Obstructive Colon Cancer Research Articles

Analysis of the effect of emergency primary resection and anastomosis in the treatment of obstructive left hemicolon cancer and the value of preventing reoperation

Objective To study and evaluate the clinical effect of emergency primary resection and anastomosis in the treatment of obstructive left hemicolon carcinoma and the value of preventing reoperation. Methods From February 1st 2013 to February 1st 2018, a total of 46 patients with obstructive left hemicolon cancer underwent surgical treatment were selected in the First People's Hospital of Jinzhong.According to the random digital table method, 46 patients with obstructive left colon cancer were randomly divided into two groups, with 23 patients in each group.The control group received stage colon resection and anastomosis, and the observation group received stage I resection and anastomosis.The operative condition, postoperative recovery, anastomotic leakage, therapeutic effect of intestinal obstruction, serum inflammatory cytokines and reoperation rate were compared between the two groups. Results There were no statistically significant differences in the number of lymph nodes dissection, the amount of blood lost during operation and time of operation (all P>0.05). The recovery time of anal exhaust[(2.34 ±0.86)d], the removal time of drainage tube[(4.36±1.52)d], the active time of getting out of bed [(3.81±1.17)d], the hospitalization time[(12.05 ±2.73)d] in the observation group were significantly shorter than those in the control group[(3.29±1.05)d, (6.17±1.84)d, (5.24±1.43)d, (15.76±3.69)d](t=3.357, 3.637, 3.712, 3.876, all P 0.05), and there was no statistically significant difference in the total effective rate of intestinal obstruction treatment between the two groups (P>0.05). The levels of serum inflammatory cytokines such as C-reactive protein, interleukin-6 and tumor necrosis factor-alpha in the two groups were significantly lower than those before operation(all P 0.05). The rates of reoperation in the observation group and control group were 8.70% and 4.35%, respectively, and there was no statistically significant difference between the two groups (P>0.05). Conclusion Stage I resection and anastomosis can be used to treat intestinal obstruction effectively, dissect lymph nodes, suppress inflammatory reaction, it is safe and reliable, and do not increase the risk of reoperation.Compared with stage I resection and anastomosis, it has more advantages in accelerating postoperative recovery, which is beneficial to reduce the cost of treatment and reduce the economic burden of patients. Key words: Intestinal obstruction; Colonic neoplasms; Gastroenterostomy; Anastomotic leak; Emergency treatment; Treatment outcome

Emergency Surgery for Obstructive Colon Cancer in Elderly Patients: Results of a Multicentric Cohort of the French National Surgical Association.

Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited. The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer. This was a multicenter, retrospective cohort study. Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging. Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years. Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population. A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure. A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75-84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09). It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration. Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964.

P-175 - The optimal time interval between self-expandable metallic stent placement and elective operation in patients with obstructive colon cancers: a multicenter retrospective analysis

P-175 - The optimal time interval between self-expandable metallic stent placement and elective operation in patients with obstructive colon cancers: a multicenter retrospective analysis

Obstruction is associated with perineural invasion in T3/T4 colon cancer

Perineural invasion (PNI) is a risk factor for recurrence and metastasis and consequently leads to decreased survival in patients with various malignancies. Recent studies showed that stent placement in obstructive colon cancer increases the frequency of PNI. We hypothesized that mechanical stress including obstruction itself may be associated with PNI. We retrospectively reviewed 496 patients with pathological T3 or T4 colon cancer who did not receive preoperative treatment. Data were collected from medical charts and pathological findings. The relationships between PNI and other clinicopathological factors were analysed using univariate and multivariate analyses. PNI was observed in 239 (48%) patients. Obstruction was markedly more frequent in PNI-positive cancer (39%) than in PNI-negative cancer (24%, P=0.0003). Multivariate analyses identified obstruction as one of the significant factors associated with PNI (OR 1.68, P=0.028). Moreover, in 414 patients without distant metastasis who underwent complete resection, PNI was an independent factor associated with poor recurrence-free survival (hazard ratio 2.35, P=0.003). The coexistence of PNI and obstruction resulted in greater decreases in recurrence-free survival than PNI-negative and/or non-obstructive cases. Our results suggest that obstruction is associated with PNI and consequently contributes to an increased postoperative recurrence in colon cancer.

