Colonic stenting as a successful bridge to surgery in a centenarian with obstructing colonic carcinoma.

Abstract

To the Editor: Acute colonic obstruction has been reported in 8% to 29% of individuals with colorectal cancer.1 Most of these individuals tend to be elderly, with severe comorbidities, poor nutrition, and advanced disease.2, 3 Emergency surgical interventions in individuals with malignant colonic obstruction have a mortality rate of 15% to 34% and a morbidity rate of 32% to 64% despite advances in perioperative care.4, 5 Extensive curative surgery of colonic cancer in very elderly adults with a limited life span remains controversial. Recently, the introduction of colonic stenting has been used as a bridge to elective single-stage surgery, as well as a definitive palliative procedure in individuals with incurable disease.6 It has also been reported that stent placement before elective surgery may improve the individuals’ general condition, optimize clinical staging, and decrease the mortality and morbidity of emergency surgery.4, 5 Herein is described an unusual experience in the treatment of a centenarian with acute malignant colonic obstruction by placing self-expandable metallic stents as a stage before scheduled laparoscopic surgery. A 103-year-old woman was admitted because of progressive abdominal distension and vomiting after eating for 2 weeks. Physical examination showed mild diffuse abdominal tenderness. No abdominal masses or enlarged lymph nodes were detected. Auscultation revealed that bowel sounds and peristaltic rushes were increased. Her medical comorbidities included hypertension and chronic renal insufficiency (serum creatinine >2 mg/dL). Abdominal computed tomography (CT) revealed an irregular mass involving the descending colon with dilation of the small intestine. Colonoscopy confirmed the diagnosis of an obstructing descending colon cancer. Initially she refused surgery and was treated conservatively with fluid and electrolyte replacement. After stabilization of the hemodynamic conditions, a colonic stent was placed to relieve the episodes of colonic obstruction. The obstructive symptoms rapidly improved over 24 hours, and she was able to tolerate a soft diet. After a short period of hospitalization she was discharged. One month later, she was readmitted and detailed investigations including cardiac and pulmonary function tests, blood biochemistry, hematological examinations, and nutritional assessment were made. Plain abdominal X-rays and CT for reevaluation showed a patent and fully expanded stent in proper position (Figure 1A). She underwent elective laparoscopic colectomy for the descending colon lesion. Intraoperatively, there was no evidence of cancer invasion in other abdominal and pelvic organs. The postoperative course was uneventful, and she left the hospital 2 weeks later. Pathology of the resected specimen showed an adenocarcinoma involving the colon and causing a stricture without involvement of the regional lymph nodes (Figure 1B). She remained well without any significant signs of recurrent cancer 1 year after surgery. With the prolongation of average life expectancy, cancer in older adults has become an increasingly common problem; 75% of colon tumors develop in individuals aged 65 and older.7 Total surgical resection provides the best chance of survival for colon cancer, but a systematic review reported that resection is performed less often in elderly adults than in younger patients.8 Previous studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery.9 Therefore, it is not reasonable to determine the therapeutic option for elderly adults with cancer based only on chronological age. More-advanced stage at diagnosis and emergency surgery may increase operative risk, leading to poor outcomes of surgery in elderly adults with colon cancer.3 Many studies have demonstrated the efficacy of colonic stenting in the management of malignant colonic obstruction, and a clinical success rate of up to 72% has been achieved as a bridge to surgery with an acceptable complication rate.4-6, 10 Stent implantation may provide a treatment option avoiding emergency surgery and allow clinical staging and thus better planning for definitive therapy. A laparoscopic approach to colon cancer surgery has been considered as the preferred option in terms of oncological safety, reduction of perioperative complications, and faster postoperative recovery. The current literature offers strong evidence that self-expanding metal stents may serve as a safe and effective bridge to subsequent laparoscopic surgery in elderly adults with obstructing left-side colon cancer, with fewer complications and lower short-term mortality.4-6, 10 The case described above also demonstrates that the use of colonic stenting followed by laparoscopic resection is well tolerated even in centenarians with obstructing colonic lesion and that extreme old age should not be considered to be a contraindication of this procedure. Conflict of Interest: The authors have no financial or any other personal conflict to report. Author Contributions: Study concept and design: Huang, Hsieh. Acquisition of subjects and data: all authors. Analysis and interpretation of data: Huang, Hsieh. Preparation of manuscript: Huang, Fan. Critical review and approval: Huang, Hsieh. Sponsor's Role: None.