Case Report Open Access
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World J Gastrointest Oncol. Mar 15, 2019; 11(3): 264-269
Published online Mar 15, 2019. doi: 10.4251/wjgo.v11.i3.264
Stent placement followed by preoperative chemotherapy and elective surgery for acute malignant colorectal obstruction: Six cases of report
Jun-Jie Liu, Teng-Hui Ma, Qi-Yuan Qin, Lei Wang, Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
ORCID number: Jun-Jie Liu (0000-0002-0005-8849); Teng-Hui Ma (0000-0003-4547-865X); Qi-Yuan Qin (0000-0002-0745-7180); Lei Wang (0000-0003-3724-7392).
Author contributions: Wang L and Ma TH designed the study; Liu JJ and Qin QY collected the patients’ clinical data; Liu JJ wrote the paper; Wang L, Ma TH and Qin QY revised the paper.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the Sixth Affiliated Hospital of Sun Yat-sen University.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The guidelines of the CARE Checklist (2016) have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Lei Wang, MD, PhD, Doctor, Professor, Surgeon, Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Erheng Road, Guangzhou 510655, Guangdong Province, China.
Telephone: +86-020-38254052 Fax: +86-020-38254000
Received: October 13, 2018
Peer-review started: October 15, 2018
First decision: October 25, 2018
Revised: December 18, 2018
Accepted: January 8, 2019
Article in press: January 9, 2019
Published online: March 15, 2019


The self-expandable metal stent is used as a bridge to surgery in the treatment of acute malignant colorectal obstruction (AMCO). However, recent studies have shown inferior long-term outcomes and increased risk of tumor dissemination after stent placement. In addition, the optimal interval between stent placement and surgery is not clear. The aim of the current study was to present a new strategy for AMCO: stent placement followed by preoperative chemotherapy and elective surgery.


Six patients were diagnosed as acute obstruction. There was one patient with descending cancer, four with sigmoid cancers and one with rectal cancer. The obstructive symptoms of these six patients were relieved within 3 d after stent placement. After receiving two cycles of preoperative chemotherapy, consisting of modified infusional fluorouracil, leucovorin and oxaliplatin [modified FOLFOX6 (mFOLFOX6)], they underwent elective surgery of primary tumor resection. None of the 6 patients received colostomy or colonic lavage during surgery. There was no complication of anastomotic leak, ileus or surgical site infection after surgery. In addition, the patients had low operation time and blood loss, adequate lymph nodes harvest and fast postoperative recovery.


The two-cycle mFOLFOX6 preoperative chemotherapy and elective surgery after stent placement is a safe and feasible strategy in the management of AMCO.

Key Words: Stent, Colorectal cancer, Obstruction, Preoperative chemotherapy, Case report

Core tip: The favorable short-term outcomes of stent placement, as a bridge to surgery for acute malignant colorectal obstruction, have been well described comparing with emergency surgery. However, the risk of tumor dissemination after stent placement is still a topic of concern. In addition, the current interval between stent placement and surgery is inadequate for the patient’s recovery and primary anastomosis. This study is to present the strategy of arranging two cycles of preoperative chemotherapy between stent placement and elective surgery for obstructive colorectal cancers. The six cases of patients showed no stoma creations and no adverse events.


Acute malignant colorectal obstruction (AMCO) occurs in approximately 8.3% of colorectal cancers[1]. Management of AMCO requires thorough assessment of patients, comprehensive understanding of the pathology and careful choice of treatment options. Since first introduced in 1994[2], stent placement has been widely used as a bridge to surgery for AMCO. Many randomized controlled trials and systematic reviews have demonstrated that stent placement followed by elective surgery is a safe and effective approach that has a lower stoma rate and reduced postoperative complications when compared with emergency surgery[3-9].

