Covered metal stents for management of inoperable malignant colorectal strictures

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.

Comparison of different types of covered self-expandable metal stents for malignant colorectal obstruction

BACKGROUND

Stent migration is one of the main drawbacks of covered self-expandable metal stent (SEMSs), occurring in up to 40% of malignant colorectal obstruction management cases. Various types of covered SEMSs have been developed to reduce this risk. We aimed to compare the effectiveness and complication rates of the flare-type covered SEMS (Flare) with those of the double-layered covered SEMS (ComVi).

METHODS

We performed a prospective, randomized study in four tertiary referral centers between July 2016 and April 2018. Patients with malignant colorectal obstruction were eligible for the study. The primary outcome was migration rate as observed within the first month. Rates of technical success, clinical success, and complications within the first month were also assessed.

RESULTS

A total of 60 patients were included (mean age, 70.5 ± 12.5 years; male, 31 [51.7%]). Flare and ComVi stents were applied in 30 patients each. The Flare and ComVi groups showed comparable technical success rates (90% [27/30] vs. 96.7% [29/30], p = 0.605) and clinical success rates (85.2% [23/27] vs. 75.9% [22/29], p = 0.589). Migration occurred in three (11.1%) and four (13.8%) cases in the Flare and ComVi groups, respectively, without significant difference (p = 0.99), and the risk of other complications, including perforation and re-obstruction, did not differ between the two groups.

CONCLUSIONS

Our study indicates that both flare-shape and double-layered covered SEMSs are equally effective options for the management of malignant colorectal obstruction with low migration rates when compared with previously reported migration risk of covered SEMS.

Novel Predictive Nomogram for Identifying Difficult Guidewire Insertion in Patients With Malignant Colorectal Obstruction and Sphincterotome-Assisted Guidewire Insertion for Improving the Success Rate of Self-Expandable Metal Stent Insertion

Aims: This study aimed to identify risk factors related to guidewire insertion (GWI) failure and construct a novel predictive nomogram. In addition, sphincterotome-assisted guidewire insertion (SAGWI) in difficult cases was evaluated for efficacy and safety.

Methods: We reviewed the data of 509 patients with malignant colorectal obstruction who underwent endoscopic self-expandable metal stent (SEMS) insertion from 2007 to 2018 in our center, retrospectively. We identify risk factors associated with GWI failure by multivariate logistic regression analysis and construct a novel predictive nomogram. Improvements in the GWI and technical and clinical success rates were assessed for the SAGWI technique.

Results: A total of 509 patients with malignant colorectal obstruction were included. Increases of 6.9% and 7.0% were found in the GWI success rate by intention-to-treat (ITT; p < 0.001) and per-protocol (PP; p < 0.001) analyses after SAGWI, respectively. Increases of 6.5% and 6.6% in the technical success rate were found by ITT (p < 0.001) and PP (p < 0.001) analyses after SAGWI, respectively. Increases of 5.8% and 6.0% in the clinical success rate were found by ITT (p < 0.001) and PP (p < 0.001) analyses after SAGWI, respectively. Regarding the GWI failure-related factors, a sharply angulated stricture was an independent risk factor, and an experienced colonoscopist was an independent protective factor. A novel effective predictive nomogram was constructed.

Conclusion: The novel predictive nomogram can be conveniently used to identify difficult cases. A sharply angulated stricture and an experienced colonoscopist are independent factors related to GWI failure. The SAGWI technique is an effective and safe method for addressing technically difficult cases.

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.

Outcomes of the use of fully covered esophageal self-expandable stent in the management of colorectal anastomotic strictures and leaks

Introduction. Colorectal anastomotic leak or stricture is a dreaded complication leading to significant morbidity and mortality. The novel use of self-expandable metal stents (SEMS) in the management of postoperative colorectal anastomotic leaks or strictures can avoid surgical reintervention. Methods. Retrospective study with particular attention to the indications, operative or postoperative complications, and clinical outcomes of SEMS placement for patients with either a colorectal anastomotic stricture or leak. Results. Eight patients had SEMS (WallFlex stent) for the management of postoperative colorectal anastomotic leak or stricture. Five had a colorectal anastomotic stricture and 3 had a colorectal anastomotic leak. Complete resolution of the anastomotic stricture or leak was achieved in all patients. Three had recurrence of the anastomotic stricture on 3-month flexible sigmoidoscopy follow-up after the initial stent was removed. Two of these patients had a stricture that was technically too difficult to place another stent. Stent migration was noted in 2 patients, one at day 3 and the other at day 14 after stent placement that required a larger 23 mm stent to be placed. Conclusions. The use of SEMS in the management of colorectal anastomotic leaks or strictures is feasible and is associated with high technical and clinical success rate.

