Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

Abstract

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.ESGE guidelines represent a consensus of best practice based on the available evidence at the time of preparation. They may not apply in all situations and should be interpreted in the light of specific clinical situations and resource availability. Further controlled clinical studies may be needed to clarify aspects of these statements, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. ESGE guidelines are intended to be an educational device to provide information that may assist endoscopists in providing care to patients. They are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment.Main recommendationsThe following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan.1.Prophylactic colonic stent placement is not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation (strong recommendation, low quality evidence).2.Colonic self-expandable metal stent (SEMS) placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction (strong recommendation, high quality evidence).3.For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, i.e. American Society of Anesthesiologists (ASA) Physical Status ≥III and/or age >70 years (weak recommendation, low quality evidence).4.SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction (strong recommendation, high quality evidence), except in patients treated or considered for treatment with antiangiogenic drugs (e.g. bevacizumab) (strong recommendation, low quality evidence).IntroductionColorectal cancer is one of the most common cancers worldwide, particularly in the economically developed world.1Jemal A. Bray F. Center M.M. et al.Global cancer statistics.CA Cancer J Clin. 2011; 61: 69-90Crossref PubMed Scopus (8718) Google Scholar Large-bowel obstruction caused by advanced colonic cancer occurs in 8%–13% of colonic cancer patients.2Winner M. Mooney S.J. Hershman D.L. et al.Incidence and predictors of bowel obstruction in elderly patients with stage IV colon cancer: a population-based cohort study.JAMA Surg. 2013; 148: 715-722Crossref PubMed Scopus (1) Google Scholar, 3Jullumstro E. Wibe A. Lydersen S. et al.Colon cancer incidence, presentation, treatment and outcomes over 25 years.Colorectal Dis. 2011; 13: 512-518Crossref PubMed Scopus (8) Google Scholar, 4Cheynel N. Cortet M. Lepage C. et al.Trends in frequency and management of obstructing colorectal cancers in a well-defined population.Dis Colon Rectum. 2007; 50: 1568-1575Crossref PubMed Scopus (13) Google Scholar The management of this severe clinical condition remains controversial.5Frago R. Ramirez E. Millan M. et al.Current management of acute malignant large bowel obstruction: a systematic review.Am J Surg. 2014; 207: 127-138Abstract Full Text Full Text PDF PubMed Google Scholar Over the last decade many articles have been published on the subject of colonic stenting for malignant colonic obstruction, including randomized controlled trials (RCTs) and systematic reviews. However, the definitive role of self-expandable metal stents (SEMSs) in the treatment of malignant colonic obstruction has not yet been clarified. This evidence- and consensus-based clinical guideline has been developed by the European Society of Gastrointestinal Endoscopy (ESGE) and endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) to provide practical guidance regarding the use of SEMS in the treatment of malignant colonic obstruction.With the exception of one trial,6Fiori E. Lamazza A. De Cesare A. et al.Palliative management of malignant rectosigmoidal obstruction. Colostomy vs. endoscopic stenting: a randomized prospective trial.Anticancer Res. 2004; 24: 265-268PubMed Google Scholar all published RCTs on colonic stenting for malignant obstruction excluded rectal cancers, which were usually defined as within 8 to 10 cm of the anal verge, and colonic cancers proximal to the splenic flexure. Rectal stenting is often avoided because of the presumed association with complications such as pain, tenesmus, incontinence, and stent migration. Proximal colonic obstruction is generally managed with primary surgery, although there are no RCTs to support this assumption. Because of the aforementioned limitations, unless indicated otherwise the recommendations in this Guideline only apply to left-sided colon cancer arising from the rectosigmoid colon, sigmoid colon, descending colon, and splenic flexure, while excluding rectal cancers and those proximal to the splenic flexure, and other causes of colonic obstruction including extracolonic obstruction.MethodsThe ESGE commissioned this Guideline (chairs C.H. and J.