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Fujisawa G, Ishibashi R, Yoshida S, Kondo R, Hata M, Oya Y, Odawara N, Nakada A, Komine Y, Hakuta R, Takahara N, Suzuki N, Nakai Y, Isayama H, Fujishiro M. Safety and Effectiveness of Colonic Stenting for Ileocecal Valve Obstruction and Usefulness of Two-Step Strategy: Single-Center Retrospective Study. J Clin Med 2025; 14:826. [PMID: 39941497 PMCID: PMC11818438 DOI: 10.3390/jcm14030826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Revised: 01/23/2025] [Accepted: 01/24/2025] [Indexed: 02/16/2025] Open
Abstract
Background: Endoscopic self-expandable metallic stent (SEMS) placement is a widely accepted treatment for malignant left-sided colorectal obstruction (LSO) because of its lower invasiveness and quicker symptomatic relief compared to surgery. However, SEMS placement for ileocecal valve obstruction (ICVO) has not been established due to its technical difficulties. Methods: This single-center retrospective study compared the clinical outcomes of patients who underwent SEMS placement for ICVO (ICVO group, n = 13) and LSO (LSO group, n = 146). Particularly in cases with severe small-intestine dilation, we applied a "Two-Step Strategy", which involved long intestinal tube insertion followed by SEMS placement to ensure safety and overcome technical challenges. Results: Patients in the ICVO group were significantly more likely to undergo SEMS placement with the Two-Step Strategy compared to those in the LSO group (76.9% vs. 6.9%, p < 0.001). Both groups achieved similarly high technical and clinical success rates (100% vs. 98.6%, p = 1.000; 92.3% vs. 88.4%, p = 1.000), and the incidence of adverse events also showed no significant difference between the groups (7.7% vs. 13.0%; p = 1.000). Furthermore, the median time to recurrent colorectal obstruction and survival time after SEMS placement did not differ between patients with palliative stenting for ICVO and LSO (not reached vs. 430 days, p = 0.586; 119 days vs. 200 days, p = 0.303). Conclusions: SEMS placement for malignant ICVO is as safe and effective as it is for malignant LSO, and the Two-Step Strategy might be useful in ICVO cases.
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Affiliation(s)
- Gota Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Rei Ishibashi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Shuntaro Yoshida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Ryo Kondo
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Masahiro Hata
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Yukiko Oya
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Nariaki Odawara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Ayako Nakada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Yumiko Komine
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Ryunosuke Hakuta
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo 162-8666, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Nobumi Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Yousuke Nakai
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo 162-8666, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
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Lueders A, Ong G, Davis P, Weyerbacher J, Saxe J. Colonic stenting for malignant obstructions-A review of current indications and outcomes. Am J Surg 2022; 224:217-227. [DOI: 10.1016/j.amjsurg.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/08/2021] [Accepted: 12/27/2021] [Indexed: 11/01/2022]
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Sano T, Nozawa Y, Iwanaga A, Azumi M, Imai M, Ishikawa T, Honma T, Yoshida T. Comparison of the efficacy of self-expandable metallic stents in colorectal obstructions caused by extracolonic malignancy and colorectal cancer. Mol Clin Oncol 2021; 15:170. [PMID: 34295470 PMCID: PMC8273924 DOI: 10.3892/mco.2021.2332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/01/2021] [Indexed: 11/05/2022] Open
Abstract
The current study aimed to compare the safety and effectiveness of self-expandable metallic stent placement among patients with extracolonic malignancy and those with colorectal cancer. Patient information, technical and clinical success rates and complication rates were compared between patients with colorectal cancer and extracolonic malignancy. The Kaplan-Meier method was used to compare the time elapsed before the onset of complications. Risk factors for re-obstruction in patients with self-expandable metallic stents were evaluated by multivariate analysis. A total of 68 patients who underwent self-expandable metallic stent placement at Saiseikai Niigata Hospital between January 2012 and September 2019 were included. The clinical success rate was significantly different between the colorectal cancer (96.6%) and extracolonic malignancy (66.7%) groups (P=0.01). The incidence of complications was significantly higher in the extracolonic malignancy group (66.7%) than in the colorectal cancer group (25.4%; P=0.02). Additionally, the time elapsed before the onset of complications was shorter in the extracolonic malignancy group than in the colorectal cancer group (P=0.0008). Risk factors for re-obstruction were higher in the extracolonic malignancy group [odds ratio, 7.76 (1.02-57.2)] than in the palliative stent placement group [odds ratio, 5.45 (1.01-29.5); P=0.04]. In extracolonic malignancy, self-expandable metallic stent placement was associated with lower clinical success rates and increased risk of complications. The time elapsed before the onset of complications was short, and extracolonic malignancy was a risk factor for re-obstruction, suggesting that the placement of self-expandable metallic stents for malignant colorectal obstruction in extracolonic malignancy is not optimal.
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Affiliation(s)
- Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Yujiro Nozawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Motoi Azumi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Michitaka Imai
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
| | - Toshiaki Yoshida
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan
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Bennedsgaard SS, Iversen LH. Biopsy sampling during self-expandable metallic stent placement in acute malignant colorectal obstruction: a narrative review. World J Surg Oncol 2021; 19:48. [PMID: 33583419 PMCID: PMC7883457 DOI: 10.1186/s12957-021-02122-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Histopathology is a crucial part of diagnosis and treatment guidance of colorectal cancer. In Denmark, it is not routine to biopsy during self-expandable metallic stent (SEMS) placement as a treatment option for acute colorectal obstruction of unknown etiology. This is due to lack of knowledge about the risks of hemorrhage, and thus the risk to aggravate the deteriorating overview conditions. Therefore, the aim of this study is to investigate whether there is evidence to avoid biopsy sampling during acute SEMS placement. METHODS The PubMed, Embase, and Cochrane Library databases were searched for relevant studies. Studies were included if they described biopsy sampling in relation to SEMS placement. Additionally, national and international guidelines were scrutinized on Google and by visiting the websites of national and international gastrointestinal societies. RESULTS In total, 43 studies were included in the review. Among these, one recommended biopsy during SEMS placement, three advised against biopsy, 23 just reported biopsy was performed during the procedure, and 16 reported biopsy before or after the procedure, or the timing was not specified. Among the 12 included guidelines, only two described biopsy during SEMS placement. CONCLUSION The literature on the subject is limited. In 24 of the 43 included studies, biopsy sampling was done during SEMS placement without reporting a decrease in the technical success rate. The included guidelines were characterized by a general lack of description of whether biopsy during SEMS placement should be performed or not. Prospective studies are needed in order to establish the real risk of hemorrhage, if any, when a biopsy is obtained.
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Colorectal stent placement assisted by a slim gastroscope: technique and outcomes. Surg Endosc 2021; 35:2398-2402. [PMID: 33528664 DOI: 10.1007/s00464-021-08334-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The distorted anatomy in patients with obstruction renders colon stent placement difficult. Here, we propose two novel techniques for stent implantation. METHODS Patients in whom there was difficulty placing the guidewire with the normal method were retrospectively included in our study. All of the patients underwent the technique of combining a slim gastroscope with a normal colonoscope. We assessed the technical success, clinical success, and adverse events associated with self-expanding metal stent placement. RESULTS From June 2018 to June 2020, 30.5% of patients with difficult catheterization were included in this study. Finally, stents in 17 of 18 patients (3 rectum, 13 sigmoid colon, 1 descending colon, and 1 hepatic flexure) (94.4%) were placed successfully, assisted by a slim gastroscope with or without radiography, and the obstruction was relieved. Only one remaining patient experienced failure. No intraoperative or 30-day postoperative morbidity or mortality was observed. CONCLUSION The present study showed that the stent implantation technique assisted by a slim gastroscope combined with a normal colonoscope was a relatively safe and effective method for abolishing difficult intestinal stenosis. More studies are needed to compare the advantages and disadvantages of this technique with normal endoscopic implantation.
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Berselli M, Borroni G, Livraghi L, Quintodei V, Sambucci D, Cortelezzi C, Segato S, Carcano G, Cocozza E. Laparoscopic Approach to Large Bowel Neoplastic Obstruction After Self-Expandable-Metal-Stent (SEMS) Placement. Surg Laparosc Endosc Percutan Tech 2019; 29:133-137. [PMID: 30629036 DOI: 10.1097/sle.0000000000000623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic self-expandable metal stent (SEMS) placement as a bridge to surgery in large bowel neoplastic obstruction is an alternative to emergency surgery for the obstructive colorectal neoplasms. This study aims to analyze postoperative and long-term outcomes in a series of patients who underwent laparoscopic colorectal resection after SEMS placement. The analysis, after the stratification based on the time elapsed between the onset of the occlusive symptoms and the SEMS positioning, revealed an interesting result, with lower mortality for patients who underwent the procedure within 24 hours of hospitalization (P=0.0159). This trend may indicate the need to reduce the endoscopic time schedules as much as possible, even if an emergency procedure is needed. The laparoscopic approach, after stent placement as bridge therapy, can be a safe alternative to emergency surgery, if the procedure is precociously applied.
