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1.  Colonic stent placement as a bridge to surgery in patients with left-sided malignant large bowel obstruction. An observational study 
Il Giornale di Chirurgia  2015;35(11-12):283-289.
Acute left-sided malignant colonic obstruction is common in elderly patients, in which emergency surgery is related with high morbidity and mortality rates, and often necessitates a two-step resection. Although the use of self-expanding metallic stents (SEMS) in elderly patients has not been adequately described yet, there are almost two international important trials which are still in progress, the stenting technique is established to be, by the international literature, an useful treatment with low morbidity and mortality. It’s also a bridge to surgery, since the insertion of a SEMS can decompress the obstruction, making bowel and patient preparation possible and facilitating single-stage surgical resection. Palliative stenting can improve quality of life when compared to surgery in patients with metastasis or high co-morbidity.
The aim of this study is to analyze mortality, avoidance of stoma, short- and long-term survival in patient with malignant left-sided large bowel obstruction who underwent to stent placement in our Emergency Surgery Unit, which is operative since November 2010 in our city Hospital in Ferrara.
Patients and methods
Between November 2010 and December 2012 a total of 15 patients with acute left-sided malignant large bowel obstruction suitable for colonic stent application were admitted to Emergency Surgery Unit. Among these patients, 9 underwent to self-expanding metallic stent placement (group A), the other (group B) 6 patient underwent to emergency surgery.
In this observational not-randomized study we analyzed the efficacy and safety of SEMS placement for patients either as a bridge to surgery or as a palliation, beside the short term and long term outcomes, versus those patients operated straight.
Self-expanding metallic stents were successfully implanted in 9 of the 15 patients with acute left-sided malignant large bowel obstruction. No acute procedure-related complication was observed. All the patients in group A kept the stent in place for an average of 7,7 days, then everyone underwent to surgery. A large bowel resection with one-time recanalization was performed in 8 of the 9 patients. None Hartmann resection was necessary. Only one underwent again to surgery because of a dehiscence, a stoma was necessary.
Between the other 6 patients in group B who underwent directly to surgery, In one case was necessary an Hartmann resection, another one incurred in dehiscence of the anastomosis that required reoperation with stoma creation.
Placement of SEMS seems to be an useful alternative to emergent surgery in the management of acute left-sided bowel obstruction, both as a bridge to surgery and as a palliative procedure. SEMS can provide an effective and safe therapeutic option compared to emergency surgery, most of all in elderly patients, with a lower mortality rate, a significantly higher rate of primary anastomosis and the avoidance of stoma.
However, to fully determine their role for these indications, more data and more high level evidence is required.
PMCID: PMC4321507  PMID: 25644730
Colorectal cancer; Large bowel obstruction; Stent placement; Bridge to surgery
2.  The cost-effectiveness of colonic stenting as a bridge to curative surgery in patients with acute left-sided malignant colonic obstruction: A Canadian perspective 
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.
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.
PMCID: PMC2660835  PMID: 17171197
Bowel obstruction; Colon cancer; Colonic stenting; Cost-effectiveness
3.  Stenting for Obstructing Colon Cancer: Fewer Complications and Colostomies 
Background and Objectives:
Colonic stenting has been used in the setting of malignant obstruction to avoid an emergent colectomy. We sought to determine whether preoperative placement of a colonic stent decreases morbidity and the rate of colostomy formation.
Cases of obstructing sigmoid, rectosigmoid, and rectal cancer from January 1, 2010, to December 31, 2011, were identified in the Nationwide Inpatient Sample (NIS) database. All patients were treated at hospitals in the United States, and the database generated national estimates. Postoperative complications, mortality, and the rate of colostomy formation were analyzed.
Of the estimated 7891 patients who presented with obstructing sigmoid, rectosigmoid, or rectal cancer necessitating intervention, 12.1% (n = 956) underwent placement of a colonic stent, and the remainder underwent surgery without stent placement. Of the patients who underwent stenting, 19.9% went on to have colon resection or stoma creation during the same admission. Patients who underwent preoperative colonic stent placement had a lower rate of total postoperative complications (10.5% vs 21.7%; P < .01). There was no significant difference in mortality (4.7% vs 4.2%; P = .69). The rate of colostomy formation was more than 2-fold higher in patients who did not undergo preoperative stenting (42.5% vs 19.5%; P < .01). Preoperative stenting was associated with increased use of laparoscopy (32.6% vs 9.7%; P < .01).