-M.D.) and appointed a guideline leader (J.v.H.) who invited the listed authors to participate in the project development. The key questions were prepared by the coordinating team (E.v.H. and J.v.H.) and then approved by the other members. The coordinating team formed task force subgroups, each with its own leader, and divided the key topics among these task forces (see Appendix e1, available online at www.giejournal.org).Each task force performed a systematic literature search to prepare evidence-based and well-balanced statements on their assigned key questions. The coordinating team independently performed systematic literature searches with the assistance of a librarian. The Medline, EMBASE and Trip databases were searched including at minimum the following key words: colon, cancer, malignancy or neoplasm, obstruction and stents. All articles studying the use of SEMS for malignant large-bowel obstruction were selected by title or abstract. After further exploration of the content, the article was then included and summarized in the literature tables of the key topics when it contained relevant data (see Appendix e2, Tables e1–e5, available online at www.giejournal.org). All selected articles were graded by the level of evidence and strength of recommendation according to the GRADE system.7Dumonceau J.M. Hassan C. Riphaus A. et al.European Society of Gastrointestinal Endoscopy (ESGE) Guideline Development Policy.Endoscopy. 2012; 44: 626-629Crossref PubMed Scopus (8) Google Scholar The literature searches were updated until January 2014.Each task force proposed statements on their assigned key questions which were discussed and voted on during the plenary meeting held in February 2014, Düsseldorf, Germany. In March 2014, a draft prepared by the coordinating team was sent to all group members. After agreement on a final version, the manuscript was submitted to Endoscopy for publication. The journal subjected the manuscript to peer review and the manuscript was amended to take into account the reviewers’ comments. All authors agreed on the final revised manuscript. The final revised manuscript was then reviewed and approved by the Governing Board of ASGE. This Guideline was issued in 2014 and will be considered for review in 2019 or sooner if new and relevant evidence becomes available. Any updates to the Guideline in the interim will be noted on the ESGE website: http://www.esge.com/esge-guidelines.html.Recommendations and statementsEvidence statements and recommendations are stated in bold italics.General considerations before stent placement (Table e1, available online at www.giejournal.org)Prophylactic colonic stent placement is not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation (strong recommendation, low quality evidence).Colonic stenting is indicated only in those patients with both obstructive symptoms and radiological or endoscopic findings suspicious of malignant large-bowel obstruction. Prophylactic stenting for patients with colonic malignancy but no evidence of symptomatic obstruction is strongly discouraged because of the potential risks associated with colonic SEMS placement. The only absolute contraindication for colonic stenting is perforation. In addition, colonic stenting is less successful in patients with peritoneal carcinomatosis and tumors close to the anal verge (<5 cm).8Yoon J.Y. Jung Y.S. Hong S.P. et al.Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction.Gastrointest Endosc. 2011; 74: 858-868Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 9Kim J.H. Ku Y.S. Jeon T.J. et al.The efficacy of self-expanding metal stents for malignant colorectal obstruction by noncolonic malignancy with peritoneal carcinomatosis.Dis Colon Rectum. 2013; 56: 1228-1232Crossref PubMed Scopus (1) Google Scholar, 10Song H.Y. Kim J.H. Kim K.R. et al.Malignant rectal obstruction within 5 cm of the anal verge: Is there a role for expandable metallic stent placement?.Gastrointest Endosc. 2008; 68: 713-720Abstract Full Text Full Text PDF PubMed Scopus (25) Google ScholarIncreasing age and American Society of Anesthesiologists (ASA) classification ≥III do not affect stent outcome (i.e. clinical success and complications) in several observational studies,11Abbott S. Eglinton T.W. Ma Y. et al.Predictors of outcome in palliative colonic stent placement for malignant obstruction.Br J Surg. 2014; 101: 121-126Crossref PubMed Scopus (3) Google Scholar, 12Meisner S. Gonzalez-Huix F. Vandervoort J.G. et al.Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients.Gastrointest Endosc. 