However, there are some concerns about the oncological safety of stent placement for AMCO. Recent studies have shown that stent use in AMCO resulted in higher local recurrence rate or inferior survival outcomes[10,11]. In clinical practice, surgery of tumor resection was arranged about one week after stent placement. However, there are still some patients who cannot recovery well or obtain primary anastomosis without stoma creation in this short time. A recent meta-analysis indicated that the postoperative complication rate of using a stent as a bridge to surgery was up to 37.84%, and that the stoma rate was 28.8%[8]. Adding preoperative chemotherapy into the prolonged interval between stent placement and elective surgery may reduce the risk of tumor dissemination and improve the general status of patients. In the current study, we presented six patients treated with two cycles of preoperative chemotherapy and elective surgery after stent placement and evaluated their outcomes.

Chief complaints

From March 2016 to October 2017, six patients were hospitalized with the chief complaints of abdominal distention, abdominal pain and stop of flatus and defecation.

History of present illness

They had the chronic symptoms of colorectal cancers for at least two week, such as abdominal pain, change of the bowel habit and change of the stool character. The acute obstruction was occurred within 48 h before hospital admission. The signs of bowel perforation and strangulated obstruction were not found in these patients.

History of past illness

The six patients had Eastern Cooperative Oncology Group (ECOG) performance status ≥ 2 and adequate hematologic, liver and renal function. They had no other cancers or clinically significant cardiovascular diseases.

Physical examination

Abdominal distention and hyperactive bowel sounds were found. Peritoneal irritation signs were not found.

Laboratory testing

The blood routine index, biochemical function and tumor biomarker were tested after hospitalization. The initial testing results of hemoglobin, albumin and creatinine were shown in Table 1.

Table 1 Patient characteristics.
CharacteristicsData ( n = 6)
Male4 (66.7%)
Female2 (33.3%)
Age, yr65 (38-76)
BMI*, kg/m220.1 (17.1-23.6)
Hemoglobin*, g/L123.5 (88-143)
Albumin*, g/L38.5 (34.1-43.1)
Creatinine*, μmoI/L66 (42.3-94.7)
Tumor site, clinical stage#
Descending colon, III1 (16.7%)
Sigmoid colon, III1 (16.7%)
Sigmoid colon, III2 (33.3%)
Sigmoid colon, IV1 (16.7%)
Rectum, II1 (16.7%)
Imaging examination

Bowel distention with gas and effusion was shown in abdominal X-ray. Computed tomography (CT) showed that the obstructing tumor was located on left-sided colon or upper rectum (more than 10 cm from the anal verge). Obvious distention of proximal bowel was also found in CT scan. The tumor stage was examined through enhanced CT scanning.


The basic characteristics of the six patients are shown in Table 1. Six patients were diagnosed with AMCO. There was one patient with descending cancer, four with sigmoid cancers and one with rectal cancer. Two patients had synchronous hepatic metastasis. One patient had two metastastic sites in the left lobe of liver (maximum diameter: 1.6 cm and 5.8 cm), and the other patient had one metastatic site in S8 (maximum diameter: 2.2 cm).

Stent placement

Before stent placement, an endoscopic biopsy was carried out to confirm the malignancy diagnosis. An endoscope was used to cross the stricture caused by the tumor. When the stricture could not be crossed, a guide wire in a catheter was used. Contrast agent was injected through the catheter to estimate the length and width of the stricture. An appropriately sized of self-expandable metal stent (SEMS) was chosen according to the estimation of the stricture. The stent delivery system was pushed into the area of the stricture with radio-endoscopic guidance. The stent was deployed to crossover the distal and proximal end of the stricture. The passing of fecal material through the stent indicated successful placement. If complications from the stent occurred, including re-obstruction, migration of the stent or bowel perforation, patients were sent to emergency surgery.

Preoperative chemotherapy

After stent placement, the six patients were scheduled for preoperative chemotherapy, which consisted of two cycles of modified infusional fluorouracil, leucovorin and oxaliplatin [modified FOLFOX6 (mFOLFOX6)], instead of direct surgery. The timing of preoperative chemotherapy after stent placement was determined by the time when the obstructive symptoms disappeared. Each cycle consisted of oxaliplatin 85 mg/m2, leucovorin 400 mg/m2 and fluorouracil 400 mg/m2 given intravenously on day 1 and fluorouracil 2400 mg/m2 given over 48-h of continuously intravenous infusion on days 1-2. Acute adverse events associated with chemotherapy were graded according to the Common Terminology Criteria Adverse Events Version 4.03.

