Up to 85% of patients who present with colonic obstruction have a colorectal cancer. Between 7% and 29% of these patients present with total or partial intestinal obstruction. Only 20% of these patients presenting with acute colonic obstruction due to malignancy survive 5 years. Emergent surgical intervention in patients with colonic obstruction is associated with significant morbidity and mortality rates. Only 40% of patients with obstructive carcinoma of the left colon can be treated with surgical resection without the need for a colostomy. The use of a temporary or permanent colostomy has a significant impact on quality of life. The decompressive effect seen with colonic stenting is a durable, simple, and effective palliative treatment of patients with advanced disease. Stent deployment provides an effective solution to acute colonic obstruction and allows surgical treatment of the patient in an elective and more favorable condition. In addition, colonic stenting reduces costs and avoids the need for a colostomy.
Colon cancer; intestinal obstruction; colonic stenting
The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress.
A literature search was undertaken using PubMed and the Cochrane Library regarding the options in emergency management of left-sided colonic obstruction focusing on outcomes such as mortality, morbidity, long-term prognosis and cost effectiveness.
Colonic stenting is the best option either for palliation or as a bridge to surgery. It reduces morbidity and mortality rate and the need for colostomy formation. Stenting is likely to be cost effective, but data are variable depending on the individual healthcare system. Nevertheless, surgical management remains relevant as colonic stenting has a small rate of failure, and it is not always available. There are various surgical options. One-stage primary resection and anastomosis is the preferred choice for low-risk patients. Intra-operative colonic irrigation has no proven benefit. Subtotal colectomy is useful in cases of proximal bowel damage or synchronous tumours. Hartmann's procedure should be reserved for high-risk patients. Simple colostomy has no role other than for use in very ill patients who are not fit for any other procedure.
Colonic neoplasms; Intestinal obstruction; Stents; Colectomy; Hartmann's operation; Colonic irrigation
A series of patients were selected to evaluate the clinical efficacy of a new self expanding metallic endoprosthesis in the management of left-sided colonic obstruction. The aim was to reduce the morbidity and mortality associated with the surgical management of patients with distal colonic obstruction. Six patients with complete sigmoid colon obstruction were managed with the Wallstent Enteral Endoprosthesis [Schneider (USA) Inc.]. Four underwent subsequent elective colonic resection, while two were placed for palliation. Stent placement was successful in all cases with resulting bowel decompression and there were no procedural complications. All four patients with resectable tumours avoided emergency surgery. Stenting allowed time for medical improvement and staging investigations in this group. Two patients with advanced metastatic colonic carcinoma were successfully palliated. We found the Wallstent Enteral Endoprosthesis to be safe and effective in relieving obstruction in patients with resectable colonic tumours, permitting elective surgery and avoiding a temporary stoma. It can also be used to palliate those patients with advanced disease.
Over the past several years, colonic stenting has been advocated as an alternative to the traditional surgical approach for relieving acute malignant left-sided colonic obstruction. The aim of the present study was to determine the most cost-effective strategy in a Canadian setting.
PATIENTS AND METHODS:
A decision analytical model was developed to compare three competing strategies: CS – emergent colonic stenting followed by elective resective surgery and reanastomosis; RS – emergent resective surgery followed by creation of either a diverting colostomy or primary reanastomosis; and DC – emergent diverting colostomy followed by elective resective surgery and reanastomosis. The costs were estimated from the perspective of the Manitoba provincial health plan.
The use of CS resulted in fewer total operative procedures per patient (mean CS 1.03, RS 1.32, DC 1.9), lower mortality rate (CS 5%, RS 11%, DC 13%) and lower likelihood of requiring a permanent stoma (CS 7%, RS 14%, DC 14%). CS is slightly more expensive than DC, but less costly than RS (DC $11,851, CS $13,164, RS $13,820). The incremental cost-effectiveness ratio associated with the use of CS versus DC is $1,415 to prevent a temporary stoma, $1,516 to prevent an additional operation and $15,734 to prevent an additional death.
Colonic stenting for patients with acute colonic obstruction secondary to a resectable colonic tumour is comparable in cost with surgical options, and reduces the likelihood of requiring both temporary and permanent stomas. Colonic stenting should be offered as the initial therapeutic modality for Canadian colorectal cancer patients presenting with acute obstruction as a bridge to definitive RS.
