Malignant Colonic Obstruction Research Articles

Self-Expanding Metallic Stents (SEMS) in Left-Sided Colonic Cancer--a Cancer Center Experience.

Self-Expanding Metallic Stents (SEMS) are a surgery-sparing option for malignant colonic obstruction. They can be inserted as a "bridge to surgery" (BTS) for potentially curable disease, or as a palliative measure, thereby avoiding the higher morbidity and mortality associated with surgery. The objective of this study was to report our local experience of left-sided colonic stents. Data on 49 patients was collected retrospectively from Oct 2008 to Nov 2014 at our cancer centre. This included demographics, baseline clinical characteristics, indications for SEMS placement (bridge to surgery/palliative), technical and clinical success, complications, and the mean patency of duration. Survival in both groups was also plotted on a Kaplan-Meier chart. A total of 49 patients with colorectal carcinoma (CRC) of the left side were enrolled. The mean age was 50 years (range 18-86). Ninety percent of patients had disease involving the rectum, sigmoid colon, or both. Forty-seven percent (n = 23) of patients had stent insertion as a BTS, whereas 53% (n = 26) had the procedure with palliative intent. Technical and clinical success rates were 96 and 88%, respectively. The clinical success rate of the palliative arm was lower than that of the BTS arm (p = 0.024). 87.5% (n = 42) had no procedure-related complications. Technical failure, perforation, and stent migration/expulsion, were each observed in 4% of cases. Mean stent patency duration was 83.9 days. SEMS insertion for left-sided malignant colonic obstruction is a safe and effective procedure when used either as a bridge to surgery or with palliative intent.

Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction

PurposeThe aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. MethodsFrom January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7–9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed. ResultsTwenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1). ConclusionDecompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.

Stenting in malignant colonic obstruction--is it a real therapeutic option?

Malignant colonic obstruction is commonly treated surgically. Colonic stents are a therapeutic option for palliation or used as a bridge to surgery or chemotherapy. The aim of the study was to evaluate the clinical success rate of stenting as a bridge to one-step surgery, chemotherapy, or as a palliative measure. This was a retrospective observational study. The study was conducted at a university-affiliated tertiary referral center. From 2007 to 2014, 45 patients with malignant colonic obstruction were referred for stent insertion. Patients were grouped according to three pre-defined treatment goals: group 1: restorative one-step procedure without an ostomy, group 2: completion of scheduled chemotherapy before surgery, and group 3: palliation without surgical intervention. Group 1 included 11 patients. Three patients (27.3 %) met the treatment goal of one-step surgery. Eight patients (72.7 %) did not reach the primary goal due to stent insertion failure (four patients), stent-related complications (two patients), and failure to perform a one-step surgery after successful stent insertion (two patients). Group 2 included 12 patients. Chemotherapy was successfully completed prior to surgery in six patients (50 %). Six patients (50 %) did not achieve treatment goal due to stent insertion failure (two patients), stent migration (two patients), stent-related perforation (one patient), and mortality (one patient). Group 3 included 20 patients. Long-term palliation without surgical intervention was achieved in eight patients (40 %). Stent insertion failed in seven patients (35 %). Five patients (25 %) needed urgent surgery due to stent complications (three migrations and two perforations). The study was limited by its retrospective nature and small sample size. This study demonstrates only a modest success rate of colonic stents in the treatment of malignant colonic obstruction. Although colonic stenting seems to be an effective method of relieving colonic obstruction, high failure rates limits its applicability.

Short-term safety and efficacy of endoscopic self-expandable metal stent implantation for malignant colonic obstruction

Objective To evaluate the short-term safety and efficacy of endoscopic implantation of self-expandable metallic stent (SEMs) for malignant colorectal obstruction. Methods A total of 208 patients who had undergone endoscopic SEMs implantation for malignant colonic obstruction from January 2012 to May 2014 at the endoscopy center of Shengjing hospital were enrolled. The technical and clinical success rate and the complications were reviewed. Results The technical and clinical success rates were 99.04%(206/208) and 96.15% (200/208), respectively. Abdominal pain, perforation and bleeding were the most common post-procedure complications, the rates of which were 13.46% (28/208), 2.88% (6/208), 1.92% (4/208), respectively. The abdominal pain in most patients was self-relieving except for 6 patients with perforation of colon. Patients with perforation were cured by emergency surgery. One patient with intraperitoneal hemorrhage was also cured by emergency surgery, the other patients developing bleeding recovered themselves. Conclusion The success rate of endoscopic SEMs implantation is satisfactory in the study. As a bridge to surgery or a palliative care method, endoscopic SEMs implantation is effective and safe for malignant colorectal obstruction. Key words: Colorectal cancer; Intestinal obstruction; Endoscopic stent implantation; Metallic stent

