Self-expanding covered esophageal ultraflex stent for palliation of malignant colorectal anastomotic obstruction complicated by multiple fistulas

Endoscopic fully covered self-expandable metal stent and vacuum-assisted drainage to treat postoperative colorectal cancer anastomotic stenosis with fistula

BACKGROUND

Digestive tract reconstruction is required after the surgical resection of a colorectal malignant tumor. Some patients may have concomitant anastomotic complications, such as anastomotic stenosis with fistula (ASF), postoperatively. Therefore, we evaluated the efficacy and safety of endoscopic fully covered self-expandable metal stent and homemade vacuum sponge-assisted drainage (FSEM-HVSD) for the treatment of ASF following the radical resection of colorectal cancer.

METHODS

Patients treated with FESM-HVSD were prospectively analyzed and followed up for ASF following colorectal cancer treatment in our medical center from 2017 to 2021 for the observation and evaluation of its safety and efficacy.

RESULTS

Fifteen patients with a mean age of 55.80 ± 11.08 years were included. Nine patients (60%) underwent protective ileostomy. All 15 patients were treated with endoscopic FSEM-HVSD. The median time from the index operation to the initiation of FSEM-HVSD was 80 ± 20.34 days in patients who underwent protective ileostomy versus 11.4 ± 4.4 days in those who did not. The average number of endoscopic treatments per patient was 5.70 ± 1.25 times. The mean length of hospital stay was 27.60 ± 4.43 days. FSEM-HVSD treatment was successful in 13 patients, and no patients had any complications. The follow-up time was 1 year. Twelve of 15 (80%) patients achieved prolonged clinical success after FSEM-HVSD treatment, 1 experienced anastomotic tumor recurrence and underwent surgery again, and 1 patient required balloon dilation for anastomotic stenosis recurrence.

CONCLUSIONS

FSEM-HVSD is an effective, safe, and minimally invasive treatment for ASF following colorectal cancer treatment. This technique could be the preferred treatment strategy for patients with ASF.

The role of stents in the management of colorectal complications: a systematic review

BACKGROUND

Complications in colorectal surgery include a wide range of clinical conditions, which increase mortality, morbidity, hospital stay and costs. In some cases, the placement of a self-expanding metal stent may represent a possible therapeutic strategy, avoiding further surgery.

METHODS

In order to verify the feasibility and safety of the technique, we reviewed the medical literature, between January 1997 and 2015, selecting 32 studies. Inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations.

RESULTS

The estimated rate of early success was 73.3% (95% CI 66.3-79.3), raising from 25 to 68% in the time frame 1997-2007. The rate of early complications was 31.4% (95% CI 25.3-38.3%), progressively decreasing from 75 to 43% up to 2009. The rate of surgery for acute complication was 9.3% (95% CI 6.0-14.2%), reduced on time course from 25 to 9%. The rate of closure of dehiscence was 74.5% (95% CI 62.8-83.5%), while the rate of long-lasting success was 57.3% (95% CI 50.3-64.0%).

CONCLUSIONS

Endoscopic stenting in the early postoperative management of anastomotic complications after colorectal surgery should be considered in patients with minimal risk for sepsis, as a safe and often effective alternative to surgery. However, in order to establish the safety and efficacy of this technique, prospective studies involving a larger cohort of patients are required.

Interventional palliative strategies for malignant bowel obstruction

Malignant bowel obstruction is the luminal narrowing of the small bowel or colon due to direct or indirect cancer growth. Small bowel obstruction usually occurs at the level of the duodenum. Interventional, nonoperative strategies for palliation of malignant bowel obstruction include endoscopic and radiologic techniques. The latter are performed by interventional radiologists. Palliation of luminal small bowel and colonic obstruction primarily is achieved through the use of endoscopically or radiologically placed self-expandable metal stents. Gastrostomy and jejunal tubes also may be placed to provide palliative decompression when other palliative methods are not possible.

Inserción endoscópica de prótesis metálicas autoexpandibles en obstrucciones tumorales del colon

BACKGROUND AND OBJECTIVE

Self-expanding metal stents are being increasingly used to resolve malignant colonic obstruction. Subsequently, patients can either undergo elective surgery, or the stent can serve as a definitive palliative treatment in patients unfit for surgery. We present our experience with this technique in our hospital, a level II center within the Spanish National Health Service, which can be considered a community hospital.

PATIENTS AND METHODS

A retrospective study was performed of a 42-month period (May 2002 to October 2005), during which malignant colonic obstruction was treated by means of endoscopically inserted stents on 43 occasions in 40 patients.

RESULTS

Stent insertion was successfully performed in 41 attempts (95%) and good clinical results were obtained on 37 occasions (86%). Endoscopic means alone were used on 23 occasions (53.5%) and in the remaining 20 (46.5%), both endoscopy and fluoroscopy were employed. Of 38 patients with successfully inserted stents, clinical success was achieved, as a whole, in 34. Twenty-four of these patients (63%) subsequently underwent elective surgery while the stent served as a definitive palliative treatment in the remaining 14 (37%). One of these patients had to undergo further surgery due to a fistula between the colon and the bladder. There were eight other complications: three stent migrations and one stent obstruction occurred, two patients had tenesmus, one patient developed bacteremia after stent insertion, and a silent bowel perforation by the stent was found in an elective surgical procedure. There was no mortality.

CONCLUSIONS

In our experience, endoscopically inserted stents seem to be a safe and effective method for the initial treatment of malignant colonic obstruction.

