Malignant Left-sided Large Bowel Obstruction Research Articles

Delaying surgery for optimization after colonic stent bridging is safe for left-sided malignant large bowel obstruction: Result from 10-year experience and risks factor analysis

AimTo evaluate the operative and oncological results after colonic stent bridging for left-sided malignant large bowel intestinal obstruction and the risk factors for survival and recurrence after definitive surgery. MethodologyConsecutive patients who underwent colonic stenting for malignant left-sided colonic obstruction were included. Patients for palliative stenting or emergency surgery, patient with low rectal tumour or peritoneal metastasis were excluded. The primary outcome was overall survival. Secondary outcomes included stent success rate, stenting related complications, rate of stoma formation and long-term oncological outcome including recurrence rate and recurrence free survival rate. ResultsFrom June 2011 to June 2021, a total of 222 patients underwent colonic stenting. 112 patients were bridged to surgery after initial stenting, but 7 patients dropped out. Overall survival was 35 months (IQR = 17.75–75.25 months) in the early operation group, 30 months (IQR = 17.5–49.5 months) in the delayed surgery group HR 0.981 (95%CI 0.70–1.395, p = 0.907). Sensitivity analysis performed by excluding stent complications and emergency surgery yielded the same conclusion. Overall stenting complications rate was 17.1%. 11 patients (10.4%) required emergency surgery. ConclusionThere was no difference between early and delayed surgery groups (>4weeks) in the overall survival and recurrence in patients who had stent-bridge to surgery for malignant left colonic obstruction. It is safe to defer definitive surgery to optimize patients and allow better recovery from initial obstruction after colonic stenting before definitive surgery without adversely affecting the oncological outcomes.

Endoscopic Stenting for Malignant Left-Sided Large-Bowel Obstruction in Patients with Colorectal Cancer: Evaluation according to Pathological Stage

Introduction: Self-expandable metallic stents (SEMSs) are widely used in patients with malignant left-sided large-bowel obstruction (MLLO) to convert an emergency situation into an elective one. However, the effects of endoscopic stenting on oncological outcomes remain unclear. This study aimed to analyze the oncological outcomes of SEMS placement in patients with MLLO stratified by pathological stage. Methods: We reviewed the data of patients with MLLO that were prospectively collected between January 2005 and December 2016. Patients were divided into those who underwent SEMS placement as a bridge to surgery and those who underwent emergency surgery. Disease-free survival (DFS) and overall survival (OS) were compared between groups, and their prognostic factors were determined by pathological stage. Results: SEMS placement and emergency surgery were performed in 130 and 45 patients, respectively. There was no difference in the 5-year DFS and OS rate between two groups. Subgroup analysis revealed a significant difference in the 5-year DFS and OS rate in patients with stage III MLLO, but was not observed in patients with stage II MLLO. Multivariate Cox regression analysis for stage III MLLO revealed endoscopic stenting (hazard ratio [HR], 2.051; 95% confidence interval [CI], 1.018–4.131; p = 0.044) as the only prognostic factor for DFS. Age, tumor differentiation, perineural invasion, and endoscopic stenting (HR, 3.189; 95% CI, 1.346–7.556; p = 0.008) were prognostic factors for OS. Conclusion: In terms of oncologic outcomes, endoscopic stenting might be more beneficial than ES in patients with stage III MLLO.

Clinical Significance of Surgical Resection Timing from Endoscopic Stenting for Left-Sided Large-Bowel Obstruction in Colorectal Cancer.

The optimal interval between self-expanding metallic stent (SEMS) insertion and surgery remains controversial in malignant left-sided large-bowel obstruction (MLLO), especially with respect to oncologic aspects. The aim of this study is to examine whether the time interval to surgery is related to oncologic outcomes. Prospectively collected database of MLLO between January 2005 and December 2017 were reviewed. They were divided according to established cut-off value of 14days for the time interval to surgery. The two groups (early and late groups) were compared with respect to disease-free survival (DFS) and overall survival (OS). Additional subgroup analysis was performed using the established cut-off values for patients with stage II and III tumors. A total of 149 patients underwent surgery after SEMS insertion. There were no significant differences between the early and late groups in the 5-year DFS (78.0% vs 72.4%; P = 0.513) and the OS (74.2% vs 75.7%; P = 0.864) rates in all MLLO. Subgroup analysis showed that there were significant differences between the two groups for DFS and OS in stage II MLLO. The multivariate Cox regression analysis in stage II MLLO demonstrated that the time to surgery was a prognostic factor for DFS (HR, 2.051; 95% CI, 1.528-42.136; P = 0.014) and for OS (HR, 4.947; 95% CI, 1.520-16.107; P = 0.008). The time to surgery was demonstrated not to be a significant prognostic factor in all MLLO. However, it was a prognostic factor for patients with stage II MLLO.