Colon endoprosthesis as a stage in treatment of malignant colon obstruction

Colon endoprosthesis as a stage in treatment of malignant colon obstruction

Resection of Obstructive Left-Sided Colon Cancer at a National Level: A Prospective Analysis of Short-Term Outcomes in 1,816 Patients

Background/Aims: The prematurely closed Stent-In II trial in patients with left-sided obstructive colon cancer may have influenced clinical decision making in The Netherlands. The aim of this study was to evaluate treatment of left-sided malignant colon obstruction at a population level since then. Methods: Short-term outcomes of all patients who underwent resection for left-sided obstructive colon cancer between 2009 and 2012 were assessed based on a prospective national registry. Results: In total, 1,816 evaluable patients were included; acute resection was performed in 1,485 (81.8%), and endoscopic stent or decompressing stoma followed by resection in 196 (10.8%) and 135 (7.4%), respectively. The use of endoscopic stenting significantly decreased from 18% (2009) to 6% (2012). Overall 30-day or in-hospital mortality rate was 6.9, 5.6, and 3.7%, respectively (p = 0.107). Mortality rate after acute resection was 2.9% in patients >70 years, but mortality rates up to 32.2% were observed in high-risk elderly patients. Conclusion: Acute resection as first choice treatment seems justified for patients >70 years of age given a mortality rate of 3%. For the elderly frail patients, mortality rates over 30% after acute resection stress the need for alternative treatment strategies.

Endoscopic stent placement in the management of malignant colonic obstruction: Experiences from two centers.

Intestinal obstruction due to colorectal tumors requires immediate surgical decompression. Endoscopic stent placement for acute malignant colonic obstruction is gaining widespread acceptance as an alternative to emergency surgery. Our aim in this study was to evaluate the success and complication rates of endoscopic stenting for malignant colonic obstruction. Patients with acute malignant colonic obstruction who underwent endoscopic stenting between 2011-2014 were retrospectively reviewed. Data included demographic features, localization of obstruction, endoscopic stenting indications, rate of technical and clinical success, complications, morbidity and mortality. Endoscopic stent was successfully placed in 77 out of 82 procedures (93.9%). A colostomy was placed in five cases in which endoscopic stent could not be inserted. There were complications in seven patients with technically successful stents (9.0%). These included three stent migrations, one perforation, and rectal hemorrhage in three patients. There were no stent-related deaths. The mortality rate of emergency surgery for malignant bowel obstruction is relatively high. The use of colonic stents can avoid surgery in patients who are not suitable for emergency surgery and may allow adequate time for preoperative preparation, counseling and staging for those who are suitable for further intervention. We believe that self-expandable metallic stent placement is a safe, effective, and minimal invasive alternative treatment method for malignant colonic obstruction.

Su1678 The Efficiency of Self-Expanding Metallic Stents Placement As a Bridge to Surgery for Malignant Colonic Obstruction: a Clinical Result From a Japanese Referral Center

Su1678 The Efficiency of Self-Expanding Metallic Stents Placement As a Bridge to Surgery for Malignant Colonic Obstruction: a Clinical Result From a Japanese Referral Center

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Tu1977 Efficacy and Safety of Stent Placement for Malignant Colonic Obstruction

Tu1977 Efficacy and Safety of Stent Placement for Malignant Colonic Obstruction

Safety and Feasibility of Self-Expandable Metallic Stent Insertion for the Right-Side Colonic Malignant Obstruction and Its Clinical Benefits