Oncologic Outcomes of Self-Expandable Metallic Stent as a Bridge to Surgery and Safety and Feasibility of Minimally Invasive Surgery for Acute Malignant Colonic Obstruction.

Although self-expandable metal stents (SEMS) are widely used as a bridge to surgery (BTS) in patients with malignant colorectal cancer obstruction, there has been some debate about their effect on long-term oncological outcomes. Furthermore, data on the safety and feasibility of minimally invasive surgery (MIS) combined with stent placement are scarce. We aimed to determine the long-term oncological outcomes of SEMS as a BTS, and the short-term outcomes of SEMS used with minimally invasive colorectal surgery. Data from patients who were admitted with malignant obstructing colon cancer between January 2006 and December 2015 were retrospectively reviewed; 71 patients underwent direct surgery and 182 patients underwent SEMS placement as a BTS. Long-term and short-term outcomes of the groups were compared. In a subgroup analysis of the BTS group, the short-term outcomes of conventional open surgery and MIS were compared. There were no differences in long-term oncologic outcomes between groups. The primary anastomosis rate was higher in the stent group than in the direct surgery group. In the stent group, postoperative complication rates were lower in the minimally invasive group than in the open surgery group. Time to flatus and time to soft diet resumption were shorter in the minimally invasive group, as was length of hospital stay. Elective surgery after stent insertion does not adversely affect long-term oncologic outcomes. Furthermore, MIS combined with stent insertion for malignant colonic obstruction is safe and feasible.

30-Day Postoperative Morbidity of Emergency Surgery for Obstructive Right- and Left-Sided Colon Cancer in Obese Patients: A Multicenter Cohort Study of the French Surgical Association

Background: Emergency surgery impairs postoperative outcomes in colorectal cancer patients. No study has assessed the relationship between obesity and postoperative results in this setting. Objective: To compare the results of emergency surgery for obstructive colon cancer (OCC) in an obese patient population with those in overweight and normal weight patient groups. Methods: From 2000 to 2015, patients undergoing emergency surgery for OCC in French surgical centers members of the French National Surgical Association were included. Three groups were defined: normal weight (body mass index [BMI] < 25.0 kg/m²), overweight (BMI 25.0–29.9 kg/m²), and obese (BMI ≥30.0 kg/m²). Results: Of 1,241 patients, 329 (26.5%) were overweight and 143 (11.5%) were obese. Obese patients had significantly higher American society of anesthesiologists score, more cardiovascular comorbidity and more hemodynamic instability at presentation. Overall postoperative mortality and morbidity were 8 and 51%, respectively, with no difference between the 3 groups. For obese patients with left-sided OCC, stoma-related complications were significantly increased (8 vs. 5 vs. 15%, p = 0.02). Conclusion: Compared with lower BMI patients, obese patients with OCC had a more severe presentation at admission but similar surgical management. Obesity did not increase 30-day postoperative morbidity except stoma-related complications for those with left-sided OCC.

The ability of positron emission tomography/computed tomography to detect synchronous colonic cancers in patients with obstructive colorectal cancer.

Positron emission tomography/computed tomography (PET/CT) is frequently used to detect colorectal cancer. The present retrospective study assessed the ability of PET/CT to identify synchronous colonic lesions in 72 patients with obstructive colorectal cancer. All patients had undergone surgical resection without undergoing preoperative total colonoscopy (TCS) at the Digestive Disease Center (April 2007 to September 2016), and subsequently underwent TCS of the proximal colon within 2 years post-surgery. A total of 11 patients exhibited 18F-fluorodeoxyglucose uptake during PET/CT of the proximal colon (4 invasive cancers, 3 advanced adenomas and 4 false-positive results), and 61 patients had no uptake in the proximal colon. Among these 61 patients, postoperative TCS revealed 2 invasive cancers and 4 advanced adenomas. The sensitivity of PET/CT for detecting synchronous invasive cancers was 66.6% (4/6), with a specificity of 89.4% (59/66), a positive predictive value of 36.4% (4/11), a negative predictive value of 96.7% (59/61), and an accuracy of 87.5% (63/72). Negative PET/CT results indicated a low probability of synchronous lesions in the proximal colon. Thus, PET/CT may be a useful tool for detecting synchronous colonic cancers in patients with obstructive colon cancer.

Long-term oncologic outcomes of laparoscopic versus open resection following stent insertion for obstructing colon cancer: a multi-center retrospective study.