2011; 74: 876-884Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 13Choi J.H. Lee Y.J. Kim E.S. et al.Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction.Surg Endosc. 2013; 27: 3220-3227Crossref PubMed Scopus (3) Google Scholar, 14Donnellan F. Cullen G. Cagney D. et al.Efficacy and safety of colonic stenting for malignant disease in the elderly.Int J Colorectal Dis. 2010; 25: 747-750Crossref PubMed Scopus (11) Google Scholar, 15Small A.J. Coelho-Prabhu N. Baron T.H. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors.Gastrointest Endosc. 2010; 71: 560-572Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 16Geraghty J. Sarkar S. Cox T. et al.Management of large bowel obstruction with self-expanding metal stents: a multicentre retrospective study of factors determining outcome.Colorectal Dis. 2014; 16: 476-483Crossref PubMed Scopus (1) Google Scholar although these are well-known risk factors for postoperative mortality after surgical treatment of large-bowel obstruction (Table 6).17Biondo S. Pares D. Frago R. et al.Large bowel obstruction: predictive factors for postoperative mortality.Dis Colon Rectum. 2004; 47: 1889-1897Crossref PubMed Scopus (71) Google Scholar, 18Tekkis P.P. Kinsman R. Thompson M.R. et al.The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer.Ann Surg. 2004; 240: 76-81Crossref PubMed Scopus (106) Google Scholar, 19Tan K.K. Sim R. Surgery for obstructed colorectal malignancy in an Asian population: predictors of morbidity and comparison between left- and right-sided cancers.J Gastrointest Surg. 2010; 14: 295-302Crossref PubMed Scopus (13) Google ScholarTable 6Outcome of surgery according to age and American Society of Anesthesiologists (ASA) classificationFirst author, yearStudy populationResultsStudy design Level of evidenceTekkis, 200418Tekkis P.P. Kinsman R. Thompson M.R. et al.The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer.Ann Surg. 2004; 240: 76-81Crossref PubMed Scopus (106) Google ScholarPatients undergoing surgery for acute colorectal cancer obstruction (n = 1046)Multivariate analysis of in-hospital postoperative mortality:-Age <65 years: 5.4%-Age 65-67 years: 13.1%; OR 2.97 (95%CI 1.26-7.08)-Age 75-84 years: 21.9%; OR 4.31 (95%CI 1.83-10.05)-Age ≥ 85 years: 27.0%; OR 5.87 (95%CI 2.27-15.14)-ASA I: 2.6%-ASA II: 7.6%; OR 3.32 (95%CI 0.73-15.18)-ASA III: 23.9%; OR 11.73 (95%CI 2.58-53.36)-ASA IV-V: 42.9%; OR 22.33 (95%CI 4.58-109.68)Nonrandomized prospective UK multicenter studyHigh quality evidenceBiondo, 200417Biondo S. Pares D. Frago R. et al.Large bowel obstruction: predictive factors for postoperative mortality.Dis Colon Rectum. 2004; 47: 1889-1897Crossref PubMed Scopus (71) Google ScholarPatients undergoing emergency surgery for acute large-bowel obstruction (n = 234)Colorectal cancer 82.1%Extracolonic cancer 4.7%Benign lesions 13.2%Univariate analysis of 30-day postoperative mortality:-Age ≤70 years: 10.7% (14/131)-Age >70 years: 29.1% (30/103); P < 0.001-ASA I-II: 8.1% (9/111)-ASA III-IV: 28.5% (35/123); P < 0.001Multivariate analysis of 30-day postoperative mortality:-Age >70 years: OR 2.05 (95%CI 0.92-4.60)-ASA III-IV: OR 2.86 (95%CI 1.15-7.11)No description of study design, most likely retrospectiveModerate quality evidenceTan, 201019Tan K.K. Sim R. Surgery for obstructed colorectal malignancy in an Asian population: predictors of morbidity and comparison between left- and right-sided cancers.J Gastrointest Surg. 2010; 14: 295-302Crossref PubMed Scopus (13) Google ScholarPatients who underwent operative intervention for acute obstruction from colorectal malignancy (n = 134)Perioperative morbidity rate: 77.6%Perioperative mortality rate: 11.9%Multivariate analysis of worse outcome (grade III-V complications, including death):-Age >60 years: OR 4.67 (95%CI 1.78-12.25)-ASA III-IV: OR 8.36 (95%CI 3.58-19.48)Retrospective analysisLow quality evidenceCI, Confidence interval; OR, odds ratio. Open table in a new tab A contrast-enhanced computed tomography (CT) scan is recommended as the primary diagnostic tool when malignant colonic obstruction is suspected (strong recommendation, low quality evidence).When malignant colonic obstruction is suspected, contrast-enhanced CT is recommended because it can diagnose obstruction (sensitivity 96%, specificity 93%), define the level of the stenosis in 94% of cases, accurately identify the etiology in 81% of cases, and provide correct local and distal staging in the majority of patients.5Frago R. Ramirez E. Millan M. et al.Current management of acute malignant large bowel obstruction: a systematic review.Am J Surg. 2014; 207: 127-138Abstract Full Text Full Text PDF PubMed Google Scholar, 20Frager D. Rovno H.D. Baer J.W. et al.Prospective evaluation of colonic obstruction with computed tomography.Abdom Imaging. 