Purpose: The efficacy of stenting for the right-side colonic malignant obstruction is unknown. The purpose of this study was to evaluate the safety and feasibility of self-expandable metallic stent insertion for the right-side colonic malignant obstruction and its clinical benefits. Methods: We retrospectively reviewed clinical data from 460 patients who underwent right hemicolectomy for right-side colon cancer from January 2006 to January 2014 at Korea University Anam Hospital. Twenty four patients who developed malignant obstruction in the right -side colon were identified and analyzed. Results: Self-expandable metallic stent insertion was attempted in 14 patients, and initial technical success was achieved in 13 patients (92.9%). No immediate stent-related complications were reported. Complete relief of obstruction was achieved in all of the 13 patients. Eleven patients who failed stenting underwent emergency operation. All of the 13 patients with stent underwent laparoscopic surgery and only one case was converted to open. Only three patients in the emergency group underwent laparoscopic surgery but one was converted. Operative time and number of retrieved lymph nodes did not differ between the two groups. Postoperative hospital stay (9.8±3.2 in stent group vs. 16.3±10.9 days in emergency group, p=0.082) tended to be shorter in the stent group. Estimated blood loss (38.5±138.7 in stent group vs. 381.8± 411.9 in emergency group, p=0.010) and duration for resuming diet (3.2±2.2 in stent group vs. 6.6±7.0 days in emergency group, p=0.017) were significantly better in the stent group. Conclusion: Self-expandable metallic stent appears to be safe and feasible in the right-side colonic malignant obstruction. It facilitates minimally invasive surgery and may result in better short-term surgical outcome.

Clinical effect of double coaxial self-expandable metallic stent in management of malignant colon obstruction.

We aimed to evaluate the clinical effectiveness and safety of double coaxial self-expandable metallic stent (DCSEMS) in management of malignant colonic obstruction as a bridge to surgery or palliation for inoperable patients. Between April 2006 and December 2012, 49 patients (27 males and 22 females; median age, 68 years; age range, 38-91 years) were selected to receive decompressive therapy for malignant colonic obstruction by implanting a DCSEMS. Application of DCSEMS was attempted in 49 patients under fluoroscopic guidance. The obstruction was located in the transverse colon (n=2), descending colon (n=7), sigmoid colon (n=24), rectosigmoid junction (n=6), and the rectum (n=10). The intended use of DCSEMS was as a bridge to elective surgery in 23 patients and palliation in 26 patients. Clinical success, defined as >50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 48 of 49 patients (98%). The stent was properly inserted in all patients. No immediate major procedure-related complications occurred. One patient in the bridge-to-surgery group had colon perforation three days after DCSEMS application. Four patients had late migrations of the double stent. Application of DCSEMS is safe and effective in management of malignant colonic obstruction; it prevents stent migration and tumor ingrowth and lowers perforation rate during the stent application.

Leitlinie der Europäischen Gesellschaft für Gastrointestinale Endoskopie (ESGE) zum Einsatz von selbstexpandierenden Metallstents bei Obstruktionen durch Kolonkarzinome und extrakolische Karzinome

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. Main recommendations The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. 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 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). 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). 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)

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

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. Main recommendations The 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).

Long-term results of palliative stent placement for acute malignant colonic obstruction.

Endoscopic placement of self-expanding-metal-stents (SEMS) is widely performed as palliative treatment for acute malignant colonic obstruction. There is ongoing debate regarding risks and benefits associated with SEMS placement. This study aimed to evaluate long-term outcomes of palliative SEMS placement in patients presenting with acute malignant colonic obstruction. A prospectively collected patient cohort (2005-2013) from a general teaching hospital was used. In this hospital, all consecutive patients presenting with acute malignant large bowel obstruction are treated with endoscopic SEMS placement. Only colon cancer patients who underwent palliative SEMS placement were selected. In total, 48 patients were included. The technical and short-term clinical success rates were 91 % (44/48) and 85 % (36/48), respectively. SEMS-related mortality occurred in 6/48 patients (13 %) (early n = 4, late n = 2) and was caused by SEMS-related perforation in all cases. The SEMS-related morbidity rate was 38 % (18/48) (early n = 7, late n = 11). Endoscopic re-intervention was performed 14 times and 13 patients eventually underwent surgical treatment during follow-up. The stoma-formation rate was 15 % (7/48). Long-term clinical success was 48 % (23/48). The estimated stent patency rate (95 % confidence interval) was 69 % (52-79) at 1 month, 54 % (37-66) at 6 months and 50 % (33-62) at 12 months. Palliative SEMS placement provides rapid relief of obstruction and avoids a stoma in most patients with acute colonic obstruction caused by incurable or inoperable colon cancer. However, these benefits should be weighed against mortality and morbidity related to SEMS placement.