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Affiliation(s)
- Mattia Berselli
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Giacomo Borroni
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Lorenzo Livraghi
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Valeria Quintodei
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Daniele Sambucci
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
| | - Claudio Cortelezzi
- Department of Specialist Medicine, Gastroenterology Division, ASST Settelaghi
| | - Sergio Segato
- Department of Specialist Medicine, Gastroenterology Division, ASST Settelaghi
| | - Giulio Carcano
- Research Centre for Trauma and Emergency Surgery, University of Insubria, Varese, Italy
| | - Eugenio Cocozza
- Department of Surgery, Surgical Oncology and Minimally Invasive Division
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Mashar M, Mashar R, Hajibandeh S. Uncovered versus covered stent in management of large bowel obstruction due to colorectal malignancy: a systematic review and meta-analysis. Int J Colorectal Dis 2019; 34:773-785. [PMID: 30903271 DOI: 10.1007/s00384-019-03277-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare outcomes of uncovered stent and covered stent in management of large bowel obstruction secondary to colorectal malignancy. METHODS We conducted a search of electronic databases identifying studies comparing outcomes of uncovered and covered stents in management of large bowel obstruction secondary to colorectal malignancy. The Cochrane risk-of-bias tool and the Newcastle-Ottawa scale were used to assess the included studies. Random or fixed effects modelling were applied as appropriate to calculate pooled outcome data. RESULTS One randomised controlled trial (RCT) and nine observational studies, enrolling 753 patients, were identified. Uncovered stent was associated with lower risks of complications (RR 0.57 95% CI 0.44-0.74, P < 0.0001), tumour overgrowth (RR 0.29 95% CI 0.09-0.93, P = 0.04), and stent migration (RR 0.29 95% CI 0.17-0.48, P < 0.00001); longer duration of patency (MD 18.47 95% CI 10.46-26.48, P < 0.00001); lower need for stent reinsertion (RR 0.38 95% CI 0.17-0.86, P = 0.02); and higher risk of tumour ingrowth (RR 4.53 95% CI 1.92-10.69, P = 0.0008). Rates of technical success (RR 1.02 95% CI 0.99-1.04, P = 0.21), clinical success (RR 1.03 95% CI 0.98-1.08, P = 0.32), perforation (RD 0.01 95% CI - 0.03-0.02, P = 0.65), bleeding (RD 0.00 95% CI - 0.03-0.03, P = 0.98), stool impaction (RR 0.56 95% CI 0.12-2.04, P = 0.38) and stent obstruction (RR 2.23 95% CI 0.94-5.34, P = 0.97) were similar. CONCLUSIONS Our results suggest that uncovered stents are superior as indicated by fewer complications, lower rates of stent migration, longer duration of patency and a reduced need for stent reinsertion. The best available evidence is mainly derived from non-randomised studies; there is a need for more RCTs.
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Affiliation(s)
- Meghavi Mashar
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Ruchir Mashar
- Department of General Surgery, Hereford County Hospital, Hereford, HR1 2BN, UK
| | - Shahab Hajibandeh
- Department of General Surgery, North Manchester General Hospital, Manchester, M8 5RB, UK
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Bokarev MI, Vodoleev AS, Mamykin AI, Muntyanu EV, Duvansky VA, Demyanov AI, Belov YV. [Effectiveness of various approaches for acute malignant colonic obstruction]. Khirurgiia (Mosk) 2018:55-60. [PMID: 30531738 DOI: 10.17116/hirurgia201810155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To determine optimal treatment strategy for acute malignant colonic obstruction. MATERIAL AND METHODS 349 patients with acute malignant colonic obstruction were retrospectively analyzed for the period 2005-2017. All patients were divided into two groups depending on surgical approach. Surgical group comprised 259 patients, endoscopic group - 90 patients. Both groups were comparable by gender, age, level of intestinal obstruction and duration of the disease. However, morbidity and mortality rate were significantly different. RESULTS In surgical group incidence of complications was 63.3%, mortality - 19.7%. In group of endoscopic stenting the same values were 8.9% and 6.7%, respectively. Significant differences of morbidity and mortality were observed between groups (p<0.05). CONCLUSION Endoscopic stenting should be preferred over surgery to eliminate colonic obstruction in patients with acute malignant ileus.
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Affiliation(s)
- M I Bokarev
- Sechenov First Moscow State Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A S Vodoleev
- Eramishantsev Municipal Clinical Hospital of Moscow Healthcare Department, Moscow, Russia
| | - A I Mamykin
- Sechenov First Moscow State Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - E V Muntyanu
- Sechenov First Moscow State Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - V A Duvansky
- Russian Peoples Friendship University, Moscow, Russia
| | - A I Demyanov
- Sechenov First Moscow State Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - Yu V Belov
- Sechenov First Moscow State Medical University of Healthcare Ministry of Russia, Moscow, Russia; Petrovsky Russian Research Center for Surgery, Moscow, Russia
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Imai M, Kamimura K, Takahashi Y, Sato T, Isokawa O, Maruyama M, Kobayashi T, Hayashi K, Terai S. The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine. Int J Colorectal Dis 2018; 33:189-197. [PMID: 29264760 DOI: 10.1007/s00384-017-2946-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine. METHODS We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65-99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction. RESULTS The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20-1377 days). On multivariate analysis, shorter stents (< 10 cm) yielded better outcomes than longer stents (≥ 10 cm) (P = 0.041), and the Cox proportional hazard model also indicated that shorter stents (P = 0.036) predicted longer event-free survival. CONCLUSIONS Elderly patients with malignant bowel obstruction receiving shorter stents had longer event-free survival after stenting with better general condition.
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Affiliation(s)
- Michitaka Imai
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan.
| | - Yoshifumi Takahashi
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Toshihiro Sato
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Osamu Isokawa
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
| | - Masaki Maruyama
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, 2-11-3, Kitahanda, Kashiwazaki, Niigata, Japan
- Department of Gastroenterology, Kashiwazaki Chuo Hospital, 2-1-25, Ekimae, Kashiwazaki, Niigata, Japan
| | - Takamasa Kobayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757, Aasahimachi-Dori, Chuo-Ku, Niigata, 9518510, Japan
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Siddiqui A, Cosgrove N, Yan LH, Brandt D, Janowski R, Kalra A, Zhan T, Baron TH, Repici A, Taylor LJ, Adler DG. Long-term outcomes of palliative colonic stenting versus emergency surgery for acute proximal malignant colonic obstruction: a multicenter trial. Endosc Int Open 2017; 5:E232-E238. [PMID: 28367495 PMCID: PMC5362371 DOI: 10.1055/s-0043-102403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Long-term data are limited regarding clinical outcomes of self-expanding metal stents as an alternative for surgery in the treatment of acute proximal MBO. The aim of this study was to compare the long-term outcomes of stenting to surgery for palliation in patients with incurable obstructive CRC for lesions proximal to the splenic flexure. Patients and methods Retrospective multicenter cohort study of obstructing proximal CRC patients with who underwent insertion of a SEMS (n = 69) or surgery (n = 36) from 1999 to 2014. The primary endpoint was relief of obstruction. Secondary endpoints included technical success, duration of hospital stay, early and late adverse events (AEs) and survival. Results Technical success was achieved in 62/69 (89.8 %) patients in the SEMS group and in 36 /36 (100 %) patients who underwent surgery (P = 0.09). In the SEMS group, 10 patients underwent stenting as a bridge to surgery and 59 underwent stent placement for palliation. Clinical relief was achieved in 78 % of patients with stenting and in 100 % of patients who underwent surgery (P < 0.001). Patients with SEMS had significantly less acute AEs compared to the surgery group (7.2 % vs. 30.5 %, P = 0.003). Hospital mortality for the SEMS group was 0 % compared to 5.6 % in the surgery group (P = 0.11). Patients in the SEMS group had a significantly shorter median hospital stay (4 days) as compared to the surgery group (8 days) (P < 0.01). Maintenance of decompression without the recurrence of bowel obstruction until death or last follow-up was lower in the SEMS group (73.9 %) than the surgery group (97.3 %; P = 0.003). SEMS placement was associated with higher long-term complication rates compared to surgery (21 % and 11 % P = 0.27). Late SEMS AEs included occlusion (10 %), migration (5 %), and colonic ulcer (6 %). At 120 weeks, survival in the SEMS group was 5.6 % vs. 0 % in the surgery group (P = 0.8). Conclusions Technical and clinical success associated with proximal colonic obstruction are higher with surgery when compared to SEMS, but surgery is associated with longer hospital stays and more early AEs. SEMS should be considered the initial mode of therapy in patients with acute proximal MBO and surgery should be reserved for SEMS failure, as surgery involves a high morbidity and mortality.
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Affiliation(s)
- Ali Siddiqui
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Natalie Cosgrove
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Linda H. Yan
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Daniel Brandt
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Raymond Janowski
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Ankush Kalra
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Tingting Zhan
- Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States
| | - Todd H. Baron
- University of North Carolina, Gastroenterology and Hepatology, Chapel Hill, North Carolina, United States
| | - Allesandro Repici
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Linda Jo Taylor
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, United States
| | - Douglas. G. Adler
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, United States,Corresponding author Douglas G. Adler MD, FACG, AGAF, FASGE, Professor of Medicine Director of Therapeutic EndoscopyDirector, GI Fellowship ProgramGastroenterology and HepatologyUniversity of Utah School of MedicineHuntsman Cancer Center30N 1900E 4R118Salt Lake City, Utah 84132
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Harilingam MR, Khushal A, Aikoye A. Self-expanding metal stenting for obstructing left colon cancer: A district hospital experience. Indian J Gastroenterol 2016; 35:305-9. [PMID: 27448435 DOI: 10.1007/s12664-016-0671-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 06/29/2016] [Indexed: 02/04/2023]
Abstract
Stenting of malignant colonic obstructions using self-expanding metal stents (SEMS) is commonly used for palliation and can be used as an interim procedure prior to definitive surgery. We retrospectively reviewed prospectively collected data from all consecutive colonic stenting procedures undertaken between September 2007 and December 2014 at a district general hospital. Technical and clinical success rates, mortality, colonic perforation, and other complications were documented and analyzed. Sixty-four colonic stenting procedures were undertaken. Fifty-three (83 %) were for palliation and eleven (17 %) were performed as a bridge to definitive surgery. Technical (98.4 %) and clinical (89.9 %) success rates were excellent. The single documented failure was secondary to complete luminal obstruction. Three stent occlusions (4.6 %), one colonic perforation (1.5 %), and one migration were encountered. There were no procedure-related deaths. Colonic stenting for obstructing left-sided colon cancer is a safe and effective procedure, even in the district general hospital setting. The use of SEMS as a bridge to elective surgery balances surgical and oncological considerations and, therefore, is most appropriate for high surgical risk patients in this setting.
