %, p = 0.001). Undergoing chemotherapy (p = 0.008) was the only independent factor related to increased survival. In the subgroup of patients managed with chemotherapy, surgical primary tumor resection was an independent factor associated with increased survival. CONCLUSION both treatments are effective for resolving obstructive manifestations in patients diagnosed with stage-IV obstructive colorectal cancer. Resection surgery has no positive impact on survival and thus cannot be recommended as a therapy of choice.
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Affiliation(s)
| | | | | | | | | | - Faust Riu Pons
- Aparato Digestivo, Parc de Salut Mar. Hospital del Mar, España
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Spannenburg L, Sanchez Gonzalez M, Brooks A, Wei S, Li X, Liang X, Gao W, Wang H. Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: A systematic review and meta-analysis of high quality prospective and randomised controlled trials. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:1404-1414. [PMID: 32418754 DOI: 10.1016/j.ejso.2020.04.052] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
Self-expanding metallic stent placement as a bridge to surgery has been reported as an alternative to emergency surgery for acute malignant colorectal obstruction. However, results from clinical trials and previous meta-analyses are conflicting. We carried out a meta-analysis to compare the surgical and oncological outcomes between emergency surgery and self-expanding metallic stents for malignant large bowel obstruction. Pubmed, Embase, CINAHL, Web of Science and Cochrane were searched for prospective and randomised controlled trials. The outcomes of focus included 3- and 5-year overall and disease-free survival, overall tumour recurrence, overall complication and 30-day mortality rate, length of hospital and ICU stay, overall blood loss, number of patients requiring transfusion, total number of lymph nodes harvested, stoma and primary anastomosis rate. Twenty-seven studies were included with a total of 3894 patients. There was no significant difference in terms of 3-year and 5-year disease-free and overall survival. Stenting resulted in less blood loss (mean difference -234.72, P < 0.00001) and higher primary anastomosis rate (RR 1.25, P < 0.00001). For curative cases, bridge to surgery groups had lower 30-day mortality rate (RR 0.65, P = 0.01), lower overall complication rate (RR 0.65, P < 0.0001), more lymph nodes harvested (mean difference 2.51, P = 0.005), shorter ICU stay (mean difference -2.27, P = 0.02) and hospital stay (mean difference -7.24, 95% P < 0.0001). Compared to emergency surgery, self-expanding metallic stent interventions improve short-term surgical outcomes, especially in the curative setting, but have similar long-term oncological and survival outcomes.
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Affiliation(s)
- Liam Spannenburg
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, QLD, 4102, Australia; Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mariana Sanchez Gonzalez
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, QLD, 4102, Australia
| | - Anastasia Brooks
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, QLD, 4102, Australia
| | - Shujun Wei
- Department of Colorectal Surgery, Changzheng Hospital, Naval Medical University, Shanghai, 200433, China
| | - Xinxing Li
- Department of Colorectal Surgery, Changzheng Hospital, Naval Medical University, Shanghai, 200433, China
| | - Xiaowen Liang
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, QLD, 4102, Australia; Department of Colorectal Surgery, Changzheng Hospital, Naval Medical University, Shanghai, 200433, China; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, QLD, Australia
| | - Wenchao Gao
- Department of Colorectal Surgery, Changzheng Hospital, Naval Medical University, Shanghai, 200433, China.
| | - Haolu Wang
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, QLD, 4102, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, QLD, Australia; Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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11
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Seo SY, Kim SW. Endoscopic Management of Malignant Colonic Obstruction. Clin Endosc 2020; 53:9-17. [PMID: 31906606 PMCID: PMC7003005 DOI: 10.5946/ce.2019.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.
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Affiliation(s)
- Seung Young Seo
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital and Medical School, Jeonju, Korea
| | - Sang Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital and Medical School, Jeonju, Korea
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Xu J, Zhang S, Jiang T, Zhao YJ. Transanal drainage tubes vs metallic stents for acute malignant left-sided bowel obstruction: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e18623. [PMID: 31914042 PMCID: PMC6959871 DOI: 10.1097/md.0000000000018623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/20/2019] [Accepted: 12/06/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The surgical management of acute malignant left-sided bowel obstruction is associated with high morbidity and mortality. Recently, transanal drainage tubes (DTs) and metallic stents (MSs) used as a "bridge to surgery" have become widely used decompression methods compared with emergency surgery. This study aims to evaluate the efficacy and safety of DTs and MSs for the decompression of acute left-sided malignant colorectal obstruction. METHODS All studies were acquired from PubMed, Medline, Embase, CNKI and the Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed with RevMan5.3. Mean differences (MDs), odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa scale were used to assess the risk of bias. RESULTS Eleven studies, which included three randomized controlled trials (RCTs) and 8 observational studies, were assessed. The methodological quality of the trials ranged from low to moderate. The pooled results of the technical success rate showed that the difference was not statistically significant between the2 devises. The differences in clinical success rate, operative time and complications were statistically significant between MSs and DTs, and MSs were associated with a better clinical success rate, increased operative time and fewer complications. Sensitivity analysis proved the stability of the pooled results, and the publication bias was low. CONCLUSION MS insertion for acute left-sided malignant bowel obstruction is effective and safe with a better technical success rate and with fewer complications than decompression using a DT, and MS insertion can avoid stoma formation. Moreover, MS insertion appears to be a useful treatment strategy for malignant colonic obstruction even if the lesion is located in the right colon. More large-sample, multicenter, high-quality RCTs are needed to verify the outcomes of this meta-analysis.
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Berselli M, Borroni G, Livraghi L, Quintodei V, Sambucci D, Cortelezzi C, Segato S, Carcano G, Cocozza E. Laparoscopic Approach to Large Bowel Neoplastic Obstruction After Self-Expandable-Metal-Stent (SEMS) Placement. Surg Laparosc Endosc Percutan Tech 2019; 29:133-137. [PMID: 30629036 DOI: 10.1097/sle.0000000000000623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic self-expandable metal stent (SEMS) placement as a bridge to surgery in large bowel neoplastic obstruction is an alternative to emergency surgery for the obstructive colorectal neoplasms. This study aims to analyze postoperative and long-term outcomes in a series of patients who underwent laparoscopic colorectal resection after SEMS placement. The analysis, after the stratification based on the time elapsed between the onset of the occlusive symptoms and the SEMS positioning, revealed an interesting result, with lower mortality for patients who underwent the procedure within 24 hours of hospitalization (P=0.0159). This trend may indicate the need to reduce the endoscopic time schedules as much as possible, even if an emergency procedure is needed. The laparoscopic approach, after stent placement as bridge therapy, can be a safe alternative to emergency surgery, if the procedure is precociously applied.
