Colorectal stents

Safety and Effectiveness of Colonic Stenting for Ileocecal Valve Obstruction and Usefulness of Two-Step Strategy: Single-Center Retrospective Study

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.

Intestinal stents: Structure, functionalization and advanced engineering innovation

Intestinal stents are a palliative treatment option that solves many shortcomings of traditional surgeries for cancer-induced intestinal obstructions. The present review provides an overview of the incidence, clinical manifestations and limitations in the treatment of intestinal cancers. The paper also discusses material property requirements, indications, complications and the future of stent-assisted therapy. The advantages and disadvantages of different materials and processing techniques for intestinal stents are reviewed along with new stent treatment combinations for colorectal cancer. Challenges that require further cooperative studies are also detailed. The future development of intestinal stents will depend on innovation in material designs as well as the utilization of multi-functional strategies and innovative engineering solutions.

Management of Colorectal Cancer Patients Undergoing a Colonic Stenting: A Multidisciplinary Team Approach

Colonic stent procedure is one of the best therapeutic medical interventions for managing a colorectal cancer patient with large bowel obstruction. This is a retrospective study that evaluated data from the past 10 years; it examined the epidemiological and clinical data of patients with colorectal cancer undergoing a colonic stent procedure. In addition, this study prospectively evaluated the nurse's roles during a colonic stent procedure, and at the same time, it explored the patient's satisfaction with the procedure at the Hospital Universitario Central de Asturias (Spain). The results revealed that for the last 10 years, a total of 102 patients underwent a colonic stent procedure. Male patients outnumbered female patients by 2:1. The palliative group consisted of patients with multiple cancer metastases, elderly patients, and patients with other comorbidities, whereas the preoperative group comprised those patients with fewer comorbidities and no multiple cancer metastases. Survival time in the palliative group was 3 months without any aggressive treatment, whereas patients with a favorable condition and fit for surgery after a colonic stent procedure had a survival time of 28 months. In the prospective study, nurses implemented care in terms of a multidisciplinary team approach of safety culture that included patient safety, equipment safety, and environment and procedure safety. Therefore, the level of patient satisfaction was high. In conclusion, management of a colorectal cancer patient undergoing colonic stenting performed at the Hospital Universitario Central de Asturias has high technical and clinical success, and it is a quality procedure that includes a multidisciplinary team approach.

Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma

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.

Endoprosthetic management of refractory ileocolonic anastomotic strictures after resection for Crohn's disease: report of nine-year follow-up and review of the literature

BACKGROUND

The role of endoluminal stenting in benign obstruction, especially for Crohn's disease (CD), is controversial, with limited data and widely disparate outcomes. The purpose of this study was to determine the long-term efficacy and safety of this technology in the treatment of fibrostenotic CD and to review the existing literature on this topic.

METHODS

We undertook a retrospective review of all patients undergoing endoluminal stenting for CD strictures at our institution from 2001 to 2010. Outcome measures included technical success, clinical improvement, duration of stent and luminal patency, and need for re-intervention.

RESULTS

Five patients underwent this procedure with a 100% rate of technical and an 80% rate of clinical success. Mean follow-up was 28 months (range 3 weeks to 109 months) and mean long-term luminal patency was 34.8 months (range 4.5-109 months). There was one complication involving reobstruction which required surgical intervention and no mortalities.

CONCLUSIONS

Endoluminal stenting of CD strictures is a safe and effective alternative to surgery which can provide lasting benefit in select patients. Further studies are necessary to clarify the full impact of this technology on long-term management of this complex disease.

Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors

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.

Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases

BACKGROUND

Self-expanding metal stents (SEMS) are an established treatment for palliation of malignant colorectal strictures and as a bridge to surgery for acute malignant colonic obstruction. Patients with benign colonic strictures may benefit from stent placement, but little data exist for this indication.

METHODS

All cases of colonic stent placement identified from a prospectively collected gastrointestinal database from April 1999 to August 2006 were reviewed. During the study period, 23 patients with benign obstructive disease underwent endoscopic SEMS placement. The etiologies of the stricture were diverticular/inflammatory (n = 16), postsurgical anastomotic (n = 3), radiation-induced (n = 3), and Crohn's (n = 1) disease. All strictures were located in the left colon. Five patients had an associated colonic fistula. Uncovered Enteral Wallstents or Ultraflex Precision Colonic stents (Boston Scientific) were endoscopically placed in all but one patient.