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Affiliation(s)
- Mohan Raj Harilingam
- Department of General and Colorectal Surgery, Queen Elizabath The Queen Mother Hospital, Margate, CT9 4AN, UK.
| | - Amjad Khushal
- Department of General and Vascular Surgery, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, CT1 3NG, UK
| | - Abdulmalik Aikoye
- Department of General and Vascular Surgery, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, CT1 3NG, UK
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Albrecht R, Hönicke H, Bochmann C, Settmacher U, Wirth T. [Colonic stenting: an opportunity with a risk : A critical evaluation]. Chirurg 2016; 86:787-93. [PMID: 26070274 DOI: 10.1007/s00104-015-0022-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Frequently, the first clinical sign of colorectal cancer is complete obstruction, which has to be considered an emergency situation. The treatment goal is to overcome ileus including reduction of the associated high morbidity and mortality. Therefore, alternative therapeutic options to emergency surgery have been sought in order to allow adequate preparation for elective surgery or stabilization of palliative patients and avoid colostoma. Therapeutic results of the placement of self-expanding metal stents (SEMS) are discussed in terms of a single-center, retrospective observational study. METHODS In 35 patients with a clinically manifest stenosis of colonic cancer, it was attempted to insert SEMS to treat ileus as the first therapeutic step. Therapeutic results were investigated with regard to technical and clinical success, spectrum and rate of complications, and survival time, differentiating between a palliative and curative group of patients. RESULTS Primary placement of a stent was achieved in 29 of 35 patients (82.9 %); 14 underwent the procedure with palliative and 15 with curative intention. Stent location was mainly the left hemicolon. In 2 of 15 patients (13.3 %), emergency surgery within 48 h was required because of complications, whereby in 13 patients (86.7 %), 6 patients (46.2 %) underwent elective open surgery and 7 patients (53.8 %) underwent a laparoscopic procedure. In all patients treated with curative intent, primary anastomosis was achieved, thus, avoiding a colostoma. Survival times of the palliative and curative patient groups were on average 7 and 28 months, respectively. CONCLUSION In carefully selected cases, placement of SEMS in malignant stenosis of the left hemicolon with ileus can be considered a reasonable therapeutic alternative to emergency surgery since it allows surgical intervention with curative intention under more favorable conditions and also avoids a colostoma.
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Affiliation(s)
- R Albrecht
- Klinik für Viszeral- und Gefäßchirurgie, HELIOS Klinikum Aue, Gartenstraße 6, 08280, Aue, Deutschland,
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Amelung FJ, de Beaufort HWL, Siersema PD, Verheijen PM, Consten ECJ. Emergency resection versus bridge to surgery with stenting in patients with acute right-sided colonic obstruction: a systematic review focusing on mortality and morbidity rates. Int J Colorectal Dis 2015; 30:1147-55. [PMID: 25935448 DOI: 10.1007/s00384-015-2216-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE No consensus exists on the optimal treatment of acute malignant right-sided colonic obstruction (RSCO). This systematic review aims to compare procedure-related mortality and morbidity rates between primary resection and stent placement as a bridge to surgery followed by elective resection for patients with acute RSCO. METHODS PubMed, Embase and Cochrane library were searched for all relevant literature. Primary endpoints were procedure-related mortality and morbidity. Methodological quality of the included studies was assessed using the MINORS criteria. RESULTS Fourteen cohort studies were eligible for analysis. A total of 2873 patients were included in the acute resection group and 155 patients in the stent group. Mean mortality rate for patients who underwent acute resection with primary anastomosis was 10.8% (8.1-18.5%). Overall mortality for patients initially treated with a colonic stent followed with elective resection was 0%. Major morbidity was 23.9% (9.3-35.6%) and 0.8% (0-4.8%), respectively. Both mortality and major morbidity were significantly different. In addition, stent placement shows lower rates of anastomotic leakages (0 vs 9.1%) and fewer permanent ileostomies (0 vs 1.0%). CONCLUSION Primary resection for patients with acute RSCO seems to be associated with higher mortality and major morbidity rates than stent placement and elective resection. In addition, stent placement resulted in fewer anastomotic leakages and permanent ileostomies. However, as no high-level studies are available on the optimal treatment of RSCO and proximal stenting is considered technically challenging, future comparative studies are warranted for the development of an evidence-based clinical decision guideline.
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Affiliation(s)
- F J Amelung
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813TZ, Amersfoort, The Netherlands,
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Godzhello EA, Khrustaleva MV, Sharipzhanova RD, Dekhtyar MA. [The results of endoscopic gastroduodenal, enteral and colorectal stenting for blastomatous stenosis: 8-year experience]. Khirurgiia (Mosk) 2015:51-55. [PMID: 26978764 DOI: 10.17116/hirurgia20151251-55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gastroduodenal, enteral and colorectal stenting of blastomatous stenosis is a reasonable alternative to operative treatment of unresectable tumors. Moreover in some cases it allows to gain time and to prepare the patient for radical surgery. MATERIAL AND METHODS For the period from 2007 to 2015 in endoscopic department of acad. B.V. Petrovskiy Russian Research Center for Surgery 76 patients with piloroduodenal, enteral and colic stenoses successfully underwent self-expanding metal stents installation. There were 21 patients with malignant stenosis of the stomach and pilorobulbar area, 17 with secondary duodenal stenosis, 17 after gastrectomy and distal gastric resection; 2 with stenosing colorectal cancer, 4 patients with rectal cancer involving rectosigmoid junction, 7 with rectosigmoid junction cancer and 8 with sigmoid cancer. RESULTS Ambulatory and hospital interventions were performed in 35.5% and 64.5% of cases respectively. Hospital-stay did not exceed 2 days. The total complication rate was 11.8% (9/76), 3 of 9 patients required surgical intervention. The attention is given to important technical aspects of intervention as well as to those clinical situations when stenting is inappropriate because of absence of favourable functional outcome. CONCLUSION Stenting should be more actively implemented in clinical practice, especially in emergency surgical hospitals. However it requires adequate technical support of hospitals with different endoprostheses, because it provides simultaneous diagnostic survey and remedial procedure.
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Affiliation(s)
- E A Godzhello
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
| | - M V Khrustaleva
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
| | | | - M A Dekhtyar
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
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Yoshida S, Isayama H, Koike K. Palliative self-expandable metallic stent placement for colorectal obstruction caused by an extracolonic malignancy. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Meta-analysis of complications of colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction. Surg Laparosc Endosc Percutan Tech 2014; 24:73-9. [PMID: 24487162 DOI: 10.1097/sle.0000000000000030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Left-sided malignant colonic obstruction is one of the most difficult clinical problems, whereas both emergency operations and colonic stenting may have their own advantages and disadvantages. The purpose of this study was to evaluate the complications of colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction. MATERIALS AND METHODS Medline, Embase, and the Cochrane Library were searched. Only prospective randomized controlled trials that compared the 2 methods were included. Evaluation indexes in our study involved hospital death rates and complications. RESULTS No significant difference in either hospital death rates or the overall complications between the 2 groups was found. Heterogeneity analysis found that there was no significant heterogeneity. Removing individual studies from the data editor did not substantially change the RR or the level of heterogeneity of significance for our 2 outcome measures. Testing for publication bias showed that hospital death rates and the overall complications had no serious publication bias. CONCLUSIONS Colonic stenting was no better than emergency surgery, and should be only used as an alternative to emergency surgery carefully.
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Han SH, Lee JH. Colonic stent-related complications and their management. Clin Endosc 2014; 47:415-9. [PMID: 25325000 PMCID: PMC4198557 DOI: 10.5946/ce.2014.47.5.415] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 12/19/2022] Open
Abstract
Since its introduction in the early 1990s, the self-expandable metal stent (SEMS) has been increasingly used for the management of malignant colorectal obstruction, not only as a palliative method but also as a preoperative treatment in surgical candidates. However, more recently, concerns have been raised over stent complication rates. Early complications include pain, perforation, and rectal bleeding, and late complications include stent migration and stent obstruction. With the increasing use of SEMS for treatment, physicians need to be more aware of complications occurring after the placement of these stents. This review covers the technical considerations and management of complications after colonic stenting.
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Affiliation(s)
- Seung-Hee Han
- Department of Gastroenterology, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Jong Hoon Lee
- Department of Gastroenterology, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
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Lujan HJ, Barbosa G, Zeichen MS, Mata WN, Maciel V, Plasencia G, Hartmann RF, Viamonte M, Fogel R. Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction. JSLS 2013; 17:204-11. [PMID: 23925013 PMCID: PMC3771786 DOI: 10.4293/108680813x13654754534990] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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. Methods: 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. Results: 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. Discussion: 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.
