WallFlex colonic stent placement for management of malignant colonic obstruction: a prospective study at two centers

Colonic stents: the modern treatment of colonic obstruction

Colonic stents traditionally have been used for the management of colorectal cancer, either as a palliative treatment or as a bridge to surgery. More recently, colonic stents have also been advocated as part of the therapy of benign strictures. A number of colonic stents are available worldwide, four of which are made in the USA. These stents are classified as covered or uncovered, with similar clinical applications. Technical and clinical success rates are similar among these different stents, as well as the rate of complications, which mainly consist of obstruction and migration. The deployment systems utilize fluoroscopy, endoscopy, or both. More recently, stents became available that are deployed "through the scope" (TTS) making the procedure faster. However, this advance does not exclude the use of fluoroscopy, particularly in those cases where the direct visualization of the proximal end of the stricture is absent. The increasing experience in the management of colorectal cancer with colonic stents decreases the morbidity and mortality, as well as cost, in comparison with surgical intervention for acute colonic obstruction. Management with colonic stents can also rule out proximal synchronous lesions after initial decompression prior to definitive surgery. Benign conditions may also be treated with stents. A multidisciplinary approach for the use of colonic stents during assessment and management of acute colonic obstruction is necessary in order to achieve a satisfactory outcome, whether that be better quality of life or improved survival.

Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society

BACKGROUND

Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.

METHODS

The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.

RESULTS

Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).

CONCLUSIONS

Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society

BACKGROUND

Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.

METHODS

The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.

RESULTS

Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).

CONCLUSIONS

Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

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.

Colonic perforation after stent placement for malignant colorectal obstruction--causes and contributing factors

Self-expanding metal stents (SEMS) are used to manage malignant colorectal obstruction. Colonic perforation is the most worrisome complication from colonic stenting. We reviewed causes and contributing factors of perforation with colonic stent placement in patients with malignant colorectal obstruction. Articles from both English and foreign language publications were identified from Medline. Data were collected on causes, timing, treatment and mortality related to perforation. A total of 2287 patients from 82 articles were included in this analysis, which showed an overall perforation rate of 4.9%. Perforation rates for palliation and bridge to surgery (BTS) were not significantly different (4.8% vs. 5.4%, p = 0.66); over 80% occurred within 30 days of stent placement (half during or within one day of the procedure). The mortality rate related to perforation was 0.8% per stented patient, but the mortality of patients experiencing perforation was 16.2%. There was no significant difference (p = 0.78) in the mortality rates between the palliation and the BTS group and concomitant chemotherapy, steroids, and radiotherapy are risk factors of perforation. The overall perforation related mortality is far less than that of patients undergoing emergency surgery for bowel obstruction.

Comparison of efficacies between stents for malignant colorectal obstruction: a randomized, prospective study

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.

A comparison of palliative stenting or emergent surgery for obstructing incurable colon cancer

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.

Comparison of the outcomes of preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer: an analysis of 248 cases

AIM: To evaluate the efficacy and safety of self-expanding metallic stents (SEMSs) and to compare the short- and long-term outcomes of preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer.

METHODS: Sixty-two patients who underwent SEMS insertion and 186 patients who underwent primary emergency surgery for left-sided colorectal cancer from 2000 to 2008 were retrospectively analyzed.

RESULTS: The SEMSs were placed successfully in 61 patients, of which 14.5% developed complications such as perforating and migration. Primary anastomosis rate was higher in patients undergoing stent insertion than in those undergoing emergency surgery (87.1% vs 34.4%, P = 0.001). The complication rate was higher in patients undergoing emergency surgery than in those undergoing stent insertion (47.3% vs 17.7%, P = 0.000). No significant difference was noted in the survival curve between the two groups (P = 0.497).

CONCLUSION: Preoperative stent insertion is safe and effective in the treatment of obstructive left-sided colorectal cancer and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.

Management of acute malignant colorectal obstruction with a novel self-expanding metallic stent as a bridge to surgery

PURPOSE

To prospectively evaluate the safety and clinical efficacy of a newly designed self-expandable metallic stent (SEMS) in the treatment of patients with acute malignant colorectal obstruction.

METHODS

Between April 2001 and October 2007, 52 patients with acute malignant colorectal obstruction were treated with a new designed SEMS as an investigational bridge to surgery. Patients were prospectively followed and relevant data collection was collected, including details regarding technique, clinical symptoms, complications, need for elective surgery, and overall survival.

RESULTS

Stent placement was technically successful in all but two patients (due to complete obstruction) with no procedure-related complications. Complications included stent migration (n=4), anal pain (n=2) and stool impaction (n=1). Clinical success was achieved in 49 (98%) of 50 patients with resolution of bowel obstruction within 2 days of stent placement. In one patient with stool impaction 2 days after stent placement, endoscopic disimpaction was successfully performed. An elective one-stage surgical procedure was performed in all 50 patients who successfully received a SEMS as a bridge to surgery within a mean of 8+/-2 days (range: 4-11 days) after stent placement. Mean follow-up time was 36+/-12 months (range 3-70 months), and all patients remained alive at the time of this report.