1998; 23: 141-146Crossref PubMed Scopus (44) Google Scholar When CT is inconclusive about the etiology of the obstructing lesion, colonoscopy may be helpful to evaluate the exact cause of the stenosis.Examination of the remaining colon with colonoscopy or CT colonography (CTC) is recommended in patients with potentially curable obstructing colonic cancer, preferably within 3 months after alleviation of the obstruction (strong recommendation, low quality evidence).European studies, including three that are population-based, show that synchronous colorectal tumors occur in 3%–4% of patients diagnosed with colorectal cancer.21Kodeda K. Nathanaelsson L. Jung B. et al.Population-based data from the Swedish Colon Cancer Registry.Br J Surg. 2013; 100: 1100-1107Crossref PubMed Scopus (3) Google Scholar, 22Mulder S.A. Kranse R. Damhuis R.A. et al.Prevalence and prognosis of synchronous colorectal cancer: a Dutch population-based study.Cancer Epidemiol. 2011; 35: 442-447Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 23Latournerie M. Jooste V. Cottet V. et al.Epidemiology and prognosis of synchronous colorectal cancers.Br J Surg. 2008; 95: 1528-1533Crossref PubMed Scopus (20) Google Scholar, 24Papadopoulos V. Michalopoulos A. Basdanis G. et al.Synchronous and metachronous colorectal carcinoma.Tech Coloproctol. 2004; : S97-S100Crossref PubMed Scopus (23) Google Scholar Therefore, imaging of the remaining colon after potentially curative resection is recommended in patients with malignant colonic obstruction. Current evidence does not justify routine preoperative assessment for synchronous tumors in obstructed patients by CTC or colonoscopy through the stent. However, preoperative CTC and colonoscopy through the stent appear feasible and safe in these patients and there are presently no data to discourage their use in this population.25Park S.H. Lee J.H. Lee S.S. et al.CT colonography for detection and characterisation of synchronous proximal colonic lesions in patients with stenosing colorectal cancer.Gut. 2012; 61: 1716-1722Crossref PubMed Scopus (5) Google Scholar, 26Cha E.Y. Park S.H. Lee S.S. et al.CT colonography after metallic stent placement for acute malignant colonic obstruction.Radiology. 2010; 254: 774-782Crossref PubMed Scopus (11) Google Scholar, 27Lim S.G. Lee K.J. Suh K.W. et al.Preoperative colonoscopy for detection of synchronous neoplasms after insertion of self-expandable metal stents in occlusive colorectal cancer: comparison of covered and uncovered stents.Gut Liver. 2013; 7: 311-316Crossref PubMed Scopus (1) Google Scholar, 28Vitale M.A. Villotti G. d’Alba L. et al.Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction.Gastrointest Endosc. 2006; 63: 814-819Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The role of positron emission tomography (PET)/CT in the diagnosis of synchronous lesions remains to be elucidated.29Nagata K. Ota Y. Okawa T. et al.PET/CT colonography for the preoperative evaluation of the colon proximal to the obstructive colorectal cancer.Dis Colon Rectum. 2008; 51: 882-890Crossref PubMed Scopus (29) Google ScholarColonic stenting should be avoided for diverticular strictures or when diverticular disease is suspected during endoscopy and/or CT scan (strong recommendation, low quality evidence). Pathological confirmation of malignancy by endoscopic biopsy and/or brush cytology is not necessary in an urgent setting, such as before stent placement. However, pathology results may help to modify further management of the stented patient (strong recommendation, low quality evidence).When malignancy is suspected after diagnostic studies, a small number of patients will have a benign cause of obstruction. Two RCTs comparing SEMS as a bridge to surgery versus emergency surgery in patients with left-sided malignant obstruction reported benign obstructive lesions in 4.6% (3/65)30Pirlet I.A. Slim K. Kwiatkowski F. et al.Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial.Surg Endosc. 2011; 25: 1814-1821Crossref PubMed Scopus (67) Google Scholar and 8.2% (8/98)31van Hooft J.E. Bemelman W.A. Oldenburg B. et al.Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial.Lancet Oncol. 