Bowel obstruction; Colon cancer; Colonic stenting; Cost-effectiveness
AIM: To investigate the effects of emergent preoperative self-expandable metallic stent (SEMS) vs emergent surgery for acute left-sided malignant colonic obstruction.
METHODS: Two investigators independently searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, as well as references of included studies to identify randomized controlled trials (RCTs) that compared two or more surgical approaches for acute colonic obstruction. Summary risk ratios (RR) and 95% CI for colonic stenting and emergent surgery were calculated.
RESULTS: Eight studies met the selection criteria, involving 444 patients, of whom 219 underwent SEMS and 225 underwent emergent surgery. Seven studies reported difference of the one-stage stoma rates between the two groups (RR, 0.60; 95% CI: 0.48-0.76; P < 0.0001). Only three RCTs described the follow-up stoma rates, which showed no significant difference between the two groups (RR, 0.80; 95% CI: 0.59-1.08; P = 0.14). Difference was not significant in the mortality between the two groups (RR, 0.91; 95% CI: 0.50-1.66; P = 0.77), but there was significant difference (RR, 0.57; 95% CI: 0.44-0.74; P < 0.0001) in the overall morbidity. There were no significant differences between the two groups in the anastomotic leak rate (RR, 0.60; 95% CI: 0.28-1.28; P = 0.19), occurrence of abscesses, including peristomal abscess, intraperitoneal abscess and parietal abscess (RR, 0.83; 95% CI: 0.36-1.95; P = 0.68), and other abdominal complications (RR: 0.67; 95% CI: 0.40-1.12; P = 0.13).
CONCLUSION: SEMS is not obviously more advantageous than emergent surgery for patients with acute left-sided malignant colonic obstruction.
Acute obstruction; Colonic cancer; Self-expandable metallic stent; Stoma placement; Meta-analysis; Systematic review
Acute surgery in the management of malignant colonic obstruction is associated with high morbidity and mortality. The use of self-expanding metal stents (SEMS) is an alternative method of decompressing colonic obstruction. SEMS may allow time to optimize the patient and to perform preoperative staging, converting acute surgery into elective. SEMS is also proposed as palliative treatment in patients with contraindications to open surgery. Aim: To review our experience of SEMS focusing on clinical outcome and complications. The method used was a review of 75 consecutive trials at SEMS on 71 patients based on stent-protocols and patient charts.
SEMS was used for palliation in 64 (85%) cases and as a bridge to surgery in 11 (15%) cases. The majority of obstructions, 53 (71%) cases, were located in the recto-sigmoid. Technical success was achieved in 65 (87%) cases and clinical decompression was achieved in 60 (80%) cases. Reasons for technical failure were inability to cannulate the stricture in 5 (7%) cases and suboptimal SEMS placement in 3 (4%) cases. Complications included 4 (5%) procedure-related bowel perforations of which 2 (3%) patients died in junction to post operative complications. Three cases of bleeding after SEMS occurred, none of which needed invasive treatment. Five of the SEMS occluded. Two cases of stent erosion were diagnosed at the time of surgery. Average survival after palliative SEMS treatment was 6 months.
Our results correspond well to previously published data and we conclude that SEMS is a relatively safe and effective method of treating malignant colonic obstruction although the risk of SEMS-related perforations has to be taken into account.
Pelvic endometriosis is an extremely rare cause of large bowel obstruction and the management can be challenging. Urgent surgery for acute colonic obstruction is known to carry high morbidity and mortality, and operation may be made more difficult in extensive pelvic endometriosis. Less invasive alternatives in the acute situation may need to be considered.
PRESENTATION OF CASE
Presented is the case of a 35-year-old lady with obstructive bowel symptoms caused by an endometriotic upper rectal stricture. She was initially treated using radiologically guided stent insertion, as an acute intervention, prior to an elective bowel resection and hysterectomy with bilateral salpingo-oophorectomy.
Colonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents (SEMS) to treat benign conditions is controversial, however, due to associated long term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial acute treatment with stenting provides the advantage of time to involve the multi-disciplinary team, to medically optimise the patient and to better plan the definitive surgery.
The use of radiologically guided stents has a place in the treatment of benign recto-sigmoid obstruction due to endometriosis and therefore should be considered as a bridge to further surgical treatment.