Short-term outcomes following the use of self-expanding metallic stents in acute malignant colonic obstruction – A single centre experience

Background: Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term outcomes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution over a 3-year period. Methods: A prospectively maintained database was reviewed to identify all patients who presented to our institution with AMCO between August 2010 and 2013 and who were treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews and operation notes. Results: Sixteen patients (12 males, 4 females) each had a single stent inserted during the study period, either palliatively (n = 11) or as a BTS (n = 5). The technical and clinical success rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and required emergency surgery while five patients with curable disease proceeded to elective resections. There was no procedure-related mortality or stent-related perforations. The mean (standard deviation) length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All patients in the BTS group were stoma-free post-operatively, while both patients who had emergency surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary to migration. Conclusions: Although limited by a small sample size, the study shows that SEMS have favourable short-term outcomes. Further adequately powered trials are needed to confirm those findings.

Long‐term outcome of stenting as a bridge to surgery for acute left‐sided malignant colonic obstruction

This study aimed to evaluate both the short- and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon. Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (n = 28) or with emergency surgical resection (n = 39) from January 1998 to December 2008 were identified from a prospectively maintained database. Short-term data on postoperative mortality, morbidity, necessity of intensive care and length of hospital stay were compared. Overall survival and disease-free survival were also analysed. Patients in the two study arms had similar demographic profiles. Those receiving preoperative stenting had a higher likelihood of a laparoscopic resection (P < 0.001). The emergency surgery group had a higher rate of postoperative complications (P = 0.024), rate of intensive care unit admission (P = 0.013) and longer total length of hospital stay (9 vs 12 days, P = 0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups, there was no difference in overall and disease-free survival (overall survival 30 vs 31 months, P = 0.858; disease-free survival 13 vs 12 months, P = 0.989). There was no difference in the rate of systemic recurrence (8 vs 13, P = 0.991). Stenting as a bridge to surgery is a safe strategy for acute left-sided colonic obstruction with improved short-term outcome and comparable long-term oncological results.

Patients who failed endoscopic stenting for left-sided malignant colorectal obstruction suffered the worst outcomes.

Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking. This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting. A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed. From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25-96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61-48.8; p < 0.001) times more likely to develop severe adverse events than those who were successfully stented. The group of patients who failed stenting was also 3.3 (95 % CI, 1.19-9.20; p = 0.026) times more likely to develop severe adverse events than those operated immediately. The only factor that predicted failure of stenting was a more acute angulation between the tumour and the distal lumen. Patients who failed endoscopic stenting fared worse than those who were successfully stented and also those who underwent emergency surgery upfront. Identification of factors that predict failures may be vital to minimise morbidity in these high-risk patients.

PWE-017 Short Term Outcomes Following The Use Of Self Expanding Metallic Stents In Acute Malignant Colonic Obstruction

IntroductionColonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients...

Long-term oncologic outcomes of endoscopic stenting as a bridge to surgery for malignant colonic obstruction: comparison with emergency surgery

Self-expandable metallic stents (SEMS) are now regarded as an effective and safe intervention for malignant colorectal obstruction (MCO). However, manipulation of the tumor might lead to the spillage of tumor cells and result in distant metastases. We aimed to compare the long-term oncologic outcomes of SEMS as a bridge to surgery with those of emergency surgery for MCO. Between June 2005 and December 2011, 60 patients who underwent elective curative resection after endoscopic SEMS insertion were included in the "SEMS group". The SEMS group was matched to 180 patients who underwent emergency curative surgery for MCO during the same period ["Emergency surgery (ES) group"]. The clinicopathologic characteristics, recurrence-free survival (RFS), and overall survival (OS) were compared between the two groups. There were no significant differences in demographics, tumor stage, location, and histology between the SEMS group and the ES group. The median follow-up times were 41.4months (IQR, 22.2-60.0months) for the SEMS group and 45.0months (IQR, 20.9-68.1months) for the ES group. The proportions of patients who received postoperative adjuvant chemotherapy were comparable (SEMS group vs. ES group, 68.3% vs. 77.8%; P=0.210). The long-term prognosis did not significantly differ between two groups in either the 5-year RFS rate (79.6% vs. 70.2%; P=0.218) or the 5-year OS rate (97.8% vs. 94.3%; P=0.469). Long-term oncologic outcomes of SEMS insertion as a bridge to surgery were comparable to those of primary curative surgery.