A novel anchoring system for colonic stents: a pilot in vivo study in a porcine model

BACKGROUND

Colorectal stents have a proven role in colorectal cancer as palliative care or a bridge to surgery. However, their efficacy and anchoring to the tissue varies according to stent design with stent migration rates up to 50 %. We present preliminary in vivo results of a new end-luminal anchoring system for stent fixation to the rectal canal. The aim was to assess the efficacy and safety of the stent using the anchoring system while subjecting the device to daily abdominal pressures related to daily activities in a porcine animal model.

METHODS

Ex vivo anatomical and physical studies were performed to improve the system's structure and safety. Four female pigs were followed for the acute and chronic (16 weeks) period. Two animals were euthanized and underwent en-bloc pelvic visceral excision and histopathological examination. Device fixation time, animal behavior, device patency, anoscopic examination and histopathological features were assessed.

RESULTS

Mean anchoring time was 13.83 weeks (standard error ± 1.38 weeks). One of the animals experienced early device expulsion with no complications. No obstruction was noted in any of the animals. Macroscopic examination revealed mild focal submucosal scarring in one animal and a normal examination in the other. Hematoxylin and eosin staining revealed mucosal ulceration and mixed inflammatory cell infiltrate, with no signs of granulomata, foreign body giant cell reaction or microabscess formation.

CONCLUSIONS

A novel fixation device designed for long-term intrarectal implantation was well tolerated and maintained anal canal patency without migration. Larger studies are needed before its implementation in humans.

Successful Self-Expandable Metallic Stent Placement for a Case of Distal Rectal Stenosis due to Gastric Cancer Metastasis

A 47-year-old woman was diagnosed as having advanced gastric cancer with malignant ascites. Despite chemotherapy, recurrent peritoneal dissemination was seen 1.5 years after operation. A computed tomography scan revealed rectal stenosis due to Schnitzler's metastasis. When the distance from the distal end of the obstruction to the anal verge is less than 5 cm, stent replacement has been said to be contraindicated due to the development of anal pain and foreign body sensation. Although the distance from the distal end of the obstruction to the anal verge was 4 cm in this case, a WallFlex^TM colonic stent could be placed. She stayed home, and luminal patency remained until she died 270 days after stent insertion. This report demonstrates that rectal obstruction located less than 5 cm from the anal verge due to Schnitzler's metastasis could be treated by stenting without any symptomatic or technical complications.

Managing acute colorectal obstruction by "bridge stenting" to laparoscopic surgery: Our experience

AIM: To verify the clinical results of the endoscopic stenting procedure for colorectal obstructions followed by laparoscopic colorectal resection with “one stage anastomosis”.

METHODS: From March 2003 to March 2009 in our surgical department, 48 patients underwent endoscopic stenting for colorectal occlusive lesion: 30 males (62.5%) and 18 females (37.5%) with an age range from 40 years to 92 years (median age 69.5). All patients enrolled in our study were diagnosed with an intestinal obstruction originating from the colorectal tract without bowel perforation signs. Obstruction was primitive colorectal cancer in 45 cases (93.7%) and benign anastomotic stricture in 3 cases (6.3%).

RESULTS: Surgical resection was totally laparoscopic in 69% of cases (24 patients) while 17% (6 patients) of cases were video-assisted due to the local extension of cancer with infiltrations of surrounding structures (urinary bladder in 2 cases, ileus and iliac vessels in the others). In 14% of cases (5 patients), resection was performed by open surgery due to the high American Society of Anesthesiologists score and the elderly age of patients (median age of 89 years). We performed a terminal stomy in only 7 patients out of 35, 6 colostomies and one ileostomy (in a total colectomy). In the other 28 cases (80%), we performed bowel anastomosis at the same time as resection, employing a temporary ileostomy only in 5 cases.

CONCLUSION: Colorectal stenting transforms an emergency operation in to an elective operation performable in a totally laparoscopic manner, limiting the confection of colostomy with its correlated complications.

Comparison of efficacy between uncovered and covered self-expanding metallic stents in malignant large bowel obstruction: a systematic review and meta-analysis

AIM

Insertion of a self-expandable metallic stent (SEMS) can rapidly relieve colorectal obstruction. This study aimed to compare the efficacy between uncovered and covered SEMSs in the treatment of malignant colorectal obstruction.

METHOD

A systematic search in Medline, Embase, the Cochrane controlled trials register and bibliographies of retrieved articles was performed. Randomized controlled trials and other comparative studies comparing uncovered and covered SEMSs for treatment of malignant colorectal obstruction were selected for this systematic review and meta-analysis. The main outcome measures were technical success, clinical success, tumour ingrowth, tumour overgrowth, early migration (≤ 7 days), late migration (> 7 days), overall complications and the duration of stent patency.