Colonic; Obstruction; Endometriosis; Radiological; Stenting
Traditionally, there are several approaches to manage left-sided colonic carcinoma obstruction, such as tumor resection with primary anastomosis, tumor resection with end-colostomy and loop-colostomy. Recently, colonic stent insertion was introduced as a bridge prior to definite surgery. We demonstrated a hybrid approach for obstructed sigmoid carcinoma using colonic stent, followed by single incision laparoscopic colectomy (SILC). A 58 year-old man presented with complete left-sided colonic obstruction. He underwent emergency colonoscopy with metallic stent placement. One week later, he was performed SILC. He recovered well after the operation without any postoperative complications. The pathological result showed adequacy of oncologic resection. This hybrid approach of colonic stent insertion and SILC can be safely performed.
Left-sided colonic obstruction; Colonic stent; Single-incision laparoscopic colectomy
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.
Left-sided large bowel obstruction; Hartmann’s procedure; Primary anastomosis; Bowel stent; Emergency treatment
AIM: To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.
METHODS: The databases of Medline, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies (prospective, retrospective, randomized controlled trials, and case-control trials) designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by self-expanding metallic stents (SEMS) or palliative surgery. No language restrictions were imposed. The main outcome measures were hospital stay, intensive care unit admission, clinical success rate, 30-d mortality, stoma formation, complications, and overall survival time. The data extraction was conducted by two investigators working independently and using a standardized form. The Mantel-Haenszel χ2 method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model; when statistical heterogeneity existed in the pooled data (as evaluated by Q test and I2 statistics, where P < 0.10 and I2 < 25% indicated heterogeneity), a random-effects model was used.
RESULTS: Thirteen relevant articles, representing 837 patients (SEMS group, n = 404; surgery group, n = 433), were selected for analysis. Compared to the surgery group, the SEMS group showed lower clinical success (99.8% vs 93.1%, P = 0.0009) but shorter durations of hospital stay (18.84 d vs 9.55 d, P < 0.00001) and time to initiation of chemotherapy (33.36 d vs 15.53 d, P < 0.00001), and lower rate of stoma formation (54.0% vs 12.7%, P < 0.00001). Additionally, the SEMS group experienced a significantly lower rate of 30-d mortality (4.2% vs 10.5%, P = 0.01). Stent-related complications were not uncommon and included perforation (10.1%), migration (9.2%), and occlusion (18.3%). Surgery-related complications were slightly less common and included wound infection (5.0%) and anastomotic leak (4.7%). The rate of total complications was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the surgery-related complications occurred earlier than stent-related complications (rate of early complications: 33.7% vs 13.7%, P = 0.03; rate of late complications: 32.3% vs 12.7%, P < 0.0001). The overall survival time of SEMS- and surgery-treated patients was not significantly different (7.64 mo vs 7.88 mo).
CONCLUSION: SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions, but is associated with a shorter time to chemotherapy and lower 30-d mortality.
Self-expandable metal stents; Palliative surgery; Incurable malignant colorectal obstruction; Large-bowel obstruction; Treatment outcomes
Stenting for obstructing large bowel malignancy is a technique that is gradually increasing in popularity. The two main indications are for palliation and as a ‘bridge to surgery’. Some of the proposed advantages of colonic stenting are safety, reduced morbidity and mortality, avoidance of a stoma and shorter hospital stay.
PATIENTS AND METHODS
This was a retrospective study of consecutive patients who had self-expanding metal stents deployed between February 2001 and June 2006. Data were collected from the MEDITECH electronic integrated healthcare information support system and case note review. Data concerning demographics, primary diagnosis, and location of malignant stricture, indication for stenting, method of stenting, outcome, complications and mortality rates were obtained and analysed on Microsoft Excel.
Colonic stenting was first performed in the Countess of Chester Hospital in 2001. Thirty-two procedures have been performed since then. The median age was 80 years and the majority of cases were palliative (28 of 32), with three of the remaining cases successfully stented as a ‘bridge to surgery’. Initially, this was performed as a radiological procedure; however, the success rate was noted to be better if a surgical endoscopist was also involved. We recorded a 57% clinical success rate in the group of patients that had the colonic stent inserted radiologically; however, the group where this was inserted as a combined radiological and endoscopic procedure yielded a clinical success rate of 78%. We experienced stent-migration in four patients (13%) and rectal perforation in one patient (3%). There was no tumour re-obstruction or stent-related mortality.