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Affiliation(s)
- Mattia Berselli
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Giacomo Borroni
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Lorenzo Livraghi
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Valeria Quintodei
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Daniele Sambucci
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Claudio Cortelezzi
- Department of Specialist Medicine, Gastroenterology Division, ASST Settelaghi
| | - Sergio Segato
- Department of Specialist Medicine, Gastroenterology Division, ASST Settelaghi
| | - Giulio Carcano
- Research Centre for Trauma and Emergency Surgery, University of Insubria, Varese, Italy
| | - Eugenio Cocozza
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
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14
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Short- and long-term clinical outcomes of self-expandable metal stents inserted for colorectal obstruction and efficacy of different insertion techniques. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:157-163. [DOI: 10.1016/j.gastrohep.2018.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 07/25/2018] [Indexed: 01/19/2023]
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Comparaison entre stent endoscopique et colostomie pour les cancers coliques gauches en occlusion : revue de la littérature. Presse Med 2019; 48:173-180. [DOI: 10.1016/j.lpm.2019.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/07/2018] [Accepted: 01/31/2019] [Indexed: 02/08/2023] Open
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Vanella G, Coluccio C, Di Giulio E, Assisi D, Lapenta R. Tertiary stent-in-stent for obstructing colorectal cancer: A case report and literature review. World J Gastrointest Endosc 2019; 11:61-67. [PMID: 30705733 PMCID: PMC6354113 DOI: 10.4253/wjge.v11.i1.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 12/05/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Giuseppe Vanella
- Department of Digestive Endoscopy, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy
| | - Chiara Coluccio
- Department of Digestive Endoscopy, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy
| | - Emilio Di Giulio
- Department of Digestive Endoscopy, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy
| | - Daniela Assisi
- Department of Digestive Endoscopy, Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Rocco Lapenta
- Department of Digestive Endoscopy, Regina Elena National Cancer Institute, Rome 00144, Italy
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Imai M, Kamimura K, Takahashi Y, Sato T, Isokawa O, Maruyama M, Kobayashi T, Hayashi K, Terai S. The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine. Int J Colorectal Dis 2018; 33:189-197. [PMID: 29264760 DOI: 10.1007/s00384-017-2946-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine. METHODS We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65-99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction. RESULTS The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20-1377 days). On multivariate analysis, shorter stents (< 10 cm) yielded better outcomes than longer stents (≥ 10 cm) (P = 0.041), and the Cox proportional hazard model also indicated that shorter stents (P = 0.036) predicted longer event-free survival. CONCLUSIONS Elderly patients with malignant bowel obstruction receiving shorter stents had longer event-free survival after stenting with better general condition.
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Affiliation(s)
- Michitaka Imai
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan.
| | - Yoshifumi Takahashi
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Toshihiro Sato
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Osamu Isokawa
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Masaki Maruyama
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
- Department of Gastroenterology, Kashiwazaki Chuo Hospital, 2-1-25, Ekimae, Kashiwazaki, Niigata, Japan
| | - Takamasa Kobayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
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Mitra V, Hu M, Majumdar D, Krishnan V, Chaudhury B, Hancock J, Dwarakanath D. Safety and efficacy of self-expandable metal stents for obstructive proximal and distal large bowel cancer. J R Coll Physicians Edinb 2017; 47:30-34. [PMID: 28569279 DOI: 10.4997/jrcpe.2017.107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Self-expandable metal stents are often used to treat obstructive large bowel cancers. This study assessed the safety and efficacy of colonic stent insertion carried out in a district general hospital. Methods A retrospective review was carried out between 1 January 2007 and 28 February 2014 to identify patients who underwent stent insertion for malignant colorectal obstruction. Results Seventy-five patients (median age 75.2 years, 70.6% male) with primary colorectal cancer underwent stent insertion - 53 underwent semi-elective self-expanded metal stent insertion (for subacute bowel obstruction) and 22 had emergency stent inserted (for acute bowel obstruction). The majority (88%) had self-expanded metal stents inserted for palliation. Technical and clinical success rates were 98.7% and 91.2%, respectively. One patient had stent-related perforation; there was no procedure-related mortality. Conclusion This study shows that self-expanded metal stent insertion in malignant colorectal obstruction is safe and effective and can be successfully delivered in a district general hospital with high technical and clinical success rates.
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Affiliation(s)
- V Mitra
- V Mitra, James Cook University Hospital, Marton Rd, Middlesbrough TS4 3BW, UK.
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19
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Siddiqui A, Cosgrove N, Yan LH, Brandt D, Janowski R, Kalra A, Zhan T, Baron TH, Repici A, Taylor LJ, Adler DG. Long-term outcomes of palliative colonic stenting versus emergency surgery for acute proximal malignant colonic obstruction: a multicenter trial. Endosc Int Open 2017; 5:E232-E238. [PMID: 28367495 PMCID: PMC5362371 DOI: 10.1055/s-0043-102403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Long-term data are limited regarding clinical outcomes of self-expanding metal stents as an alternative for surgery in the treatment of acute proximal MBO. The aim of this study was to compare the long-term outcomes of stenting to surgery for palliation in patients with incurable obstructive CRC for lesions proximal to the splenic flexure. Patients and methods Retrospective multicenter cohort study of obstructing proximal CRC patients with who underwent insertion of a SEMS (n = 69) or surgery (n = 36) from 1999 to 2014. The primary endpoint was relief of obstruction. Secondary endpoints included technical success, duration of hospital stay, early and late adverse events (AEs) and survival. Results Technical success was achieved in 62/69 (89.8 %) patients in the SEMS group and in 36 /36 (100 %) patients who underwent surgery (P = 0.09). In the SEMS group, 10 patients underwent stenting as a bridge to surgery and 59 underwent stent placement for palliation. Clinical relief was achieved in 78 % of patients with stenting and in 100 % of patients who underwent surgery (P < 0.001). Patients with SEMS had significantly less acute AEs compared to the surgery group (7.2 % vs. 30.5 %, P = 0.003). Hospital mortality for the SEMS group was 0 % compared to 5.6 % in the surgery group (P = 0.11). Patients in the SEMS group had a significantly shorter median hospital stay (4 days) as compared to the surgery group (8 days) (P < 0.01). Maintenance of decompression without the recurrence of bowel obstruction until death or last follow-up was lower in the SEMS group (73.9 %) than the surgery group (97.3 %; P = 0.003). SEMS placement was associated with higher long-term complication rates compared to surgery (21 % and 11 % P = 0.27). Late SEMS AEs included occlusion (10 %), migration (5 %), and colonic ulcer (6 %). At 120 weeks, survival in the SEMS group was 5.6 % vs. 0 % in the surgery group (P = 0.8). Conclusions Technical and clinical success associated with proximal colonic obstruction are higher with surgery when compared to SEMS, but surgery is associated with longer hospital stays and more early AEs. SEMS should be considered the initial mode of therapy in patients with acute proximal MBO and surgery should be reserved for SEMS failure, as surgery involves a high morbidity and mortality.