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Lee KJ, Kim SW, Kim TI, Lee JH, Lee BI, Keum B, Cheung DY, Yang CH. Evidence-based recommendations on colorectal stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy. Clin Endosc 2013; 46:355-67. [PMID: 23964332 PMCID: PMC3746140 DOI: 10.5946/ce.2013.46.4.355] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/13/2012] [Accepted: 10/29/2012] [Indexed: 12/11/2022] Open
Abstract
Recently, placement of self-expandable metallic stents has been used for the treatment of colorectal obstruction. As domestic awareness of colorectal cancer has increased, the number of colorectal stenting procedures performed has also increased. We aimed to provide evidence-based recommendations for colorectal stenting to aid gastroenterologists in making informed decisions regarding the management of patients who present with colorectal obstruction. The working group consisted of eight gastroenterologists who actively practice and conduct research in the field of colorectal stenting and are the members of the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy. A literature search was conducted using the PubMed, Embase, KoreaMed, and the Cochrane Library databases to identify relevant articles published between January 2001 and June 2012. Based on the modified Delphi process, 10 recommendation statements regarding indications, usefulness, methodology and complications of colorectal stenting, and alternative treatments for malignant colorectal obstruction were determined. The contents will be widely distributed, and periodically revised to reflect the latest knowledge. These evidence-based recommendations for colorectal stenting will provide gastroenterologists and patients with appropriate and balanced information, and will improve the quality of care.
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Affiliation(s)
- Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Lee JG, Yoo KH, Kwon CI, Ko KH, Hong SP. Angular positioning of stent increases bowel perforation after self-expandable metal stent placement for malignant colorectal obstruction. Clin Endosc 2013; 46:384-9. [PMID: 23964336 PMCID: PMC3746144 DOI: 10.5946/ce.2013.46.4.384] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Revised: 01/22/2013] [Accepted: 04/04/2013] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Some factors like stent wires, balloon dilatation and use of guide wires seems to increase perforation after self-expandable metal stent (SEMS) placement, but few studies mentioned about the relationship between angulation of malignant stricture and perforation. The present study aimed to confirm that more angular positioning of stents increases perforation. Methods This study was conducted with retrospectively evaluation at Digestive Disease Center, CHA Bundang Medical Center, CHA University. Between January 2002 and August 2011, SEMS was inserted in 130 patients with malignant colorectal obstruction. We studied the difference in the angle of stenosis between perforation and non-perforation groups using fluorography images. Results SEMS insertion was performed in 130 cases of obstruction due to colon cancer. Perforation occurred in eight patients (6.2%) of them. Thirteen cases were excluded from the analysis due to poor fluoroscopic images. Among the eight patients with perforation, the mean stenosis angle was 109.9° compared to 153.1° in the nonperforation group, indicating that the angle was more acute in the perforation group (p=0.016). Conclusions This study shows that more angular positioning of stent increases bowel perforation after SEMS placement for malignant colorectal obstruction.
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Affiliation(s)
- Jeong Guil Lee
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Ghazal AHA, El-Shazly WG, Bessa SS, El-Riwini MT, Hussein AM. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg 2013; 17:1123-9. [PMID: 23358847 DOI: 10.1007/s11605-013-2152-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditionally, left-sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. Total abdominal colectomy is a one-stage procedure that will remove synchronous proximal neoplasms, reduce the risk of subsequent metachronous tumor, and avoid stoma. Colorectal stents are being used for palliation and as a bridge to surgery in obstructing colorectal carcinoma, making elective surgery straightforward, enabling easily mobilization and resection of the colon with a possible trend toward reduction in postoperative complication rates compared to emergency surgery. The purpose of this work was to compare the procedures of endoscopic stenting followed by elective colectomy versus total abdominal colectomy and ileorectal anastomosis in the management of acute obstructed carcinoma of the left colon as regards feasibility, safety, and clinical outcomes METHODS From January 2009 through May 2012, 60 patients were randomized to either emergency stenting followed by elective resection (ESER group) or total abdominal colectomy and ileorectal anastomosis (TACIR group). RESULTS Twenty nine patients (96.7 %) had successful stenting and underwent elective surgery 7-10 days later (ESER group). Postoperative complications were encountered in four patients in the ESER group compared to 15 patients in the TACIR group (p = 0.012). Anastomotic leakage was encountered in one patient (3.3 %) in the TACIR group. There were no operative mortalities in the present study. Within the first three postoperative months, the TACIR group patients had significantly more frequent bowel motions per day compared to the ESER group patients although (p = 0.013). In both study groups, the follow-up duration ranged from 6 to 40 months with a median of 18 months. Recurrent disease was encountered in five patients (17.2 %) in the ESER group compared to four patients (13.3 %) in the TACIR group (p = 0.228). CONCLUSION Both techniques are feasible, safe, and produce comparable oncological outcomes. However, endoscopic stenting followed by elective resection was associated with significantly less postoperative complications and bowel motions per day.
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Affiliation(s)
- Abdel-Hamid A Ghazal
- General Surgery Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
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Lee GJ, Kim HJ, Baek JH, Lee WS, Kwon KA. Comparison of short-term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer. Int J Surg 2013; 11:442-6. [PMID: 23639803 DOI: 10.1016/j.ijsu.2013.04.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/18/2013] [Accepted: 04/22/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to compare short-term morbidities and mortalities of elective surgery after stent insertion and emergency surgery in obstructive colorectal cancer. METHODS We retrospectively reviewed 77 patients with obstructive colorectal cancer that underwent elective surgery after stenting (stent group: SG, n = 49) or emergent surgery (emergency group: EG, n = 28) from January 2000 to July 2010. RESULTS The American Society of Anesthesiologists (ASA) score of SG was lower than that of EG (p = 0.015). The percentages of open and laparoscopic surgery in SG were 73.5% (36/49) and 26.5% (13/49), respectively, whereas surgery in EG was performed using an open technique (p = 0.003). The rate of primary anastomosis, without constructing a stoma, was 87.8% in SG and 42.9% in EG (p < 0.001). There was no difference in a postoperative complication. Anastomotic leakage according to time between stent placement and surgery in SG were 3 cases for 1-9 days and 0 for more than 10 days (p = 0.037). Three-year overall survival rates were 68.8% and 51.3% (p = 0.430), respectively. CONCLUSION Preoperative stent insertion in obstructive colorectal cancer seems to be safe and feasible, and may decrease second stage procedure. Waiting 10 days after stent placement may be a more optimal time for surgical intervention. Further prospective randomized studies are needed to determine the proper time bridge to surgery following stent insertion in obstructive colorectal cancer.
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Affiliation(s)
- Gil Jae Lee
- Department of Surgery, Gachon University, Gil Medical Center, Incheon, Republic of Korea
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Choi JH, Lee YJ, Kim ES, Choi JH, Cho KB, Park KS, Jang BK, Chung WJ, Hwang JS. Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction. Surg Endosc 2013; 27:3220-7. [PMID: 23494513 DOI: 10.1007/s00464-013-2897-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 02/15/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications. METHODS Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy. RESULTS A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100% and the clinical success rate 94.1%. Overall complications were observed in 49 patients (32.2%) during the follow-up period (median, 98 days; interquartile range, 19-302 days). Obstruction (17.1%), migration (7.9%), perforation (5.2%), bleeding (1.3%), and tenesmus (0.7%) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan-Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group. CONCLUSIONS Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.
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Affiliation(s)
- Jae Hyuk Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, 194 Dong San-dong, Jung-gu, Daegu 700-712, South Korea
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Song HY, Nam DH, Lee H. Usefulness of a guiding sheath for fluoroscopic colorectal stent placement. Korean J Radiol 2012; 13 Suppl 1:S83-8. [PMID: 22563292 PMCID: PMC3341465 DOI: 10.3348/kjr.2012.13.s1.s83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 12/02/2011] [Indexed: 12/11/2022] Open
Abstract
Objective To investigate the technical feasibility, clinical usefulness, and safety of a guiding sheath in fluoroscopic stent placement for patients with malignant colorectal obstructions. Materials and Methods Between June 2007 and January 2011, fluoroscopic placement of a dual colorectal stent was attempted in a total of 97 patients with malignant colorectal obstructions. A polytetrafluoroethylene guiding sheath was used in patients in whom a stent delivery system failed to reach the obstruction. Usefulness of the sheath was evaluated depending on whether the sheath could successfully assist the stent delivery system reach its area of interest. Results The guiding sheath was needed in 22 patients (15 men, 7 women; age range, 33-77 years; mean age, 59 years). The overall success rate for passing the sheath to the area of interest was 100%. There were no procedure-related deaths or major complications. The majority of the patients reported mild discomfort. In 2 of 22 patients with successful passing of the sheath to the area of interest, stent placement failed because of failure in the negotiation of a guide wire through the obstruction. Conclusion Using a guiding sheath seems to be easy, safe and useful in fluoroscopic stent placement for patients with malignant colorectal obstructions.