A colonic stenting service can be introduced into a district general hospital with low morbidity and mortality. A well-motivated team is required and combined endoscopic and radiological approach in our hands appears to offer the best results.
Self-expanding metal stent; Large bowel obstruction; Stent
Managing bowel obstruction produced by colon cancer requires an emergency intervention to patients usually in poor conditions, and it requires creating an intestinal stoma in most cases. Regardless of that the tumor may be resectable, a two-stage surgery is mandatory. To avoid these disadvantages, endoscopic placement of self-expanding stents has been introduced more than 10 years ago, as an alternative to relieve colonic obstruction. It can be used as a bridge to elective single-stage surgery avoiding a stoma or as a definitive palliative solution in patients with irresectable tumor or poor estimated survival. Stents must be capable of exerting an adequate radial pressure on the stenosed wall, keeping in mind that stent must not move or be crushed, guaranteeing an adequate lumen when affected by peristaltic waves. A finite element simulation of bell-shaped nitinol stent functionality has been done. Catheter introduction, releasing at position, and the effect of peristaltic wave were simulated. To check the reliability of the simulation, a clinical experimentation with porcine specimens was carried out. The stent presented a good deployment and flexibility. Stent behavior was excellent, expanding from the very narrow lumen corresponding to the maximum peristaltic pressure to the complete recovery of operative lumen when the pressure disappears.
Background. Self-expanding metal stents can alleviate malignant colonic obstruction in incurable patients and avoid palliative stoma surgery. Objective. Evaluate stent effectiveness and safety on palliation of patients with malignant colorectal strictures. Design. Two prospective, one Spanish and one global, multicenter studies. Settings. 39 centers (22 academic, 17 community hospitals) from 13 countries. Patients. A total of 257 patients were enrolled, and 255 patients were treated with a WallFlex uncovered enteral colonic stent. Follow-up was up to 12 months or until death or retreatment. Interventions(s). Self-expanding metal stent placement. Main Outcome Measures. Procedural success, clinical success, and safety. Results. Procedural success was 98.4% (251). Clinical success rates were 87.8% at 30 days, 89.7% at 3 months, 92.8% at 6 months, and 96% at 12 months. Overall perforation rate was 5.1%. Overall migration rate was 5.5%. Overall death rate during follow-up was 48.6% (124), with 67.7% of deaths related to the patient's colorectal cancer, unrelated in 32.3%. Only 2 deaths were related to the stent or procedure. Limitations. No control group. Conclusions. The primary palliative option for patients with malignant colonic obstruction should be self-expanding metal stent placement due to high rates of technical success and efficacy in symptom palliation and few complications.
Tumoral obstructions in almost the entire gastrointestinal tract can be resolved with interventional digestive endoscopy techniques. Self-expanding metal stent (SEMS) insertion in the obstructed colon is a minimally invasive and relatively simple procedure providing an effective first-line treatment for relief of acute malignant obstruction symptoms and serving either as a preoperative or “bridge to surgery” procedure or as palliative definitive care. This technique was introduced in the early 1990s. Although there is still debate about its real value, a lot of reports have been published since then and the procedure is advocated by many surgical groups as the method of choice for the initial treatment of left-sided tumoral colonic obstruction. Before the procedure, colonic obstruction has to be diagnosed by abdominal radiographs, water contrast enema and/or a computed tomography scan. The greatest information is provided by the latter and it is perhaps the method of choice prior to stenting. Skills and training are mandatory, as in all interventional procedures. The key step for success is to cross the malignant stricture with a guidewire. Care must be taken not to over insufflate an obstructed colon during the procedure. SEMS slide over the guidewire through the endoscope working channel or in parallel, outside the endoscope. An average 7% perforation rate has been reported during the procedure and other minor complications can appear in the follow up. However, as a whole, this technique seems to compare favorably with surgery.
Self-expanding metal stent; Malignant colorectal obstruction; Emergency surgery; Interventional endoscopy
Perforation of the bowel during placement of a biliary stent is a known complication of this procedure. We report the endoluminal loss of a biliary stent during routine stent extraction that ultimately led to a chronic colovaginal fistula. This case emphasizes the need for evaluation of fecal passage of stents in patients with a known dislodged prosthesis.