2011; 12: 344-352Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar of the randomized patients. These benign colonic lesions that mimic malignancy are usually due to diverticular disease. Further evidence of the difficulty of this distinction is also reflected by a systematic review showing a 2.1% prevalence of underlying adenocarcinoma of the colon in 771 patients in whom acute diverticulitis was diagnosed via CT scan.32Sai V.F. Velayos F. Neuhaus J. et al.Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review.Radiology. 2012; 263: 383-390Crossref PubMed Scopus (12) Google Scholar Stent placement in active diverticular inflammation is associated with a risk of perforation and should therefore be avoided.33Currie A. Christmas C. Aldean H. et al.Systematic review of self-expanding stents in the management of benign colorectal obstruction.Colorectal Dis. 2014; 16: 239-245Crossref PubMed Google Scholar Furthermore, pathological confirmation of malignancy before emergency stent placement is often not feasible and is not required prior to colonic stent placement. Endoscopic biopsy and/or brush cytology for confirmation of malignancy should be obtained during the stent placement procedure, because it may be helpful in modifying the further management of the stented patient.34Brouwer R. MacDonald A. Matthews R. et al.Brush cytology for the diagnosis of colorectal cancer.Dis Colon Rectum. 2009; 52: 598-601Crossref PubMed Scopus (1) Google Scholar, 35Geramizadeh B. Hooshmand F. Kumar P.V. Brush cytology of colorectal malignancies.Acta Cytol. 2003; 47: 431-444Crossref PubMed Google Scholar, 36Farouk R. Edwards J. Thorne M. et al.Brush cytology for the diagnosis of rectal carcinoma.Br J Surg. 1996; 83: 1456-1458Crossref PubMed Scopus (5) Google ScholarPreparation of obstructed patients with an enema to clean the colon distal to the stenosis is suggested to facilitate the stent placement procedure (weak recommendation, low quality evidence). Antibiotic prophylaxis in obstructed patients undergoing colon stenting is not indicated because the risk of post-procedural infections is very low (strong recommendation, moderate quality evidence).There are no studies to date that have focused on bowel preparation before stent placement in obstructed patients. Symptomatic bowel obstruction is a relative contraindication to oral bowel cleansing. An enema is advisable to facilitate the stent placement procedure by cleaning the bowel distal to the stenosis.Antibiotic prophylaxis before stent placement in patients with malignant colonic obstruction is not indicated because the risk of fever and bacteremia after stent insertion is very low. One prospective study analyzed 64 patients with colorectal cancer who underwent a stent procedure. Four of 64 patients (6.3%) had a positive post-stenting blood culture and none of the patients developed symptoms of infection within 48 hours following stent placement. Prolonged procedure time was associated with transient bacteremia (36 vs. 16 minutes, P < 0.01).37Chun Y.J. Yoon N.R. Park J.M. et al.Prospective assessment of risk of bacteremia following colorectal stent placement.Dig Dis Sci. 2012; 57: 1045-1049Crossref PubMed Google Scholar One other retrospective series of 233 patients undergoing colonic stent placement for malignant obstruction described that blood cultures had been drawn for unspecified reasons in 30 patients within 2 weeks after stent placement, showing bacteremia/fever in 7 patients (3%), which was reported as a minor complication.15Small A.J. Coelho-Prabhu N. Baron T.H. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors.Gastrointest Endosc. 2010; 71: 560-572Abstract Full Text Full Text PDF PubMed Scopus (101) Google ScholarColonic stent placement should be performed or directly supervised by an experienced operator who has performed at least 20 colonic stent placement procedures (strong recommendation, low quality evidence).Two noncomparative studies addressed the learning curve of a single endoscopist performing colonic stent placement. Both showed an increase in technical success and a decrease in the number of stents used per procedure after performance of at least 20 procedures.38Williams D, Law R, Pullyblank AM. Colorectal stenting in malignant large bowel obstruction: the learning curve. Int J Surg Oncol. Epub 2011 Oct 11.Google Scholar, 39Lee J.H. Yoon J.Y. Park S.J. et al.The learning curve for colorectal stent insertion for the treatment of malignant colorectal obstruction.Gut Liver. 