Our study characterizes the national incidence of preoperative placement of a colonic stent in the setting of malignant obstruction. Preoperative stent placement is associated with lower postoperative complications and a lower rate of colostomy formation. The results support the hypothesis that stenting as a bridge to surgery may benefit patients by converting an emergent surgery into an elective one.
PMCID: PMC4379870  PMID: 25848200
Colonic obstruction; Malignant bowel obstruction; Obstructing colon cancer
4.  Surgical failure after colonic stenting as a bridge to surgery 
World Journal of Gastroenterology : WJG  2014;20(33):11826-11834.
AIM: To identify risk factors for surgical failure after colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction.
METHODS: The medical records of patients who underwent stent insertion for malignant colonic obstruction between February 2004 and August 2012 were retrospectively reviewed. Patients with malignant colonic obstruction had overt clinical symptoms and signs of obstruction. Malignant colonic obstruction was diagnosed by computed tomography and colonoscopy. A total of 181 patients underwent stent insertion during the study period; of these, 68 consecutive patients were included in our study when they had undergone stent placement as a bridge to surgery in acute left-sided malignant colonic obstruction due to primary colon cancer.
RESULTS: Out of 68 patients, forty-eight (70.6%) were male, and the mean age was 64.9 (range, 38-89) years. The technical and clinical success rates were 97.1% (66/68) and 88.2% (60/68), respectively. Overall, 85.3% (58/68) of patients underwent primary tumor resection and primary anastomosis. Surgically successful preoperative colonic stenting was achieved in 77.9% (53/68). The mean duration, defined as the time between the SEMS attempt and surgery, was 11.3 d (range, 0-26 d). The mean hospital stay after surgery was 12.5 d (range, 6-55 d). On multivariate analysis, the use of multiple self-expanding metal stents (OR = 28.872; 95%CI: 1.939-429.956, P = 0.015) was a significant independent risk factor for surgical failure of preoperative stenting as a bridge to surgery. Morbidity and mortality rates in surgery after stent insertion were 4.4% (3/68) and 1.5% (1/68), respectively.
CONCLUSION: The use of multiple self-expanding metal stents appears to be a risk factor for surgical failure.
PMCID: PMC4155374  PMID: 25206288
Colorectal neoplasms; Endoscopy; Intestinal obstruction; Risk factors; Stents
5.  Colon Stenting: A Review 
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.
PMCID: PMC3036228  PMID: 21331130
Colon cancer; intestinal obstruction; colonic stenting
6.  Emergency management with resection versus proximal stoma or stent treatment and planned resection in malignant left-sided colon obstruction 
Emergency surgery for colon cancer, as a result of obstruction, has been vitiated by a high frequency of complications and poor survival. The concept of “bridge to surgery” includes either placement of self-expanding metallic stents (SEMS) or diverting stoma of an obstructing tumour and subsequent planned resection. The aim of this study was to compare acute resection with stoma or stent and later resection regarding surgical and oncological outcomes and total hospital stay.
This is a retrospective cohort study. All 2424 patients diagnosed with colorectal cancer during 1997–2013 were reviewed. All whom underwent acute surgery with curative intention for left-sided malignant obstruction were included in the study.
One hundred patients fulfilled the inclusion criteria. Among them, 57 patients were treated with acute resection and 43 with planned resection after either acute diverting colostomy (n = 23) or stent placement (n = 20). The number of harvested lymph nodes in the resected specimen was higher in the planned resection group compared with acute resection group (21 vs. 8.7; p = 0.001). Fewer patients were treated with adjuvant chemotherapy in the acute resection group than in the stoma group (14 % (8/57 patients) vs. 43 %, (10/23 patients; p = 0.024)). Patients operated with acute resection had a higher 30-day mortality rate and were more frequently left with a permanent stoma.
Decompression of emergency obstructive left colon cancer with stent or stoma and subsequent curative resection appears safer and results in a higher yield of lymph node harvest, and fewer patients are left with a permanent stoma.