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Affiliation(s)
- Ali Siddiqui
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Natalie Cosgrove
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Linda H. Yan
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Daniel Brandt
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Raymond Janowski
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Ankush Kalra
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Tingting Zhan
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Todd H. Baron
- University of North Carolina, Gastroenterology and Hepatology, Chapel Hill, North Carolina, United States
| | - Allesandro Repici
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Linda Jo Taylor
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, United States
| | - Douglas. G. Adler
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, United States,Corresponding author Douglas G. Adler MD, FACG, AGAF, FASGE, Professor of Medicine Director of Therapeutic EndoscopyDirector, GI Fellowship ProgramGastroenterology and HepatologyUniversity of Utah School of MedicineHuntsman Cancer Center30N 1900E 4R118Salt Lake City, Utah 84132
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20
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Faucheron JL, Paquette B, Trilling B, Heyd B, Koch S, Mantion G. Emergency surgery for obstructing colonic cancer: a comparison between right-sided and left-sided lesions. Eur J Trauma Emerg Surg 2017; 44:71-77. [PMID: 28271148 DOI: 10.1007/s00068-017-0766-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/20/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE Few studies compare management and outcomes of obstructive colonic cancer, depending on the tumor site. We aim to evaluate the differences in patient characteristics, tumor characteristics, and outcomes of emergency surgery for obstructive right-sided versus left-sided colonic cancers. METHODS Between 2000 and 2009, 71 consecutive patients had an emergency colectomy following strict and clear definition of obstruction in a single institution. We retrospectively analyzed pre, per, and postoperative data that were prospectively collected. RESULTS There were 31 and 40 patients in the right and left group, respectively. Patients aged over 80 were more frequent in the right group (p = 0.03). At operation, ileocecal valve was less often competent in the right group (p = 0.03). The one-stage strategy was more frequent in the right group (p = 0.008). Patients in the right group had a higher rate of nodes invasion (p = 0.04). One- and two-year mortality rate in the right group had a tendency to be higher. CONCLUSIONS Patients presenting with a right obstructive colonic cancer are older, have a more advanced locoregional disease, and are more often treated in a one-stage strategy than patients with a left obstructive tumor.
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Affiliation(s)
- J-L Faucheron
- Colorectal Unit, Department of Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France.
- University Grenoble Alps, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France.
| | - B Paquette
- Department of Surgery, University Hospital, 25030, Besançon Cedex, France
| | - B Trilling
- Colorectal Unit, Department of Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France
- University Grenoble Alps, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France
| | - B Heyd
- Department of Surgery, University Hospital, 25030, Besançon Cedex, France
| | - S Koch
- Department of Gastroenterology, University Hospital, 25030, Besançon Cedex, France
| | - G Mantion
- Department of Surgery, University Hospital, 25030, Besançon Cedex, France
- Department of Gastroenterology, University Hospital, 25030, Besançon Cedex, France
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Predictors of outcome for endoscopic colorectal stenting: a decade experience. Int J Colorectal Dis 2017; 32:375-382. [PMID: 27817034 DOI: 10.1007/s00384-016-2696-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various factors on the short- and long-term results of colorectal stenting. METHODS A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome. RESULTS Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90 %) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22 % of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio [AOR] 0.2 [95 % confidence interval (CI) 0.1-0.8]; p = 0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 [95 % CI 1.4-10.3]; p = 0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 [95 % CI 1.0-10.0]; p = 0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 [95 % CI 1.5-11.7]; p = 0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 [95 % CI 2.6-71.2]; p = 0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 [95 % CI 1.3-16.2]; p = 0.017). CONCLUSIONS Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.
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Elective Surgery After Endoscopic Self-Expandable Metallic Stent Placement for Patients With Obstructive Colon Cancer: Preoperative Systemic Evaluation and Management. Int Surg 2017. [DOI: 10.9738/intsurg-d-17-00024.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
One-stage curative surgical resection for obstructive colon cancer is challenging. Self-expandable metallic stents (SEMSs) are known as an alternative treatment used to avoid emergency operation. We aimed to evaluate the significance of SEMS placement as a bridge to surgery and the surgical outcomes of the elective operation. A consecutive 20 patients with obstructive colon cancer undergoing SEMS placement between June 2014 and February 2016 were included. The technical outcomes of the SEMS placement, surgical procedures, and surgical outcomes were evaluated retrospectively. Among them, 2 patients were treated with a SEMS palliatively, and the others were treated with a SEMS as a bridge to surgery. All SEMS were placed successfully at the first attempt, and there was no SEMS-related complication. Before surgery, all patients could be diagnosed histologically, and they were evaluated systemically including proximal colon or distant metastasis. The median time to operation after SEMS placement was 14 days (range 9–20 days). Seven of the 18 patients underwent a laparoscopic colectomy without conversion to laparotomy. All patients with stage II or III colon cancer underwent curative surgery, and 2 patients with stage IV colon cancer underwent a one-stage resection of the primary colon cancer and simultaneous liver metastasis after the evaluation of hepatic functional reserve. There was no mortality or SEMS-related complication in the perioperative period. SEMS placement as a bridge to surgery for patients with obstructive colon cancer is safe and effective to provide an adequate amount of time for a preoperative systemic management and evaluation.
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Palliative Stent Insertion for Acute Malignant Colorectal Obstruction: Long-term Patency and Survival. Surg Laparosc Endosc Percutan Tech 2016; 25:500-4. [PMID: 26492458 DOI: 10.1097/sle.0000000000000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate the long-term outcome of palliative stent insertion for acute malignant colorectal obstruction. METHODS From May 2009 to February 2015, consecutive patients with acute malignant colorectal obstruction underwent palliative stent insertion in our center. Technical success, clinical success, and long-term outcomes were analyzed retrospectively. RESULTS A total of 45 patients with acute malignant colorectal obstruction underwent palliative stent insertion. Technical success was achieved in 42 of 45 patients. Clinical success was achieved in 41 of 42 patients. During a follow-up of 5 days to 25 months (mean, 6.9±4.5 mo), the cumulative 6- and 12-month patency rates were 88.6% and 72.7%, respectively. The cumulative 6- and 12-month survival rates were 60.1% and 14.3%, respectively. The independent predictor of prolonging survival was subsequent chemotherapy after stenting (P=0.017). CONCLUSION Palliative colorectal stent insertion can provide a good long-term outcome in patients with malignant colorectal obstruction.