Technology insight: Enteral stenting and new technology

Self-expandable metal stents (SEMS) have gained acceptance for use in the gastrointestinal tract in order to relieve malignant luminal obstruction. In the upper gastrointestinal tract SEMS are used as an alternative to surgical bypass for palliation of malignant gastric-outlet obstruction. In the colon, SEMS are used to avoid colostomy during palliation and as a bridge to surgery for left-sided colonic obstruction. Enteral SEMS appear to be cost effective. This article reviews the latest in stent technology as well as the outcomes following their placement.

Endoluminal palliation

Endoluminal palliation involves the application of endoscopic techniques or devices to relieve the symptoms of malignant gastrointestinal obstruction. This is most often achieved with the use of self-expandable metal stents (SEMS). SEMS can be deployed as far distally or proximally in the gastrointestinal tract as the reach of an adult colonoscope. This article outlines the use of endoscopic techniques to provide endoluminal palliation.

Endoscopic stenting of colonic tumours

Self-expandable metal stents (SEMS) are useful for the non-surgical relief of malignant colonic obstruction. They may be used both as a palliative measure and as a pre-operative bridge to facilitate a one-stage surgical resection of primary colonic tumours. SEMS may be placed endoscopically or by interventional radiologists without the use of endoscopy. In experienced centres SEMS can be successfully placed in approximately 90% of cases. Although it is known that the placement of these devices is feasible, there are no prospective trials comparing stent placement for colonic obstruction to routine surgical care. Additionally, there are no studies comparing the outcome of the method of placement (endoscopic versus radiological). This chapter reviews the types of expandable metal stent used for treatment of colonic obstruction, the indications for their insertion, their methods of insertion, and outcomes following insertion. Future research directions using expandable stents for colonic tumours are also addressed.

Urinary tract involvement by colorectal cancer

PURPOSE

Involvement of the urinary tract by colorectal cancer is sufficiently rare to be encountered by an individual surgeon on an infrequent basis. The aim of this review is to highlight technical and oncologic issues that should be considered when dealing with complex colorectal cancer that involves the urinary tract.

METHODS

The relevant literature from 1975 to 2001 was identified using the MEDLINE database of the U.S. National Library of Medicine and reviewed. Because of the diversity of forms of presentation of urologic involvement, few randomized, controlled trials are available, with most evidence derived from retrospective studies.

RESULTS

Three distinct clinical situations in which the urinary tract may be affected by colorectal cancer were identified: involvement by primary colorectal cancer, involvement by recurrent cancer, and unexpected intraoperative findings of urinary tract involvement. Management strategies to identify and treat locally advanced primary or recurrent colorectal cancer involving the urinary tract improve survival with acceptable morbidity and mortality. Careful preoperative assessment of all patients with colorectal cancer will reduce unexpected identification of urinary tract invasion at the time of surgery. In patients in whom cure is not possible, endourologic techniques combined with judicious surgical resection can provide high-quality palliation. Optimal care of many of these conditions is facilitated by specialist urologic advice.

CONCLUSIONS

The wide spectrum of possible urinary tract involvement by colorectal cancer requires individual patient-specific and disease-specific consideration. The literature offers important guidelines that aid decision making and improve management of these challenging problems.

Metallic stents in the treatment of benign diseases of the colon: preliminary experience in 10 cases

PURPOSE

To assess the effectiveness of and complications associated with metallic stent placement for treatment of benign diseases of the colon.

MATERIALS AND METHODS

With radiologic guidance, the authors placed metallic stents in 10 patients with benign diseases of the colon: Nine stents were placed in the rectosigmoid colon, and one was placed in the descending colon. The stents were placed in two cases of diverticulitis complicated by pelvic abscess, four cases of colonic fistula following surgery, and four cases of postsurgical anastomotic stricture. Coated stents were placed in the cases involving fistulas and diverticulitis.

RESULTS

In the two cases of diverticulitis complicated by pelvic abscess, the coated stents helped to resolve the abscesses, but both patients subsequently developed complications: fistula and perforation. Of the four cases of colonic fistula, two were resolved with stent placement. In the four cases of postsurgical stenosis, the stents temporarily relieved the symptoms of obstruction, but additional treatments were required before the patients became entirely asymptomatic.

CONCLUSION

Metallic stents may represent an effective temporary treatment for certain benign colonic conditions in the absence of other therapeutic alternatives.

Covered metal stents for management of inoperable malignant colorectal strictures

BACKGROUND

Metal stents have been reported as an effective alternative to surgery for the palliation of patients with colorectal neoplastic obstruction. Because most of the published series describe the use of uncovered stents, the purpose of our study was to prospectively evaluate the effectiveness, feasibility, safety, and outcome of covered stents for the palliative treatment of malignant colorectal strictures.

METHODS

Sixteen patients with advanced distal colorectal cancer underwent placement of 10 and 12 cm long, 23 mm diameter covered stents under fluoroscopic and endoscopic control. Clinical and endoscopic follow-up was scheduled at 3- to 6-week intervals.

RESULTS

Stent insertion was successful in 15 of 16 patients (93%). Perforation occurred in one patient during stent placement requiring colostomy. Relief of bowel obstruction was documented in all successfully treated patients. The median follow-up was 21 weeks (range 1 to 46). No recurrence of obstruction was observed during the follow-up period. Stent migration occurred in 2 patients, 7 and 21 days after stent placement.

CONCLUSIONS

Covered stents may provide safe and effective palliation of patients with malignant rectosigmoid strictures. Prolonged luminal patency and sealing of fistulous tracts are potential advantages of covered versus uncovered stents in the palliative treatment of colorectal malignancies. ¿