PMCID: PMC5006427  PMID: 27577887
Colon cancer; Emergency resection; Stoma; Self-expanded metallic stent (SEMS)
7.  Colonic stenting vs emergent surgery for acute left-sided malignant colonic obstruction: A systematic review and meta-analysis 
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.
PMCID: PMC3482649  PMID: 23112555
Acute obstruction; Colonic cancer; Self-expandable metallic stent; Stoma placement; Meta-analysis; Systematic review
8.  Emergency Management of Malignant Acute Left-Sided Colonic Obstruction 
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.
PMCID: PMC2430461  PMID: 18430330
Colonic neoplasms; Intestinal obstruction; Stents; Colectomy; Hartmann's operation; Colonic irrigation
9.  Endoscopic stent placement in the management of malignant colonic obstruction: Experiences from two centers 
Intestinal obstruction due to colorectal tumors requires immediate surgical decompression. Endoscopic stent placement for acute malignant colonic obstruction is gaining widespread acceptance as an alternative to emergency surgery. Our aim in this study was to evaluate the success and complication rates of endoscopic stenting for malignant colonic obstruction.
Material and Methods:
Patients with acute malignant colonic obstruction who underwent endoscopic stenting between 2011–2014 were retrospectively reviewed. Data included demographic features, localization of obstruction, endoscopic stenting indications, rate of technical and clinical success, complications, morbidity and mortality.
Endoscopic stent was successfully placed in 77 out of 82 procedures (93.9%). A colostomy was placed in five cases in which endoscopic stent could not be inserted. There were complications in seven patients with technically successful stents (9.0%). These included three stent migrations, one perforation, and rectal hemorrhage in three patients. There were no stent-related deaths.
The mortality rate of emergency surgery for malignant bowel obstruction is relatively high. The use of colonic stents can avoid surgery in patients who are not suitable for emergency surgery and may allow adequate time for preoperative preparation, counseling and staging for those who are suitable for further intervention. We believe that self-expandable metallic stent placement is a safe, effective, and minimal invasive alternative treatment method for malignant colonic obstruction.
PMCID: PMC4605108  PMID: 26504416
Colorectal carcinoma; self-expandable colonic stent; malignant intestinal obstruction
10.  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.
PMCID: PMC3600563  PMID: 23515179
Left-sided large bowel obstruction; Hartmann’s procedure; Primary anastomosis; Bowel stent; Emergency treatment
11.  A comparison of two methods of palliation of large bowel obstruction due to irremovable colon cancer. 
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.
PMCID: PMC1964159  PMID: 15005927
12.  Colonic stenting for malignant colonic obstruction with pneumatosis intestinalis: A case report 
•Pneumatosis intestinalis is characterized by the presence of air localizing in the submucosa and subserosa layers of the bowel wall.•Because of its risk of impending perforation, emergency surgery is generally required to be a definite treatment.•Colonic stenting can be used as a safe alternative procedure in the selected patient.
Pneumatosis intestinalis is one of serious conditions following mechanical bowel obstruction. Emergency surgery is generally required to be a definite treatment in these patients of pneumatosis intestinalis, because of its risk of bowel ischemia and perforation. Since the operation in unprepared colon usually resulted in unfavorable outcome, the use of colonic stent is considered one of potential options as a bridge to definitive surgery. Presently, there is no widely published report of using colonic stent in these patients, particularly for stepping to curative surgery. Therefore, we herein report a case of obstructing sigmoid cancer with pneumatosis intestinalis who underwent successfully emergency metallic stent placement to convert from emergency to elective surgery.
Presentation of case
A 50-year-old woman presented with 3-day history of abdominal pain and obstipation. Abdominal computed tomography demonstrated a short segment of circumferential luminal narrowing at sigmoid colon, the presence of pneumatosis intestinalis at cecum, including ascending colon, and no extraluminal air. We performed colonoscopy and placed the metallic stent. The patient was then improved. After 1 week, the patient underwent elective hand-assisted laparoscopic sigmoidectomy and was discharged 5 days later. Pathological report showed stage IIa sigmoid cancer. The patient had no local recurrence or distant metastasis in 1 year follow up.
In obstructing colonic patient with pneumatosis intestinalis, nonsurgical treatment by colonic stenting can be used in selected patient as a bridge to definitive surgery. This will result in decreased morbidity and mortality and lower rate of stoma formation.