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Colonic self-expanding metal stent (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction: an 8-year review. Surg Endosc 2016; 31:2255-2262. [PMID: 27631312 DOI: 10.1007/s00464-016-5227-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/25/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Colonic stenting has evolved to be an alternative to emergency laparotomy in the management of acute left-sided malignant colonic obstruction. This retrospective comparative study aimed to review the outcomes of colonic stent as bridge to surgery with emergency operation in a regional hospital in Hong Kong. METHOD Consecutive patients who were admitted from January 2006 to July 2014 with diagnosis of malignant left-sided colonic obstruction (from splenic flexure to rectosigmoid colon) were included. Patients with peritonitis or disseminated disease were excluded. Colonic stenting was attempted in all eligible patients when fluoroscopy was available in the endoscopy suite during office hour. Otherwise, emergency operation was performed. For patients with clinical success in colonic stenting, interval colectomies were performed. The postoperative outcomes, including the 30-days mortality, the stoma creation rate, the complication rate as well as the survival data were analyzed on an intention-to-treat (ITT) basis. RESULTS From January 2006 to July 2014, 62 patients underwent colonic stenting and 40 patients underwent emergency operations. The technical success rate and the clinical success rate of stenting were 95.2 and 83.9 %, respectively. Laparoscopic resection was achieved in 74.2 % in the stenting group. More primary anastomoses were performed in the stenting group (71.0 vs. 27.5 %, p = 0.000). The stenting group had a significantly lower permanent stoma rate (16.1 vs. 52.5 %, p < 0.000), fewer Dindo grade III to IV postoperative morbidity (16.1 vs. 40 %, p = 0.007), and the 30-day mortality rate was lower (3.2 vs. 17.5 %, p = 0.018), translating into a better overall 5-year survival rate. The disease-free survival was comparable between the two groups. CONCLUSIONS Colonic self-expanding metal stent is effective in the management of acute left-sided colonic obstruction. It is associated with reduced stoma creation rate and postoperative morbidity. The oncological safety is not jeopardized by stenting and the interval operation.
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Haraguchi N, Ikeda M, Miyake M, Yamada T, Sakakibara Y, Mita E, Doki Y, Mori M, Sekimoto M. Colonic stenting as a bridge to surgery for obstructive colorectal cancer: advantages and disadvantages. Surg Today 2016; 46:1310-7. [PMID: 27048552 DOI: 10.1007/s00595-016-1333-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/14/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE To clarify the advantages and disadvantages of stenting as a bridge to surgery (BTS) by comparing the clinical features and outcomes of patients who underwent BTS with those of patients who underwent emergency surgery (ES). METHODS We assessed technical success, clinical success, surgical procedures, stoma formation, complications, clinicopathological features, and Onodera's prognostic nutritional index (OPNI) in patients who underwent BTS and those who underwent ES. RESULTS Twenty-six patients underwent stenting, which was successful in 22 (BTS group). The remaining four patients with unsuccessful stenting underwent emergency surgery. A total of 22 patients underwent emergency surgery (ES group). The rates of technical and clinical success were 85.0 and 81.0 %, respectively. The proportion of patients able to be treated by laparoscopic surgery (P = 0.0001) and avoid colostomy (P = 0.0042) was significantly higher in the BTS group. Although the incidence of anastomotic leakage in the two groups was not significantly different, it was significantly reduced by colonoscopic evaluation of obstructive colitis (P = 0.0251). The mean number of harvested lymph nodes (P = 0.0056) and the proportion of D3 lymphadenectomy (P = 0.0241) were significantly greater in the BTS group. Perineural invasion (PNI) was noted in 59.1 and 18.2 % of the BTS group and ES group patients, respectively (P = 0.0053). OPNI and serum albumin decreased significantly after stenting (P = 0.0084). CONCLUSIONS The advantages of stenting as a BTS were that it avoided colostomy and allowed for laparoscopic surgery and lymphadenectomy, whereas its disadvantage lay in the decreased PNI and OPNI levels. A larger study including an analysis of prognosis is warranted.
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Affiliation(s)
- Naotsugu Haraguchi
- Department of Surgery, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan.
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita Yamadaoka 2-2-E2, Osaka, 565-0871, Japan.
| | - Masataka Ikeda
- Department of Surgery, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan
| | - Takuya Yamada
- Department of Gastroenterology, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan
| | - Yuko Sakakibara
- Department of Gastroenterology, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan
| | - Eiji Mita
- Department of Gastroenterology, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita Yamadaoka 2-2-E2, Osaka, 565-0871, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita Yamadaoka 2-2-E2, Osaka, 565-0871, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, National Hospital Organization Osaka National Hospital, Chuouku Hoenzaka 2-1-14, Osaka, 540-0006, Japan
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Cézé N, Charachon A, Locher C, Aparicio T, Mitry E, Barbieux JP, Landi B, Dorval E, Moussata D, Lecomte T. Safety and efficacy of palliative systemic chemotherapy combined with colorectal self-expandable metallic stents in advanced colorectal cancer: A multicenter study. Clin Res Hepatol Gastroenterol 2016; 40:230-8. [PMID: 26500200 DOI: 10.1016/j.clinre.2015.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 07/27/2015] [Accepted: 09/07/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE Self-expandable metallic stent (SEMS) placement is an accepted palliative therapy for management of acute malignant bowel obstruction in advanced colorectal cancer. Nevertheless, data are lacking on the effects of systemic chemotherapy combined with colorectal SEMS. The aim of this study was to investigate the safety and efficacy of palliative chemotherapy for advanced colorectal cancer combined with colorectal SEMS placement. PATIENTS AND METHODS This multicentre retrospective study included all consecutive advanced colorectal cancer patients who received first-line palliative chemotherapy combined with endoscopic stenting for colorectal cancer with obstruction. We analyzed the number of cycles and the type of combination used. The primary endpoint was overall survival. Secondary endpoints included progression-free survival, response rate, grade 3-4 toxicity and the outcomes of SEMS for malignant colorectal obstruction. RESULTS A total of 38 patients were included. Among them, 25 patients received oxaliplatin and 5-fluorouracil combination chemotherapy. Objective response and stabilization occurred in 38 and 24% of patients, respectively. The median overall survival and progression-free survival from the start of chemotherapy were 18 and 5months, respectively. The objective response rate and overall disease control rate were 38 and 62%, respectively. Toxicity was generally acceptable. Major complications related to stenting included perforation (8%), stent migration (5%), and reobstruction secondary to tumor ingrowths (13%). CONCLUSIONS Chemotherapy combined with colonic stenting as a first-line treatment seems to be a valid option in advanced colorectal cancer patients with malignant colorectal obstruction.
