Malignant Colonic Obstruction Research Articles

Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer.

We speculated that a laparoscopic approach to emergent/urgent partial colectomy for colonic obstruction would be associated with less morbidity and shorter length of stay with similar mortality to open colectomy. We compared the outcomes of laparoscopic and open approaches to emergent/urgent partial colectomy for colonic obstruction from colonic cancer using data from the National Surgical Quality Improvement Program (NSQIP) database for the period of 2012-2017. Multivariate analysis compared NSQIP data points following laparoscopic, laparoscopic converted to open, and open colectomy for emergent/urgent colectomy for colonic obstruction from colon cancer from 2012 to 2017. A total of 1293 patients who underwent emergent colectomy for colon obstruction from colon cancer during 2012-2017 were identified within the NSQIP database. Laparoscopic approach was used for colonic obstruction in 19.3% of operations with a conversion rate of 28.5%. A laparoscopic approach to obstructing colonic cancers was associated with lower morbidity (50% vs. 61.8%, AOR: 0.67, P = 0.01) and shorter hospitalization length (10days vs. 13days, mean difference: 3days, P < 0.01) compared with an open approach. However, the mean operation duration was longer in laparoscopic operations than open operations (159min vs. 137min, P < 0.01). A laparoscopic approach to malignant colonic obstruction is associated with decreased morbidity. This suggests that efforts should be directed towards increasing the utilization of laparoscopic approaches for the surgical treatment of colonic obstruction.

Mo1742 COLONIC STENT PLACEMENT IS ASSOCIATED WITH LOWER RISK OF IN-HOSPITAL DEATH AND NEED FOR SURGERY AMONG PATIENTS ADMITTED WITH MALIGNANT LARGE BOWEL OBSTRUCTION: AN ANALYSIS OF A LARGE NATIONAL SAMPLE

Prior studies have demonstrated efficacy of stent placement for palliation or as a bridge to surgery in small cohorts of patients with malignant colonic obstruction. Our aim is to evaluate the effect of stent placement on in-hospital mortality and need for surgery in a large nationally representative sample of patients admitted with malignant colonic obstruction. National Inpatient Sample (NIS) data from 2002 to 2014 were used. NIS is a nationally representative sample of all elective and non-elective hospital inpatient stays. Patients who were admitted non-electively with diagnoses of colorectal cancer and intestinal obstruction were included in this study. Colonic stent placement was ascertained using ICD-9 procedure codes. The main outcomes of the study were death or need for surgery during the admission, length of stay, and total cost of admission. Exploratory analyses were performed in patients with right and left colon cancers separately. Analysis was performed after matching patients who did or did not receive stent for age, gender, presence and severity of comorbidites using Elixhauser comorbidity index, and location of colon cancer and presence of metastatic cancer. Separate multivariable regressions were used to evaluate the effect of these covariates on outcomes as appropriate. 654,197 patients were admitted with a diagnosis of colon cancer, out of which 41,790 were admitted non-electively with a diagnosis of bowel obstruction and were included in the analysis (Table 1). 1,153 patients underwent colonic stenting for an overall rate of 2.76%. There was a significant secular trend for increased rate of stent placement over the study period (p<0.001). Colonic stenting was associated with a 3.5% lower risk of death during admission (p=0.001) in matched analysis. Similarly, colonic stenting was associated with a significant 29% lower chance of need for surgery during the same admission (p<0.001). Colonic stenting was not associated with a significant change in the length of admission but was associated with increased cost (Table 2). Separate analysis showed significant association between stenting and lower risk of death and surgery in patients with cancer of left colon, however the trend for lower risk of death in patients with cancer of right colon did not reach statistical significance (Table 2). Amongst patients who underwent surgery, stenting before surgery was associated with a 10% decrease in the risk of creating a stoma (p=0.026). Stenting was associated with a significant decrease in the risk of creating a stoma among patients with cancer of left colon, but not right colon. In patients who were admitted non-electively with malignant colon obstruction, stenting was associated with lower risk of death and need for surgery during admission, as well as lower rate of stoma creation during inpatient surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mo1704 USEFULLNESS OF COLONIC STENTING FOR PALLIATIVE TREATMENT OF MALIGNANT COLONIC OBSTRUCTION