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Affiliation(s)
- Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
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Colonic stent placement via colostomy for recurrent metastatic rectal carcinoma. Gastrointest Endosc 2012; 75:930-1. [PMID: 22440211 DOI: 10.1016/j.gie.2011.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/01/2011] [Indexed: 02/08/2023]
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Kim BK, Hong SP, Heo HM, Kim JY, Hur H, Lee KY, Cheon JH, Kim TI, Kim WH. Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery. Gastrointest Endosc 2012; 75:294-301. [PMID: 22154416 DOI: 10.1016/j.gie.2011.09.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 09/14/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although self-expandable metal stent (SEMS) insertion has been shown to be an effective therapy for palliation of obstruction from colorectal malignancy, the clinical efficacy of SEMS insertion in the palliation of colorectal obstruction from an extracolonic malignancy (ECM) has not been extensively evaluated. OBJECTIVE The aim of this study was to evaluate the clinical outcomes and complications of SEMSs compared with those of emergency surgery for relief of colorectal obstruction in patients with advanced gastric cancer (AGC). DESIGN Retrospective study. PATIENTS From January 2000 to December 2009, patients with AGC who were treated with SEMSs (N = 111) or emergency surgery (N = 69) for palliation of malignant colorectal obstruction were included. INTERVENTION SEMS insertion or surgery. RESULTS Although acute complications and stoma formations were lower in the SEMS group than in the surgery group, the clinical efficacy of SEMSs was inferior to emergency surgery (technical success, 73.9% vs 94.2%, P = .001; clinical success, 54.1% vs 75.4%, P = .005). SEMS-related complications occurred in 64.5%, including reobstruction (36.8%), stent migration (10.5%), perforation (13.2%), and bleeding (3.9%). The median duration of patency was not statistically different between the patients who underwent SEMS insertion and those who underwent emergency surgery (117 days vs 183 days, P = .105). Patients with fewer than 2 obstructive sites or less than 2 years to obstructive symptom onset after diagnosis of AGC showed better clinical outcomes after endoscopic stenting. LIMITATIONS Retrospective and single-center study. CONCLUSIONS SEMS insertion seems to be less effective than emergency surgery for the palliation of colorectal obstruction in patients with AGC. Further study is necessary to define those patients with ECM who may benefit from SEMS insertion.
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Affiliation(s)
- Bo Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Abstract
<b><i>Hintergrund: </i></b>Die Implantation von selbstexpandierenden Metallstents (SEMS) in das Kolorektum – insbesondere als «bridge to surgery» – hat sich zunehmend etabliert, obwohl die Charakteristika des Kolons eine Prothesenimplantation erschweren und bisher noch keine optimalen Stents für diese Lokalisation verfügbar sind. Mit einem Stent lässt sich beim Kolonileus sehr patientenschonend eine sofortige Dekompression des Darms herbeiführen und die sonst notwendige Notfalloperation mit hoher Letalität und Komplikationsrate vermeiden. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Trotz zahlreicher positiver Studienergebnisse («... Stenting ist sehr effektiv, sicher und komplikationsarm im Vergleich zur Operation ...») ergibt eine kritische Analyse der Publikationen aufgrund vieler Faktoren (Patientenselektion, Stenttyp, Implantationsmethode usw.) jedoch eine hohe Heterogenität. <b><i>Schlussfolgerungen: </i></b>Um gute Resultate zu erzielen, sollte eine Stentimplantation ins Kolon nur nach strenger Indikationsstellung von einem erfahrenen Endoskopiker durchgeführt werden. Dabei ist auch die mögliche Alternative einer endoskopisch eingelegten Dekompressionssonde zu prüfen; ebenso sind onkologische Gesichtspunkte (chirurgische Resektion als einziger kurativer Ansatz) zu beachten.
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Yao LQ, Zhong YS, Xu MD, Xu JM, Zhou PH, Cai XL. Self-expanding metallic stents drainage for acute proximal colon obstruction. World J Gastroenterol 2011; 17:3342-6. [PMID: 21876623 PMCID: PMC3160539 DOI: 10.3748/wjg.v17.i28.3342] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Revised: 02/26/2011] [Accepted: 03/05/2011] [Indexed: 02/06/2023] Open
Abstract
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.
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Cho YK, Kim SW, Lee BI, Lee KM, Lim CH, Kim JS, Chang JH, Park JM, Lee IS, Choi MG, Choi KY, Chung IS. Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction. Gut Liver 2011; 5:165-70. [PMID: 21814596 PMCID: PMC3140661 DOI: 10.5009/gnl.2011.5.2.165] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 12/20/2010] [Indexed: 12/22/2022] Open
Abstract
Background/Aims There are limited data regarding the clinical outcomes of self-expandable metal stents in the treatment of proximal colon obstruction. We compared the clinical outcomes of stent placement in patients with malignant proximal to distal colon obstructions. Methods We reviewed medical records from 37 consecutive patients from three institutions (19 men; mean age, 72 years) who underwent endoscopic stent placement at a malignant obstruction of the proximal colon. We also examined the records from 99 patients (50 men; mean age, 65 years) who underwent endoscopic stent placement for a distal colon obstruction. Technical success, clinical improvements, complications and stent patency were compared between treatments. Results The technical success rate tended to be lower in stents inserted to treat proximal colon obstructions than in those used to treat distal colon obstructions (86% vs 97%, p=0.06). Clinical improvement was achieved in 78% of patients (29/37) with proximal colonic stenting and in 91% of patients (90/99) with distal colonic stenting (p=0.08). Complications (24% vs 27%), stent migration (8% vs 8%) and stent reocclusion rates (11% vs 17%) did not differ significantly between groups. Two cases of bowel perforation related to stenting (5%) occurred in patients with proximal colonic stenting. Conclusions The technical success and clinical improvement associated with self-expandable metal stents used to treat proximal colon obstruction tend to be lower than cases of distal colon obstruction. Technical failure is an important cause of poor clinical improvement in patients with proximal colon stenting. Complication rates and stent patency appear to be similar in both groups.
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Affiliation(s)
- Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Luigiano C, Ferrara F, Fabbri C, Ghersi S, Bassi M, Billi P, Polifemo AM, Landi P, Cennamo V, Consolo P, Morace C, Alibrandi A, D'Imperio N. Through-the-scope large diameter self-expanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: a single center experience with a long-term follow-up. Scand J Gastroenterol 2011; 46:591-6. [PMID: 21271788 DOI: 10.3109/00365521.2011.551886] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the outcomes of through-the-scope (TTS) large diameter self-expanding metal stent (SEMS) placement for palliation of malignant colorectal obstruction. MATERIAL AND METHODS Between January 2005 and December 2009, all patients who underwent endoscopic SEMS placement for palliation of malignant colorectal obstruction were prospectively enrolled. RESULTS Thirty-nine patients (17M and 22F; mean age 75.9 ± 10.6 years, range 50-91) were enrolled. The most frequent location was the sigmoid colon (13 cases). The causes of obstruction were colorectal malignancy in 32 patients and extracolonic malignancy in 7. Technical success was achieved in 36/39 patients (92.3%) and clinical success in 35/39 patients (89.7%). Technical failure was related to female sex (p = 0.04) and the extracolonic etiology of the stricture (p < 0.001). There were three early complications: two procedure-related perforations successfully managed conservatively and one hemorrhage treated with APC. Early complications were related to the location of strictures at the recto-sigmoid junction (p < 0.001). Late complications occurred in 10 patients: 8 of these patients experienced occlusive symptoms (attributable to tumor ingrowth in 5 cases and stool impaction in 3 cases); the remaining 2 were one case of tumor ingrowth with sub-occlusive symptoms and hemorrhage, and one case of distal migration. There was no procedure-related mortality and all complications were managed without surgical intervention. SEMS patency duration was 236 ± 128 days (range 31-497) and mean survival of the patients was 259 ± 121 days (range, 32-511). CONCLUSIONS In our experience, TTS large-diameter SEMS placement is a safe and effective treatment for palliation of malignant colorectal obstruction.
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Affiliation(s)
- Carmelo Luigiano
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna, Italy.
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Lee EYT, Bourke MJ, Williams SJ, Alrubaie A, Kwan V, Bailey AA, Lynch PM, Loh SM. Severity of initial stent angulation predicts reintervention after successful palliative enteral stenting for malignant luminal obstruction. J Gastroenterol Hepatol 2011; 26:484-91. [PMID: 21155877 DOI: 10.1111/j.1440-1746.2010.06523.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Recurrent stent obstruction necessitating reintervention is problematic and incompletely understood. The aim of the present study was to identify factor(s) predisposing to reintervention. METHODS Retrospective review of patients (n = 117) referred to a single major endoscopic referral centre for palliative enteral stenting from 1999 to 2006. Twelve were excluded due to inadequate follow-up data (n = 7) or initial radiographic documentation (n = 5). A total of 105 patients (gastroduodenal n = 57, colonic n = 48) were therefore analyzed. The primary outcome of interest was recurrent obstruction necessitating reintervention. Kaplan-Meier analysis of potential factors predisposing to reintervention, including stent angulation (mild [<15°], moderate [15°-90°], severe [>90°]) was completed for 98 patients (technically successful enteral stenting). RESULTS Technical and clinical success were achieved in 98 of 105 (93.3%) and 92 of 98 (93.9%) cases, respectively. Post-stenting median survival was 97.5 days (range 3-1054). Eighteen patients (18.4%) required reintervention for stent obstruction at a median time to reintervention of 85 days (range 7-481). Increased stent angulation (severe vs mild hazard ratio 6.73 (95% confidence interval 1.59-27.59), P = 0.009) was the only statistically significant factor in multivariate analysis predicting reintervention. CONCLUSIONS Despite its limitation as a retrospective review, this study found that reintervention for stent obstruction is necessary in almost one in five cases, and increasing severity of stent angulation is the most important risk factor.