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Affiliation(s)
- Nicolas Cézé
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Antoine Charachon
- Department of Hepatogastroenterology, Henri Mondor University Hospital, AP-HP, Créteil, France
| | - Christophe Locher
- Department of Hepatogastroenterology, General Hospital of Meaux, France
| | - Thomas Aparicio
- Department of Hepatogastroenterology, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France
| | - Emmanuel Mitry
- Department of Clinical Oncology, Institut Curie St Cloud and Versailles St-Quentin University, France
| | - Jean-Pierre Barbieux
- Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Bruno Landi
- Department of Hepatogastroenterology and Digestive Oncology, Georges Pompidou European University Hospital, AP-HP, Paris, France
| | - Etienne Dorval
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Driffa Moussata
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France
| | - Thierry Lecomte
- François Rabelais University, Tours, France; Department of Hepatogastroenterology and Digestive Oncology, University Hospital of Tours, Tours, France.
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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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Safety and efficacy of palliative colorectal stent placement using a nasal endoscope technique. Surg Laparosc Endosc Percutan Tech 2016; 25:262-5. [PMID: 26018052 PMCID: PMC4454541 DOI: 10.1097/sle.0000000000000159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to evaluate the safety and efficacy of palliative self-expanding metallic stent (SEMS) placement using a nasal endoscope technique in the context of colorectal malignant obstruction. Eighteen patients with malignant colorectal obstruction who underwent palliative SEMS insertion using a nasal endoscope technique at the Toyonaka Municipal Hospital from August 2005 to August 2011 were enrolled and retrospectively analyzed. In all cases, a guidewire could be inserted on the oral side of the tumor. The placement success rate was 94.4% (17/18), and the complication rate was 23.5% (4 cases). The stent migrated in 3 cases, and perforation occurred in 1 case following bevacizumab chemotherapy. These outcomes indicate that stenting is useful for terminal patients and that nasal endoscopy is useful in cases of difficult guidewire placement.
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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: 1.9] [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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Zahid A, Young CJ. How to decide on stent insertion or surgery in colorectal obstruction? World J Gastrointest Surg 2016; 8:84-89. [PMID: 26843916 PMCID: PMC4724591 DOI: 10.4240/wjgs.v8.i1.84] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/23/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the most common cancers in western society and malignant obstruction of the colon accounts for 8%-29% of all large bowel obstructions. Conventional treatment of these patients with malignant obstruction requiring urgent surgery is associated with a greater physiological insult on already nutritionally replete patients. Of late the utility of colonic stents has offered an option in the management of these patients in both the palliative and bridge to surgery setting. This has been the subject of many reviews which highlight its efficacy, particulary in reducing ostomy rates, allowing quicker return to oral diet, minimising extended post-operative recovery as well as some quality of life benefits. The uncertainity in managing patients with malignant colonic obstructions has lead to a more cautious use of stenting technology as community equipoise exists. Decision making analysis has demonstrated that surgeons’ favored the use of stents in the palliative setting preferentially when compared to the curative setting where surgery was preferred. We aim to review the literature regarding the use of stent or surgery in colorectal obstruction, and then provide a discourse with regards to the approach in synthesising the data and applying it when deciding the appropriate application of stent or surgery in colorectal obstruction.
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Kim EJ, Kim YJ. Stents for colorectal obstruction: Past, present, and future. World J Gastroenterol 2016; 22:842-852. [PMID: 26811630 PMCID: PMC4716082 DOI: 10.3748/wjg.v22.i2.842] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/22/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
Since the development of uncovered self-expanding metal stents (SEMS) in the 1990s, endoscopic stents have evolved dramatically. Application of new materials and new designs has expanded the indications for enteral SEMS. At present, enteral stents are considered the first-line modality for palliative care, and numerous types of enteral stents are under development for extended clinical usage, beyond a merely palliative purpose. Herein, we will discuss the current status and the future development of lower enteral stents.
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Colonic Stents for Colorectal Cancer Are Seldom Used and Mainly for Palliation of Obstruction: A Population-Based Study. Can J Gastroenterol Hepatol 2016; 2016:1945172. [PMID: 27446826 PMCID: PMC4904648 DOI: 10.1155/2016/1945172] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/18/2015] [Indexed: 01/01/2023] Open
Abstract
Self-expandable stents for obstructing colorectal cancer (CRC) offer an alternative to operative management. The objective of the study was to determine stent utilization for CRC obstruction in the province of Ontario between April 1, 2000, and March 30, 2009. Colonic stent utilization characteristics, poststent insertion health outcomes, and health care encounters were recorded. 225 patients were identified over the study period. Median age was 69 years, 2/3 were male, and 2/3 had metastatic disease. Stent use for CRC increased over the study period and gastroenterologists inserted most stents. The median survival after stent insertion was 199 (IQR, 69-834) days. 37% of patients required an additional procedure. Patients with metastatic disease were less likely to go on to surgery (HR 0.14, 95% CI 0.06-0.32, p < 0.0001). There were 2.4/person-year emergency department visits (95% CI 2.2-2.7) and 2.3 hospital admissions/person-year (95% CI 2.1-2.5) following stent insertion. Most admissions were cancer or procedure related or for palliation. Factors associated with hospital admissions were presence of metastatic disease, lack of chemotherapy treatment, and stoma surgery. Overall the use of stents for CRC obstruction remains low. Stents are predominantly used for palliation with low rates of postinsertion health care encounters.
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Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction. J Gastrointest Surg 2015; 19:2243-8. [PMID: 26354721 DOI: 10.1007/s11605-015-2936-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/01/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. METHODS From January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7-9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed. RESULTS Twenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1). CONCLUSION Decompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.
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Meta-analysis of complications of colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction. Surg Laparosc Endosc Percutan Tech 2014; 24:73-9. [PMID: 24487162 DOI: 10.1097/sle.0000000000000030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Left-sided malignant colonic obstruction is one of the most difficult clinical problems, whereas both emergency operations and colonic stenting may have their own advantages and disadvantages. The purpose of this study was to evaluate the complications of colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction. MATERIALS AND METHODS Medline, Embase, and the Cochrane Library were searched. Only prospective randomized controlled trials that compared the 2 methods were included. Evaluation indexes in our study involved hospital death rates and complications. RESULTS No significant difference in either hospital death rates or the overall complications between the 2 groups was found. Heterogeneity analysis found that there was no significant heterogeneity. Removing individual studies from the data editor did not substantially change the RR or the level of heterogeneity of significance for our 2 outcome measures. Testing for publication bias showed that hospital death rates and the overall complications had no serious publication bias. CONCLUSIONS Colonic stenting was no better than emergency surgery, and should be only used as an alternative to emergency surgery carefully.