2012; 6: 328-333Crossref PubMed Google Scholar Two other retrospective series have shown that operator experience affects stenting outcome. The first reported significantly higher technical and clinical success rates when the stent was inserted by an operator who had performed at least 10 SEMS procedures.16Geraghty J. Sarkar S. Cox T. et al.Management of large bowel obstruction with self-expanding metal stents: a multicentre retrospective study of factors determining outcome.Colorectal Dis. 2014; 16: 476-483Crossref PubMed Scopus (1) Google Scholar The second showed a significantly increased immediate perforation rate when colonic stent placement was performed by endoscopists inexperienced in pancreaticobiliary endoscopy.15Small A.J. Coelho-Prabhu N. Baron T.H. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors.Gastrointest Endosc. 2010; 71: 560-572Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar The authors of the latter article explained the lower immediate perforation rate by the skills that therapeutic ERCP endoscopists have in traversing complex strictures, understanding fluoroscopy, and deploying stents.15Small A.J. Coelho-Prabhu N. Baron T.H. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors.Gastrointest Endosc. 2010; 71: 560-572Abstract Full Text Full Text PDF PubMed Scopus (101) Google ScholarTechnical considerations of stent placement (Table e2, available online at www.giejournal.org)Colonic stent placement is recommended with the combined use of endoscopy and fluoroscopy (weak recommendation, low quality evidence).SEMS placement can be performed by using either the through-the-scope (TTS) or the over-the-guidewire (OTW) technique. The majority of SEMS are inserted through the endoscope with the use of fluoroscopic guidance. The OTW technique is performed using fluoroscopic guidance with or without tandem endoscopic monitoring. Purely radiologic stent placement is performed by advancing the stent deployment system over a stiff guidewire, and technical and clinical success rates of 83%–100% and 77%–98%, respectively, have been reported in observational studies.40Kim S.Y. Kwon S.H. Oh J.H. Radiologic placement of uncovered stents for the treatment of malignant colorectal obstruction.J Vasc Interv Radiol. 2010; 21: 1244-1249Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 41Kim H. Kim S.H. Choi S.Y. et al.Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts in the treatment of acute malignant colorectal obstruction.J Vasc Interv Radiol. 2008; 19: 1709-1716Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 42Shrivastava V. Tariq O. Tiam R. et al.Palliation of obstructing malignant colonic lesions using self-expanding metal stents: a single-center experience.Cardiovasc Intervent Radiol. 2008; 31: 931-936Crossref PubMed Scopus (11) Google Scholar, 43Kim J.H. Song H.Y. Li Y.D. et al.Dual-design expandable colorectal stent for malignant colorectal obstruction: comparison of flared ends and bent ends.AJR Am J Roentgenol. 2009; 193: 248-254Crossref PubMed Scopus (12) Google Scholar, 44Alcantara M. Serra X. Bombardo J. et al.Colorectal stenting as an effective therapy for preoperative and palliative treatment of large bowel obstruction: 9 years’ experience.Tech Coloproctol. 2007; 11: 316-322Crossref PubMed Scopus (32) Google Scholar, 45Selinger C.P. Ramesh J. Martin D.F. Long-term success of colonic stent insertion is influenced by indication but not by length of stent or site of obstruction.Int J Colorectal Dis. 2011; 26: 215-218Crossref PubMed Scopus (3) Google Scholar Retrospective studies that compared endoscopy combined with fluoroscopic guidance versus solely radiography for stent placement show comparable success rates, although with a trend towards higher technical success when the combined technique is used.16Geraghty J. Sarkar S. Cox T. et al.Management of large bowel obstruction with self-expanding metal stents: a multicentre retrospective study of factors determining outcome.Colorectal Dis. 2014; 16: 476-483Crossref PubMed Scopus (1) Google Scholar, 46Kim J.W. Jeong J.B. Lee K.L. et al.Comparison of clinical outcomes between endoscopic and radiologic placement of self-expandable metal stent in patients with malignant colorectal obstruction.Korean J Gastroenterol. 2013; 61: 22-29Crossref PubMed Google Scholar, 47Sebastian S. Johnston S. Geoghegan T. et al.Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction.Am J Gastroenterol. 2004; 99: 2051-2057Crossref PubMed Scopus (332) Google Scholar, 48de Gregorio M.A. Laborda A. Tejero E. et al.Ten-year retrospective study of treatment of malignant colonic obstructions with self-expandable stents.J Vasc Interv Radiol. 2011; 22: 870-878Abstract Full Text Full Text PDF PubMed Scopus (1) Google ScholarStricture dilation either before or after stent placement is discouraged in the setting of obstructing colorectal cancer