Malignant Colorectal Obstruction Research Articles

Clinical impact of prophylactic antibiotic treatment for self-expandable metallic stent insertion in patients with malignant colorectal obstruction.

Purpose. The aim of this study was to determine the efficacy of prophylactic antibiotics (PA) for reducing the infectious complications and the potential risk factors responsible for the infectious complications after stent insertion for malignant colorectal obstruction. Methods. We performed a retrospective review of 224 patients who underwent self-expandable metallic stent (SEMS) insertion for malignant colorectal obstruction from May 2004 to December 2012. Results. There were 145 patients in the PA group and 79 in non-PA group. The CRP level in PA group was significantly higher than that in non-PA. Abdominal tenderness and mechanical ileus were significantly more frequent in PA group than those in non-PA. The frequency of post-SEMS insertion fever, systemic inflammatory response syndrome (SIRS), and bacteremia was not significantly different between PA and non-PA groups. In multivariate analysis, the CRP level was risk factor related to post-SEMS insertion SIRS. However, in propensity score matching analysis, there was no independent risk factor related to post-SEMS insertion fever, SIRS, and bacteremia. Conclusion. The use of PA in patients with malignant colorectal obstruction may be not effective to prevent the development of infectious complications after SEMS insertion.

Role of self-expanding metal stents in patients with malignant colorectal obstruction: A systematic review and meta-analysis

Role of self-expanding metal stents in patients with malignant colorectal obstruction: A systematic review and meta-analysis

Outcome of endoscopic self-expandable metal stents in acute malignant colorectal obstruction at a tertiary center.

Malignant colorectal obstruction (MCRO) by advanced colonic cancer occurs in 8-13% of colonic cancer patients. Emergent surgery carries a high mortality and morbidity risk. Endoscopic self-expanding metal stents (SEMS) may be used in acute MCRO. Evaluate clinical outcome of SEMS in acute MCRO and efficacy of SEMS placement considering fluoroscopy guidance. Retrospective study of patients with acute MCRO that placed SEMS in a 3 years period. SEMS were placed in 47 patients, followed-up for a median time of 150 days. The intent of stenting was bridge to definitive surgery in 40% of the patients (n = 19) and palliation in the remaining 60% (n = 28). The location of the tumor did not influence the presence of lymph node involvement (p = 0.764) nor metastasis (p = 0.885). Mortality rate at year 1 was 61%. Survival was significantly higher in patients submitted later to combination therapy compared to chemotherapy, surgery or symptomatic treatment (p < 0.001). Fluoroscopy was used in 57% of the procedures. Clinical success was 79%. A second SEMS was needed during the procedure in 6% of the patients. Rate of early and late complications was 11% and 5%, respectively. Fluoroscopy guidance did not influence the occurrence of immediate (p = 0.385), early (p = 0.950) or late complications (p = 0.057). Thirty-three percent of patients underwent surgery at a later stage, with neo-adjuvant therapy in 18%. SEMS provide a relative safe and successful treatment in a palliative or bridge-to-surgery indication. No significant differences were found in SEMS placement success, early complications or late complications considering fluoroscopy guidance.

What is the necessity of endoscopist for successful endoscopic stenting in patients with malignant colorectal obstruction?

Recently, self-expandable metal stents (SEMSs) have been widely used as an initial therapy for relieving malignant colorectal obstructions. However, several factors, including the endoscopist's experience, affect the clinical outcome of SEMSs. The aim of this study was to define the adequate level of experience necessary to perform endoscopic stenting effectively and safely and to identify technical factors for successful stenting. Between March 2009 and June 2012, 160 patients underwent SEMS placement for malignant colorectal obstruction with the intent of palliation or as a bridge to surgery by a single endoscopist who experienced colonoscopy and endoscopic retrograde cholangiopancreatography. The overall technical and clinical success rates were 86.9 and 86.4%, respectively, and 18 complications (11.3%) were observed. There were no differences in any of the clinical outcomes between the consecutive blocks; however, the procedure time decreased significantly after the first 30 procedures (17.4, 16.9, 13.5, and 12.8 min; P = 0.044). American Society of Anesthesiologists (ASA) class, history of a previous operation, proximal colon obstruction, obstruction caused by an extracolonic malignancy, and palliative SEMS placement were associated with technical failure. An endoscopist who experiences a colonoscopy and fluoroscopy performs SEMS placement successfully regardless of the level of experience. After the first 30 procedures, a SEMS insertion could be safely and effectively performed with short procedure time in patients with malignant colorectal obstruction.

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.

Stenting for Emergency Colorectal Obstruction: An Analysis of 204 Patients in Relation to Predictors of Failure and Complications.