Elective surgery

Surgery of primary tumor resection was performed two to three weeks after the end of chemotherapy. Mechanical bowel preparation was used preoperatively. Laparoscopic or open surgery was performed by senior surgeons. Complete mesocolic or mesorectal excision with central vascular ligation was adopted as the standard technique. Stoma creation or colonic lavage was selectively performed in the cases with obvious bowel edema or distention, or doubtful anastomosis.

Postoperative treatment

The patient with one metastatic site in S8 underwent microwave ablation. The patient with two hepatic metastatic tumors in left liver lobe underwent partial hepatectomy, but he refused postoperative chemotherapy. The other five patients received postoperative chemotherapy for three to six months.


The obstructive symptoms of these six patients were disappeared within 3 d after stent placement. No patients had complications caused by stents. The median time between stent placement and preoperative chemotherapy was 9 d (range, 3-34). None of the grade 3/4 toxicities were found. The median time between stent placement and elective surgery was 38 d (range, 33-43). All of the six patients underwent primary tumor resections with primary anastomosis. No patient had stoma creation, colonic lavage or postoperative complication. Five patients (83.3%) received laparoscopic surgery. The median operation time was 162.5 min (range, 112-270). The median blood loss was 50 mL (range, 30-100). The median lymph node harvest was 26 (range, 13-45). The median time to first flatus was 2 d (range, 2-4). The median postoperative stay was 11.5 d (range, 9-17). The perioperative outcomes are shown in Table 2.

Table 2 Perioperative outcomes.
VariablesData (n = 6)
Grade 3/4 toxicities; Surgical approach0
Laparoscopic5 (83.3%)
Open1 (16.7%)
Operation time, min162.5 (112-270)
Blood loss, mL50 (30-100)
Lymph nodes harvest26 (13-45)
Stoma creation0
Colonic lavage0
Anastomotic leakage0
Surgical site infection0
Time to first flatus, d2 (2-4)
Postoperative stay, d11.5 (9-17)

Eighteen months after surgery of primary tumor resection was set for the follow-up period. Two patients were found with peritoneal metastasis at the end of follow-up period (both of them received postoperative chemotherapy).


The use of SEMS as a bridge to surgery for AMCO has been an increasingly common practice in qualified medical centers. In the present study, we introduced the clinical use of preoperative chemotherapy and elective resection after stent placement for AMCO. The case series showed that this new approach provided no stoma creation and no morbidity.

The original intention of adding preoperative chemotherapy after stent placement was to lighten the potential adverse effect of stent placement. Maruthachalam et al[12] found that insertion of a stent resulted in increased levels of CK20 mRNA in the peripheral blood of patients with colorectal cancer, which was considered to promote the distribution of occult tumor cells. Fryer et al[13] analyzed the histopathological changes induced by stent placement in 72 patients and concluded that the changes of the tumor included tumor necrosis (100%) and flat ulceration (77.8%). Colonic perforation caused by the stent may potentially result in the peritoneal seeding[14]. In a retrospective study of Korea, a higher rate of perineural invasion was observed in patients of the stent group compared to surgery group (76% vs 51.4%, respectively)[15]. Sabbagh et al[11] first reported significantly lower overall survival for the patients with stent placement after conducting a propensity score analysis. Although receiving preoperative and postoperative chemotherapy, two patients in our study were found with peritoneal metastasis at the end of follow-up period. It demonstrates that the evidence about the inferior oncological outcomes of stent placement may be underestimated in our clinical practice.

Most obstructing colorectal cancers are in the advanced stage. For the metastatic colorectal cancers that are suitable for curative resection, it is appropriate to carry out preoperative chemotherapy in order to reduce the tumor load. In terms of tumors without macroscopic metastasis, preoperative chemotherapy was considered to eradicate micrometastasis and to reduce the risk of incomplete excision. Preoperative chemotherapy in locally advanced rectal cancer has been recommended by clinical guidelines. For locally advanced and operable colon cancers, preoperative chemotherapy is feasible with encouraging pathological responses, although long-term outcomes are unknown[16].