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Kaplan J, Strongin A, Adler DG, Siddiqui AA. Enteral stents for the management of malignant colorectal obstruction. World J Gastroenterol 2014; 20:13239-13245. [PMID: 25309061 PMCID: PMC4188882 DOI: 10.3748/wjg.v20.i37.13239] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/22/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the 3rd most common cancer in the United States with more than 10000 new cases diagnosed annually. Approximately 20% of patients with CRC will have distant metastasis at time of diagnosis, making them poor candidates for primary surgical resection. Similarly, 8%-25% of patients with CRC will present with bowel obstruction and will require palliative therapy. Emergent surgical decompression has a high mortality and morbidity, and often leads to a colostomy which impairs the patient’s quality of life. In the last decade, there has been an increasing use of colonic stents for palliative therapy to relieve malignant colonic obstruction. Colonic stents have been shown to be effective and safe to treat obstruction from CRC, and are now the therapy of choice in this scenario. In the setting of an acute bowel obstruction in patients with potentially resectable colon cancer, stents may be used to delay surgery and thus allow for decompression, adequate bowel preparation, and optimization of the patient’s condition for curative surgical intervention. An overall complication rate (major and minor) of up to 25% has been associated with the procedure. Long term failure of stents may result from stent migration and tumor ingrowth. In the majority of cases, repeat stenting or surgical intervention can successfully overcome these adverse effects.
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Sahebally SM, Sarwar A, Cooke F. Short-term outcomes following the use of self-expanding metallic stents in acute malignant colonic obstruction--a single centre experience. Int J Surg 2014; 12:1198-202. [PMID: 25300737 DOI: 10.1016/j.ijsu.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/10/2014] [Accepted: 09/19/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term outcomes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution over a 3-year period. METHODS A prospectively maintained database was reviewed to identify all patients who presented to our institution with AMCO between August 2010 and 2013 and who were treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews and operation notes. RESULTS Sixteen patients (12 males, 4 females) each had a single stent inserted during the study period, either palliatively (n = 11) or as a BTS (n = 5). The technical and clinical success rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and required emergency surgery while five patients with curable disease proceeded to elective resections. There was no procedure-related mortality or stent-related perforations. The mean (standard deviation) length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All patients in the BTS group were stoma-free post-operatively, while both patients who had emergency surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary to migration. CONCLUSIONS Although limited by a small sample size, the study shows that SEMS have favourable short-term outcomes. Further adequately powered trials are needed to confirm those findings.
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Affiliation(s)
- Shaheel M Sahebally
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Azhar Sarwar
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Fiachra Cooke
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland.
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Srinivasan N, Kozarek RA. Stents for colonic strictures: Materials, designs, and more. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Geraghty J, Sarkar S, Cox T, Lal S, Willert R, Ramesh J, Bodger K, Carlson GL. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis 2014; 16:476-83. [PMID: 24506142 DOI: 10.1111/codi.12582] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/18/2013] [Indexed: 12/12/2022]
Abstract
AIM UK cancer guidelines recommend patients with colonic obstruction due to suspected malignancy be considered for stenting with a self-expanding metal stent (SEMS). Considerable variation in practice exists due to a lack of expertise, technical difficulties and other, as yet ill-defined features. This retrospective multi-centre study aims to determine the outcome following colonic stenting for large bowel obstruction and identify factors associated with successful intervention. METHOD A regional programme of colonic stenting for large bowel obstruction, in five UK centres from 2005 to 2010 was evaluated for outcome including technical and clinical success, survival, complications and reoperation. RESULTS A SEMS was inserted in 334 patients, including 264 (79.0%) for palliation and 52 (15.6%) as a bridge to surgery. Technical success was achieved in 292 (87.4%) patients, with 46 (13.8%) experiencing a complication or technical failure. Reoperation was required in 39 (14.8%) patients stented for palliation of colorectal cancer of whom 16 (6.1%) subsequently required a colostomy. A one-stage primary anastomosis was achieved in 35 (67.3%) of the 52 patients undergoing stenting as a bridge to resection. Technical success did not vary by indication or site of obstruction (P = 0.60) but was higher for operators who had performed more than 10 procedures (OR 3.34, P = 0.001). ASA grade ≥3 predicted a worse clinical outcome (OR 0.43, P = 0.04). The through-the-scope (TTS) endoscopy technique was more successful than radiological placement alone (90.3% vs 74.8%, P < 0.001). CONCLUSION Experienced operators using a TTS technique achieved a better outcome for the emergency management of large bowel obstruction. Older, sicker patients and those with extracolonic and benign strictures fared less well.
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Affiliation(s)
- J Geraghty
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
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Huang X, Lv B, Zhang S, Meng L. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg 2014; 18:584-91. [PMID: 24170606 DOI: 10.1007/s11605-013-2344-9] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 08/26/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this paper is to evaluate the efficacy and safety of colonic stenting as a bridge to surgery versus emergency surgery for acute left-sided malignant colonic obstruction. METHODS Randomized clinical trials (RCT) that compared the efficacy or safety of preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction were searched in medical databases, including PubMed, OVID, EMBASE, and the Cochrane Library. Statistical heterogeneity between trials was evaluated by Revman 5.1 and was considered to exist at I(2) > 50%. RESULTS Seven RCTs were identified. There was a total of 382 patients, 195 who received a colonic stent and 187 who received emergency surgery. Compared with the emergency surgery group, the colonic stent group achieved significantly more favorable rates of permanent stoma, primary anastomosis, wound infection, and overall complications. There was no significant difference between the two groups in anastomotic leakage, mortality, or intra-abdominal infection. Inspection of funnel plots for all outcome measures did not reveal evidence of publication bias. CONCLUSIONS Self-expanding metal stents serve as a safe and effective bridge to subsequent surgery in patients with obstructing left-sided colon cancer. They can significantly improve one-stage surgery rates, and decrease the rates of permanent stoma and wound infection.
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Affiliation(s)
- Xuan Huang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang Chinese Medical University, 54 Youdian Road, Shangcheng District, Hangzhou City, 310006, Zhejiang Province, China
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Wong RF, Bhutani MS. Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies. Expert Rev Anticancer Ther 2014; 5:705-18. [PMID: 16111470 DOI: 10.1586/14737140.5.4.705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.