Transanal decompression tube is superior to self‐expandable metallic colonic stent for malignant colorectal obstruction: a retrospective study

The surgical management of left-sided malignant large bowel obstruction (MLBO) is associated with high morbidity and mortality. Recently, self-expandable metallic colonic stent (SEMS) and transanal decompression tube (TDT) used as a 'bridge to surgery' (BTS) have been widely used. This study aims to compare the clinical outcomes and oncological safety of SEMS and TDT as BTS to transform MLBO into elective surgery. Between February 2013 and March 2019, 62 patients with MLBO received SEMS (n=32) or TDT (n=30), and elective one-stage surgery later. We evaluated decompression efficiency and oncological safety in selective operation in TDT and SEMS groups, including preoperative preparation time, surgical approach, number of lymphatic dissection and vascular invasion, ulcer formation and histopathological findings of resected specimens. The preoperative preparation time in the SEMS group was shorter than that of the TDT group (P < 0.05). However, there was no significant difference between the groups in postoperative length of hospital stay (P > 0.05). The number of vascular invasions in the TDT group was less than that in the SEMS group (P < 0.05). Furthermore, the risk of wound abscess and ulcer formation in the TDT group was significantly lower than that in the SEMS group (P < 0.05). Our findings suggest that SEMS is associated with a relatively poor oncological outcome and the placement of TDT as BTS in MLBO patients may be a better alternation.

Long-term Oncologic Results After Stenting as a Bridge to Surgery Versus Emergency Surgery for Malignant Left-sided Colonic Obstruction: A Multicenter Randomized Controlled Trial (ESCO Trial).

To assess overall (OS), time to progression (TTP), and disease-free survival (DFS) at 3 years after treatment, comparing stenting as bridge-to-surgery (SBTS) versus emergency surgery (ES) in neoplastic left colon obstruction, secondary endpoints of the previously published randomized controlled trial. While SBTS in neoplastic colon obstruction may reduce morbidity and need for a stoma compared with ES, concern has been raised, about long-term survival. Individuals affected by left-sided malignant large-bowel obstruction were enrolled from 5 European hospitals and randomly assigned (1:1 ratio) to receive SBTS or ES. The computer-generated randomization sequence was stratified by center on cT and concealed by the use of a web-based application. Investigators and participants were unmasked to treatment assignment. The secondary outcomes analyzed here were OS, TTP, and DFS. Analysis was by intention to treat. This study is registered, ID-code NCT00591695. Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 115 (SBTS n = 56, ES n = 59) were eligible for analysis, while 20 participants were excluded for a benign disease, 1 for unavailability of the endoscopist while 8 withdrew from the trial. With a median follow-up of 37 months (range 1-62), no difference was observed in the SBTS group compared with ES in terms of OS (HR 0.93 (95% CI 0.49-1.76), P = 0.822), TTP (HR 0.81 (95% CI 0.42-1.54), P = 0.512), and DFS (HR 1.01 (95% CI 0.56-1.81), P = 0.972). Planned subgroup analysis showed no difference in respect to age, sex, American Society for Anesthesiology score, body mass index, and pT between SBTS and ES groups. Those participants randomized for the SBTS group whose obstruction was located in the descending colon had a better TTP compared with ES group (HR 0.44 (95% CI 0.20-0.97), P = 0.042), but no difference was observed in terms of OS (HR 0.73 (95% CI 0.33-1.63), P = 0.442) and DFS (HR 0.68 (95% CI 0.34-1.34), P = 0.261) in the same individuals. This randomized controlled trial shows that, although not powered for these seconday outcomes, OS, TTP, and DFS did not differ between groups at a minimum follow-up of 36 months.