Self-expanding metallic stents are increasingly used in the management of malignant and benign colorectal obstructions. We aimed to identify relevant predictive factors for stent failure and stent-related complications. We conducted a retrospective single-center analysis of 204 consecutive patients who underwent emergency colorectal stenting procedures because of symptomatic bowel obstructions from 1996 to 2011 at the Sisters of Charity Hospital Linz, Austria. A total of 204 patients (median age 74 years) with 36 (17.7%) benign and 168 (82.3%) malignant obstructions were included in the study. Technical success was achieved in 92.5% and clinical success in 86.8% of the cases. Major complications occurred in 2.9% and minor ones in 19.6%. Overall mortality during a median follow-up period of 4.3 years was 73% (149 patients). Relevant predictors of increased risk of complications were extracolonic obstruction (p = 0.001), complete obstruction (p = 0.066), and inflammatory bowel disease (p = 0.05). Stent localization at the splenic flexure, a stenosis of >8 cm in length, and the need for endoscopic guidance were associated with higher rates of technical and/or clinical stenting failure. Colorectal stenting is less invasive than other means of emergency treatment for large bowel obstruction; it is generally safe and effective in different types of colorectal obstruction. However, relevant rates of failure and complications were recorded and predictors could be determined.

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...

Palliative self-expandable metal stents for acute malignant colorectal obstruction: clinical outcomes and risk factors for complications

Objective. Self-expandable metal stents (SEMSs) have been used as palliative treatment or bridge to surgery for obstructions caused by colorectal cancer (CRC). We assessed the long-term outcomes of palliative SEMSs and evaluated the risk factors influencing complications. Materials and methods. One hundred and seventy-five patients underwent SEMS placement for acute malignant colorectal obstruction. Of the 72 patients who underwent palliative treatment for primary CRC, 30 patients received chemotherapy (CT) for primary cancer (CT group) and 42 underwent best supportive treatment (BST) without CT (BST group). Results. There was a significant difference in late migration between the CT group and the BST group (20.0% in CT group, 2.4% in BST group, p = 0.018). Response to CT influenced the rate of late obstruction (0% in disease control, 35.7% in disease progression, p = 0.014). However, late obstruction was not associated with stent properties, such as diameter or type (≤22 mm vs. >22 mm, 13.5% vs. 14.3%, p = 1.00; uncovered stent vs. covered stent, 15.5% vs. 7.1%, p = 0.675) and migration (≤22 mm vs. >22 mm, 16.2% vs. 2.9%, p = 0.108; uncovered stent vs. covered stent, 8.6% vs. 14.3%, p = 0.615) in palliative SEMS. Conclusion. The administration of CT increases the rate of stent migration, and disease control by CT can reduce the risk of obstruction by maintaining the luminal patency of palliative SEMSs.

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.

Decompression of Acute Left-sided Malignant Colorectal Obstruction

Acute left-sided colorectal malignant obstruction is a life-threatening condition and need emergent treatment. Many nonsurgical treatments to palliate obstruction have been developed in clinics. The aim of this study was to evaluate the clinical effects of transanal drainage tube (TDT) and metallic stent for the decompression of acute left-sided malignant colorectal obstruction. Twenty-nine patients with acute left-sided malignant colorectal obstruction were enrolled in this study from January 2005 to December 2010, they were randomly divided into TDT group (13 patients) and metallic stent group (16 patients). There were 13 cases in TDT group (male:female=8:5, age from 65 to 80 y, mean age was 72.6±4.7 y). The sites of lesions were located in the rectum of 3 patients, sigmoid colon of 7 patients, and descending colon of 3 patients. TDT was successfully inserted in 11 cases (84.6%). Among the 11 patients, 1-stage operation with sufficient lymph node dissection was performed in 8 cases after adequate lavage without complications. One case underwent emergent Hartmann operation because of colonic tumor perforation 3 days after ileus tube decompression. Two cases were discharged without surgery after relief of symptom. There were 16 cases in the metallic stent group (male:female=10:6 age from 48 to 86 y, mean age was 73.3±8.5 y). The sites of the lesions were located in the rectum of 4 patients, sigmoid colon of 6 patients, and descending colon of 6 patients. Successful stent placement was achieved in 13 cases (81.3%) with no severe complications. Among the 13 patients, 1-stage operation with sufficient lymph node dissection was performed in 7 cases and 6 cases refused to underwent surgery with stent as the definitive palliative treatment. The price of a TDT is only one third of an expandable metallic stent. Both TDT and metallic stent can achieve preoperative colonic lavage for 1-stage operation for patients with acute left-sided malignant colorectal obstruction with no increase in complications.