RESULTS

Compared with covered SEMSs, uncovered SEMSs were associated with a lower late migration rate (relative risk 0.25; 95% CI 0.08, 0.80; P = 0.02), a higher tumour ingrowth rate (relative risk 5.99; 95% CI 2.23, 16.10; P = 0.0004) and a prolonged stent patency (weighted mean difference 15.34 days; 95% CI 4.31, 26.37; P = 0.006). There was no significant difference in technical success, clinical success, tumour overgrowth, early migration, perforation or overall complications between the two groups.

CONCLUSION

Tumour ingrowth occurred more frequently in the uncovered SEMS group, while late migration was more common in the covered SEMS group.

Clinical outcomes of palliative self-expanding metallic stents in patients with malignant colorectal obstruction

OBJECTIVE

Self-expanding metallic stents (SEMS) are useful palliative option and a bridge to surgery in malignant colorectal obstruction. The aim of this study was to evaluate the clinical outcomes of SEMS to palliate colorectal malignant obstruction.

METHODS

Malignant colorectal obstructive patients who underwent SEMS insertion at the National Cancer Center, Korea from January 2004 to June 2008 were enrolled in the study. Patients' clinical characteristics, outcomes and complications for palliative SEMS insertion were retrospectively analyzed.

RESULTS

A total of 54 patients were enrolled in the palliative SEMS group and 48 patients with obstructive CRC were included in the SEMS as the bridge to surgery group. Obstruction of the left colon occurred in 52 patients of the palliative SEMS group and all patients in SEMS as bridge to surgery group. For primary SEMS insertion, the technical success (TS) rate was 87.0% and the clinical success (CS) rate 89.4%, while the rates of early and late complications were 24.1% and 23.4%, respectively. There was no procedure-related mortality. Stent migration rate was higher in the cases treated with small diameter and covered type of stents. Median time to reobstruction and migration were 85 and 101 days, respectively. TS and CS rates for SEMS reinsertion were comparable to those for primary SEMS insertion.

CONCLUSIONS

Palliative SEMS are effective and favorable procedures for malignant colorectal obstruction but with some complications. Stent migration is associated with covered type and small diameter stents while other factors including length of stent and chemotherapy do not affect stent complications in the present study.

Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction

BACKGROUND

Although self-expandable metal stent (SEMS) insertion is widely used for relief of malignant colorectal obstructions, the immediate technical and clinical failure rates of SEMSs and the associated risk factors remain largely unknown.

OBJECTIVE

To identify rates and factors predictive of technical and clinical failure of SEMSs when their use is attempted for the decompression of malignant colorectal obstruction.

DESIGN

Retrospective chart review.

SETTING

A tertiary-care academic medical center in South Korea.

PATIENTS

This study involved a total of 412 patients with malignant colorectal obstruction in whom SEMS insertion was attempted.

INTERVENTION

Placement of colonic SEMSs.

MAIN OUTCOME MEASUREMENTS

Technical success and immediate and long-term clinical success rates.

RESULTS

Technical and clinical failures were found in 36 of 276 patients (13.0%) and 39 of 240 patients (16.3%) in the palliative group, respectively, and in 3 of 136 patients (2.2%) and 7 of 133 patients (5.3%) in the preoperative group, respectively. Factors associated with technical failure were extracolonic origin of tumor, the presence of carcinomatosis, and a proximal obstruction site. Factors associated with long-term clinical failure in the palliative group were combined dilation procedure, no additional chemotherapy, and extracolonic origin of the tumor. In the preoperative group, only older patients had both higher technical failure and clinical failure rates.

LIMITATIONS

This was a single-institution, retrospective analysis.

CONCLUSION

Although colorectal SEMS placement is generally safe and effective, it is associated with clinically important technical and clinical failure rates. The identification of risk factors for the failure of colorectal SEMSs found in this study might help physicians decide between surgical decompression and endoscopic stenting in patients with malignant colorectal obstruction.

Colorectal stents: do we have enough evidence?

BACKGROUND

The use of colonic stents has significantly evolved over the last few years. Emergency surgery for colonic obstructions is usually associated with significant mortality, morbidity and often stoma formation. Colonic stents provide an alternative way to relieve colonic obstruction, and hence avoiding the risks associated with emergency surgery. This literature review aims to summarize the important current evidence regarding colorectal stenting and show whether further evaluation of the procedure is required.

RESULTS

The available large number of non-randomized studies suggests that Self-Expandable-Metal-Stents (SEMS) placement for acute colonic obstruction could be considered as safe and effective alternative to surgery in experienced hands either as a bridge to surgery or as a palliative measure. This evidence has led to SEMS being widely adopted. However, randomized evidence has begun to show the defects that are inherent in the low level evidence that has so far supported SEMS use and it may be that reports of randomized controlled trials may clarify the patient population where SEMS placement is appropriate.