Comparative study between colonic metallic stent and anal tube decompression for Japanese patients with left-sided malignant large bowel obstruction

BackgroundSurgical management of malignant bowel obstruction carries with high morbidity and mortality. Placement of a trans-anal decompression tube (TDT) has traditionally been used for malignant bowel obstruction as a bridge to surgery. Recently, colonic metallic stent (CMS) as a bridge to surgery for malignant bowel obstruction, particularly left-sided malignant large bowel obstruction (LMLBO) caused by colorectal cancer, has been reported to be both a safe and feasible option. The aim of this retrospective study is to evaluate the clinical effects of CMS for LMLBO as a bridge to surgery compared to TDT.MethodsBetween January 2000 and December 2015, we retrospectively evaluated outcomes of 59 patients with LMLBO. We compared the outcomes of 26 patients with CMS for LMLBO between 2013 and 2015 (CMS group) with those of 33 patients managed with TDT between 2003 and 2011 (TDT group) by the historical study. LMLBO was defined as a large bowel obstruction due to a colorectal cancer that was diagnosed by computed tomography and required emergent decompression.ResultsAll patients in the CMS group were successfully decompressed (p = 0.03) and could initiate oral intake after the procedure (p < 0.01). Outcomes in the CMS group were superior to the TDT group in the following areas: duration of tube placement (p < 0.01), surgical approach (p < 0.01), operation time (p < 0.01), number of resected lymph nodes (p < 0.001), and rate of curative resection (p < 0.01). However, no significant differences were found in the overall postoperative complication rate (p = 0.151), surgical site infection rate (p = 0.685), hospital length of stay (p = 0.502), and the need for permanent ostomy (p = 0.745). The 3-year overall survival rate of patients in the CMS and TDT groups was 73.0% and 80.9%, respectively, and this was not significant (p = 0.423).ConclusionsTreatment with CMS for patients with LMLBO as a bridge to surgery is safe and demonstrated higher rates of resumption of solid food intake and temporary discharge prior to elective surgery compared to TDT. Oncological outcomes during mid-term were equivalent.

Endoscopic Stenting as Bridge to Surgery versus Emergency Resection for Left-Sided Malignant Colorectal Obstruction: An Updated Meta-Analysis.

Introduction Emergency resection represents the traditional treatment for left-sided malignant obstruction. However, the placement of self-expanding metallic stents and delayed surgery has been proposed as an alternative approach. The aim of the current meta-analysis was to review the available evidence, with particular interest for the short-term outcomes, including a recent multicentre RCT. MethodsWe considered randomized controlled trials comparing stenting as a bridge to surgery and emergency surgery for the management of left-sided malignant large bowel obstruction, performing a systematic review in MEDLINE, PubMed database, and the Cochrane libraries. ResultsWe initially identified a total of 2543 studies. After the elimination of duplicates and the screening of titles and abstracts, seven studies, for a total of 448 patients, were considered. The current meta-analysis revealed no difference in the mortality rate between the stent group and the emergency surgery group; the postoperative complication rate (37.84% versus 54.87%, P = 0.02), the stoma rate (28.8% versus 46.02%, P < 0.0001), and the incidence of wound infection (8.11% versus 15.49%, P = 0.01) were reduced after stent as a bridge to surgery. Conclusion Colonic stenting as a bridge to surgery appears to be a safe approach to malignant large bowel obstruction. Possible advantages of this treatment can be identified in a reduced incidence of postoperative complications and a lower stoma rate. Further RCTs considering long-term outcomes and cost-effectiveness analysis are needed.