RESULTS

Stent placement was technically successful for all 23 patients, and obstruction was relieved for 22 patients (95%). Major complications occurred in 38% of the patients including migration (n = 2), reobstruction (n = 4), and perforation (n = 2). Of these major complications, 87% occurred after 7 days. Four patients did not undergo an operation. Of the 19 patients who underwent planned surgical resection, 16 were successfully decompressed and converted from an emergent operation to an elective one with a median time to surgical resection of 12 days (range, 2 days to 18 months). Surgery was delayed more than 30 days after stent placement for six of these patients. Of the 19 patients who underwent a colectomy, 8 (42%) did not need a stoma after stent insertion.

CONCLUSIONS

SEMS can effectively decompress high-grade, benign colonic obstruction, thereby allowing elective surgery. The use of SEMS can offer medium-term symptom relief for benign colorectal strictures, but this approach is associated with a high rate of delayed complications. Thus, if elective surgery is planned, data from this small study suggest that it should be performed within 7 days of stent placement.

Comparison of Wallstent and Ultraflex stents for palliation of malignant left-sided colon obstruction: a retrospective, case-matched analysis

BACKGROUND

Self-expandable metal stents (SEMSs) are accepted palliation for malignant colon obstruction. Outcomes of different stent types is unknown.

OBJECTIVE

Our purpose was to compare outcomes after palliative placement of the Enteral Wallstent (EW) and the Precision Colonic Ultraflex (PCU) stent.

DESIGN

Retrospective study of all SEMS placement during a 7-year period.

SETTING

Tertiary care academic medical center.

PATIENTS

Malignant left-sided colon obstruction in which through-the-scope (TTS) or non-TTS stent placement was possible.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success rates, stent-related complications, reintervention.

RESULTS

Demographics, degree, site, and cause of obstruction were comparable. Technical difficulties were more frequent with EW than PCU (16% vs 9%, P not significant), insufficient stent expansion and stent misplacement being most common. Relief of obstruction occurred in all patients when placement was technically successful. Mean follow-up was 93 days (range 7-691 days). Early (<7 days) stent occlusion (6% vs 0%, P not significant) and migration (4% vs 0%, P not significant) occurred more frequently in the EW group. Self-limited hematochezia was more common with PCU (20% vs 2%, P = .002). Delayed complications (perforation, stent occlusion, migration, and erosion) occurred significantly more often in the EW group (38% vs 20%). Reintervention was needed more frequently for EW, endoscopic (40% vs 17%, P = .01) and operative (46% vs 26%, P = .03).

CONCLUSIONS

Enteral Wallstents and Precision Ultraflex Colonic stents adequately relieve colonic obstruction. Stent dysfunction, stent-related complications, and need for reintervention are higher after EW placement. Precision Colonic Ultraflex stents appear better suited for palliation of left-sided malignant colon obstruction.

Use of self-expanding metal stents to treat malignant colorectal obstruction in general endoscopic practice (with videos)

BACKGROUND

Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction (MCRO). Patients can then either undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. The majority of reports on the use of SEMS in MCRO come from single centers; therefore, its use in general endoscopic practice is not clearly known.

OBJECTIVE

To study the use of SEMS for MCRO in a wide endoscopic practice.

DESIGN

Retrospective study.

SETTING

A survey was carried out among endoscopists in 13 hospitals in Spain (6 tertiary referral centers and 7 community hospitals).

PATIENTS

Those who presented with MCRO.

INTERVENTIONS

A total of 175 attempts to insert colorectal SEMS were made during a 12-month period (October 2003 to September 2004).

MAIN OUTCOME MEASURES

Technical and clinical success and possible differences according to the type of hospital.

RESULTS

There was a mean of 1.2 attempts/mo per center (range, 2-0.5 attempts/mo per center). Insertion success was achieved in 162 (92.6%) and acceptable colonic decompression in 138 of 175 (78.8%) attempts and in 138 of 162 (85.1%) of successfully inserted stents. SEMS served as a bridge to scheduled surgery in 72 of 175 (41%) and as a palliative definitive treatment in 66 of 175 (37.7%). The major complication was perforation, which occurred in 7 of 175 occasions (4%) and led to death in 2 patients (1%). There were other less severe complications (25 [14%]). No significant differences in outcome of stent placement procedures were found between both categories of centers.

LIMITATIONS

Retrospective study involving many centers and the possibility of bias for different assessments of outcomes.

CONCLUSIONS

In this study, success rates for SEMS placement and colonic decompression in MCRO were acceptable, without substantial differences according to the type of hospital. This procedure appeared to be feasible in general endoscopic practice.

[Endoscopic insertion of self-expanding metal stents in malignant colonic obstructions]

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.