CONCLUSION

While we are still waiting for the outcome of the multicentre randomized controlled trials in the UK and Europe, clinicians must be aware of the current evidence limitations and apply SEMS use pragmatically.

Varadarajulu S, Banerjee S, Barth B, Desilets D, Kaul V, Kethu S, Pedrosa M, Pfau P, Tokar J, Wang A, Song LMWK, Rodriguez S. Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Outcomes of secondary stent-in-stent self-expandable metal stent insertion for malignant colorectal obstruction

BACKGROUND

Although self-expandable metal stents (SEMSs) are widely used for the treatment of malignant colorectal obstruction, they often become occluded by tumor ingrowth.

OBJECTIVES

To determine the therapeutic effectiveness of secondary stent-in-stent SEMS insertion for the management of occluded SEMS in patients with malignant colorectal obstruction and to identify predictive factors associated with clinical outcomes in terms of immediate clinical success, stent patency, and complications.

DESIGN

Retrospective case series.

SETTING

A tertiary-care academic medical center in South Korea.

PATIENTS

Between November 2005 and July 2010, among a total of 309 patients who underwent SEMS insertion for unresectable malignant colorectal obstruction at Severance Hospital, 87 underwent secondary SEMS insertion. Of these, 36 patients underwent secondary SEMS placement as stent-in-stent.

INTERVENTIONS

Placement of secondary colorectal stent-in-stent SEMSs.

MAIN OUTCOME MEASUREMENTS

Immediate and long-term clinical success and complications.

RESULTS

Immediate clinical success was achieved in 27 of 36 patients (75%), and the median duration of stent patency was 170 days. Factors associated with immediate clinical success included a long duration between the previous stent and stent-in-stent insertion. Moreover, the absence of carcinomatosis was associated with long-term clinical success.

LIMITATIONS

This was a retrospective, nonrandomized, single-center study.

CONCLUSIONS

Secondary stent-in-stent SEMS placement led to good outcomes in patients with malignant colorectal obstruction, despite a slightly lower success rate compared with primary SEMS placement. Patency duration of the primary SEMS and carcinomatosis were important factors predictive of immediate and long-term clinical success of stent-in-stent insertion, respectively.

Treatment recommendations for metastatic colorectal cancer

Metastatic colorectal cancer (CRC) represents an important health problem in which several biological predictive and prognostic factors have been identified, including clinical features and molecular markers that might influence the response to treatment. Actually, certain prognostic factors are considered key elements, along with disease extent, for deciding the therapeutic approach. However, a distinction between resectable/potentially resectable and unresectable patients must be made in order to establish an adequate therapeutic strategy. Different drugs and chemotherapy regimens are currently available, and their administration depends on patient characteristics, disease-related factors and the treatment objective. Moreover, special situations such as peritoneal carcinomatosis and local treatment of CRC in the setting of metastatic disease should be considered when deciding the most appropriate treatment strategy. This article reviews all the previously mentioned issues involved in the management of metastatic CRC and suggests some general recommendations for its treatment.

Ten-year retrospective study of treatment of malignant colonic obstructions with self-expandable stents

PURPOSE

To describe the use of self-expandable metallic stents to manage malignant colorectal obstructions and to compare the radiation dose between fluoroscopic guidance of stent placement and combined endoscopic and fluoroscopic guidance.

MATERIALS AND METHODS

From January 1998 to December 2007, 467 oncology patients undergoing colorectal stent placement in a single center were included in the study. Informed consent was obtained in all cases. All procedures were performed with fluoroscopic or combined fluoroscopic and endoscopic guidance. Inclusion criteria were total or partial colorectal obstruction of neoplastic origin. Exclusion criteria were life expectancy shorter than 1 month, suspicion of perforation, and/or severe colonic neoplastic bleeding. Procedure time and radiation dose were recorded, and technical and clinical success were evaluated. Follow-up was performed by clinical examination and simple abdominal radiographs at 1 day and at 1, 3, 6, and 12 months.

RESULTS

Of 467 procedures, technical success was achieved in 432 (92.5%). Thirty-five treatments (7.5%) were technical failures, and the patients were advised to undergo surgery. Significant differences in radiation dose and clinical success were found between the fluoroscopy and combined-technique groups (P < .001). Total decompression was achieved in 372 cases, 29 patients showed remarkable improvement, 11 showed slight improvement, and 20 showed clinical failure. Complications were recorded in 89 patients (19%); the most significant were perforation (2.3%) and stent migration (6.9%). Mean interventional time and radiation dose were 67 minutes and 3,378 dGy·cm(2), respectively.