CONCLUSION

The newly designed SEMS placement as a bridge to surgery was a safe and effective intervention for colonic decompression in patients with acute malignant colorectal obstruction and allowed a high proportion of patients to be successfully proceeded to elective surgery.

Does stent placement for advanced colon cancer increase the risk of perforation during bevacizumab-based therapy?

BACKGROUND & AIMS

Data on the safety of bevacizumab-based therapies for patients carrying a self-expandable metallic stent (SEMS) for occlusive colon cancer are lacking. We report 2 cases of colon perforation observed in our case series of patients with SEMS for occlusive colon cancer.

METHODS

Patients with occlusive symptoms caused by colon cancer received a colonic stent under endoscopic and radiologic guidance.

RESULTS

Over a 10-month period, 28 patients with occlusive colon cancer were treated with stent placement. The stent was placed as a bridge to surgery in 12 patients who were treated surgically within 4 to 78 days after the endoscopic procedures, without any stent-related complications. Seven patients did not receive any other antitumor treatment as a result of concomitant comorbidities. Nine patients with both primary tumor and metastatic lesions were treated with medical therapy. Over a median follow-up period of 131 days colonic perforation occurred in the 2 patients treated with a combination of capecitabine and oxaliplatin plus bevacizumab.

CONCLUSIONS

Further studies are needed to clarify whether SEMS placement increases the risk of perforation caused by bevacizumab-based therapies.

Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial

OBJECTIVES

We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet.

METHODS

In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement.

RESULTS

Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients.

CONCLUSIONS

Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.

Dual-design expandable colorectal stent for malignant colorectal obstruction: comparison of flared ends and bent ends

OBJECTIVE

The purpose of this study was to compare, focusing on colonic perforation and stent migration, the clinical safety and efficacy of dual-design expandable colorectal stents with flared ends with those of stents with bent ends in the treatment of patients with malignant colorectal obstruction.

SUBJECTS AND METHODS

A total of 122 patients with malignant colorectal obstruction underwent implantation of dual-design stents with flared (n = 69) or bent (n = 53) ends.

RESULTS

Stent placement was technically successful in 116 of 122 patients (95.1%), 65 of 69 patients (94.2%) with flared-end stents and 51 of 53 patients (96.2%) with bent-end stents (p > 0.05). Clinical success was achieved within 2 days in 61 of 65 patients (93.8%) with bent-end stents and in 46 of 51 patients (90.2%) with flared-end stents (p > 0.05). Complications included seven cases of colonic perforation (6%), seven cases of stent migration (6%), three cases of tumor overgrowth (2.6%), four cases of severe rectal pain (3.4%), and four cases of bleeding (3.4%). There were no significant differences between the rates of colonic perforation and stent migration in the two groups (6.2% vs 5.9%), and the overall complication rates were similar (p > 0.05).

CONCLUSION

Dual-design expandable colorectal stents with flared ends and those with bent ends are equally safe and effective, having similar perforation and migration rates.

Side-viewing endoscope for colonic self-expandable metal stenting in patients with malignant colonic obstruction

Malignant colon obstruction is a medical emergency and endoscopic decompression, achieved by self-expandable metal stent placement, has been broadly used for both palliation in patients with advanced, nonresectable carcinoma and as a bridge to surgery in those patients with resectable disease. We propose stent insertion assisted by a side-viewing endoscope, in sharply angulated and remarkably stenotic lesions located at the distal sigmoid. Endoscopists should consider, at least for lesions situated in the distal colon, the insertion of a side-viewing endoscope for stenting of technically difficult cases of malignant intestinal obstruction.

Stents and stentability: treatment for malignant bowel obstruction

Colonic stents offer a palliative treatment for patients with malignant bowel obstruction otherwise requiring surgery and possible stoma, or as a bridge to surgery for potentially curative malignant disease. This article reviews the indications, risks and benefits of stent insertion.

Endoscopic treatment of colonic obstruction

PURPOSE OF REVIEW

Over the past 15 years, great strides have been made in the nonsurgical management of malignant large bowel obstruction. Progress continues, particularly in the area of self-expanding metal stents. The purpose of this review is to assess the available endoscopic techniques for colonic decompression and document the inexorable trend toward supremacy of the self-expanding metal stent in this arena.

RECENT FINDINGS

Stents are being designed with the structure and function of the colon in mind allowing better and longer-lasting palliation. Improvement in the design of the colonic decompression tube allows a low-tech approach to the palliation of colonic obstruction. Argon plasma coagulation is helpful in restoring continuity of the obstructed colonic lumen in certain circumstances.

SUMMARY

As a consequence of technological innovation and growing expertise in the community, gastroenterology is becoming the go to specialty in the early management and palliation of malignant bowel obstruction.