Sa1978 A Novel Flexible Endoscopy-Capable Oxygen Probe Can Detect Pancreatic Ischemia in a Rat Model of Chronic Pancreatitis

BACKGROUND: Placement of SES is a therapeutic option for the resolution of malignant colorectal obstruction. AIMS: 1) to evaluate the short and long term clinical outcomes, including survival, of patients after SES placement, 2) to analyze factors that could have an impact in such outcomes and, 3) to assess the safety and efficacy of the SES to resolve the obstruction according to the insertion technique used [radiologic or endoscopic under fluoroscopic guidance (ER method)]. METHODS: The medical records of patients admitted due to obstruction and who underwent insertion of a SES from 2002 to 2012 were reviewed retrospectively. Comparison of patients with obstructive colon cancer (CCR) with patients with non obstructive CCR to assess the influence of the obstruction on survival. Kaplan Meier curves and Cox regression for survival analysis. RESULTS: A total of 196 SES were placed in 179 patients (103 male, mean age 72±12 years). Location of obstruction was distal to splenic flexure in 149 patients (83%). Overall, the causes of obstruction were CCR in 158 patients(88%), diverticulitis in 7(4%) and anastomotic stenosis in 6(3%). 92 SES(47%) were placed by radiologic method and 104 (53%) by ER method. Technical success rates were 95% in both placement method groups. Clinical success rates were 77% and 82% in the radiologic group and in the ER group respectively (p>0.05). Among SES with initial clinical success, rate of complications was higher when using radiologic placement than when using ER method (34% vs 18.5%; p =0.04). Among patients with CCR, SES were used as definitive palliative treatment in 66 patients (42%). Nevertheless, 30% of them (20) required surgery finally due to technical, clinical failure or complications (perforation or reobstruction). In 85 patients with obstructive CCR (54%), SES were used as "bridge to surgery" and avoid emergency surgery, but still 15 patients (18%) required emergency surgery due to technical, clinical failure or SES complications. The median survival was 18 months. Factors associated with a worse survival were: a higher Charlson index (p< 0.001), age (p<0.001), D stage (p< 0.001), no clinical success (p = 0.001), presence of complications (p=0.014) and time to surgery after SES(p=0.002). Patients with obstructive CCR showed a worse survival than patients with non-obstructive CCR [HR: 1.9 (IC95:1.4-2.6), p < 0.001]. There were no differences in gender, age, tumor stage and comorbidity between the two populations. CONCLUSIONS: 1) Clinical outcomes of patients after SES placement for colonic obstruction depend on tumor stage, age, comorbidity, clinical success, complications and time to surgery. Rate of definitive palliative SES placement requiring surgery was high. 2) ER method of SES placement is safer than radiologic method. 3) Obstruction is an independent factor of poor prognosis in patients with CCR.

Sa1429 Dose Carcinomatosis Affect Clinical Outcomes of Patients Receiving SEMS for Malignant Colorectal Obstruction ?

Although carcinomatosis can affect the clinical outcomes of patients receiving self-expandable metallic stents (SEMS) for malignant colorectal obstruction, data dealing with this issue is sparse. We aimed to evaluate clinical outcomes of patients who underwent SEMS insertion for malignant colorectal obstruction based on carcinomatosis status.

Tu1433 Is Endoscopic Colorectal Stenting As a Bridge to Surgery Really Useful for For Obstructive Colorectal Cancer?

Endoscopic colorectal stenting in malignant colorectal obstruction has been reported to have the advantages such as high successful primary anastomosis and low overall stoma rate as a bridge to surgery, shorter hospital stay and cost effectiveness. But recent studies reported that colorectal stenting was no more effective and safe compared to emergency surgery in clinical success rate and overall complication rate. The aim of this study was to compare the outcomes between operation after colorectal stenting and surgery only for curative purpose in patients with colorectal obstruction.