CONCLUSIONS

Treatment of colonic obstruction with stents requires a long time in the interventional room and considerable radiation dose. Nevertheless, the clinical benefits and improvement in quality of life justify the radiation risk.

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.

Clinical application of self-expandable metallic stent for treatment of colorectal obstruction caused by extrinsic invasive tumors

PURPOSE

The purpose of this study was to extend the application of self-expandable metallic stents by investigating their usefulness in treating colorectal obstructions caused by unresectable extrinsic tumors.

METHODS

From January 2000 to November 2005, a total of 60 colorectal stenting procedures were performed, and 57 stents were deployed in 39 patients with extrinsic tumors. The success rate and complications were analyzed retrospectively.

RESULTS

The most common etiology and location of obstruction were advanced gastric cancer and transverse colon. Technical success was 34 of 39 patients (87.2 percent). The causes of technical failure were immediate stent migration (n = 1), technical problems (n = 1), and access failure because of bowel immobilization (n = 3). Clinical success was 32 of 34 technical successes (82.1 percent). The two patients without clinical success had multifocal strictures of the bowel. Complications occurred in 22 of 57 stents (38.6 percent), including stent reobstruction (n = 14) and stent migration (n = 5). All of stent migrations except one developed with covered stents.

CONCLUSIONS

In patients with colonic obstruction caused by extrinsic tumors, stent insertion provided effective symptom relief and can be a reasonable alternative choice to a colostomy. An uncovered stent might be more preferable, considering less migration and remaining short life expectancy, compared with a covered stent.

Palliative nonvascular interventions

Interventional radiologists are often called on to help with quality of life issues in end-stage cancer patients. Many times, the discomfort can be directly associated to the tumor mass itself, but in other instances, tumors can cause secondary obstruction of normal structures that can lead to patient distress. As with most palliative care patients, their medical conditions are not conducive to major surgery; therefore minimally invasive techniques are ideal for the treatment of these conditions. The following discussion addresses the various nonvascular interventions available to these patients, including the indications and limitations of these procedures.

Ultraflex precision colonic stent placement for palliation of malignant colonic obstruction: a prospective multicenter study

BACKGROUND

Many patients who develop obstructive colonic symptoms secondary to inoperable colorectal cancer will require palliative treatment. A minimally invasive and potentially long-lasting approach is placement of nitinol self-expanding metal stents (SEMS).

OBJECTIVE

To determine the effectiveness and safety of a nitinol SEMS designed for colorectal use in the palliative treatment of malignant colonic obstruction.

DESIGN

Prospective multicenter clinical study.

SETTING

Nine European study centers.

PATIENTS

Forty-four patients with malignant colonic obstruction.

INTERVENTIONS

Placement of nitinol SEMS designed for colorectal use.

MAIN OUTCOME MEASURES

Technical success, defined as accurate SEMS deployment with adequate stricture coverage, and clinical success, defined as decompression and relief of obstructive colonic symptoms maintained without intervention or serious device-related complications.

RESULTS

Technical success was attained in 95% of patients, with 95% CI 85%-99%. After 6 months, the rate of clinical success was 81%, 95% CI 69%-96%. Survival at 6 months was 67%, 95% CI 54%-84%. Clinical success was maintained until death in 86% of the nonsurvivors. No perforations or SEMS-related deaths occurred.

LIMITATION

This investigation was nonrandomized and did not include a control group.

CONCLUSIONS

In a large prospective investigation, palliative placement of a nitinol SEMS designed for colorectal use was accomplished with a high rate of technical success. Durable clinical success was achieved in a high proportion of patients with low morbidity.

Comparison of uncovered stent with covered stent for treatment of malignant colorectal obstruction

BACKGROUND

Insertion of self-expandable metallic stents (SEMS) can provide rapid relief of malignant colorectal obstruction and can be used as a palliative treatment or as a bridge to surgery. A SEMS can be classified as an uncovered or covered stent. Both types of stents have their own merits and demerits.

OBJECTIVE

The objectives of this study were to compare success rates, durability, and complication rates of uncovered and covered stent groups of malignant colorectal obstruction. DESIGNS AND SETTING: A nonrandomized prospective, single-center study.

METHODS

We studied 80 patients with malignant colorectal obstruction: colon cancer in 70 patients, metastatic lesion of advanced gastric cancer in 8 patients, and cervix cancer in 2 patients. Insertion of uncovered stents was attempted in 39 patients (before surgery in 20, palliative in 19), and covered stents were used in 41 (before surgery in 23, palliative in 18).

INTERVENTION

The stent was inserted into the obstructive sites for preoperative or palliative purposes by using the through-the-scope method. After stent insertion, the patients had regular follow-ups, either as clinical checkups or telephone interviews.