Primary colon resection or Hartmann's procedure in malignant left-sided large bowel obstruction? The use of stents as a bridge to surgery

There is still significant debate regarding the best surgical treatment for malignant left-sided large bowel obstruction. Primary resection and anastomosis offers the advantages of a definite procedure without need for further surgery. Its main disadvantages are related to the increased technical challenge and to the potential higher risk of anastomotic leakage that occurs in the emergency setting. Primary resection with end colostomy (Hartmann's procedure) is considered the safer option. Tan et al compared in a systematic review and meta-analysis the use of self-expanding metallic stents (SEMS) as a bridge to surgery vs emergency surgery in the management of acute malignant left-sided large bowel obstruction. The authors concluded that the technical and clinical success rates for stenting were lower than expected. SEMS was associated with a high incidence of clinical and silent perforation. Stenting instead of loop colostomy can be recommended only if the appropriate expertise is available in the hospital. The goal of stenting, a decrease of the stoma rate, may be advocated only if the complication rates of stenting are lower than those of stoma creation in the emergency situation. Until now, this was not demonstrated in a prospective randomized trial.

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction (Br J Surg 2012; 99: 469–476)

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery <i>versus</i> emergency surgery for malignant left-sided large bowel obstruction (<i>Br J Surg</i> 2012; 99: 469–476)

Authors' reply: Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction (Br J Surg 2012; 99: 469–476)

Authors' reply: Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery <i>versus</i> emergency surgery for malignant left-sided large bowel obstruction (<i>Br J Surg</i> 2012; 99: 469–476)

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction (Br J Surg 2012; 99: 469–476)

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery <i>versus</i> emergency surgery for malignant left-sided large bowel obstruction (<i>Br J Surg</i> 2012; 99: 469–476)

Authors' reply: Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction (Br J Surg 2012; 99: 469–476)

Authors' reply: Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery <i>versus</i> emergency surgery for malignant left-sided large bowel obstruction (<i>Br J Surg</i> 2012; 99: 469–476)

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction

Use of self-expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left-sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta-analysis evaluated high-quality evidence comparing preoperative SEMS with emergency surgery. Relevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990-2011). Primary outcomes were primary anastomosis, stoma and in-hospital mortality rates. Secondary outcomes included anastomotic leak, 30-day reoperation and surgical-site infection rates. Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in-hospital mortality, anastomotic leak, 30-day reoperation and surgical-site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent-related complications and increased 30-day morbidity following SEMS management. Technical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality.

Malignant left-sided large bowel obstruction managed by subtotal/total colectomy

Of 60 patients presenting with acute obstructing carcinoma of the left colon, 49 underwent immediate resection either by radical subtotal/total colectomy (31 patients, group I) or by radical segmental resection (18 patients, group II) of whom three had immediate anastomosis after on-table bowel irrigation and 15 had a planned staged procedure. The operative mortality rate was 3 per cent in group I and 11 per cent in group II (not a statistically significant difference). However, substantial differences were found for major morbidity (6 versus 44 per cent in groups I and II respectively; P less than 0.01) and mean length of hospital stay (17 days in group I versus 35 days in group II; P less than 0.05). All three patients who had on-table lavage developed anastomotic leaks which necessitated a second operation to form a stoma. Six patients (19 per cent) in group I required antidiarrhoeal medication in the immediate postoperative period. However, subsequent improvement in stool frequency was noted in all patients. It is concluded that subtotal/total colectomy is an acceptable means of managing patients with obstructing carcinoma of the left colon in that it is associated with a low morbidity and mortality rate and good functional results.

Stenting for obstructing colorectal malignancy: an interim or definitive procedure.

The purpose of this paper is to review and report our experience with colorectal stenting in the management of malignant large bowel obstruction. Twelve consecutive patients with malignant left-sided large bowel obstruction between June 1998 and January 2001 underwent insertion of self-expanding metallic stents. One patient required two stents. Eight stents were inserted under fluoroscopic guidance, and five were inserted with combined fluoroscopic and endoscopic guidance. Patients were followed up until death, stent removal or the time of publication. Thirteen stents were inserted. Eleven patients with acute large bowel obstruction had relief of obstruction with stenting, and one of these patients required a second stent because relief had been incomplete. One patient was stented in order to subsequently close a problematic stoma. Technical success was 92.9% and clinical success was 100%. Three patients proceeded to surgical resection. In nine patients, the stent was left as the definitive procedure. Of these, six patients have died within 4 months. Complications included one case of migration, one case of reobstruction, one intestinal haematoma and one case of cheesewiring. Colorectal stenting is an important treatment modality for malignant large bowel obstruction. It may be definitive treatment alone, or a bridge to elective surgical resection.