PMCID: PMC4957606  PMID: 27448227
PI, Pneumatosis intestinalis; SEMS, Self-expandable metallic stent; CT, Computed tomography; WBC, White blood cell; Pneumatosis intestinalis; Stenting; Bridge to surgery; Sigmoid cancer; Colonic obstruction; Case report
13.  Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction 
AIM: To summarize our experience with the application of self-expanding metallic stent (SEMS) in the management of acute left-sided colorectal malignant obstruction.
METHODS: A retrospective chart review of all patients undergoing placement of SEMS between April 2000 and January 2004 was performed.
RESULTS: Insertion of SEMS was attempted in 26 patients under fluoroscopic guidance with occasional endoscopic assistance. The sites of lesions were located in splenic flexure of two patients, left colon of seven patients, sigmoid colon of eight patients and rectum of nine patients. The intended uses of SEMS were for palliation in 7 patients and as a bridge to elective surgery in 19 patients. In the latter group, placement of SEMS allowed for preoperative systemic and bowel preparation and the following one-stage anastomosis. Successful stent placement was achieved in 22 (85%) of the 26 patients. The clinical bowel obstruction resolved 24 hours after successful stent placement in 21 (95%) patients. Three SEMS-related minor complications occurred, two stents migrated and one caused anal pain.
CONCLUSION: SEMS represents an effective and safe tool in the management of acute malignant colorectal obstruction. As a bridge to surgery, SEMS can provide time for systematic support and bowel preparation and obviate the need for fecal diversion or on-table lavage. As a palliative measure, SEMS can eliminate the need for emergent colostomy.
PMCID: PMC4066126  PMID: 16521189
SEMS; Acute left-sided colorectal malignant obstruction
14.  A Population-Based Analysis of Three Treatment Modalities for Malignant Obstruction of the Proximal Colon: Acute Resection Versus Stent or Stoma as a Bridge to Surgery 
Annals of Surgical Oncology  2016;23(11):3660-3668.
Malignant obstruction of the proximal colon (MOPC) traditionally has been treated with acute resection. However, morbidity and mortality rates following these emergency surgeries are high. Initial bowel decompression by stent placement or stoma construction has been used for distal obstructions as an alternative approach. This study evaluated whether these alternative treatment strategies could be beneficial for patients with a MOPC as well.
All patients undergoing a colonic resection for a MOPC between January 2009 and December 2013 and who were registered in the Dutch Surgical Colorectal Audit were analyzed.
From the 49,013 patients registered in the DSCA, 1860 (3.8 %) were selected for further analysis. Acute resection was performed in 1774 patients (95.4 %), 44 patients (2.4 %) were treated with initial decompression using stent placement and resection, and 42 patients (2.3 %) with stoma construction followed by resection. Thirty-day mortality was 8.8, 2.4, and 2.4 %, respectively. Mortality was significantly lower after a bridging strategy (stent or stoma) compared with acute resection (p = 0.04). Complications following the resection occurred in 39.6% in the acute resection group and in 27.3 and 31.7% in the stent and stoma group, respectively (p = 0.167).
Acute resection was performed in the vast majority of patients with obstructive proximal colon cancer and resulted in a 40 % morbidity and 9 % mortality rate. A bridging strategy may be a valid alternative in some of these patients, because a significantly lower postoperative mortality rate was seen in a subgroup of patients initially treated with a stent or stoma.
PMCID: PMC5009151  PMID: 27221360
15.  Enteral stents for the management of malignant colorectal obstruction 
World Journal of Gastroenterology : WJG  2014;20(37):13239-13245.
Colorectal cancer (CRC) is the 3rd most common cancer in the United States with more than 10000 new cases diagnosed annually. Approximately 20% of patients with CRC will have distant metastasis at time of diagnosis, making them poor candidates for primary surgical resection. Similarly, 8%-25% of patients with CRC will present with bowel obstruction and will require palliative therapy. Emergent surgical decompression has a high mortality and morbidity, and often leads to a colostomy which impairs the patient’s quality of life. In the last decade, there has been an increasing use of colonic stents for palliative therapy to relieve malignant colonic obstruction. Colonic stents have been shown to be effective and safe to treat obstruction from CRC, and are now the therapy of choice in this scenario. In the setting of an acute bowel obstruction in patients with potentially resectable colon cancer, stents may be used to delay surgery and thus allow for decompression, adequate bowel preparation, and optimization of the patient’s condition for curative surgical intervention. An overall complication rate (major and minor) of up to 25% has been associated with the procedure. Long term failure of stents may result from stent migration and tumor ingrowth. In the majority of cases, repeat stenting or surgical intervention can successfully overcome these adverse effects.
