Expandable Metal Stents for Obstructing Lesions of the Colon as Bridge Therapy: An Alternative to Emergent Surgery

Abstract

Purpose: Emergent colorectal surgery for colonic obstruction is associated with higher morbidity and mortality in comparison to elective non-emergent surgery. Endoscopically placed self expanding metal stents (SEMS) allow decompression of the colon and are used as palliative treatment obviating the need for surgery. The use of SEMS in the treatment of acute colonic obstruction in a resectable operative patient however has not been widely studied. We hypothesized that SEMS when used as bridge therapy prior to elective surgery for obstructing colon lesions (malignant or benign) would be a cost-effective strategy allowing for colon preparation, optimization of medical condition and a one-stage operation with resection and primary reanastomosis. Methods: Review of medical records over a 4-year period identified 11 patients in Group A (mean age 71 ± 10.4, male 9, female 2) and 6 patients in Group B (mean age 60 ± 12.7, male 1, female 5). Two patients in Group A had benign strictures. Eight of 11 patients in Group A underwent elective resection with primary re-anastomosis, 2 underwent resection with colostomy due to low-lying tumors and 1 patient expired (refused surgery). Two patients in group B had adenocarcinoma and 4 had benign strictures. Surgical interventions included sigmoidectomy with colostomy (N = 3) and diverting loop colostomy (N = 3). Procedural cost data were collected. Cost and complications of further surgical interventions in Group B were not included. Data were compared by the rank sum test and Chi squared test where appropriate. Results: There were no technical difficulties in placing the stents. The mean duration between stent placement and elective surgery was 37.5 ± 57.0 days. Mean survival in Group A was 507.9 ± 404.4 days. One patient (9%) required SEMS removal due to stent migration post neoadjuvant chemoradiation. Two patients (33%) in Group B had post-operative complications. Mean survival in Group B was 605 ± 644.4 days. Conclusion: We conclude that SEMS followed by elective surgery for acute obstructive lesions of the colon in a resectable, operative patient is efficacious and more cost-effective compared to the traditional alternative of emergent surgery.Table: Cost-benefit analysis of SEMS and elective surgery versus emergent surgery