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Affiliation(s)
- Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
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Placement of stents in proximal colonic obstructions using a percutaneous retroperitoneal colostomy. Surg Laparosc Endosc Percutan Tech 2011; 19:e202-5. [PMID: 19851253 DOI: 10.1097/sle.0b013e3181badb00] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In cases of proximal colonic obstruction, the long distances and the tortuosity of the distal bowel make it difficult to advance and position the stent in the target lesion. We report 2 cases of stent placement for malignant obstruction of the proximal colon in which access was obtained through percutaneous retroperitoneal colostomy. In these cases, we initially tried to place a stent through the rectum under endoscopic guidance, but it was not possible to reach the lesion. We then decided to cross the lesion through percutaneous puncture of the retroperitoneum. The procedures were completed without complications and the patients' symptoms improved. A percutaneous retroperitoneal approach for the deployment of colonic stents has not been described earlier in the literature. We suggest that our technique provides an alternative means of colonic decompression in cases in which conventional retrograde methods fail to provide acceptable palliation in nonsurgical candidates.
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Al-Jundi W, Kadam S, Giagtzidis I, Ashouri F, Chandarana K, Downes M, Khushal A. Self-Expanding Metal Stenting for Malignant Colonic Tumours: A Prospective Study. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ss.2011.23032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Park JK, Lee MS, Ko BM, Kim HK, Kim YJ, Choi HJ, Hong SJ, Ryu CB, Moon JH, Kim JO, Cho JY, Lee JS. Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer. Surg Endosc 2010; 25:1293-9. [PMID: 20976501 DOI: 10.1007/s00464-010-1366-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 09/03/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction. METHODS From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method. RESULTS Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p = ns) and 100 and 96.6% (p > 0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p = 0.274) and 13.7 and 16.7% (p = 0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p = 0.761) and 25.9, 15, and 0% (p = 0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively. CONCLUSIONS The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.
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Affiliation(s)
- Jong Kyu Park
- Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Bucheon, Korea
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Kozarek RA. The society for gastrointestinal intervention. Are we, as an organization of disparate disciplines, cooperative or competitive? Gut Liver 2010; 4 Suppl 1:S1-S8. [PMID: 21103287 PMCID: PMC2989558 DOI: 10.5009/gnl.2010.4.s1.s1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This is the Fourth Annual Meeting of the Society for Gastrointestinal Intervention, a multi-disciplinary group of practitioners committed to a minimally invasive approach to both the diagnosis and treatment of digestive disorders. The key concepts are minimally invasive and multi-disciplinary which can be construed as practicing in parallel with occasional lines of procedural and clinical interaction or inter-disciplinary in which patients are acutely cared for by a team, with treatments tailored to the patient and not the discipline that touches the patient first. In reality, many of us exist in both worlds. Most universities and large clinics are structured in departments along traditional training lines. As such, Interventional Radiology is housed in the Radiology Department, Laparoscopic Surgery (and potentially NOTES), as a component of the General Surgery Division, and Therapeutic Endoscopy usually resides within a gastroenterology structural framework. These divisions have historically been kept separate by multiple forces: salaries and budgets usually reside in a larger division. As a group, the amount of practice devoted to GI disorders is variable (for instance, minimally invasive surgeons may approach the adrenal glands or lung lesions in some institutions and interventional radiologists often sample tissue in multiple areas outside the GI tract, and by virtue of access to the vascular tree, can stent, embolize, or TPA almost any area of the body), as well as inherent differences in our individual abilities to access organs. I have already mentioned that angiographic capabilities allow the interventional radiologist access to virtually every GI organ and those capabilities allow therapeutic options for bleeding, tumor embolization, stenting of stenotic lesions, and formation of intravascular shunts. As such, there is very limited interdisciplinary competition here although capsule endoscopy as well as double and single balloon enteroscopy have improved the endoscopist's diagnostic and potential therapeutic reach. However, many of these diagnostic triumphs for obscure or massive GI bleed are simply to tattoo lesions that require surgical removal by laparoscopic or traditional surgery. Cooperation. However, there are potential competitive areas in the treatment of GI vascular lesions also. Whereas endoscopic band ligation has supplanted EVS, splenic devascularization, and most shunting procedures for patients with esophageal varices, endoscopic techniques have had less long-term success with glue injection for gastric varices. Multiple randomized, prospective trials have suggested therapeutic primacy of TIPS with embolization of recalcitrant vessels as an option or back-up. Despite this, therapeutic endoscopists have learned valuable lesions from our IR colleagues and studies are underway using endoscopically injected coils in addition to cyanoacrylate in an attempt to improve acute and long-term bleeding control. Nor is there any major competition in the treatment of primary or metastatic liver tumors by chemoembolization, RF current, or other thermal modalities, although selected patients with single lesions or multiple lesions isolated to a single lobe may be better handled surgically if there is curative intent. Finally, there is little IR, and progressively less, surgical competition for the treatment of high-grade dysplasia or superficial malignancies in the setting of Barrett's esophagus which are adequately treated in most patients by mucosectomy, RF ablation, or cryotherapy but require direct mucosal visualization to direct this therapy. The same has proven true for many years for colorectal polyps, superficial gastric cancers, and ampullary adenomas that had historically all been treated with major surgical resections. Still, there are many patients with advanced lesions who are good operative candidates who should be approached with conventional or minimally invasive surgery with the intent of operative cure. Cooperative, not competitive. The potential for competition between disciplines comes in mundane situations and clinical settings that have historically been "owned" by a single discipline. On the one hand, placement of PEGS and PEJs, initially done endoscopically, can be done with equal facility and occasional failure, by endoscopists and interventional radiologists, reserving failed attempts for minimally invasive surgery. What resources are utilized with these three methods? Are there advantages to defining the mucosa of the gut lumen in all, or even a subset of patients? By way of contrast, acute cholecystectomy tubes in high surgical risk patients have usually been the domain of the radiologist, although I described transcystic duct gallbladder decompression endoscopically 2½ decades ago. With the advent of new devices delivered under EUS control, the gallbladder will now be readily accessible endoscopically. What does this mean both for the acutely ill patient without a window to approach their gallbladder radiologically? Will this play a bit part and a cooperative technique to expand our therapeutic armamentarium or will it become competitive therapeutically not only for IR but for minimally invasive surgeons? The same may be said for EUS's ability to inject genes, caustics, or chemo-therapeutic agents into organs adjacent to the lumen. What is the role of TNFerade injection into unresectable pancreatic cancers and the role of absolute alcohol or Taxitol to treat cystic neoplasms of the pancreas? The real issue of competition or cooperation between the disciplines comes when treating patients with unresectable and obstructing GI neoplasms, from my perspective. The latter may occur almost anywhere in the GI tract but, of course, are more commonly noted proximally (esophagus, stomach, duodenum) and distally (left colon) as well as proximal and distal biliary obstructions. Recognizing that the occasional mid-small bowel and many proximal colon lesions are better handled with an endoscopic approach because of loss of vector force and difficulty pushing a catheter through large diameter, acutely angulated lumens, all others are fair game from my perspective. To my knowledge, although there are studies demonstrating the superiority of SEMS over open or laparoscopic bypass for malignant gastric outlet obstruction insofar as return of gut function, hospitalization time, and resource utilization, there are no studies demonstrating the superiority of one discipline or another in the placement of SEMS. Nor have cost data emerged suggesting the superiority of one technique over another from a cost standpoint. Unless or until we have such studies, this suggests to me that institutional interest and expertise should play a major role in how these unfortunate patients have continuity of their GI tract re-established. The situation is a bit more complex in pancreaticobiliary malignancy. There are 2 prospective randomized trials (level 1 evidence) that suggest that patients with proximal strictures (Bismuth II-IV) in conjunction with bile duct and gallbladder cancer, respectively, may be more successfully stented percutaneously and certainly it is easier to deliver brachytherapy or PDT under protocol to these patients who have indwelling external drains. In contrast, there are no data, positive or negative, to suggest that PTBD is a preferable treatment for distal biliary malignant obstruction, and in most parts of the world, the endoscopic approach has supplanted the percutaneous one just as metal stents have replaced plastic prostheses to preclude recurrent bouts of stent dysfunction and need for additional ERCP. The question posed at the beginning of this syllabus contribution: Are we competitive or cooperative? The answer is obviously both but, hopefully, our choice of treatment should depend less on who touches the patient first and more on skill sets within an institution and what is the best treatment for this particular individual. The importance of the SGI is technical and informational cross-fertilization. If your university or clinic will not allow blurring of training barriers to put therapeutic endoscopists, minimally invasive surgeons, and interventional radiologists together as a department or institute, you can nevertheless work together as a team in the best interest of your patients.