The optimal time interval between stent placement and subsequent surgery has not been clearly mentioned by previous studies. Five to ten days was recommended by the guidelines of the European Society of Digestive Endoscopy[17]. A meta-analysis showed a median interval of ten days from stent placement to surgery[9]. A retrospective study from Turkey concluded that time intervals of seven to nine days after stent placement is sufficient for safe surgery[18]. However, extending the time interval will lead to better recovery of bowel and nutritional status. The six cases showed that primary anastomosis without stoma creation was obtained after the interval of four weeks. In our experiences, a time interval of ten days is not enough for the bowel to restore. We considered that the better bowel environment could be obtained at least four weeks after stent placement. However, a prolonged interval may increase the technical difficulty of surgery because of more local tumor infiltration and fibrosis in patients with stents. In addition, more cycles of chemotherapy during stent placement might induce more complications such as bowel reobstruction, stent migration and bowel perforation. In our study, the two cycles of preoperative chemotherapy have excellent clinical outcomes and patient compliance. However, it needs further studies to confirm.


The study demonstrates that the placement of SEMS followed by two-cycle preoperative chemotherapy and elective surgery is a safe and feasible strategy for the treatment of AMCO. This new strategy brings no stoma creation and low postoperative morbidity. Surgeons can apply this method to selected patients after thorough evaluations and multidisciplinary collaborations. However, the oncological improvement of this strategy and the optimal cycles of preoperative chemotherapy need confirmation in further studies, in particular clinical trials.


Manuscript source: Unsolicited manuscript

Specialty type: Oncology

Country of origin: China

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P- Reviewer: Sawaki A, Yarema R, Lin Q S- Editor: Dou Y L- Editor: A E- Editor: Song H