A 65-year-old white female underwent biliary stent placement for an episode of choledocholithiasis. The stent was lost in the duodenum during routine extraction. The patient was managed expectantly. She denied ever passing this stent via the rectum and began to develop symptoms of colovaginal fistula. Evaluation found a retained biliary stent in the sigmoid colon and a fistula into the vagina. The patient underwent elective low anterior resection and colovaginal fistula repair.
Reports exist of migration of stents that lead to acute colonic perforation and the need for emergent surgery. For this reason, it has been suggested that dropped or migrated stents be purposefully retrieved. However, if the option of expectant observation is used, it is important to clearly document the fecal passage of these stents and be prepared to retrieve these objects if they have a prolonged bowel transit time.
Biliary stent; Colovaginal fistula; Diverticulitis
INTRODUCTION: Untreated malignant large bowel obstruction is rapidly fatal. Short-term palliation of symptoms can be achieved by formation of a stoma in those patients for whom resection surgery is inappropriate. In the final months of life, a stoma represents a significant burden for both patients and carers. Palliative endoluminal stenting may therefore be an attractive alternative option for this poor prognostic group. PATIENTS: Thirty-six patients were studied of whom 18 had obstructing left-sided colon cancer relieved by placement of endoluminal stents. These were compared with 18 historical controls with similar clinicopathological features that were treated more conventionally with palliative stoma formation in the same hospital. RESULTS: Patients in the two groups had similar sex distribution (P = 0.5); however, patients undergoing palliative stoma formation were significantly younger than patients being stented (P = 0.0065). As well as being older, there was a trend towards greater co-morbidities, stent patients having higher ASA grades (P = 0.01). Both groups of patients gained relief of obstructive symptoms. There were no differences in survival (P = 0.5) or in hospital mortality (2 in each group). The median length of palliation is 92 days (42-infinity days) for stenting and 121 days (89-281 days) for palliative stoma formation. Formation of a stoma required a significantly longer stay in ITU (P = 0.003) but total hospital stay was similar. CONCLUSIONS: As an alternative to palliative surgery, selected patients benefit from colonic endoluminal stenting with relief of obstructive symptoms and no adverse effect on survival. They may be spared the potential problems associated with palliative stoma formation and the morbidity of surgery. Stenting can be offered to the very frail patient who would otherwise be managed conservatively.
Self-expanding metallic stents are effective for the palliation of malignant obstruction. This study indicates that stents for bowel obstruction may allow for minimally invasive surgical intervention with a shorter hospital stay, lower stoma rate, and earlier chemotherapy administration.
Background and Objectives:
Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group's experience.
We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up.
The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications.
The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.
Colon obstruction; Self-expandable metallic stents; SEMS; Intraluminal stents
Aim. Self-expanding metal stents (SEMSs) are increasingly used for the palliation of metastatic colorectal cancer and as a bridge to surgery for obstructing tumours. This case series analyses the learning curve and changes in practice of colorectal stenting over a three year period. Methods. A study of 40 patients who underwent placement of SEMS for the management of colorectal cancer. Patients spanned the learning curve of a single surgeon endoscopist. Results. Technical success rates increased from 82% initially, using an average of 1.7 stents per procedure, to a 94% success rate where all patients were stented using a single stent. There has been a change in practice from elective palliative stenting toward emergency preoperative stenting. Conclusion. There is a steep learning curve for the use of SEMS in the management of malignant colorectal bowel obstruction. We suggest that at least 20 cases are required for an operator to be considered experienced.
The use of self-expandable metallic stents in the management of obstructing colorectal cancer has been described with increasing frequency in the literature. Our goal was to evaluate the efficacy and associated morbidity of the use of self-expandable metallic stents to relieve colorectal obstruction at our institution.
A retrospective chart review of patients who underwent colorectal stent placement between December 2001 and December 2003 in a tertiary referral center was performed.
Stents were placed successfully in 17 of 21 patients (81%) with colorectal obstruction. Placement was achieved endoscopically in 13 patients and radiologically in 4. Ten self-expandable metallic stents were used as a bridge to surgery, and 7 were used for palliation. The obstructions were located in the sigmoid colon (11 patients), the rectosigmoid (3), the splenic flexure, the hepatic flexure, and the rectum. Malignant obstruction was noted in 14 patients. One patient with malignancy experienced a sigmoid perforation, and 2 patients with benign disease had complications (1 stent migration and 1 re-obstruction). Stent patency in obstruction secondary to colonic adenocarcinoma was 100% in our follow-up period (range, 5 to 15 months).