Colorectal cancer is the most common form of cancer in Japan, and it is the second most common cause of cancer deaths worldwide. Awareness of colonic stents in the treatment of malignant colonic obstruction (MCO) has increased in Japan, and there have been many studies of their short-term usefulness as a bridge to surgery. On the other hand, the place of colonic stents as palliative treatment also deserves attention in our super-aged society. We conducted a retrospective study of MCO cases in which stenting was performed for palliative purposes in our hospital. The subjects were the 20 patients who underwent stenting as palliative treatment among the 76 patients who underwent colonic stenting for MOC in our hospital during the period from February 2013 to October 2019. We defined the technical success of stenting as the placement of a stent that passed beyond the obstruction, and we defined its clinical success as improvement in the abdominal symptoms. We used the Colorectal Obstruction Scoring System (CROSS) advocated by the Colonic Stent Safe Procedure Research Group to conduct the clinical evaluation. We evaluated complications in an early phase (day 0-30) and late phase (day 31 and after), the site of the mass, type of stent, technical and clinical success rates of stenting, whether there were any complications, changes in the CROSS scores as a reduced pressure effect, and the duration of stent patency. Median age was 80 years (62-93 years), and there were 12 males (60%). The site of the mass was the ascending colon in 3 cases, transverse colon in 4 cases, descending colon in 3 cases, and sigmoid colon and rectum in 5 cases each. The type of stent used was a covered stent in all cases. The technical success rate was 100%, and the clinical success rate was 89%. There was an early-phase complication in 2 cases; it consisted of a perforation in both cases, and in both cases stent placement was in the ascending colon. There was a late-phase complication in 3 cases; it consisted of recurrent obstruction in all 3 cases, and the cause was occlusion by an increase in size of the mass, not occlusion by a valve. When the early-phase complication cases were excluded, the mean CROSS scores tended to improve, rising from 3 points before stenting to 4 points after stenting, and the mean oral feeding resumption date was 2 days (0-4 days) after the procedure. The median average duration of stent patency of the patients stented 1 month or more was 148 days (35-1634 days), and there was even a patient whose stent was still patent after more than 4 years. The success rate of stenting for MCO was very high, and it was a safe treatment. We concluded that palliative colonic stenting for MCO is very useful in our super-aged society, and that it improves life expectancy and quality of life.

Fluoroscopic Stenting as a Bridge to Surgery versus Emergency Management for Malignant Obstruction of the Colon.

Aim To investigate the feasibility of a SEMS (self-expandable metallic stent) as a bridge to surgery for malignant colonic obstruction. Methods We retrospectively reviewed 83 patients that were in accordance with inclusion criteria; of these, 33 patients that underwent fluoroscopy-guided SEMS placement followed by elective curative resection were classified as a SEMS group and 50 patients, who received emergency surgery (ES), were classified as an ES group. The clinicopathological characteristics, surgery-related parameters, complications, and three-year survival rate were compared between the two groups. Results No significant differences between the two groups were observed in any of the clinicopathologic characteristics except for higher preoperative absolute neutrophil count in the ES group (P < 0.001). Compared to the ES group, the SEMS group has significantly more cases, which featured a laparoscopic approach (72.7% vs. 14.0%, P < 0.001), lower overall stoma rate (0% vs. 34.0%, P < 0.001), and lower overall postoperative morbidity (27.3% vs. 56.0%, P=0.010). The oncological outcomes did not differ significantly between the two groups in terms of three-year overall survival (P=0.125). The technical and clinical success rates of stent placement were 91.7% and 100%, respectively. Conclusion Patients treated with the stent-surgery approach had significant short-term superiorities and similar long-term outcomes, compared to patients who had emergency surgery alone. The SEMS is, therefore, safe and feasible as a bridge to surgery for malignant colonic obstruction.

Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction.

Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness. A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses. Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of -$58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time. In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Safety and Efficacy of Through-the-Scope Placement of Colonic Self-expandable Metal Stents Without Fluoroscopic Guidance: A Retrospective Cohort Study.

Colonic self-expandable metal stents (SEMSs) are usually placed through an endoscope under fluoroscopic guidance. In this retrospective study, we measured the safety and efficacy of through-the-scope colonic stent placement without fluoroscopic guidance. We included consecutive patients with malignant colonic obstruction who underwent SEMS placement through the endoscope without fluoroscopic guidance (NF group) from 2016 to June 2019 in a single tertiary medical center. Technical and clinical success rates and complication rates were compared with those of a historical control group consisting of consecutive patients who underwent stent placement through the endoscope under fluoroscopic guidance (F group) from 2012 to 2015. Of 136 patients analyzed, 67 were in the NF group and 69 were in the F group. For the NF and F groups, technical success rates were 97.0% and 95.7%, respectively (P=0.763); clinical success rates were 92.5% and 89.9%, respectively (P=0.581). Major complications included perforation (NF group, 1.5%; F group, 1.4%), stent migration (NF group, 0; F group, 1.4%), and stent occlusion (NF group, 1.5%; F group, 2.9%) (P=0.425). The median procedure time was significantly lower in the NF group (25.90±18.68 min) than in the F group (44.23±20.40 min) (P<0.001). Colonic SEMS placement without fluoroscopy is as safe and effective as the conventional fluoroscopically guided approach. This new method significantly reduced the procedure time.