MAIN OUTCOME MEASUREMENT

Insertion success rate, durability, and complication rate according to stent type.

RESULTS

Technical and clinical success rates of uncovered and covered stents were not different (100%; 95.1%, P > .05, 100%; 97.4%, P > .05). The early stent migration rate was not different in both groups. The late stent migration was more common in the covered stent group than the uncovered stent group (0% vs 40%, respectively, P = .005). Loss of stent function during the long-term follow-up period was more frequent in the covered stent group than in the uncovered stent group (18.8% vs 60%, respectively, P = .018).

LIMITATION

This was a small-sized, nonrandomized, prospective, single-center study. Confirmation of large-scale, multicenter, randomized, prospective outcome is required.

CONCLUSIONS

Insertion of either an uncovered or covered stent is similarly an effective treatment modality of malignant colorectal obstruction for preoperative purposes. However, there are no advantages of covered stents over uncovered stents during the follow-up period in the palliative purpose.

Trimming a metallic biliary stent using an argon plasma coagulator

BACKGROUND

Distal migration is one of the common complications after insertion of a covered metallic stent. Stent repositioning or removal is not always possible in every patient. Therefore, trimming using an argon plasma coagulator (APC) may be a good alternative method to solve this problem.

METHODS

Metallic stent trimming by APC was performed in 2 patients with biliary Wallstent migration and in another patient with esophageal Ultraflex stent migration. The power setting was 60-100 watts with an argon flow of 0.8 l/min.

OBSERVATIONS

The procedure was successfully performed and all distal parts of the stents were removed. No significant collateral damage to the nearby mucosa was observed.

CONCLUSIONS

In a patient with a distally migrated metallic stent, trimming of the stent is possible by means of an APC. This new method may be applicable to other sites of metallic stent migration.

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.

Complications of colonic stenting: a pictorial review

Surgical resection of colorectal carcinoma is the only curative treatment currently available. In the elective setting peri-operative mortality is low and refinements in surgical technique and peri-operative care have resulted in high primary anastamosis rates and progressively reduced postoperative morbidity. In those presenting with large bowel obstruction the mortality and morbidity remains high. Many of those undergoing surgery will have incurable disease and a short life expectancy. Increasingly self-expanding metal stents are being deployed as either a 'bridge to surgery' or for palliation. This review covers the imaging appearances, detection and management of complications of colonic stenting.

Metal stents for malignant colorectal obstruction

Malignant obstruction of the colon occurs in 7-25% of patients with colorectal cancer. As emergency laparotomy is reported to have relatively high morbidity and mortality rate, there is a need for alternative procedures with reduced complication rates. Over the last decade colorectal stenting has been reported as an alternative endoscopic method to relieve acute colonic obstruction. With the availability of more sophisticated stents and stent delivery systems, this approach has been used as a palliative method and as a pre-operative bridge to facilitate one-stage surgical resection of primary colonic tumors. Technical and clinical successes have been reported in 80-100% of treated patients. Distal lesions are more common and theoretically easier to stent although lesions within the ascending colon have been successfully managed. Minor complications include transient anorectal pain, tenesmus and rectal bleeding. However, stent migration and colonic perforation are also well recognized. Despite the fact that no randomized controlled studies have yet been performed, literature data show that colonic stenting is a safe and effective procedure and can reduce costs, avoiding the need for colostomy and improving the quality of life of patients with advanced disease.

Interventional management of malignant colorectal obstruction: use of covered and uncovered stents

Objective

We wanted to evaluate usefulness of uncovered stent in comparison with covered stent for the palliative treatment of malignant colorectal obstruction.

Materials and Methods

Covered (n = 52, type 1 and type 2) and uncovered (n = 22, type 3) stents were placed in 74 patients with malignant colorectal obstruction. Stent insertion was performed for palliative treatment in 37 patients (covered stent: n = 23 and uncovered stent: n = 14). In the palliative group, the data on the success of the procedure, the stent patency and the complications between the two groups (covered versus uncovered stents) were compared.

Results

The technical success rate was 89% (33/37). Symptomatic improvement was achieved in 86% (18/21) of the covered stent group and in 92% (11/12) of the uncovered stent group patients. The period of follow-up ranged from three to 319 days (mean period: 116±85 days). The mean period of stent patency was 157±33 days in the covered stent group and 165±25 days in the uncovered stent group. In the covered stent group, stent migration (n = 11), stent fracture (n = 2) and poor expansion of the stent (n = 2) were noted. In the uncovered stent group, tumor ingrowth into the stents (n = 3) was noted.

Conclusion

Self-expanding metallic stents are effective for relieving malignant colorectal obstruction. The rate of complications is lower in the uncovered stent group than in the covered stent group.