The use of stents as a bridge to surgery is associated with low morbidity, allows for bowel preparation, and thus avoids the need for a temporary colostomy. Long-term patency suggests that stents may allow for the avoidance of an operation in patients with metastatic disease and further defines their role in the palliation of malignant obstruction. Further prospective randomized studies are necessary to fully elucidate the use of stents in the management of colorectal cancer.
Stent; Colorectal obstruction; Colorectal cancer; Surgery; Palliation
Malignant obstruction develops frequently in advanced gastric cancer. Although it is primarily the gastric outlet that is obstructed, there are occasional reports of colonic obstruction. Treating intestinal obstruction usually requires emergency surgery or stent insertion. There are several kinds of complications with stent insertion, such as bowel perforation, stent migration, bleeding, abdominal pain and reobstruction. Nevertheless, endoscopic stent insertion could be a better treatment than emergency surgery in cases of malignant bowel obstruction in cancer patients with poor performance status. We report a case of advanced gastric cancer with carcinomatosis in which a recurrent colonic stent was inserted at the same site because of cancer growth into the stent. The patient maintained a good condition for chemotherapy, thus improving their chances for survival.
Gastric cancer; carcinomatosis; colonic stent; benefit
Self expanding metal stents (SEMS) play an important role in the management of malignant obstructing lesions in the gastrointestinal tract. Traditionally, they have been used for palliation in malignant gastric outlet and colonic obstruction and esophageal malignancy. The development of the polyflex stent, which is a removable self expanding plastic stent, allows temporary stent insertion for benign esophageal disease and possibly for patients undergoing neoadjuvant chemotherapy prior to esophagectomy. Potential complications of SEMS insertion include perforation, tumour overgrowth or ingrowth, and stent migration. Newer stents are being developed with the aim of increasing technical and clinical success rates, while reducing complication rates. Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease. It is hoped that, in the future, newer stents will improve our management of these difficult conditions and, possibly, provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.
Endoscopy; Stent; Palliation; Bowel obstruction; Malignancy
Although stent placement is increasingly performed, colostomy still is considered the gold standard for emergent relief of malignant colonic obstruction (MCO). This study aimed to compare hospital costs and clinical outcomes between patients undergoing colostomy and those undergoing stenting for the management of MCO.
A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) data set was conducted to identify inpatient hospitalizations for colostomy or stent placement for the treatment of colon cancer (2007–2008). The outcomes evaluated using MedPAR compared the total length of hospital stay (LOS) and the costs associated with both techniques. Because MedPAR is a claims data set that does not provide outcomes at a patient level, a single-institution retrospective case–control study was conducted in which each stent placement patient was matched with two colostomy patients during the same period. Outcome measures (institutional data) were used to compare rates of treatment success, postprocedure LOS, and reinterventions between the two cohorts.
The MedPAR data evaluated 778 stent placements and 5,868 colostomy hospitalizations. There were no differences in gender, age distribution, or comorbidity between the two groups. Compared with colostomy, the median LOS (8 vs. 12 days; p < 0.0001) and the median cost ($15,071 vs. $24,695; p < 0.001) per claim were significantly less for stent placement. Stent placement was more commonly performed at urban versus rural hospitals (84% vs. 16%; p < 0.0001), teaching versus nonteaching hospitals (56% vs. 44%; p = 0.0058) and larger versus smaller institutions (mean bed capacity, 331 vs. 227; p < 0.0001). The institution data included 12 patients who underwent stent placement and 24 who underwent colostomy. Although both methods were technically successful, the median postprocedure LOS (2.17 vs. 10.58 days; p = 0.0004) and the rate of readmissions for complications (0% vs. 25%; p = 0.01) were significantly lower for stent placement.
Although the technical and clinical outcomes for colostomy and stent placement appear comparable, stent placement is less costly and associated with shorter LOS and fewer complications. Dissemination of stent placement beyond large teaching hospitals located in urban areas as a treatment for MCO is important given its implications for patient care and resource use.