This study compared oncologic outcomes between open and laparoscopic surgery following self-expanding metallic stents insertion for obstructing colon cancer. This retrospective study included 50 patients who underwent open surgery and 44 patients who underwent laparoscopic surgery for obstructing left-sided colon cancer at four tertiary referral hospitals between June 2005 and December 2013. The median follow-up periods were 48months and 47months in the open and laparoscopic groups, respectively. The median operative time, time to soft diet, and length of stay were comparable between the groups. Four cases converted to open surgery (9.1%) in the laparoscopic group. The morbidity within 30days after surgery was comparable between the groups (OR 0.931; 95% CI 0.357-2.426; p = 0.884). The proximal and distal resection margins, the histologic grade of tumor, TNM stage, median tumor size, and presence of lymphovascular invasion did not differ significantly between the groups. The 5-year overall survival (OS) rates of the open and laparoscopic groups were 67.1% and 71.7% (HR 1.028, 95% CI 0.491-2.15, p = 0.942) and the 5-year disease-free survival (DFS) rates were 55.8% and 61.5% (HR 0.982; 95% CI 0.522-1.847; p = 0.955), respectively. The recurrence pattern did not differ between the groups. Multivariate analysis showed that sex (p = 0.027), nodal stage (p = 0.043), and the proportion of patients receiving postoperative adjuvant chemotherapy (p = 0.002) were independent prognostic factors for OS. The proportion of patients receiving postoperative adjuvant chemotherapy (p = 0.017) was an independent prognostic factor for DFS. Laparoscopic resection following stent insertion for obstructing colon cancer can be performed safely, with long-term oncologic outcomes comparable with those of open surgery.

Correlation between a continent ileocecal valve and CT signs of severity in patients presenting with obstructive colonic cancer.

To study the association of a continent ileocecal valve and the degree of severity of the CT signs in patients presenting with large bowel obstruction due to colonic cancer. Sixty-six patients undergoing emergency surgery for confirmed obstructive colonic cancer were included. The CT examinations were analyzed without consultation of the surgical results. For each patient, the diameter of the cecum at its widest point and that of the last ileal loop were measured. The ileocecal valve was considered incontinent when there was a distension of the last ileal loop greater than or equal to 25mm. Below 25mm, the ileocecal valve was considered continent. The presence of CT signs of severity of the LBO was noted, i.e., intestinal pneumatosis, absence of contrast enhancement of the large bowel wall, defect in the large bowel wall, and presence of extra-digestive air and ascites. Among the 66 patients included, 42 had an incontinent ileocecal valve and 24 had a continental ileocecal valve. There was a statistically significant difference between the two groups in the diametrical measurements of the cecum's widest point (mean diameter measured at 10.3cm in patients with continent ileocecal valve vs 8.4cm in patients with incontinent ileocecal valve, P = 0.0023). Patients with a continent valve had statistically higher rates of CT severity (79% vs 40%, P < 0.005). Perforation of the cecum remained rare (8%) and was only observed in patients with continent ileocecal valve in our series. Continence of the ileocecal valve appears to be statistically correlated both with cecum distension and the presence of CT signs of severity in patients with obstructive colonic cancer. As such, its presence must be retained as a risk factor for a pejorative evolution of this type of LBO and must be specified in the CT report of these patients.

The efficacy of endoscopic stenting combined with laparoscopy in the treatment of left colon cancer with obstruction.

Endoscopic self-expandable metal stents (SEMSs) are the bridge of obstructive colorectal cancer surgery. The debate is still open on whether the procedure and effects can be the same between the SEMS combined obstructive colon cancer resection and nonobstructive colon cancer resection, both of which were under laparoscopic. This retrospective study was designed to compare whether the same effects could be achieved in both resections. The retrospective analysis was from September 2016 to November 2017. In the observation group (OG), 20 patients hospitalized for obstruction of the left colon cancer were included, who received obstructive colon cancer laparoscopic resection (LR) combined with SEMS insertion. In control group (CG), 20 patients were randomly selected, who underwent nonobstructive colon cancer LR during this period. The differences between the two groups were compared, including operation time, intraoperative blood loss, the number of removed lymph nodes, postoperative anal exhaust time, and hospital stay. Both groups were comparable in the age, gender, weight, the distribution of tumor, lymph node metastasis, tumor, node, and metastasis staging, operation time, intraoperative blood loss, the number of removed lymph nodes, and postoperative anal exhaust time. The hospital stay was 15.2 ± 1.3 days and 14.2 ± 1.5 days in OG and CG, respectively, and it was longer in OG than that of in CG (P = 0.032). Obstructive colon cancer LR combined with SEMS insertion was a safe and feasible radical treatment strategy. The same level of procedure and effects could be achieved, compared to that of nonobstructive colon cancer LR.