Newly developed self-expandable Niti-S MD colonic metal stent for malignant colonic obstruction.

Colonic stents are increasingly used to treat acute malignant colonic obstructions. The WallFlex and Niti-S D type stents are the commonly used self-expandable metallic stents available in Japan since 2012. WallFlex stent has a risk of stent-related perforation because of its axial force, while the Niti-S D type stent has a risk of obstructive colitis because of its weaker radial force. Niti-S MD type stents not only overcome these limitations but also permit delivery through highly flexible-tipped smaller-caliber colonoscopes. To compare the efficacy and safety of the newly developed Niti-S MD type colonic stents. This single-center retrospective observational study included 110 patients with endoscopic self-expandable metallic stents placed between November 2011 and December 2018: WallFlex (Group W, n = 37), Niti-S D type (Group N, n = 53), and Niti-S MD type (Group MD, n = 20). The primary outcome was clinical success, defined as a resolution of obstructive colonic symptoms, confirmed by clinical and radiological assessment within 48 h. The secondary outcome was technical success, defined as accurate stent placement with adequate stricture coverage on the first attempt without complications. The technical success rate was 100% in Groups W, N, and MD, and the overall clinical success rate was 89.2% (33/37), 96.2% (51/53), and 100% (20/20) in Groups W, N, and MD, respectively. Early adverse events included pain (3/37, 8.1%), poor expansion (1/37, 2.7%), and fever (1/37, 2.6%) in Group W and perforation due to obstructive colitis (2/53, 3.8%) in Group N (likely due to poor expansion). Late adverse events (after 7 d) included stent-related perforations (4/36, 11.1%) and stent occlusion (1/36, 2.8%) in Group W and stent occlusion (2/51, 3.9%) in Group N. The stent-related perforation rate in Group W was significantly higher than that in Group N (P < 0.05). No adverse event was observed in Group MD. In our early and limited experience, the newly developed Niti-S MD type colonic stent was effective and safe for treating acute malignant colonic obstruction.

Stent as a bridge to surgery or immediate colectomy for malignant right colonic obstruction: propensity-scored, national database study.

The aim of this study was to compare perioperative outcomes of urgent colectomy and placement of a self-expanding metallic stent followed by colectomy for patients with malignant right colonic obstruction. Right-sided malignant obstruction is less common than left-sided. Stenting for malignant left colonic obstruction has been reported to reduce postoperative complications. However, the impact of stenting for malignant right colonic obstruction remains undefined. The study included patients with right-sided malignant obstruction or stenosis undergoing colectomy between April 2012 and March 2017 identified from a nationwide database. Propensity score matching analysis was used to compare mortality and morbidity rates, proportion receiving a stoma and postoperative stay between urgent colectomy and stent groups. From 9572 patients, 1500 pairs were generated by propensity score matching. There was no significant difference in in-hospital mortality between the urgent colostomy and stent groups (1·6 versus 0·9 per cent respectively; P = 0·069). Complications were more common after urgent colectomy than stenting (22·1 versus 19·1 per cent; P = 0·042). Surgical-site infection was more likely with urgent colectomy (7·1 versus 4·4 per cent; P = 0·001). There was no significant difference between the two groups in anastomotic leakage (3·8 versus 2·6 per cent; P = 0·062). The proportion of patients needing a stoma was higher with urgent colectomy than primary treatment with stents (5·1 versus 1·7 per cent; P < 0·001). Postoperative stay was longer after urgent colectomy (15 versus 13 days; P < 0·001). Stenting followed by colectomy in patients with malignant right colonic obstruction may provide more favourable perioperative outcomes than urgent colectomy.

Outcomes of Stenting as a Bridge to Surgery in Malignant Colonic Obstruction, With Emphasis on Perforation Rate and Clinical Success.

