Stenting For Large Bowel Obstruction Research Articles

Early surgery after bridge-to-surgery stenting for malignant bowel obstruction is associated with better oncological outcomes.

Placement of self-expanding metal stents has been increasingly adopted as a bridge to surgery in patients presenting with obstructed left-sided colorectal cancers. The optimal bridging time has yet to be widely established, hence this retrospective study aims to determine the optimal bridging time to elective surgery post endoluminal stenting. All patients who underwent colorectal stenting for large bowel obstruction in a single, tertiary hospital in Singapore between January 2003 and December 2017 were retrospectively identified. Patients' baseline demographics, tumour characteristics, stent-related complications, intra-operative details, post-operative complications and oncological outcomes were analysed. Of the 53 patients who successfully underwent colonic stenting for malignant left sided obstruction, 33.96% of patients underwent surgery within two weeks of stent placement while 66.04% of patients underwent surgery after 2weeks of stent placement. Univariate analysis between both groups did not demonstrate significant differences in postoperative complications and stoma formation. Significant differences were observed between both groups for stent complications (38.89% vs 8.57%, p = 0.022), on-table decompression (38.89% vs 2.86%, p = 0.001) and systemic recurrence (11.11% vs 40.00%, p = 0.030). Increased bridging interval to surgery (OR 13.16, CI 1.37-126.96, p = 0.026) was a significant risk factor for systemic recurrence on multivariate analysis. Patients undergoing definitive surgery within 2weeks of colonic stenting may have better oncological outcomes without compromising on postoperative outcomes. Further prospective studies are required to compare outcomes between emergency surgery and different bridging intervals.

Su1710 ENDOSCOPIC MANAGEMENT OF MALIGNANT LARGE BOWEL OBSTRUCTION: A SINGLE-CENTER, COMMUNITY-BASED STUDY

Colonic stents are used to relieve large bowel obstruction in the setting of primary or metastatic colonic malignancy. Self-expandable metal stents (SEMS) are indicated as a bridge to elective surgery (BTS) allowing for thorough preoperative colonoscopy and to enable a primary anastomosis after resection without the need for a temporary colostomy. They are also indicated for palliative treatment of patients who are inoperable. We sought to better understand the clinical patterns of colonic stent insertion as this technique becomes more widely available in the community setting. All patients who underwent colonic stent placement for large bowel obstruction due to malignancy at New York-Presbyterian Queens between January 2011 and April 2017 were retrospectively reviewed. Demographic characteristics, tumor pathology, surgical follow up, colonic location of stenosis, technical success rate, clinical success, complications, in-hospital mortality and 30-day readmission rate were evaluated. 64 patients underwent colonic stenting for large bowel obstruction as diagnosed by radiographic imaging. 3 patients received multiple stents. Mean age was 72. (range 33-98). Forty (62%) were male and 24 were female (38%). 49 (77%) were primary colon or rectal carcinoma; 11 (17%) were metastatic lesions with extrinsic compression. Diagnosis was undetermined in 4 patients (6%). The majority of obstructions occurred in the sigmoid colon (43%) (Table 1). Eighty-five percent of colonic stents were placed in the left colon, and 15% on the right. Stent placement was successful in 63 patients (98%). There were 3 stent failures (two left sided and one right sided occlusion). One patient had a left sided perforation requiring emergent exploratory laparotomy. There were no deaths caused directly by stent placement. Surgery was performed in 33 out of 64 patients (52%), whereas 48% were palliative. There was no difference in outcome in terms of successful stent deployment, in-hospital mortality or 30-day readmission rate between primary colorectal lesions and metastatic lesions. There was no significant difference in complication rate or 30-day readmission rate between BTS and palliative groups. Colonic stenting is a safe and effective procedure for relief of large bowel obstruction for palliation or as a BTS in a community hospital setting. Our study showed a relatively low complication/stent failure rate (2% perforation and 5% stent occlusion) for both left and right colon lesions. Stenting of extrinsic compressing lesions appears to be safe and effective.

Endoscopic Stenting Does Not Worsen Long Term Outcomes Amongst Patients Presenting with Obstruction from Colorectal Cancers.