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Affiliation(s)
- Robert F Wong
- Division of Gastroenterology, Department of Internal Medicine, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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Lee KM, Lim SG, Shin SJ, Kim JH, Kang DH, Kim JK, Hwang JC, Kwon CI, Cheong JY, Yoo BM. Novel method of stent insertion for malignant lower rectal obstruction with proximal releasing delivery system (with video). Gastrointest Endosc 2013; 78:930-933. [PMID: 24237948 DOI: 10.1016/j.gie.2013.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expandable metal stents are an alternative to preoperative and palliative colostomy for patients with malignant colorectal obstruction. However, self-expandable metal stent placement is considered unsuitable or contraindicated for patients with malignant lower rectal obstruction within 5 cm of the anal verge because the exposed stent portion can irritate the distal rectum and cause anal pain and a foreign body sensation. OBJECTIVE To describe our experience with 6 patients with malignant lower rectal obstruction who underwent stent insertion with a proximal releasing delivery system (PRDS). DESIGN Prospective clinical series outcome study. SETTING A tertiary-care referral university hospital. PATIENTS This study involved all patients at our center who had a malignant lower rectal obstruction within 5 cm of the anal verge caused by rectal cancer and bladder cancer. INTERVENTION Uncovered stent with the PRDS with endoscopic and fluoroscopic guidance. MAIN OUTCOME MEASUREMENTS Technical and clinical success rate, adverse event rate, and stent migration rate. RESULTS All stents were placed at the expected location. Technical and clinical success rates were 100%. Two patients reported anal pain, which was controlled with analgesics. One case of tumor ingrowth occurred after 5 months and was treated with reinsertion of a stent with the PRDS. After stent insertion, the patients received chemotherapy, chemoradiotherapy, or conservative care. LIMITATIONS Small number of patients and no comparison group. Further prospective, randomized, controlled trials are needed. CONCLUSIONS Uncovered stent insertion with the PRDS is a feasible, safe, and effective treatment for the patient with malignant lower rectal obstruction within 5 cm from the anal verge.
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Affiliation(s)
- Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea; Korean Society of Gastrointestinal Stent Research Group, Seoul, South Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Sung Jae Shin
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Dae Hwan Kang
- Korean Society of Gastrointestinal Stent Research Group, Seoul, South Korea; Department of Internal Medicine, Pusan National University School of Medicine, Pusan, South Korea
| | - Jae Keun Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, South Korea
| | - Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Chang-Il Kwon
- Korean Society of Gastrointestinal Stent Research Group, Seoul, South Korea; Department of Internal Medicine, CHA University School of Medicine, Seoul, South Korea
| | - Jae Yeon Cheong
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Byung Moo Yoo
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
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Nevler A, Willantz U, Doron O, Sandbank J, Ziv Y. A novel anchoring system for colonic stents: a pilot in vivo study in a porcine model. Tech Coloproctol 2013; 18:551-6. [PMID: 24287642 DOI: 10.1007/s10151-013-1097-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 11/14/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Colorectal stents have a proven role in colorectal cancer as palliative care or a bridge to surgery. However, their efficacy and anchoring to the tissue varies according to stent design with stent migration rates up to 50 %. We present preliminary in vivo results of a new end-luminal anchoring system for stent fixation to the rectal canal. The aim was to assess the efficacy and safety of the stent using the anchoring system while subjecting the device to daily abdominal pressures related to daily activities in a porcine animal model. METHODS Ex vivo anatomical and physical studies were performed to improve the system's structure and safety. Four female pigs were followed for the acute and chronic (16 weeks) period. Two animals were euthanized and underwent en-bloc pelvic visceral excision and histopathological examination. Device fixation time, animal behavior, device patency, anoscopic examination and histopathological features were assessed. RESULTS Mean anchoring time was 13.83 weeks (standard error ± 1.38 weeks). One of the animals experienced early device expulsion with no complications. No obstruction was noted in any of the animals. Macroscopic examination revealed mild focal submucosal scarring in one animal and a normal examination in the other. Hematoxylin and eosin staining revealed mucosal ulceration and mixed inflammatory cell infiltrate, with no signs of granulomata, foreign body giant cell reaction or microabscess formation. CONCLUSIONS A novel fixation device designed for long-term intrarectal implantation was well tolerated and maintained anal canal patency without migration. Larger studies are needed before its implementation in humans.
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Affiliation(s)
- A Nevler
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
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Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg 2013; 207:127-38. [PMID: 24124659 DOI: 10.1016/j.amjsurg.2013.07.027] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 07/11/2013] [Accepted: 07/18/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The management of colonic obstruction has changed in recent years. In distal obstruction, optimal treatment remains controversial, particularly after the appearance and use of colonic endoluminal stents. The purpose of this study was to review the current treatment of acute malignant large bowel obstruction according to the level of evidence of the available literature. METHODS A systematic search was conducted in PubMed, MEDLINE, Embase, and Google Scholar for articles published through January 2013 to identify studies of large bowel obstruction and colorectal cancer. Included studies were randomized and nonrandomized controlled trials, reviews, systematic reviews, and meta-analysis. RESULTS After a literature search of 1,768 titles and abstracts, 218 were selected for full-text assessment; 59 studies were ultimately included. Twenty-five studies of the diagnosis and treatment of obstruction and 34 studies of the use of stents were assessed. CONCLUSIONS In view of the various alternatives and the lack of high-grade evidence, the treatment of distal colonic obstruction should be individually tailored to each patient.
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Lujan HJ, Barbosa G, Zeichen MS, Mata WN, Maciel V, Plasencia G, Hartmann RF, Viamonte M, Fogel R. Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction. JSLS 2013; 17:204-11. [PMID: 23925013 PMCID: PMC3771786 DOI: 10.4293/108680813x13654754534990] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Self-expanding metallic stents are effective for the palliation of malignant obstruction. This study indicates that stents for bowel obstruction may allow for minimally invasive surgical intervention with a shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Background and Objectives: Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group's experience. Methods: We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up. Results: The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications. Discussion: The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.
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Zhao XD, Cai BB, Cao RS, Shi RH. Palliative treatment for incurable malignant colorectal obstructions: A meta-analysis. World J Gastroenterol 2013; 19:5565-5574. [PMID: 24023502 PMCID: PMC3761112 DOI: 10.3748/wjg.v19.i33.5565] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.
METHODS: The databases of Medline, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies (prospective, retrospective, randomized controlled trials, and case-control trials) designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by self-expanding metallic stents (SEMS) or palliative surgery. No language restrictions were imposed. The main outcome measures were hospital stay, intensive care unit admission, clinical success rate, 30-d mortality, stoma formation, complications, and overall survival time. The data extraction was conducted by two investigators working independently and using a standardized form. The Mantel-Haenszel χ2 method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model; when statistical heterogeneity existed in the pooled data (as evaluated by Q test and I2 statistics, where P < 0.10 and I2 < 25% indicated heterogeneity), a random-effects model was used.