Colonic stent placement in acute malignant obstruction has proven to be an alternative for emergency surgery. It has been associated with reduced stoma creation and postoperative morbidity. Concerns have risen that manipulation of the tumor and risk of perforation might result in lower disease-free survival. Therefore, we investigated the long-term outcomes of stenting as a bridge to surgery in these patients, with emphasis on clinical success of the stenting procedure. We performed a comparative study in the Rijnstate Hospital in Arnhem, The Netherlands. Data were collected from patients who underwent colonic stenting procedures or acute surgical resection due to malignant obstruction performed between 2007 and 2015. Patients treated with palliative intent were excluded. We included 92 patients, 66 underwent stent placement and 26 had an acute surgical resection. Technical and clinical success rates of the stenting procedures were 94% and 82%, respectively. No significant differences in demographic, tumor or stenting characteristics were found for patients with clinically (un)successful stent placement or stent-related perforations. Patients with unsuccessful stent procedures or perforation had higher rates of open procedures and rescue colostomy. Survival rates were similar for patients who underwent stent placements compared with acute resection. We found no significant differences in survival between patients with successful compared with unsuccessful procedures or perforation. Survival rates of patients who underwent colonic stenting are similar to those of patients who had an acute resection. No negative effects on survival were observed for clinically failed stenting procedures or stent-related perforations.

Comparison of short-term outcome between diverting colostomy and colonic stent as a bridge to surgery for left colonic malignant obstruction.

The self-expanding metallic stent (SEMS) has been comprehensively investigated as a bridge to surgery. SEMS enables the control of acute colonic obstruction. However, comparison between SEMS and diverting colostomy as another bridge procedure was still challenging issue. Thus, the aim of this study was to compare these 2 procedures.In this retrospective cohort study, patients who received diverting colostomy and SEMS for acute left colonic obstruction between February 2016 and August 2018 were included. They were classified into the colostomy group (n = 27), including 5 patients who had SEMS failure previously, and the SEMS group (n = 23). The clinicopathologic parameters, pathologic results, and short-term outcomes were compared.No significant differences were found in clinicopathologic characteristics and complication rates between the 2 groups. After the bridge procedures, the SEMS group showed a higher rate of laparoscopic colonic resection than the colostomy group (100% vs 76%, P = .023). The colostomy group showed a higher rate of rectal cancer (24.0% vs 9.1%, P = .019) and later recovery of flatus (3 vs 2 days, P = .011) than the SEMS group. Additionally, the length of resected colon was longer in the colostomy group than in the SEMS group (33.9 vs 23.4 cm, P = .007).Although SEMS might permit higher laparoscopic resection rates and faster recovery of bowel habits than diverting colostomy, SEMS showed meaningful failure rate including migration and perforation. In addition, diverting colostomy showed acceptable complication rates and feasible performance. An individualized approach is necessary considering the advantages and disadvantages of both procedures.

COMPARATIVE EVALUATION OF THE USE OF COATED AND UNCOATED SELF-EXPANDABLE METALLIC STENTS IN MALIGNANT COLORECTAL OBSTRUCTION

THE OBJECTIVE was to compare the efficacy and rate of complications in patients of groups with uncovered and covered colorectal stents.METHODS AND MATERIALS. The study included 102 patients who were admitted for emergency with symptoms of malignant colon obstruction, who were randomly installed covered and uncovered SEMS from December 2012 to September 2017.RESULTS. Clinical success was achieved with uncovered stents in 98 % of cases and 96 % with covered stents (relative risk (RR) 1.02). 95 % confidence interval (CI) 0.954–1.092). The incidence of complications in the group of uncovered stents was 9.8 %, in the group of covered stents – 3.9 % (RR 0.938, CI 0.841–1.046); the frequency of recurrences of obstruction did not significantly different between groups. The median duration of cumulative stent patency was 181 days in the group of uncovered stents and 218 days in the group of covered stents (p=0.427), the difference was statistically insignificant.CONCLUSION. The use of double covered and double uncovered stents is equally effectively and safely for patients with malignant colorectal obstruction. The frequency of reobstructions did not exceed 4 % and did not differ in the groups of covered and uncovered stents. The choice of the type of stent should be determined individually depending on the clinical situation.

Long-term oncologic safety of self-expandable metal stent as a bridge to surgery for malignant colorectal obstruction: Our experience.