Stenting has been increasingly adopted in colorectal cancer patients presenting with acute large bowel obstruction. However, long-term outcomes of stenting are lacking in the literature. Our study attempts to compare the long-term outcomes of colonic stenting and emergency surgery amongst left-sided colorectal cancer patients presenting with acute large bowel obstruction. A retrospective review of all patients who presented with nonmetastatic colorectal cancer who underwent either endoscopic stenting or emergency surgery for acute large bowel obstruction was performed from January 2007 to April 2016. Patients were analysed in an intention-to-treat analysis. Forty-seven (46.1%) patients underwent emergency surgery, whereas 55 (53.9%) underwent colonic stenting with a technical success rate of 71.0%. Patients who underwent emergency surgery were more likely to develop severe complications compared with patients who underwent successful colonic stenting, but the difference was not statistically significant (odds ratio [OR] 2.84; 95% confidence interval [CI] 0.71-11.3, p=0.139). Patients were followed up for a median of 48.3 months (3.1-111) in the stenting group and 51.2 months (1.2-117.1) in the emergency surgery group. Recurrence rates between colonic stenting and emergency surgery were similar (25.6% vs. 21.3%, p=0.500), with more anastomotic and peritoneal recurrences were noted in the emergency surgery group. 5 year disease free survival (77% vs. 73%, p=0.708) and overall survival (86% vs. 62%, p=0.064) also were similar. Patients who underwent endoscopic stenting for large bowel obstruction have comparable long-term outcomes as those who undergo emergency surgery. The role of endoscopic stenting in obstructed colorectal cancers merits further evaluation.

Technical and Clinical Outcomes Following Colonic Stenting: A Seven-Year Analysis of 268 Procedures.

To assess the factors contributing to the technical and clinical success of colorectal stenting for large bowel obstruction. 268 cases of colonic stenting for large bowel obstruction were performed in 249 patients of mean age of 72years (28-98) between 2006 and 2013. The majority of strictures were due to malignant disease, 244/268 (91%). Diverticular strictures accounted for 24/268 (9%). Overall technical success rate was 81% (217/268), with a clinical success rate of 65% (174/268). Duration of symptoms ranged from 0 to 180days (mean 8days). Technical success rate was seen to decrease with increasing symptom duration. For symptom duration of less than 1week, technical success was 85.4% (181/212) versus 69.6% (39/56) for those with symptoms of greater than a week (p<0.05). Clinical success rates fell from 71.3% (107/150) to 59.3% (70/118) (p<0.05) when attempting to stent lesions of greater than 5cm. There was also a significant reduction in clinical success when stenting lesions on a bend rather than a straight segment of colon 75.7% (109/144) versus 59.7% (74/124) (p<0.05). A total of 20 (7.46%) perforations were identified during the study. Stent migration occurred in 6.6% of cases. In-stent stenosis occurred in 3.3%. The overall 30-day all cause mortality rate was 9%. Lesion size, location and duration of obstructive symptoms are statistically significant determinants of patient outcome. These factors could be used to advise patient selection for colonic stenting or direct progression to surgical intervention.

PWE-314 Efficacy and complications in the use of self-expanding colonic stents for large bowel obstruction at a single centre: an analysis of 13 years experience

Introduction Self-expandable metal stents (SEMS) may be used in patients presenting with large bowel obstruction (LBO) and offer a less invasive alternative to surgery and thus avoid the potential need for a stoma. Method A retrospective analysis of all patients who underwent attempted SEMS placement for LBO between 2001 and 2014 at a university teaching hospital. Patients were identified from the radiology database and hospital coding via the hospital’s informatics system. Results Over the 13-year review period, a primary SEMS was attempted in 143 patients, median age 72 (range 25–108) years, sex ratio 83 males: 60 females. Indications for SEMS were palliative treatment of colorectal cancer (CRC) 101; as bridging prior to resectional surgery for CRC 14; extrinsic compression in 19 and for benign disease in 8 patients. SEMS placement was successful in 110 (77%) patients: in 83 (82%) palliative; 13 (93%) bridging; 12 (63%) compression and 2 (25%) benign groups. 85% of SEMS were placed in the distal colon. In the bridged patients 54% did not require a stoma at subsequent surgery. 91(83%) patients successfully stented had no complication. Of the complications that occurred, 13(15.7%) occurred in palliative, 3(23.1%) bridging, and 3(25%) compression groups. Early complications ( 1 month) occurred in 4 patients, 3 required surgery. Overall median survival post SEMS was 212 days. According to indication for SEMS, 30- and 90-day survival was respectively: palliative 81.2% and 68.2%; bridging 92.3%; compressive 50% and 33.3% and benign 100%. Median (IQR) survival was: palliative 205 (49–425); bridging 766 (408–960) and compression 27 (12–158) days. Conclusion The commonest indication for SEMS placement was malignant LBO from CRC. In palliative patients it has a good success rate and avoids the need for surgery in patients with a limited median survival. As a bridge to surgery in patients undergoing subsequent surgery it has a high success rate but does not always avoid the need for a stoma. Disclosure of interest None Declared.