Sensitivity and positive predictive value of the registration of self-expanding metal stent treatment for obstructive colorectal cancer in two Danish nationwide registries.

BackgroundRandomized controlled trials have not provided clear evidence for the use of self-expanding metal stents (SEMS) for colonic cancer obstruction. Existing observational research mainly originates from highly specialized single-center settings with limited generalizability. The conduct of population-based nationwide studies is possible by using Danish medical databases. However, the quality of the coding of SEMS procedures in these databases is unclear.MethodsFrom March 1, 2010 through December 31, 2013, we compared the registration of SEMS procedures among obstructive colorectal cancer patients in the Danish National Patient Register (DNPR) and the Danish Colorectal Cancer Group (DCCG) database to the registration in a prospective SEMS database (the reference standard).ResultsNinety-three patients were included in the reference standard for the evaluation of DNPR data. In the DNPR, only two patients were incorrectly registered (positive predictive value [PPV]=98%, 95% CI: 92%–100%) whereas six patients were not captured by the DNPR (sensitivity =94%, 95% CI: 87%–98%). For the evaluation of the DCCG database, the reference standard included 54 patients. Only two patients in the DCCG database were incorrectly recorded (PPV =95%, 95% CI: 82%–99%), whereas 19 patients were not captured by the DCCG database (sensitivity =65%, 95% CI: 51%–77%).ConclusionWe found high PPV and sensitivity of SEMS coding in the DNPR, supporting the use of these data in future research. The PPV of SEMS data in the DCCG database was high, but the sensitivity was low, suggesting that data on SEMS treatment from this database should be used with caution.

Safety and feasibility of the combined medial and caudal approach in laparoscopic D3 lymphadenectomy plus complete mesocolic excision for right hemicolectomy in the treatment of right hemicolon cancer complicated with incomplete ileus

To explore the safety and feasibility of the combined medial and caudal approach in laparoscopic D3 lymphadenectomy plus complete mesocolic excision(CME) for right hemicolectomy in the treatment of right hemicolon cancer complicated with incomplete ileus. Clinical data of 65 patients with incomplete obstructive right-sided colon cancer (T1 to 4M0) diagnosed by abdominal CT enhanced scan or MRI and/or electric colonscope undergoing laparoscopic right hemicolectomy (D3 lymphadenectomy + CME) at Department of Emergency Medicine and Department of Gastrointestinal Surgery from June 2014 to June 2017 were retrospectively analyzed. Among them, 33 patients received the combined medial and caudal approach (combined medial and caudal approach group) and the other 32 patients received the cephalo medial-to-lateral approach (cephalo medial-to-lateral approach group). The operation highlights of the combined medial and caudal approach group were as follows: (1) The superior mesenteric vein (SMV) was first identified and exposed using the combined medial and caudal approach, and lymph node dissection along the anterior and right of SMV was performed. (2) With horizontal part of duodenum as landmarks, the dorsal mesenteric membrane of terminal ileum was opened by caudal-to-cranial approach, and right retroperitoneal space along the Toldt's space was separated. The anterior of pancreatic head and the right Toldt's space were then exposed. (3) Finally using medial-to-lateral approach, the roots of ileocolic vessels, middle colic vessel and right colic vessel were disconnected and ligated along the left border of SMV. The right branch of gastrocolic trunk of Henle was ligated and lymph node dissection along SMV was performed again. Patients in cephalo medial-to-lateral approach group underwent conventional operation. Baseline information, intraoperative blood loss, operation time, number of harvested lymph nodes, proportion of no less than 12 harvested lymph nodes per case, postoperative hospital stay and postoperative morbidity in both groups were analyzed and compared. Thirty-eight males and 27 females with age of 31 to 72 (56.8±11.7) years were enrolled in this study. There was no significant difference in baseline information between combined medial and caudal approach group and cephalo medial-to-lateral approach group(all P>0.05). Intraoperative blood loss [(106.5±24.5) ml vs. (308.4±27.1) ml, t=-31.501, P=0.000] was significantly less, and operative time [(176.3 ± 18.0) minutes vs. (208.4 ± 47.3) minutes, t=-3.602, P=0.001] was significantly shorter in the combined medial and caudal approach group. The proportion of no less than 2 harvested lymph nodes per case [87.9%(29/33) vs. 84.4%(27/32)], the number of harvested lymph nodes (22.5±8.9 vs. 21.5± 7.6), postoperative morbidity of complication [6.1%(2/33) vs. 12.5%(4/32)] and postoperative hospital stay [(11.9±1.5) days vs. (13.4±4.4) days] were not significantly different between the two groups(all P>0.05). The combined medial and caudal approach in laparoscopic right hemicolectomy (D3+CME) in the treatment of incomplete obstructive right-sided colon cancer is safe and feasible, and has advantages of less intraoperative blood loss and shorter operation time compared to the cephalo medial-to-lateral approach.