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Affiliation(s)
- Richard A. Kozarek
- SGI President 2008-2010; Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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Park S, Cheon JH, Park JJ, Moon CM, Hong SP, Lee SK, Kim TI, Kim WH. Comparison of efficacies between stents for malignant colorectal obstruction: a randomized, prospective study. Gastrointest Endosc 2010; 72:304-10. [PMID: 20561619 DOI: 10.1016/j.gie.2010.02.046] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 02/23/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonoscopic insertion of a self-expandable metallic stent (SEMS) has been widely performed for the treatment of malignant colorectal obstruction. Different types of stents could influence the efficacy and complication rate of stent use. OBJECTIVE To compare the efficacy and complication rates between two SEMSs, the uncovered WallFlex stent and the covered Comvi stent. DESIGN A prospective, randomized study. SETTING Tertiary-care academic medical center. PATIENTS Between 2007 and 2009, a total of 151 patients with malignant colorectal obstruction were enrolled. INTERVENTION Two types of colorectal SEMSs (the uncovered WallFlex stent by Boston Scientific Corp and the newly developed covered Comvi stent by Taewoong Medical Co) were inserted. MAIN OUTCOME MEASUREMENTS Technical success, clinical success, stent patency, and complication rate according to stent type. RESULTS Technical failure occurred in 2 patients (1.3%); one was in the WallFlex group and the other in the Comvi group. Clinical failure developed in 9 patients (6.0%): 6 patients from the WallFlex group and 3 from the Comvi group. Complications because of cancer infiltration occurred more frequently in the WallFlex group (14.5% vs 3.8%). However, the rate of stent migration was higher in the Comvi group (21.1% vs 1.8%). The mean patency of the stent did not differ between the two groups (P = .50). LIMITATIONS This was a single-center study. CONCLUSION Both uncovered WallFlex and covered Comvi stents were suitable for relieving malignant colorectal obstruction. Tumor ingrowth was more common in the WallFlex group, but stent migration was more common in the Comvi group.
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Affiliation(s)
- Semi Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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A comparison of palliative stenting or emergent surgery for obstructing incurable colon cancer. Dig Dis Sci 2010; 55:1732-7. [PMID: 19693667 DOI: 10.1007/s10620-009-0945-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Accepted: 08/06/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute colonic obstruction because of advanced colonic malignancy is a surgical emergency. Our aim was to review our experience with self-expanding metal stents (SEMS) compared to emergent surgery as the initial therapy for the management of patients with incurable obstructing colon cancer. METHODS A retrospective review of patients with obstructing colon cancer who underwent insertion of a SEMS (n = 53) or surgery (n = 70) from 2002 to 2008 was performed. The primary endpoint was relief of obstruction. Secondary endpoints include technical success of the procedure, duration of hospital stay, early and long-term complications, and overall survival. RESULTS Both groups were similar in age, sex, and tumor distribution. Placement of SEMS was successful in 50/53 (94%) patients. Surgery was effective in relieving obstruction in 70/70 (100%) patients. Patients in the SEMS group have a significantly shorter median hospital stay (2 days) as compared to the surgery group (8 days) (P < 0.001). Patients with SEMS also had significantly less acute complications compared to the surgery group (8 vs. 30%, P = 0.03). The hospital mortality for the SEMS group was 0% compared to 8.5% in patients that underwent surgical decompression (P = 0.04). There was no difference in survival between the two groups (P = 0.76). CONCLUSIONS In patients with colorectal cancer and obstructive symptoms, SEMS provide a highly effective and safe therapy when compared to surgery. In most patients with metastatic colorectal cancer and obstruction, SEMS provide a minimally invasive alternative to surgical intervention.
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Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010; 71:560-72. [PMID: 20189515 DOI: 10.1016/j.gie.2009.10.012] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 10/08/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively. OBJECTIVE Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction. DESIGN Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008. SETTING Tertiary-care center. PATIENTS This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a "bridge to surgery." INTERVENTION Colonic SEMS placement. MAIN OUTCOME MEASUREMENTS Stricture location, stent-induced complications, time to adverse events, need for reintervention. RESULTS Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter < or = 22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation. LIMITATIONS Retrospective analysis, single institution. CONCLUSION Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.
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Affiliation(s)
- Aaron J Small
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA
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Abstract
Advances in stent design have led to a substantial increase in the use of stents for a variety of malignant and benign strictures in the gastrointestinal tract and biliary system. Whereas early stents were mostly composed of plastic, the majority of contemporary stents are self-expanding metal stents that are composed of either nitinol or stainless steel. These stents are able to exert an adequate expansile force and, at the same time, are highly flexible and biocompatible. Covered stents have been introduced to minimize tumor ingrowth through the metal mesh but are associated with higher rates for spontaneous migration. This has led to the development of covered stents with uncovered ends and stents with both covered and uncovered layers. Drug-eluting and biodegradable stents are also likely to become available in the near future. Although stents appear to be the preferred form of palliation for some patients with advanced cancer, many patients will benefit from a multidisciplinary approach that usually includes surgeons and oncologists.
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Affiliation(s)
- Hoon Jai Chun
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Kim JS, Oh SY, Seo KU, Lee MH, Cheon SJ, Im HC, Kim JH, Lee KJ. [Comparison of effects of preoperative stenting for obstructing colorectal cancers according to the location of the obstructing lesion]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 54:384-9. [PMID: 20026893 DOI: 10.4166/kjg.2009.54.6.384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS With the development of self-expanding metallic stents, colonic obstruction can be relieved without the need for surgery. The results of preoperative placement of stents for malignant colorectal obstruction might be different according to the obstructing lesion. The objective of this study was to compare clinical improvement rates and operative results after preoperative placement of stents for malignant colorectal obstruction according to the location of the obstructing lesion. METHODS This is a retrospective study including 57 patients who underwent self-expanding metallic stent insertion for obstructing resectable colorectal cancers. Patients were classified into three groups according to the location of the lesion as follows: proximal to the sigmoid colon (Group A), sigmoid colon (Group B), and rectum (Group C). RESULTS The number of patients in A, B, and C groups was 13, 22, and 22, respectively. No significant differences in age, gender, stent type, and accompanying diseases among the three groups were observed. There were no significant differences in stent-related complications, clinical improvement rates, and one-stage resection rates among the three groups. The postoperative complications, the requirement rate of ICU care, the period of ICU stay, postoperative hospital stay, and hospital mortality did not significantly differ among the three groups. CONCLUSIONS Clinical improvement rates and operative results after successful placement of stents for obstructing resectable colorectal cancers are not different according to the location of the obstructing lesion, suggesting that preoperative stenting for one-stage curative resection is useful, irrespective of the location of lesion.
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Affiliation(s)
- Jong Su Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Jung MK, Park SY, Jeon SW, Cho CM, Tak WY, Kweon YO, Kim SK, Choi YH, Kim GC, Ryeom HK. Factors associated with the long-term outcome of a self-expandable colon stent used for palliation of malignant colorectal obstruction. Surg Endosc 2009; 24:525-30. [PMID: 19597776 DOI: 10.1007/s00464-009-0604-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 04/24/2009] [Accepted: 06/16/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND The placement of self-expanding metal stents (SEMS) is a safe and effective definitive procedure for the palliation of malignant colorectal obstruction. In this study, the clinical outcomes, including the technical and clinical success rates, and the risk factors associated with the long-term outcomes of palliative SEMS were evaluated. METHODS From February 2002 to April 2008, 39 patients (18 men and 21 women) with malignant colorectal obstruction underwent placement of uncovered or covered stents under fluoroscopic or endoscopic guidance. The mean age of the patients was 64.5 +/- 14.6 years (range, 37-96 years). RESULTS The technical success rate was 100% (39/39), and the clinical success rate was 87.2% (34/39). Five cases had failed relief of the obstruction due to the development of migration in two patients, two malfunctions, and one perforation. Four patients experienced late complications: migration managed with a palliative colostomy in two patients, tumor ingrowth managed successfully with a second stent in one patient, perforation with an intraabdominal abscess at the upper margin of the stent 4 months after stenting in one patient. The location of the obstruction and the length of the stent were significant factors associated with a good outcome. Shorter stents (<10 cm) had better outcomes than longer stents (>or=10 cm; p = 0.008), and patients with a distal colorectal obstruction had better outcomes than those with a proximal colorectal obstruction (p = 0.015). CONCLUSION Patients with bowel obstruction involving a short segment and those with a distal obstruction had better stent outcomes.
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Affiliation(s)
- Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, 50 Samduk-Dong 2 Ga, Chung-Gu, Daegu 700-721, South Korea
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Xu M, Zhong Y, Yao L, Xu J, Zhou P, Wang P, Wang H. Endoscopic decompression using a transanal drainage tube for acute obstruction of the rectum and left colon as a bridge to curative surgery. Colorectal Dis 2009; 11:405-9. [PMID: 18513190 DOI: 10.1111/j.1463-1318.2008.01595.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to clarify the usefulness of the management of acute left colon and rectum obstruction because of colorectal carcinoma using a transanal ileus drainage tube before curative surgery. METHOD Forty-six patients (24 males and 22 females, aged 24-94 years, mean = 56.2) treated between September 2005 and March 2007 for acute left colon and rectal obstruction were identified in a colorectal obstruction database, and their clinical and radiological features were reviewed. After a cleaning enema was administered, urgent colonoscopy was performed. Subsequently, endoscopic decompression using a ileus tube was attempted. RESULTS Endoscopic decompression using the ileus tube was technically successful in 45 of 46 patients (97.8%). Perforation occurred in one patient 3 days later and emergent operation was performed. The site of obstruction was the rectum in 15 patients, the sigmoid colon in 18, the descending colon in 13. Following adequate cleansing of the colon, patients' abdominal girth were decreased from 91 +/- 4 cm before drainage to 82 +/- 2 cm 7 days later, and one-stage surgery after 8 +/- 1 days (SD; range 7-10 days) were performed. No anastomotic leakage or postoperative stenosis occurred after operation. CONCLUSION Management of acute left colon and rectum obstruction because of colorectal carcinoma using the ileus tube was found to be effective and safe, considered as a bridged method before curative surgery.