Management of large bowel obstruction with self‐expanding metal stents. A multicentre retrospective study of factors determining outcome

UK cancer guidelines recommend patients with colonic obstruction due to suspected malignancy be considered for stenting with a self-expanding metal stent (SEMS). Considerable variation in practice exists due to a lack of expertise, technical difficulties and other, as yet ill-defined features. This retrospective multi-centre study aims to determine the outcome following colonic stenting for large bowel obstruction and identify factors associated with successful intervention. A regional programme of colonic stenting for large bowel obstruction, in five UK centres from 2005 to 2010 was evaluated for outcome including technical and clinical success, survival, complications and reoperation. A SEMS was inserted in 334 patients, including 264 (79.0%) for palliation and 52 (15.6%) as a bridge to surgery. Technical success was achieved in 292 (87.4%) patients, with 46 (13.8%) experiencing a complication or technical failure. Reoperation was required in 39 (14.8%) patients stented for palliation of colorectal cancer of whom 16 (6.1%) subsequently required a colostomy. A one-stage primary anastomosis was achieved in 35 (67.3%) of the 52 patients undergoing stenting as a bridge to resection. Technical success did not vary by indication or site of obstruction (P = 0.60) but was higher for operators who had performed more than 10 procedures (OR 3.34, P = 0.001). ASA grade ≥3 predicted a worse clinical outcome (OR 0.43, P = 0.04). The through-the-scope (TTS) endoscopy technique was more successful than radiological placement alone (90.3% vs 74.8%, P < 0.001). Experienced operators using a TTS technique achieved a better outcome for the emergency management of large bowel obstruction. Older, sicker patients and those with extracolonic and benign strictures fared less well.

Author's reply: Self-expanding metallic stents for large bowel obstruction (Br J Surg 2011; 98: 1625–1629)

Author's reply: Self-expanding metallic stents for large bowel obstruction (<i>Br J Surg</i> 2011; 98: 1625–1629)

Self-expanding metallic stents for large bowel obstruction (Br J Surg 2011; 98: 1625–1629)

Self-expanding metallic stents for large bowel obstruction (<i>Br J Surg</i> 2011; 98: 1625–1629)

Self-expanding metallic stents for large bowel obstruction

Self-expanding metallic stents (SEMS) may relieve colonic obstruction as definitive therapy or as a bridge to elective surgery. This was a retrospective longitudinal cohort study of patients undergoing insertion of SEMS for large bowel obstruction at one institution. Scrutiny of the radiology department's coding system allowed identification of all patients undergoing colonic stent insertion between 2002 and 2008. Data were extracted from patient case notes and investigation reports. Eighty-two patients with a median age of 75 (interquartile range (i.q.r.) 43-94) years underwent stent insertion, 71 for palliation and 11 as a bridge to surgery. Obstruction was due to malignant disease in 67 patients and had a benign cause in 15. Median survival in the palliative setting was 103 (i.q.r. 44-317) days. Complications occurred in 43 patients, of whom 22 underwent unplanned surgery. High-grade obstruction (relative risk (RR) 2·05; P = 0·055) and benign disease (RR 3·45; P < 0·001) were associated with risk of adverse events. SEMS should not be used for large bowel obstruction with benign pathology.