Critical appraisal of oncological safety of stent as bridge to surgery in left-sided obstructing colon cancer; a systematic review and meta-analysis.

This meta-analysis aims to determine the long-term oncological outcomes of SEMS as bridge to surgery (BTS) versus emergency surgery (ES). A systematic search without restrictions was conducted, and all studies comparing SEMS with ES reporting on long-term outcomes were included. Methodological quality was assessed using the appropriate tools. Twenty-one comparative studies were selected, reporting on 1919 patients. Meta-analysis showed no significant difference regarding three- and five-year overall survival (OR = 0·85 (0·68-1·08) and OR = 1·04 (0·68-1·57), respectively), disease-free survival (OR = 0·96 (0·73-1·26) and OR = 0·86 (0·54-1·36), respectively) and local recurrence rate (OR = 1·32 (0·78-2·23)). Permanent stomas were significantly lower in the SEMS group (OR 0·49 (0·32-0·74)). Sensitivity analysis on three-year survival showed opposite outcomes, with a trend towards worse survival in the SEMS group when only RCTs are taken into account. In conclusion, when in experienced hands, SEMS placement as BTS seems oncologically safe.

Postoperative morbidity and mortality for malignant colon obstruction: the American College of Surgeon calculator reliability

BackgroundThe American College of surgical risk calculator (SRC) score has never been validated specifically for surgery in emergency. The objective was to evaluate the reliability of this calculator in patients with malignant colon obstruction. Materials and methodsWe retrospectively have analyzed the morbidity and mortality observed in operated patients. Risk factors for postoperative morbidity and mortality were analyzed by logistic regression model. We have compared the morbidity and mortality estimated by the SRC score with that observed using the Brier Score (BS). A BS of 0 indicated perfect prediction, whereas a BS of 1 indicated the poorest prediction. ResultsSixty-nine patients aged 75 y (41-93) have been operated on emergency from November 2001 to August 2015. The tumor was localized in the sigmoid in 33 cases (48%), in the splenic flexure in nine cases (13%), and in the right colon in 17 cases (25%). The surgical procedures were as follows: right colectomy with anastomosis (29%), diverting proximal iliac colostomy (23%), and subtotal colectomy with anastomosis (19%). The SRC score indicated a good predictivity for mortality (9.8% predicted versus 8.7% observed, BS = 0.058), for morbidity (33.4% versus 40.6%, BS = 0.209), and for serious morbidity (25.5% versus 17.4%, BS = 0.131). In multivariate analysis, SRC was an independent risk factor for mortality (P = 0.030 odds ratio [OR] = 1.07 [1.01-1.15]) and morbidity (P = 0.001 OR = 1.16 [1.08-1.27]). ConclusionsSRC score is a reliable tool for assessing the morbidity and mortality of obstructive colon cancer and could help with adapting the surgical gesture to the risks predicted.