MMP-9 Expression after Metallic Stent Placement in Patients with Colorectal Cancer: Association with In-Stent Restenosis

To verify the expression of matrix metalloproteinase (MMP)-9 in stent-induced hyperplastic tissue from patients with colorectal cancer who received colorectal stents as a bridge to surgery. This prospective study was institutional review board-approved, and informed consent was obtained from all patients. Eleven patients (nine men, two women; mean age, 67 years; age range, 53-82 years) with malignant colorectal obstructions who received a colorectal stent between May and December 2010 were included. Tissue specimens were analyzed for MMP-9 and MMP-2 expression. After resection, the tissue was segmented into three parts: tumor tissue, stent-induced tissue hyperplasia, and normal colon tissue. MMP-9 and MMP-2 expression were determined by using zymography, Western blot analysis, and real-time reverse-transcription (qRT) polymerase chain reaction (PCR). Significance of differences between groups was evaluated with Friedman analysis of variance test. Signed-rank test was used to determine differences between malignant tumor tissue and stent-induced hyperplastic tissue groups. Stent placement was technically successful in all 11 patients. Stent-induced hyperplastic tissues were found in all patients. Zymography (P = .003) and Western blot analysis (P = .008) showed that expression of MMP-9 was higher in malignant tumor tissue and stent-induced hyperplastic tissue groups compared with normal colorectal tissue group, demonstrating significant differences between groups but no significant differences between malignant tumor and stent-induced hyperplastic tissues. As for results of qRT PCR analysis, the stent-induced hyperplastic tissue group showed increases in messenger RNA expression level of MMP-9 compared with the malignant tumor tissue group (50.42-fold ± 66.30 higher). High expression of MMP-9 is closely associated with stent-induced colorectal tissue hyperplasia in patients with colorectal cancer.

The New Nitinol Conformable Self-Expandable Metal Stents for Malignant Colonic Obstruction: A Pilot Experience as Bridge to Surgery Treatment

Introduction. Self-expandable metal stents (SEMS) are a nonsurgical option for treatment of malignant colorectal obstruction also as a bridge to surgery approach. The new nitinol conformable stent has improved clinical outcomes in these kinds of patients. We report a pilot experience with nitinol conformable SEMS placement as bridge to surgery treatment in patients with colorectal obstruction. Materials and Methods. Between April and August 2012, we collected data on colonic nitinol conformable SEMS placement in a cohort of consecutive symptomatic patients, with malignant colorectal obstruction, who were treated as a bridge to surgery. Technical success, clinical success, and adverse events were recorded. Results. Ten patients (7 male (70%)), with a mean age of 69.2 ± 10.1, were evaluated. The mean length of the stenosis was 3.6 ± 0.6 cm. Five patients (50%) were treated on an emergency basis. The median time from stent placement to surgery was 16 days (interquartile range 7–21). Technical and clinical success was achieved in all patients with a significant early improvement of symptoms. No adverse events due to the SEMS placement were observed. Conclusion. This pilot study confirmed the important role of nitinol conformable SEMS as a bridge to surgery option in the treatment of symptomatic malignant colorectal obstruction.

The role of colorectal stent placement in the management of acute malignant obstruction

In recent decades, the use of colorectal stents for palliation or as a bridge to surgery in acute malignant colorectal obstruction has increased. We aimed to evaluate the technical and clinical efficacy, safety and clinical outcomes of endoscopic stenting for the relief of acute colorectal obstruction secondary to cancer. From March 2006 to December 2012, among 100 patients with acute malignant colorectal obstruction, stenting procedures were performed on 42 patients for relief of obstruction. Uncovered self-expanding metal stents (SEMS) were placed endoscopically under fluoroscopic guidance in all patients. Using the patient database, a review was conducted to determine the effectiveness of the procedure and the short- and long-term complications. Stent placement was technically successful in 39/42 (92.8%) and clinically successful in 38/42 (90.4%) patients. Sixteen patients later underwent an elective surgical resection, and in 26 patients with metastatic disease or comorbidity, stent placement was palliative. Complications occurred in 10 (23.8%) patients, and the most common was tenesmus (n=3). Migration, bleeding, and recto-sigmoid perforation occurred in two patients each. Stent obstruction due to fecal impaction was seen in one case. Stent placement for colorectal obstruction is an effective and relatively safe procedure, with minor complications. It not only allows subsequent elective resection, but is also definitive for palliative treatment in patients with obstructive colorectal cancer.

Colonic stent-related complications and their management.

Since its introduction in the early 1990s, the self-expandable metal stent (SEMS) has been increasingly used for the management of malignant colorectal obstruction, not only as a palliative method but also as a preoperative treatment in surgical candidates. However, more recently, concerns have been raised over stent complication rates. Early complications include pain, perforation, and rectal bleeding, and late complications include stent migration and stent obstruction. With the increasing use of SEMS for treatment, physicians need to be more aware of complications occurring after the placement of these stents. This review covers the technical considerations and management of complications after colonic stenting.

Status and Literature Review of Self-Expandable Metallic Stents for Malignant Colorectal Obstruction

Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.

Colorectal stenting vs ileus tube drainage for treatment of acute malignant colorectal obstruction

Colorectal stenting vs ileus tube drainage for treatment of acute malignant colorectal obstruction