RESULTS: Thirteen relevant articles, representing 837 patients (SEMS group, n = 404; surgery group, n = 433), were selected for analysis. Compared to the surgery group, the SEMS group showed lower clinical success (99.8% vs 93.1%, P = 0.0009) but shorter durations of hospital stay (18.84 d vs 9.55 d, P < 0.00001) and time to initiation of chemotherapy (33.36 d vs 15.53 d, P < 0.00001), and lower rate of stoma formation (54.0% vs 12.7%, P < 0.00001). Additionally, the SEMS group experienced a significantly lower rate of 30-d mortality (4.2% vs 10.5%, P = 0.01). Stent-related complications were not uncommon and included perforation (10.1%), migration (9.2%), and occlusion (18.3%). Surgery-related complications were slightly less common and included wound infection (5.0%) and anastomotic leak (4.7%). The rate of total complications was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the surgery-related complications occurred earlier than stent-related complications (rate of early complications: 33.7% vs 13.7%, P = 0.03; rate of late complications: 32.3% vs 12.7%, P < 0.0001). The overall survival time of SEMS- and surgery-treated patients was not significantly different (7.64 mo vs 7.88 mo).
CONCLUSION: SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions, but is associated with a shorter time to chemotherapy and lower 30-d mortality.
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Liang TW, Sun Y, Wei YC, Yang DX. Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: a self-expanding metallic stent or surgery? A system review and meta-analysis. Surg Today 2013; 44:22-33. [PMID: 23893158 DOI: 10.1007/s00595-013-0665-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 12/17/2012] [Indexed: 01/11/2023]
Abstract
We conducted a meta-analysis to compare the outcomes of a self-expanding metallic stent (SEMS) vs. surgery for the palliative treatment of colorectal obstruction caused by advanced colorectal malignancy. The databases of MEDLINE, EMBASE, Cochrane controlled trials registry and the Chinese Wanfang were retrieved (updated to 31 August 2011) to identify eligible studies. We calculated the odds ratio or weighted mean difference and its corresponding 95 % confidence interval. In total, nine primary studies were included in this analysis. The success rate of SEMS placement was 93.9 %, with short-term and long-term complication rates of 26.2 and 16.1 %, respectively. Combined analyses revealed that the SEMS group had a similar risk of short-term complications as the surgical group (P = 0.22). Moreover, SEMS was not associated with a higher mortality risk than surgical intervention (P = 0.22) and it required a significantly shorter hospitalization time (P < 0.01); however, SEMS patients had a higher risk of long-term complications (P = 0.03). Because of great heterogeneities between patients and chemoradiotherapy, we did not analyze the survival times of the two groups. These results support the feasibility of SEMS as a palliative treatment for malignant colorectal obstruction caused by incurable malignancy, as it requires shorter hospitalization and is followed by quick recovery. However, the risk of long-term complications such as perforation and stent migration should be borne in mind.
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Affiliation(s)
- Tian-wei Liang
- Department of General Surgery, Wuming County People's Hospital, 26 Yongning Road, 530100, Wuming, China
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Augustine MM, Pawlik TM. Palliation of advanced gastrointestinal malignancies using minimally invasive strategies. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/096992609x12455871937260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Lee GJ, Kim HJ, Baek JH, Lee WS, Kwon KA. Comparison of short-term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer. Int J Surg 2013; 11:442-6. [PMID: 23639803 DOI: 10.1016/j.ijsu.2013.04.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/18/2013] [Accepted: 04/22/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to compare short-term morbidities and mortalities of elective surgery after stent insertion and emergency surgery in obstructive colorectal cancer. METHODS We retrospectively reviewed 77 patients with obstructive colorectal cancer that underwent elective surgery after stenting (stent group: SG, n = 49) or emergent surgery (emergency group: EG, n = 28) from January 2000 to July 2010. RESULTS The American Society of Anesthesiologists (ASA) score of SG was lower than that of EG (p = 0.015). The percentages of open and laparoscopic surgery in SG were 73.5% (36/49) and 26.5% (13/49), respectively, whereas surgery in EG was performed using an open technique (p = 0.003). The rate of primary anastomosis, without constructing a stoma, was 87.8% in SG and 42.9% in EG (p < 0.001). There was no difference in a postoperative complication. Anastomotic leakage according to time between stent placement and surgery in SG were 3 cases for 1-9 days and 0 for more than 10 days (p = 0.037). Three-year overall survival rates were 68.8% and 51.3% (p = 0.430), respectively. CONCLUSION Preoperative stent insertion in obstructive colorectal cancer seems to be safe and feasible, and may decrease second stage procedure. Waiting 10 days after stent placement may be a more optimal time for surgical intervention. Further prospective randomized studies are needed to determine the proper time bridge to surgery following stent insertion in obstructive colorectal cancer.
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Affiliation(s)
- Gil Jae Lee
- Department of Surgery, Gachon University, Gil Medical Center, Incheon, Republic of Korea
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Kim HJ, Choi GS, Park JS, Park SY, Jun SH. Higher rate of perineural invasion in stent-laparoscopic approach in comparison to emergent open resection for obstructing left-sided colon cancer. Int J Colorectal Dis 2013; 28:407-14. [PMID: 22885839 DOI: 10.1007/s00384-012-1556-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE We compared oncologic outcomes of laparoscopic surgery following self-expandable metallic stent (SEMS) insertion with one-stage emergency surgical treatment of obstructive left-sided colon and rectal cancers. METHODS From April 1996 to October 2007, 95 consecutive patients with left-sided obstructive colorectal cancers were included: 25 underwent preoperative stenting and elective laparoscopic surgery (SLAP) and 70 underwent emergency open surgery with intraoperative colon lavage (OLAV). Long-term oncologic outcomes were analyzed on an intention-to-treat basis. RESULTS There were no significant differences in baseline characteristics of patients between groups. Perineural invasion of the primary tumor was more frequent with SLAP (76 vs. 51.4 %, p = 0.033). The median follow-up was 51 months (range, 4-139 months). There were no significant differences between groups in 5-year overall survival rates (SLAP vs. OLAV, 67.2 vs. 61.6 %, p = 0.385). Five-year disease-free survival rates were also similar between groups (SLAP vs. OLAV, 61.2 vs. 60.0 %, p = 0.932). CONCLUSIONS Laparoscopic surgery after SEMS was feasible and safe for patients with obstructive left-sided colorectal cancer, and oncologic outcomes were comparable to emergency open surgery with intraoperative colon lavage. These results support the continued use of SLAP in this setting. Further large-scale study is needed to investigate any clinical impact attached to the higher rates of perineural invasion observed in SLAP.
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Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu 702-210, South Korea
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Zbar AP, Audisio RA. Palliative Surgical Approaches for Older Patients with Colorectal Cancer. MANAGEMENT OF COLORECTAL CANCERS IN OLDER PEOPLE 2013:65-80. [DOI: 10.1007/978-0-85729-984-0_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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