153 Background: About 10-25% patients of colorectal cancer suffer from acute colonic obstruction. Traditional management of acute malignant bowel obstruction has focused on emergency resection but showed high mortality and morbidity rates. Recently, placement of a self-expanding metal stent(SEMS) was widely used and SEMS seems to be as a safe and effective “bridge to surgery” and to offer good palliation. But there is concern about long-term survival after the use of SEMS. Theoretically, tumor cell seeding can occur due to mechanical force during the stent insertion. To identify this theoretical validity, we surveyed long-term survival of malignant colonic obstruction using SEMS placement. Methods: This retrospective study included 303 patients who presented in Korea University Anam Hospital between 2006 and 2014 with obstructing CRC, and underwent surgical resection. Patients were devided into two group: the “SEMS” group included 148 patients who underwent endoscopic stent as a bridge to surgery, and the surgery group included 155 patients who underwent emergency or elective surgery without stenting. In addition, candidates for curative resection were identified (98 patients in “SEMS” group vs 101 patients in “surgery” group). The clinicopathologic characteristics, overall survival(OS), and recurrence-free survival (RFS) were compared between the two groups. Results: There was no significant difference in demographics, tumor stage between the two group. The median follow-up times were 48.5 months (IQR, 19.1-73.1 months) for the SEMS group and 39.4 months (IQR, 15.1-39.4 months) for the surgery group. There was no significant difference in 5-year OS rate between two groups (59.6% vs 56.8%; p = 0.3). The 5-year RFS rate did not significantly differ between two groups (71.0% vs. 61.3%; p = 0.221). The long-term oncologic safety did not significantly differ between two groups in either the 5-year OS rate (79.5% vs 74.5%; P= 0.6). or the 5-year RFS rate (95.8% vs 95.8%; P = 0.3). Conclusions: SEMS as bridge to surgery in obstructive CRC did not worsen the long-term oncologic outcomes compared to those of the primary surgery.

Outcomes of Stenting as a Bridge to Surgery in Malignant Colonic Obstruction, With Emphasis on Perforation Rate and Clinical Success

BACKGROUND Colonic stent placement in acute malignant obstruction has proven to be an alternative for emergency surgery. It has been associated with reduced stoma creation and postoperative morbidity. Concerns have risen that manipulation of the tumor and risk of perforation might result in lower disease-free survival. Therefore, we investigated the long-term outcomes of stenting as a bridge to surgery in these patients, with emphasis on clinical success of the stenting procedure. METHODS We performed a comparative study in the Rijnstate Hospital in Arnhem, The Netherlands. Data were collected from patients who underwent colonic stenting procedures or acute surgical resection due to malignant obstruction performed between 2007 and 2015. Patients treated with palliative intent were excluded. RESULTS We included 92 patients, 66 underwent stent placement and 26 had an acute surgical resection. Technical and clinical success rates of the stenting procedures were 94% and 82%, respectively. No significant differences in demographic, tumor or stenting characteristics were found for patients with clinically (un)successful stent placement or stent-related perforations. Patients with unsuccessful stent procedures or perforation had higher rates of open procedures and rescue colostomy. Survival rates were similar for patients who underwent stent placements compared with acute resection. We found no significant differences in survival between patients with successful compared with unsuccessful procedures or perforation. CONCLUSIONS Survival rates of patients who underwent colonic stenting are similar to those of patients who had an acute resection. No negative effects on survival were observed for clinically failed stenting procedures or stent-related perforations.

Endoscopic Management of Malignant Colonic Obstruction.

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.

Eosinophilic gastroenteritis in the setting of colorectal neoplasia

Eosinophilic gastroenteritis is a rare inflammatory disease of one or more segments of the gastrointestinal tract. Clinical features vary depending on the site and layer of involvement. We present a case of a 61-year-old female with malignant colonic obstruction and several months of abdominal discomfort, nausea, and altered bowel habits. She had a colonic stent as a bridge to her definitive surgery. She continued to have diarrhea and abdominal discomfort until her definitive surgery. Interestingly, histopathology showed colonic cancer with segments of eosinophilic colitis. This is a unique case given the rarity of eosinophilic gastroenteritis and its potential predisposition to neoplastic disease. We review the clinical and pathological features of eosinophilic gastroenteritis and the possible linkage with colorectal cancer.

Colonic stenting is a more effective treatment of the malignant colonic obstruction compare with emergency surgery

Colonic stenting is a more effective treatment of the malignant colonic obstruction compare with emergency surgery

Transanal drainage tubes vs metallic stents for acute malignant left-sided bowel obstruction: A systematic review and meta-analysis.

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.