Electronic supplementary material
The online version of this article (doi:10.1007/s00464-010-1523-y) contains supplementary material, which is available to authorized users.
Colonic stenting; Colostomy; Costs; Health resources
The development of non-surgical techniques for the relief of malignant low bileduct obstruction has cast doubt on the best way of relieving jaundice, particularly in patients fit for surgery whose life expectancy is more than a few weeks.
We did a randomised prospective controlled trial comparing endoscopic stent insertion and surgical biliary bypass in patients with malignant low bileduct obstruction. 204 patients were randomised (surgery 103, stent 101); 3 subsequently proved to have benign disease and were excluded, leaving 101 surgical and 100 stented patients for assessment. Technical success was achieved in 94 surgical and 95 stent patients, with functional biliary decompression obtained in 92 patients in both groups. In stented patients, there was a lower procedure-related mortality (3% vs 14%, p=0.01), major complication rate (11% vs 29%, p=0.02), and median total hospital stay (20 vs 26 days, p=0.001). Recurrent jaundice occurred in 36 stented patients and 2 surgical patients. Late gastric outlet obstruction occurred in 17% of stented patients and 7% of the surgical group. Despite the early benefits of stenting there was no significant difference in overall survival between the two groups (median survival: surgical 26 weeks; stented 21 weeks; p=0.065).
Endoscopic stenting and surgery are effective palliative treatments with the former having fewer early treatment-related complications and the latter fewer late complications.
AIM: To clarify the usefulness of the self-expanding metallic stents (SEMS) in the management of acute proximal colon obstruction due to colon carcinoma before curative surgery.
METHODS: Eighty-one colon (proximal to spleen flex) carcinoma patients (47 males and 34 females, aged 18-94 years, mean = 66.2 years) treated between September 2004 and June 2010 for acute colon obstruction were enrolled to this study, and their clinical and radiological features were reviewed. After a cleaning enema was administered, urgent colonoscopy was performed. Subsequently, endoscopic decompression using SEMS placement was attempted.
RESULTS: Endoscopic decompression using SEMS placement was technically successful in 78 (96.3%) of 81 patients. Three patients’ symptoms could not be relieved after SEMS placement and emergent operation was performed 1 d later. The site of obstruction was transverse colon in 18 patients, the hepatic flex in 42, and the ascending colon in 21. Following adequate cleansing of the colon, patients’ abdominal girth was decreased from 88 ± 3 cm before drainage to 72 ± 6 cm 7 d later, and one-stage surgery after 8 ± 1 d (range, 7-10 d) was performed. No anastomotic leakage or postoperative stenosis occurred after operation.
CONCLUSION: SEMS placement is effective and safe in the management of acute proximal colon obstruction due to colon carcinoma, and is considered as a bridged method before curative surgery.
Endoscope; Proximal colon cancer; Obstruction; Self-expanding metallic stents; Drainage
Colorectal cancer is rare in teenagers, especially without known risk factors. Colon cancer in young age is more likely to be diagnosed at advanced-stage, to present unfavorable tumor histology such as mucinous carcinoma, and poor outcome. We report a case of sporadic mucinous adenocarcinoma of the colon in a 19-year-old male patient without any risk factors. He complained of severe left abdominal pain that developed 1 month ago. He had a distended abdomen with severe tenderness on the left lower quadrant. A distal descending colon mass causing mechanical obstruction was observed on abdominal computed tomography. Emergency colonoscopy showed a large, fungating mass obstructing the lumen at 40 cm from the anal verge. Biopsy of the colonic mass suggested a mucinous adenocarcinoma. After decompression by colonic stent, the patient was transferred to the general surgery department for left hemicolectomy. The lesion was confirmed to be a mucinous adenocarcinoma (7.0×4.5 cm). For hereditary nonpolyposis colorectal cancer evaluation, immunohistochemical staining for MLH1 and MSH2 was normal. Reverse transcription polymerase chain reaction analysis did not detect microinstability in any of the markers tested. The patient had no familial history of cancer. Mucinous adenocarcinoma has high frequencies of poor differentiation, advanced tumor stage, loss of mismatch repair gene expression, and increased MUC2 expression. A mucinous histology is considerably more frequent in children and adolescent than in adults. Adequate invasive study is also necessary for young age patients.
Mucinous adenocarcinoma; Young age sporadic colorectal cancer