Use of an introducer sheath for colonic stent placement

Definition of large bowel obstruction by primary colorectal cancer: A systematic review

AIM

Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies.

METHOD

A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements.

RESULTS

A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07).

CONCLUSION

In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.

Radiologic Placement of Uncovered Stents for the Treatment of Malignant Colonic Obstruction Proximal to the Descending Colon

PURPOSE

To evaluate the safety, feasibility, and patency rates of radiologic placement of uncovered stents for the treatment of malignant colonic obstruction proximal to the descending colon.

MATERIALS AND METHODS

This was a retrospective, single-center study. From May 2003 to March 2015, 53 image-guided placements of uncovered stents (44 initial placements, 9 secondary placements) were attempted in 44 patients (male:female = 23:21; mean age, 71.8 years). The technical and clinical success, complication rates, and patency rates of the stents were also evaluated. Technical success was defined as the successful deployment of the stent under fluoroscopic guidance alone and clinical success was defined as the relief of obstructive symptoms or signs within 48 h of stent deployment.

RESULTS

In total, 12 (27.3 %) patients underwent preoperative decompression, while 32 (72.7 %) underwent decompression with palliative intent. The technical success rate was 93.2 % (41/44) for initial placement and 88.9 % (8/9) for secondary placement. Secondary stent placement in the palliative group was required in nine patients after successful initial stent placement due to stent obstruction from tumor ingrowth (n = 7) and stent migration (n = 2). The symptoms of obstruction were relieved in all successful cases (100 %). In the palliative group, the patency rates were 94.4 % at 1 month, 84.0 % at 3 months, 64.8 % at 6 months, and 48.6 % at 12 months.

CONCLUSIONS

The radiologic placement of uncovered stents for the treatment of malignant obstruction proximal to the descending colon is feasible and safe, and provides acceptable clinical results.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

OBJECTIVE

To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature.

SUMMARY BACKGROUND DATA

Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers.

METHODS

A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review.

RESULTS

Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates.

CONCLUSIONS

Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

OBJECTIVE

To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature.

SUMMARY BACKGROUND DATA

Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers.

METHODS

A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review.

RESULTS

Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates.

CONCLUSIONS

Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.

Management of acute malignant large-bowel obstruction with self-expanding metal stent

BACKGROUND

Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction.

METHODS

Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum.

RESULTS

In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication.

CONCLUSIONS

Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.

Survival benefit in patients after palliative resection vs non-resection colon cancer surgery

AIM: To evaluate survival in patients undergoing palliative resection versus non-resection surgery for primary colorectal cancer in a retrospective analysis.

METHODS: Demographics, TNM status, operating details and survival were reviewed for 67 patients undergoing surgery for incurable colorectal cancer. Palliative resection of the primary tumor was performed in 46 cases in contrast to 21 patients with non-resection of the primary tumor and bypass surgery. Risk factors for postoperative mortality and poor survival were analyzed with univariate and multivariate analyses.

RESULTS: The two groups were comparable in terms of age, gender, preoperative presence of ileus and tumor stage. Multivariate analysis showed that median survival was significantly higher in patients with palliative resection surgery (544 vs 233 d). Differentiation of the tumor and tumor size were additional independent factors that were associated with a significantly poorer survival rate.

CONCLUSION: Palliative resection surgery for primary colorectal cancer is associated with a higher median survival rate. Also, the presence of liver metastasis and tumor size are associated with poor survival. Therefore, resection of the primary tumor should be considered in patients with non-curable colon cancer.

Bronchial Catheterization with a TIPS Dilator After Failure of Conventional Technique

OBJECTIVE

A technique is presented for catheterization of an obstructed bronchus when use of a conventional vascular catheter has failed. In some cases, strictures become too stenotic or blunt for passage of a guidewire, making further intervention impossible. We attempted to negotiate a stricture opening using a transjugular intrahepatic portosystemic shunt (TIPS) dilator with a guidewire inside it.

CONCLUSION

The catheterization technique with a TIPS dilator was successful in nine cases in which use of conventional catheters and guidewires had failed.

Colon stenting: a review

Up to 85% of patients who present with colonic obstruction have a colorectal cancer. Between 7% and 29% of these patients present with total or partial intestinal obstruction. Only 20% of these patients presenting with acute colonic obstruction due to malignancy survive 5 years. Emergent surgical intervention in patients with colonic obstruction is associated with significant morbidity and mortality rates. Only 40% of patients with obstructive carcinoma of the left colon can be treated with surgical resection without the need for a colostomy. The use of a temporary or permanent colostomy has a significant impact on quality of life. The decompressive effect seen with colonic stenting is a durable, simple, and effective palliative treatment of patients with advanced disease. Stent deployment provides an effective solution to acute colonic obstruction and allows surgical treatment of the patient in an elective and more favorable condition. In addition, colonic stenting reduces costs and avoids the need for a colostomy.

Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center

PURPOSE

In the past, colonic obstruction caused by malignancy most often resulted in high-risk operations, usually involving two-step procedures or leaving the patient with a stoma in case of disseminated disease.

METHODS

Between May 1997 and January 2003, 104 procedures with self-expanding metal stents have been performed in 96 patients at our institution. The goals of the procedure were either postponement of emergency operation or definitive palliative treatment. Surgeons with combined endoscopic and fluoroscopic technique performed all procedures. In most cases no analgesia or only slight sedation was used. Seven types of stents were used, CHOO stents and Wallstents accounting for the majority.

RESULTS

A total of 96 patients were included, 44 men and 52 women, with a mean age of 78 (range, 41-100) years. Technical success was achieved in 92 percent; clinical success, in 82 percent. Thirty-eight patients presented with an acute obstruction and were treated with self-expanding metal stents. Seventeen patients later underwent an elective resection, 9 patients were not decompressed, and 12 patients had disseminated disease and were not treated further. Eight patients had benign strictures. These eight patients accounted for several of the reinterventions, and only three patients truly gained benefit from stenting. In the remaining patients disseminated disease was diagnosed and the acute stenting served as the definitive palliative treatment. Procedure-related complications were few: perforation occurred in three patients during stenting and in one instance 6 to 7 hours after. Other technical problems could mainly be overcome by introducing an additional stent. Complications seen in the group treated with self-expanding metal stents and subsequent resection [mortality N = 3 (18 percent)], anastomotic leakage [N = 3 (18 percent)], do not differ from the number of complications we usually see in our patients who undergo elective colorectal resection.

CONCLUSIONS

The use of self-expanding metal stents in malignant colonic obstruction is a safe and effective procedure with a low mortality and morbidity. In our experience the stenting of benign strictures is ineffective and combined with a high rate of complications.