PMCID: PMC4188882  PMID: 25309061
Colorectal cancer; Colonic obstruction; Self expanding metal stents; Intestinal obstruction/etiology; Intestinal obstruction/mortality; Intestinal obstruction/surgery; Survival rate
16.  The Safety and Efficiency of Surgery with Colonic Stents in Left-Sided Malignant Colonic Obstruction: A Meta-Analysis 
Objective. This meta-analysis is aimed at assessing the safety and efficiency of colonic self-expanding metallic stents (SEMS) used as a bridge to surgery in the management of left-sided malignant colonic obstruction (LMCO). Methods. A systematic search was conducted in PubMed, Web of Knowledge, OVID, Google Scholar, CNKI, and WANGFANG for relevant randomized trials comparing colonic stenting used as a bridge in semielective surgery versus emergency surgery from January 2001 to September 2013. Result. Five published studies were included in this systematic review, including 273 patients (140 male/133 female). 136 patients received semielective surgery after SEMS installation while 137 patients underwent emergency surgery without SEMS. SEMS intervention resulted in significantly lower overall colostomy rate (41.9% versus 56.2%, P = 0.02), surgical site infection rate (10.2% versus 19.7%, P = 0.03), and overall complication rate (29.2% versus 60.5%, P = 0.05). There was no statistic difference for the rate of primary anastomosis, anastomotic leak and operation-related mortality between two groups. Conclusions. semielective surgery with SEMS as a bridge for proper patients of LMCO can lower the overall rate for colostomy, surgical site infection, and complications.
PMCID: PMC4053219  PMID: 24959174
17.  Endovascular Repair of Descending Thoracic Aortic Aneurysm 
Executive Summary
To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA).
Clinical Need
Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition.
The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases.
The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia.
The Technology
Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs.
The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall.
The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration.
Review Strategy
To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach
To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs
Measures of Effectiveness
Primary Outcome
Mortality rates (30-day and longer term)
Secondary Outcomes
Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation
Rate of reintervention (through surgical or endovascular approach)
Measures of Safety
Complications were categorized into 2 classes:
Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and
Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.
Inclusion Criteria
Studies comparing the clinical outcomes of ESG treatment with surgical approaches
Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs
Exclusion Criteria
Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta
Studies investigating the aneurysms of the ascending and the arch of the aorta
Studies using custom-made grafts
Literature Search
The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies.
One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria.
Summary of Findings
The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).
Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.
Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.
Technical Success Rate
Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).
Surgical Reintervention
In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.
Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).
Endovascular Revision
In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.
Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.
Graft Migration
Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.
Aortic Rupture
In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.
Postprocedural Complications
In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.
Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).
Time-Related Outcomes
The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).
The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively.
Ontario-Based Economic Analysis
In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure.
Hospitalization Costs
The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative).
Professional (Ontario Health Insurance Plan) Costs
Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations.
The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes.
The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes.
Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured.
Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair.
There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention.
However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay.
PMCID: PMC3382300  PMID: 23074469
18.  Colonic Stent as Bridge to Surgery in Patients with Obstructive Left-Sided Colon Cancer 
We assessed the optimal time interval between endoscopic stenting and subsequent surgery in patients with obstructive left-sided colon cancer.
We reviewed the medical records of patients who underwent endoscopic colonic stenting for obstructive left-sided colon cancer between January 2009 and January 2012. Patients who had successful endoscopic intervention as a bridge to surgery were included in the study. Other variables studied were the duration between endoscopic stenting and surgery, the reobstruction rate, the stoma creation rate, the anastomotic leak rate, and the in-hospital mortality rate.
The medical records of 53 patients who underwent endoscopic stenting for obstructive left-sided colon cancer were reviewed, and 43 were included in the study. The median duration between endoscopic stenting and surgery was 7 days (range, 5–33).