Repeated coaxial colonic stenting in the palliative management of benign colonic obstruction

In inflammatory bowel disease, strictures of the colon, causing bowel obstruction, is not uncommon. Usually an operative procedure can deal with these strictures. We describe a case of an unfit patient with pulmonary malignancy having a Crohn's stricture of the recto-sigmoid junction in which repeated coaxial placement of self-expanding metallic stents eliminated the need to perform an operation. This is the first report of multiple coaxial colonic stenting. It shows that there is a place for stents in selected cases of inflammatory bowel disease with a limited life expectancy and that repeated colonic stenting makes colonic stenting possible also in patients requiring stents for longer time periods.

Management of complications in surgery of the colon

BACKGROUND

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

METHODS

We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

RESULTS

Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery.

CONCLUSIONS

To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.

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.

Advances in gastrointestinal endoscopic techniques

An increasing number of techniques for endoscopic diagnosis and treatment is being described. Endoscopic surgeons should be familiar with these techniques. Although many of the diagnostic techniques, other than marking, do not have widespread clinical application, the therapeutic techniques that were described in this article are being used successfully in increasing numbers of appropriately selected patients. Additional experience and technologic advances will refine the endoscopic therapy that is available to patients with colorectal diseases.

Colorectal stenting for colonic obstruction: the indications, complications, effectiveness and outcome--5 year review

INTRODUCTION

Currently self-expanding metallic stents are being used for palliation and acute decompression of colonic obstruction. The aim of this study is to review our experience of using these metallic stents over a 5-year period.

MATERIALS AND METHODS

Case records of 102 patients who had colorectal stenting between 1998 and 2004 were reviewed retrospectively. The indications for colorectal stenting, efficacy of the procedure in relieving the obstruction, complications and clinical outcome were analysed.

RESULTS

Ninety-nine patients had malignant disease and in three patients a benign cause of obstruction was demonstrated. All procedures were performed during normal working hours. Stenting was technically successful in 87 patients (85%). A single stent was placed in 80 patients. Seven patients required two stents. Of the successful cases, 67 had stents placed by fluoroscopy alone and 20 by a combined fluoroscopy/endoscopy procedure. Four percent had early complications (within 30 days) which included four perforations. There were late complications (over 30 days) in 9% which included five stent migrations, two blocked stents and one colovesical fistula. Ninety percent (n=76) of the successful patients needed no further radiological or surgical intervention later. Survival ranged from 14 days to 2 years.

CONCLUSION

Colorectal stenting when technically successful is an effective procedure for both preoperative and palliative decompression of colonic obstruction.

Endoscopic treatment of acute colorectal obstruction with self-expandable metallic stents: experience in a community hospital

BACKGROUND

The purpose of this study was to evaluate the efficacy and security of treatment with self-expandable metallic stents for acute colonic obstruction.

METHODS

Retrospectively, we analyzed our experience in placing colonic stents in patients with acute colonic obstruction. Sixty-two patients with malignant colon obstruction were sent to our hospital endoscopic unit from February 1999 through September 2003. The mean age was 75.21 years. A total of 63 self-expandable metallic stents were implanted. All procedures were done under endoscopic and fluoroscopic guidance.

RESULTS

Technical success was obtained in 58 patients (93.54%). Clinical improvement and resolution of the obstruction were confirmed in 56 of these 58 patients (96.55%) within 48-72 h. Sixteen complications were observed in 11 patients (19%). Twelve cases were minor complications: five patients had pain and rectal tenesmus, and there were seven cases of distal migration of the stent. Four patients (6.9%) had severe complications. Three patients underwent surgery to resolve colonic perforations and one patient developed a colovesical fistula 7 months after stent placement. The stent was used as a bridge to the elective surgery in 22 patients (37.93%). The mean time between stent placement and surgery was 7.66 days (range, 2-20). The stent was used as a definitive palliative treatment in 36 patients (62.07%).

CONCLUSION

Stenting was a useful treatment of acute malignant colonic obstruction. The use of stents as a "bridge to the elective surgery" allowed the intestinal preparation, general status restoration, and a one-stage operation with resection and primary reanastomosis. We have also used the stents as a definitive palliative treatment, avoiding surgery in those patients with a very widely metastatic disease or who cannot undergo operation because of comorbid underlying conditions.

Metal stent placement in acute malignant colorectal obstruction

BACKGROUND

Obstruction is a common complication of advanced colorectal cancer. Stent insertion can reduce the need for emergency surgery and allows chemotherapy to begin immediately.

AIMS

To evaluate the technical and clinical success and long-term outcome of stent placement in the management of acute malignant colorectal obstruction.