Assessment of Colonic Anastomosis after Surgical Management of Obstructed Left Colonic Cancer Performing Primary Repair with or without Proximal Diversion

Background: Up to 20% of patients with colorectal cancer present with obstruction. The goal of this study was to compare the short-term outcomes of patients with obstructing colon cancer who underwent resection and primary anastomosis with or without proximal diversion. Objective: This study was carried out in Surgery Department of Zagazig University Hospitals from February 2000 to February 2018 to compare the on-table irrigation and primary anastomosis versus proximal diversion with loop proximal diversion. Patients and methods: This study comprised 2525 patients who were divided into 2 groups: Group A included 2322 patients who have undergone on table lavage and primary anastomosis. Group B included 203 patients who have undergone primary anastomosis with proximal ileostomy. In our study, 1431 patients were males and 1094 patients were females. All patients were well prepared and investigated for selection of patients who can be operated. All patients were operated and discharged from the hospital and followed up in outpatient clinic of Zagazig University Hospitals, Surgery department. Results: As regard the age, there was a highly significant difference in the age of the two groups (p=0.004) while there was no significance in the sex of the studied groups (p=0.61). As regard the tumor location there was no significance (p=0.298). The intraoperative time was increased in case of on table irrigation with a significant difference (p=0.001). There was also a significant difference in the postoperative hospital stay (p=0.001). There was no significance regarding the postoperative complications of the studied groups expect stoma complications in case of diversion (p=0.001). Conclusion: On table colonic lavage and primary anastomosis is favored in surgical management of acute obstructed left sided colon cancer in low risk patients while in high risk older patients primary anastomosis with a covering stoma is preferred for fear of leakage and a covering loop ileostomy is preferred than loop colostomy.

Staged Treatment for Obstructive Colon Cancer with Severe Aortic Valve Stenosis following Insertion of a Colonic Stent of Two Cases

Staged Treatment for Obstructive Colon Cancer with Severe Aortic Valve Stenosis following Insertion of a Colonic Stent of Two Cases

Timing of Definitive Operative Intervention in Cases of Obstructing Colon Cancers Following Emergent Stent Placement: A Retrospective Review

Timing of Definitive Operative Intervention in Cases of Obstructing Colon Cancers Following Emergent Stent Placement: A Retrospective Review

Ten-year survival after endoscopic stent placement as a bridge to surgery in obstructing colon cancer

Self-expandable metal stents are used increasingly in the treatment of obstructing colorectal cancer (CRC). Although endoscopic colon stenting is widely accepted in palliation, disagreement exists about its role in a curative setting. This study aims to describe long-term survival data in a large patient group treated with colon stenting as a bridge to surgery for CRC. This prospective study included 97 patients who presented in a Belgian hospital between 1998 and 2013 with obstructing, although potentially curable, CRC. All patients underwent endoscopic stenting as a bridge to surgery. Procedure-related adverse events and long-term follow-up data were retrospectively collected and compared with the CRC mortality in Belgium in the same time span. Overall survival in this observational cohort did not differ significantly from survival in all Belgian patients with CRC in the same period (P= .14). One-year, 5-year, and 10-year survival rates were similar in both groups (95.9% vs 79.0%; 54.7% vs 51.2%; 41.0% vs 35.6%, respectively). The technical success rate was 94.8%. Seventy-three patients did not experience any adverse event. Stent migration occurred in 9 patients, whereas micro-perforations and macro-perforations were observed in 14 patients, without influence on survival. Incidence rates of peritoneal metastases did not differ between patients with and without any type of perforation (22.2% vs 15.2%, respectively; P= .47). The type of stent influenced the overall adverse event risk, mainly driven by a significant increase in stent migration in case of Wallstent enteral (Boston Scientific Corporation, Natick, Mass). Colon stenting before surgery is effective and did not worsen the survival outcome in patients with obstructing CRC who were treated with curative intent, which affirms the role for stenting as a bridge to surgery.

Self-Expanding Metallic Stent as a Bridge to Surgery in the Treatment of Left Colon Cancer Obstruction: Cost–Benefit Analysis and Oncologic Results

IntroductionThe use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost–benefit and long-term oncological outcomes of both therapeutic options. MethodsThis is a prospective, comparative, controlled, non-randomized study (2005–2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost–benefit, stoma rate and long-term oncological outcomes) were compared based on an “intention-to-treat” analysis. ResultsThere were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. ConclusionsThe use of self-expanding metallic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.

Stents metálicos autoexpandibles como puente a la cirugía en el tratamiento del cáncer de colon izquierdo en oclusión. Análisis coste-beneficio y resultados oncológicos

IntroductionThe use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. MethodsThis is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an “intention-to-treat” analysis. ResultsThere were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. ConclusionsThe use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.