A median duration of 7 to 9 days after endoscopic stenting in patients with obstructive left-sided colon cancer is enough time to subsequently perform a safe surgical procedure. Extending this duration may expose the patient to the risk of reobstruction and emergency surgery.
PMCID: PMC4232405  PMID: 25408602
Large bowel obstruction; Endoscopic stenting; Bridge to surgery; Emergency colorectal surgery
19.  Acute endometrial bowel obstruction—A rare indication for colonic stenting 
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.
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.
PMCID: PMC3540235  PMID: 23276756
Colonic; Obstruction; Endometriosis; Radiological; Stenting
20.  Self-Expanding Metallic Stents for Palliation and as a Bridge to Minimally Invasive Surgery in Colorectal Obstruction 
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.
PMCID: PMC3771786  PMID: 23925013
Colon obstruction; Self-expandable metallic stents; SEMS; Intraluminal stents
21.  Colorectal stenting for palliation and as a bridge to surgery: A 5-year follow-up study 
AIM: To evaluate the long-term effectiveness of colonic stents in colorectal tumors causing large bowel obstruction.
METHODS: We retrospectively analyzed data from 49 patients with colorectal cancer who had undergone colorectal stent placement between January 2008 and January 2013. Patients’ symptoms, characteristics and clinicopathological data were obtained by reviewing medical records. The obstruction was diagnosed clinically and radiologically. Histopathological diagnosis was achieved endoscopically. Technical success rate (TSR) was defined as the ratio of patients with correctly placed SEMS upon stent deployment across the entire stricture length to total number of patients. Clinical success rate (CSR) was defined as the ratio of patients with technical success and successful maintenance of stent function before elective surgery (regardless of number of SEMS deployed) to total number of patients. The surgical success rate (SSR) of colorectal stent as a bridge to surgery was defined as the ratio of patients with successful surgical procedures. Unsuccessful surgical outcomes were defined as being due to insufficient colonic decompression. The technical, clinical, surgical success rates and complications after stenting were assessed.
RESULTS: The median age of patients was 64 (36 to 89). 44.9% of patients were male and 55.1% were female. Eighteen patients had the obstruction located in the rectum, 15 patients in the rectosigmoid region, 10 patients in the sigmoid region, and 6 patients had a tumor causing obstruction in the proximal colon. Each patient was categorized pathologically as stage 2 (32.7%, 16 patients) or stage 3 (42.9%, 21 patients) and 12 patients (24.4%) had metastatic disease. None of the patients received chemotherapy before stenting. Stenting was undertaken in 37 patients as a bridge to surgery, and in 12 patients stents were used for palliation. Median time to surgery after stenting was 30 ± 91.9 d. All surgery was completed in one single operation and thus no colostomy with stoma was needed. The median overall survival rate of patients with stage 2-3 colorectal cancer was 53.1 mo and stage 4 was 37.1 mo (P = 0.04). Metastatic colorectal patients who were treated palliatively with stents had backbone chemotherapy with oxaliplatin and/or irinotecan-based regimens plus antiangiogenic therapies, especially bevacizumab. Resolution of the obstruction and clinical improvement was achieved in all patients. The technical, clinical and surgical success rates were 95.9%, 100% and 94.6%, respectively.
CONCLUSION: The efficacy and safety of colonic stents was demonstrated both as a bridge to surgery and for palliative decompression. In addition, results emphasize the importance of the skills of the endoscopist in colonic stenting.
PMCID: PMC4541389  PMID: 26309363
Large bowel obstruction; Colonic decompression; Colorectal tumors; Metallic stent; Palliative therapy
22.  Stenting for Large Bowel Obstruction – Evolution of a Service in a District General Hospital 
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.
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.
PMCID: PMC2752245  PMID: 19126335
Self-expanding metal stent; Large bowel obstruction; Stent
23.  Endoluminal stenting of obstructed colorectal tumours. 
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.
PMCID: PMC2503259  PMID: 10615192
24.  Self-expanding metal stents in malignant colonic obstruction: experiences from Sweden 
BMC Research Notes  2011;4:274.
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.
PMCID: PMC3163214  PMID: 21801447
25.  Safety and Efficacy of Metallic Stents in the Management of Colorectal Obstruction 
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.
PMCID: PMC3015633  PMID: 16381366
Stent; Colorectal obstruction; Colorectal cancer; Surgery; Palliation

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