1.  Cheynel N, Cortet M, Lepage C, Benoit L, Faivre J, Bouvier AM. Trends in frequency and management of obstructing colorectal cancers in a well-defined population. Dis Colon Rectum. 2007;50:1568-1575.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 69]  [Cited by in F6Publishing: 72]  [Article Influence: 4.2]  [Reference Citation Analysis (0)]
2.  Tejero E, Mainar A, Fernández L, Tobío R, De Gregorio MA. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum. 1994;37:1158-1159.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 188]  [Cited by in F6Publishing: 169]  [Article Influence: 5.6]  [Reference Citation Analysis (0)]
3.  Arezzo A, Balague C, Targarona E, Borghi F, Giraudo G, Ghezzo L, Arroyo A, Sola-Vera J, De Paolis P, Bossotti M, Bannone E, Forcignanò E, Bonino MA, Passera R, Morino M. Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial). Surg Endosc. 2017;31:3297-3305.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 94]  [Cited by in F6Publishing: 108]  [Article Influence: 13.5]  [Reference Citation Analysis (0)]
4.  Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc. 2011;25:1814-1821.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 217]  [Cited by in F6Publishing: 204]  [Article Influence: 14.6]  [Reference Citation Analysis (0)]
5.  van Hooft JE, Bemelman WA, Oldenburg B, Marinelli AW, Lutke Holzik MF, Grubben MJ, Sprangers MA, Dijkgraaf MG, Fockens P; collaborative Dutch Stent-In study group. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol. 2011;12:344-352.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 303]  [Cited by in F6Publishing: 293]  [Article Influence: 22.5]  [Reference Citation Analysis (0)]
6.  Ho KS, Quah HM, Lim JF, Tang CL, Eu KW. Endoscopic stenting and elective surgery versus emergency surgery for left-sided malignant colonic obstruction: a prospective randomized trial. Int J Colorectal Dis. 2012;27:355-362.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 104]  [Cited by in F6Publishing: 106]  [Article Influence: 8.8]  [Reference Citation Analysis (0)]
7.  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;18:584-591.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 132]  [Cited by in F6Publishing: 127]  [Article Influence: 12.7]  [Reference Citation Analysis (0)]
8.  Allievi N, Ceresoli M, Fugazzola P, Montori G, Coccolini F, Ansaloni L. Endoscopic Stenting as Bridge to Surgery versus Emergency Resection for Left-Sided Malignant Colorectal Obstruction: An Updated Meta-Analysis. Int J Surg Oncol. 2017;2017:2863272.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 27]  [Cited by in F6Publishing: 43]  [Article Influence: 6.1]  [Reference Citation Analysis (0)]
9.  De Ceglie A, Filiberti R, Baron TH, Ceppi M, Conio M. A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction. Crit Rev Oncol Hematol. 2013;88:387-403.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 64]  [Cited by in F6Publishing: 62]  [Article Influence: 5.6]  [Reference Citation Analysis (0)]
10.  Gorissen KJ, Tuynman JB, Fryer E, Wang L, Uberoi R, Jones OM, Cunningham C, Lindsey I. Local recurrence after stenting for obstructing left-sided colonic cancer. Br J Surg. 2013;100:1805-1809.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 107]  [Cited by in F6Publishing: 116]  [Article Influence: 11.6]  [Reference Citation Analysis (0)]
11.  Sabbagh C, Browet F, Diouf M, Cosse C, Brehant O, Bartoli E, Mauvais F, Chauffert B, Dupas JL, Nguyen-Khac E, Regimbeau JM. Is stenting as "a bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis. Ann Surg. 2013;258:107-115.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 196]  [Cited by in F6Publishing: 207]  [Article Influence: 18.8]  [Reference Citation Analysis (0)]
12.  Maruthachalam K, Lash GE, Shenton BK, Horgan AF. Tumour cell dissemination following endoscopic stent insertion. Br J Surg. 2007;94:1151-1154.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 177]  [Cited by in F6Publishing: 181]  [Article Influence: 10.6]  [Reference Citation Analysis (0)]
13.  Fryer E, Gorissen KJ, Wang LM, Guy R, Chetty R. Spectrum of histopathological changes encountered in stented colorectal carcinomas. Histopathology. 2015;66:480-484.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 13]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
14.  Kim SJ, Kim HW, Park SB, Kang DH, Choi CW, Song BJ, Hong JB, Kim DJ, Park BS, Son GM. Colonic perforation either during or after stent insertion as a bridge to surgery for malignant colorectal obstruction increases the risk of peritoneal seeding. Surg Endosc. 2015;29:3499-3506.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 37]  [Article Influence: 4.1]  [Reference Citation Analysis (0)]
15.  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;28:407-414.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 79]  [Cited by in F6Publishing: 76]  [Article Influence: 6.9]  [Reference Citation Analysis (0)]
16.  Foxtrot Collaborative Group. Feasibility of preoperative chemotherapy for locally advanced, operable colon cancer: the pilot phase of a randomised controlled trial. Lancet Oncol. 2012;13:1152-1160.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 270]  [Cited by in F6Publishing: 314]  [Article Influence: 26.2]  [Reference Citation Analysis (0)]
17.  van Hooft JE, van Halsema EE, Vanbiervliet G, Beets-Tan RG, DeWitt JM, Donnellan F, Dumonceau JM, Glynne-Jones RG, Hassan C, Jiménez-Perez J, Meisner S, Muthusamy VR, Parker MC, Regimbeau JM, Sabbagh C, Sagar J, Tanis PJ, Vandervoort J, Webster GJ, Manes G, Barthet MA, Repici A; European Society of Gastrointestinal Endoscopy. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2014;46:990-1053.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 238]  [Cited by in F6Publishing: 249]  [Article Influence: 24.9]  [Reference Citation Analysis (0)]
18.  Abdussamet Bozkurt M, Gonenc M, Kapan S, Kocatasş A, Temizgönül B, Alis H. Colonic stent as bridge to surgery in patients with obstructive left-sided colon cancer. JSLS. 2014;18.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 16]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]