Outcome of self-expandable metal stents placement for obstructive colorectal cancer: 7 years' experience from a Swedish tertiary center

Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes

Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.

Laparoscopic versus open surgery in obstructive colorectal cancer patients following stents placement: a comprehensive meta-analysis of cohort studies

BACKGROUND

Over the past decade, the use of stent placement as a bridge to surgery (BTS) has emerged as an alternative to emergency surgery for patients with (OCRC). However, the optimal surgical approach remains indeterminate. This study seeks to evaluate the safety and feasibility of a combined treatment modality involving stent placement and laparoscopic surgery for OCRC presenting with malignant obstruction.

METHODS

A comprehensive search of PubMed, Cochrane Library, EMBASE, Web of Science, and ClinicalTrials.gov was conducted until June 2023 to identify studies that compared laparoscopic to open surgery in patients with OCBC following stent insertion.

RESULTS

The meta-analysis incorporated 12 cohort studies, encompassing 933 patients. There was no statistically significant difference in the 30-day mortality rates between the two groups (relative risk [RR], 1.09; 95% confidence interval [CI] 0.26 to 4.48; P = 0.95). Compared to the laparoscopic approach group, the open approach group had a higher rate of overall postoperative complications (POCs) (RR 0.52; 95% CI 0.37 to 0.72, P < 0.0001). There was no significant variance in lymph node (LN) dissection number between the groups (mean differences [MD], 1.64; 95% CI - 1.51 to 4.78; P = 0.31). Notably, laparoscopic surgery resulted in less intraoperative blood loss (MD, - 25.84 ml; 95% CI - 52.16 to 0.49; P = 0.05) and a longer operation time (MD, 20.99 mins; 95% CI 2.31 to 39.44; P = 0.03). The laparoscopic approach was associated with a shorter length of hospital stay (LOS) (MD - 3.29 days; 95% CI - 5.27 to 1.31; P = 0.001). Conversely, the open approach group had a higher rate of postoperative surgical site infection (SSI) (RR 0.47; 95% CI 0.23 to 0.96, P = 0.04). Although the number of included studies was insufficient to conduct a meta-analysis, several of them imply that laparoscopic surgery may yield more favorable outcomes in terms of the 3-year overall survival rate (OS), 3-year disease-free survival rate (DFS), 5-year OS, and 5-year DFS when compared to open surgery. It is worth noting that these differences lack statistical significance.

CONCLUSION

In patients with OCRC subjected to stent insertion, laparoscopic surgery arguably presents a modest superiority over open surgery by diminishing the overall postoperative risk and potentially reducing the LOS.

Similar success rate in proximal and distal colonic stent placement: a retrospective multi-center study

OBJECTIVES

Stenting of malignant colon obstruction is used as a bridge to surgery or as an alternative to surgical colostomy in a palliative setting. Current guidelines recommend stent placement as the first line of treatment in colonic obstruction in both curative and palliative settings. However, it is unclear whether the location of the malignant obstruction influences the outcome of the stenting procedure. The goal of this study was to compare the outcomes of colonic stents between proximal and distal colonic strictures with regard to technical and clinical success and the risk of adverse events.

METHODS

A multi-center retrospective cohort was composed of patients who underwent a colonic stent placement at two tertiary hospitals between 2013 and 2021. The technical and clinical outcome, stent type used, duration of post-procedural hospital stay and complications were noted.

RESULTS

A total of 148 patients who underwent colonic stenting were identified. 41 patients underwent stent placement in the proximal colon and 107 patients underwent a distal stent placement. There was no difference in technical success (100% vs 96.3%, p = 0.209), clinical success (97.0% vs 89.6%, p = 0.199) or complications (24.4% vs 37.4%, p = 0,135).

CONCLUSION

Technical success and clinical success rates are high and do not differ between stent locations. There is no significant difference in complication rates between proximal and distal colonic stents.

Rectal stump leakage: A neglected complication after Hartmann's procedure for colorectal cancer

BACKGROUND

Hartmann's procedure is widely used in large bowel obstruction caused by colorectal cancer. However, rectal stump leakage, one of its serious complications, has not been well investigated in the literature.

METHODS

Patients with colorectal cancer who underwent Hartmann's procedure between January 2015 and January 2022 were retrospectively assessed. Rectal stump leakage was diagnosed based on the clinical symptoms, nature of drainage fluid, and computed tomography characteristics. The patients were categorized into the following 2 groups: non-rectal stump leakage group and rectal stump leakage group. A multivariate logistic regression model was used to identify independent risk factors for rectal stump leakage.

RESULTS

The incidence rate of postoperative rectal stump leakage was 11.6% in our patients. Univariate analysis revealed that male sex, body mass index (underweight), and tumor location (below the peritoneal reflection) were risk factors for rectal stump leakage (P < .05). Multivariate regression analysis confirmed these 3 factors were independent risk factors for rectal stump leakage (P < .05). Computed tomography imaging characteristics of patients with rectal stump leakage usually included inflammatory exudate and edema of the rectal stump, fluid, or gas-containing abscess around the rectal stump. The computed tomography imaging characteristics of a gas-containing abscess around the rectal stump and an abdominal drainage tube advanced into the rectum via the rectal stump could confirm the diagnosis of rectal stump leakage. The incidence rate of small bowel obstruction in group 2 (69.2%) was significantly higher than that in group 1 (15.7%) (P = .000).

CONCLUSION

Male sex, body mass index (underweight), and tumor location (below the peritoneal reflection) were independent risk factors for rectal stump leakage after Hartmann's procedure. We suggested that rectal stump leakage be classified into inflammatory exudation and abscess stages on computed tomography imaging. Unexplained small bowel obstruction after Hartmann's procedure may be an important clue to the early diagnosis of rectal stump leakage.