Role of endoscopic colonic stent insertion in patients with colonic obstructing malignancy: a single-center study

BackgroundLeft-sided colonic malignant lesions have the potential of acute bowel obstruction. Emergency surgery with stoma construction is considered the standard of management. Insertion of colonic stent to allow bowel decompression, primary resection, and re-anastomosis, avoiding the need of colostomy formation, can be an alternative. We describe our experience with the use of colonic stent in left-sided malignant obstruction as a step to relieve the obstruction before definitive surgical intervention.Patients and methodsA total of 30 patients with left-sided colonic malignant obstruction were included; 15 patients were offered colonic self-expandable metal stent insertion, and the other fifteen patients were offered emergent surgery.ResultsOf the 15 patients, 10 (66.6%) had successful stent insertion (technical and clinical). We failed to insert stent in four (26%) patients, and one (6.6%) patient had colonic perforation. All patients with successful colonic stent insertion underwent one-step resection and primary anastomosis.ConclusionColonic stent for left-sided colonic malignant obstruction represents a valuable procedure for one-step resection and primary anastomosis without the need for colostomy.

2142 Endoscopic Management Cases for Small Bowel Obstruction

INTRODUCTION: Small bowel obstruction (SBO) is a common disease in the gastrointestinal surgery field. Although causes of SBO are highly variable, surgical management is usually selected for adhesive obstruction if nasogastric tube decompression has failed. There have been no reports of endoscopic cure for SBO, despite several reports of endoscopic management of colonic voluvulus or malignant colonic obstruction. Here we report three cases in which endoscopic reduction was safely performed for SBO. CASE DESCRIPTION/METHODS: Case1: An 86-year-old woman developed obstruction one month after right hemicolectomy for colorectal cancer. Preprocedural CT scan imaging detected a lumen caliber change near the ileocolonic anastomosis, and no recovery sign was acquired even after decompression treatment by nasogastric tube for 3 days. Colonoscopy with fluoroscopy showed ileum kinking at 10 cm proximal from the anastomosis. Case2: A 68-year-old woman developed obstruction during hospitalization for myelodysplastic syndrome. She had past surgcal history of 7 caesarean sections. Preprocedural CT scan imaging showed terminal ileum with transition point at 20 cm from ileocecal valve. Colonoscopy was performed after one week of conservative management. Colonoscopy with fluoroscopy revealed strong angulation and stricture accompanied by ulcerations at the terminal ileum. Case3: A 79-year-old woman developed obstruction one year after cystectomy with Indiana pouch reconstruction for bladder cancer. There was no improvement sign after 5 days of nasogastric tube and supportive treatment. Colonoscopy with fluoroscopy revealed ileum kinking 20 cm proximal to the ileocolic anastomosis, consistent with preprocedural imaging. In all 3 cases, the scope passed through the obstruction site following insertion of a guide wire and stiff catheter through above the obstruction area. All obstructions were successfully released. The passage of the contrast intraoperatively through the site was clearly observed. In Case 3 was added balloon dilation after the endoscope withdrawal. All patients were discharged without additional surgery or postprocedural complications, with 1.5-4 months follow up. DISCUSSION: We report three cases in which endoscopic treatment safely treated for SBO likely due to adhesions. Endoscopic management could release the obstruction earlier than predictable course in these three cases. These cases show the potential for endoscopic treatment to replace surgical treatment in a certain type of SBO.

Current status of colonic stent for obstructive colorectal cancer in Japan; a review of the literature.

Colorectal cancer is the most common cancer in Japan. Approximately 10%-20% of the patients with colorectal cancer present with large bowel obstruction, and those who present with malignant colonic obstruction (MCO) require urgent decompression because MCO can cause electrolytic fluid imbalance, colonic necrosis, bacterial translocation, and death. Placement of colonic stents (self-expandable metallic stents) for MCO is a major and standard endoscopic treatment that has been available since 2012 in Japan. This review presents the current conditions and future prospects of this procedure based on the literature. The current indication of colonic stent placement is malignant colorectal stenosis. One of the purposes of using stents is palliative treatment; further, its advantages over emergency surgery with colostomy include avoidance of colostomy, relief of obstruction, shorter hospitalization, and better quality of life. In addition, stent placement can also be used as a bridge to surgery since the duration of the hospitalization is shorter and postoperative complications, colostomy rates, and mortality rates are lower with elective than with emergency surgery. Although recent studies have reported low complication rates related to colonic stents, complications may still occur, highlighting the importance of good preparation, adequate staffing, backup systems, and informed consent. The current major problem related to colonic stents is the lack of evidence on patients' long-term prognoses for bridge to surgery purposes, awaiting the results of ongoing clinical research.