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Affiliation(s)
- M Xu
- Department of Endoscopic center, Zhongshan Hospital, Fudan University Medical Center, Shanghai, China
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Olubaniyi BO, McFaul CD, Yip VSK, Abbott G, Johnson M. Stenting for large bowel obstruction - evolution of a service in a district general hospital. Ann R Coll Surg Engl 2009; 91:55-8. [PMID: 19126335 DOI: 10.1308/003588409x359015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- B O Olubaniyi
- Department of Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
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Kim HH, Kim HK, Cho SH, Huh JW, Rhyu SY, Kim HR, Kim DY, Kim YJ, Ju JK. Usefulness of Self-expandable Metallic Stents for Malignant Colon Obstruction. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2009. [DOI: 10.3393/jksc.2009.25.2.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ho Hyun Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Kun Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Hyuk Cho
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Wook Huh
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Yeop Rhyu
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Heong Rok Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Yi Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
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Kim TH, Song HY, Shin JH, Park IK, Kim JH, Lim JO, Kim KR, Choi EK. Usefulness of multifunctional gastrointestinal coil catheter for colorectal stent placement. Eur Radiol 2008; 18:2530-2534. [PMID: 18523778 DOI: 10.1007/s00330-008-1042-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 02/12/2008] [Accepted: 03/29/2008] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to evaluate the usefulness of a multifunctional gastrointestinal coil catheter for stent placement in 98 patients with colorectal strictures. The catheter was used in 98 consecutive patients for stent placement in the rectum (n = 24), recto-sigmoid (n = 13), sigmoid (n = 38), descending (n = 6), transverse (n = 11), splenic flexure (n = 3), hepatic flexure (n = 2), and ascending (n = 1) colon. The catheter was made of a stainless steel coil (1.3 mm in inner diameter), a 0.4-mm nitinol wire, a polyolefin tube, and a hemostasis valve. Usefulness of the catheter was evaluated depending on whether the catheter could pass a stricture over a guide wire and whether measurement of the stricture length was possible. The passage of the catheter over a guide wire beyond the stricture was technically successful and well tolerated in 93 (94.9%) of 98 patients. In the failed five patients, it was not possible to negotiate the guide wire due to presence of nearly complete small bowel obstruction. The average length of stricture was 6.15 cm (range, 3 cm to 20 cm) in patients with the colorectal stricture. There were no procedure-related complications. In conclusion, the multifunctional coil catheter seems to be useful in colorectal stent placement.
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Affiliation(s)
- Tae-Hyung Kim
- Asan Medical Center, Radiology and Research Institute of Radiology, Seoul, South Korea
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Baraza W, Lee F, Brown S, Hurlstone DP. Combination endo-radiological colorectal stenting: a prospective 5-year clinical evaluation. Colorectal Dis 2008; 10:901-6. [PMID: 18400040 DOI: 10.1111/j.1463-1318.2008.01512.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Self-expanding metallic stents have found increasing use in the palliation of malignant large-bowel obstruction or as a 'bridge to surgery' to facilitate a planned operative procedure. We describe a 5-year experience of using the combined endoscopic/fluoroscopic through-the-scope method of stent placement in a tertiary referral centre. METHOD A prospective database of patients referred for colorectal stenting was compiled. Technical success, clinical success (decompression) and procedure-related complications were measured as end-points. RESULTS Sixty-three patients underwent 71 stenting procedures; 39 (62%) patients were male and the median age of patients was 78 years; 32 patients had metastatic disease and seven strictures were due to extrinsic compression. The indication for stenting was palliation in 56 patients and preoperative in seven patients. There was a technical success rate of 91% and a clinical success rate of 89%. Complications occurred in 24% of the cohort: overgrowth, (8%), migration (6%), fistulation (4%), stent fracture (3%), tenesmus (3%) and faecal urgency (1%). There was no procedure-related death within the cohort and no technical failures proximal to the descending colon. CONCLUSION Combination endoscopic/fluoroscopic colorectal stenting is effective and safe. It may be particularly useful in the stenting of more proximal colonic strictures.
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Affiliation(s)
- W Baraza
- The University of Sheffield, Sheffield, UK
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Geiger TM, Miedema BW, Tsereteli Z, Sporn E, Thaler K. Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data. Int J Colorectal Dis 2008; 23:1007-12. [PMID: 18594837 DOI: 10.1007/s00384-008-0518-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Permanent metal stent placement for malignant intestinal obstruction has been proven to be efficient. Temporary stents for benign conditions of the colon and rectum are less studied. This is a case study, review of the literature, and observation from an animal model on placement of stents in the colorectum for benign disease. MATERIALS AND METHODS A 55-year-old man presented with recurrent obstructions from a benign stricture of the distal sigmoid colon. After failed balloon dilations, a polyester coated stent was placed. The purpose of the stent was to improve symptoms and avoid surgery. The stent was expelled after 5 days. We conducted a literature review of stents placed for benign colorectal strictures and an animal study to evaluate stent migration. RESULTS In the literature, there were 53 reports of uncovered metal stents, four covered metal stents, and six polyester stents. Patency rates were 71%, and migration rate was 43%. Migration occurred earlier with polyester stents (mean=8 days) versus covered (32 days) or uncovered metal stents (112 days). Severe complications were seen in 23% of patients. Four 45-kg pigs underwent rectosigmoid transection with a 21-mm anastomosis and endoscopic placement of a Polyflex stent. Two stents were secured with suture. Stents without fixation were expelled within 24 h of surgery. Stents with fixation were expelled between postoperative days 2 and 14. CONCLUSION Stents for the treatment of benign colorectal strictures are safe, with comparable patency rates between stent types. Metal stents can cause severe complications. In a pig model, covered polyester stents tend to migrate early even with fixation. Further investigation needs to focus on new stent designs and/or better fixation.
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Affiliation(s)
- Timothy M Geiger
- Division of General Surgery, University of Missouri-Columbia, Columbia, MO 65212, USA
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Tsurumaru D, Hidaka H, Okada S, Sakoguchi T, Matsuda H, Matsumata T, Nomiyama H, Utsunomiya T, Irie H, Honda H. Self-expandable metallic stents as palliative treatment for malignant colorectal obstruction. ACTA ACUST UNITED AC 2008; 32:619-23. [PMID: 17151898 DOI: 10.1007/s00261-006-9159-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In recent years, stent placement for malignant colorectal obstruction has become an accepted alternative to surgery. The purpose of this study was to evaluate the usefulness of self-expandable metallic stents (SEMS) as palliative management for patients with unresectable malignant colorectal obstruction. METHODS Twelve patients with unresectable malignant colorectal obstruction were treated with SEMS as palliative therapy. The sites of obstruction were located in the rectum (n = 9), the descending colon (n = 1), and the transverse colon (n = 2). All procedures were performed with combined endoscopic and fluoroscopic guidance. We analyzed the technical and clinical success rates of stent placement and the complications associated with the procedure. RESULTS The stents were successfully implanted and bowel obstruction was relieved in all cases; the technical and clinical success rates were 100%. Two complications occurred, including stent migration. There was no case requiring reintervention. All patients died of initial disease or another coexisting disease between 9 and 534 days (mean 133 +/- 148 days) after stent placement. None of the patients with stent in position at death had clinical or radiologic signs of bowel obstruction. CONCLUSIONS SEMS placement in patients with malignant colorectal obstruction is technically feasible and safe, making it useful as a palliative treatment.
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Affiliation(s)
- Daisuke Tsurumaru
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka City 812-8582, Japan.
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Repici A, De Caro G, Luigiano C, Fabbri C, Pagano N, Preatoni P, Danese S, Fuccio L, Consolo P, Malesci A, D'Imperio N, Cennamo V, Cennamo V. WallFlex colonic stent placement for management of malignant colonic obstruction: a prospective study at two centers. Gastrointest Endosc 2008; 67:77-84. [PMID: 18155427 DOI: 10.1016/j.gie.2007.08.019] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Accepted: 08/09/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expanding metal stents (SEMSs) can alleviate malignant colonic obstruction and avoid emergency decompressive surgery. The use of colonic larger-diameter SEMSs may improve bowel function and reduce migration risk. OBJECTIVE To evaluate the effectiveness and safety of a novel large-diameter SEMS (WallFlex) designed for delivery through the endoscope in treating malignant colonic obstruction. DESIGN Prospective clinical cohort study. SETTING Two Italian study centers. PATIENTS Forty-two consecutive patients with malignant colonic obstruction: 23 requiring palliation and 19 bridging to surgery. INTERVENTIONS Colorectal SEMS placement. MAIN OUTCOME MEASUREMENTS Technical success, defined as accurate SEMS deployment across the stricture on the first attempt; clinical success, ie, complete relief of bowel obstruction without complications; and bridging to surgery, denoting the performance of elective one-stage surgery. RESULTS The rate of technical success was 93% (95% CI, 81%-99%) and of initial clinical success was 95% (95% CI, 84%-99%). In 58% (95% CI, 40%-84%) of the palliation group, clinical success was maintained after 6 months. All 19 patients with operable tumors were successfully bridged to one-stage elective surgery within a median of 5 days. One perforation and one stent migration occurred. All complications could be resolved nonsurgically. LIMITATIONS No control group was included. CONCLUSIONS In a prospective study of through-the-scope WallFlex stent placement for malignant colonic obstruction, high rates of technical and initial clinical success, and bridging to surgery were achieved. Complications could be readily managed.
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