METHODS

From July 2002 to April 2005, 29 self-expanding metal stents were placed in 24 patients (13 men, mean age 67 years, range 36-83). Stents were inserted under endoscopic and fluoroscopic control. Patients were clinically and endoscopically followed up.

RESULTS

Twenty-eight out of 29 stents were successfully placed (96.5%) in 23 out of 24 patients with 25 strictures. The clinical success rate was 95.8% (23/24). Two early stent migrations were observed in two patients (8.3%). Late complications developed in eight patients (33.3%) after a median of 3.8 months (range <1-8.6): two migrations and six occlusions. The median survival was 9.8 months (range <1-27). Eleven patients (45.8%) died from progressive disease without any clinical evidence of recurrent obstruction.

CONCLUSION

Stent placement is safe and effective. Stent complications are frequent but not life-threatening, and are easy to manage. An improvement in stent design and well-scheduled follow-up are needed in order to prevent such complications.

Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction

AIM

To summarize our experience with the application of self-expanding metallic stent (SEMS) in the management of acute left-sided colorectal malignant obstruction.

METHODS

A retrospective chart review of all patients undergoing placement of SEMS between April 2000 and January 2004 was performed.

RESULTS

Insertion of SEMS was attempted in 26 patients under fluoroscopic guidance with occasional endoscopic assistance. The sites of lesions were located in splenic flexure of two patients, left colon of seven patients, sigmoid colon of eight patients and rectum of nine patients. The intended uses of SEMS were for palliation in 7 patients and as a bridge to elective surgery in 19 patients. In the latter group, placement of SEMS allowed for preoperative systemic and bowel preparation and the following one-stage anastomosis. Successful stent placement was achieved in 22 (85%) of the 26 patients. The clinical bowel obstruction resolved 24 hours after successful stent placement in 21 (95%) patients. Three SEMS-related minor complications occurred, two stents migrated and one caused anal pain.

CONCLUSION

SEMS represents an effective and safe tool in the management of acute malignant colorectal obstruction. As a bridge to surgery, SEMS can provide time for systematic support and bowel preparation and obviate the need for fecal diversion or on-table lavage. As a palliative measure, SEMS can eliminate the need for emergent colostomy.

The role of SEMS in malignant and benign colon obstruction

SEMS are highly valuable in the management of pati-ents with malignant colon obstruction with high technical and clinical success. Currently, their role is in colon deco-mpression as a bridge before surgery and in the palliative management of inoperative patients. SEMS appear to be more effective and less costly than emergency surgery. SEMS should be avoided in benign strictures. More data is needed in reference to the role of plastic expandable stents in the management of patients with benign colon strictures.

Colonic stenting: technique, technology, and outcomes for malignant and benign disease

Self-expandable metal stents (SEMS) have gained acceptance for use in the gastrointestinal tract to relieve malignant lumenal obstruction. In the colon, SEMS are used to avoid permanent or temporary colostomy during palliation and as a bridge to surgery for left-sided colonic obstruction. Limited data exist on their use for benign disease. This article reviews the latest in stent technology and the outcomes after their placement for benign and malignant disease.

Self-expandable stents in malignant colonic obstruction: insertion assisted with a sphincterotome in technically difficult cases

BACKGROUND

Stent placement is effective in relieving malignant colonic obstruction. Nevertheless, the technique may offer difficulties in sharply angulated lesions.

METHODS

Guidewire insertion assisted with a sphincterotome was performed in 4 patients with intestinal obstruction caused by malignant colonic strictures. The manipulation of the sphincterotome by turning and bending its tip allows the cannulation of the lesion with the guidewire and, as a consequence, the stent insertion.

OBSERVATIONS

The procedure was successfully performed in 4 technically difficult cases in which it had been impossible to pass the guidewire with the standard catheter.

CONCLUSIONS

In technically difficult cases, with the use of a sphincterotome, insertion of the guidewire appears to be easier. This new method may improve technical success rates in stent placement.

Surgical resection of primary tumors in patients who present with stage IV colorectal cancer: an analysis of surveillance, epidemiology, and end results data, 1988 to 2000

BACKGROUND

Surgical resection of the primary tumor for patients who present with incurable stage IV colorectal cancer is controversial. National practice patterns have not been described. We evaluated the use of primary tumor resection in patients presenting with stage IV colorectal cancer.

METHODS

Patients with stage IV colorectal cancer diagnosed between 1988 and 2000 were selected from the Surveillance, Epidemiology, and End Results database. Patients undergoing primary tumor resection were analyzed on the basis of sex, race, year of diagnosis, and the anatomical site of the primary tumor. We compared the survival of resected and nonresected patients.

RESULTS

A total of 17,658 (66%) of the 26,754 patients presenting with stage IV colorectal cancer underwent primary tumor resection. Patients with resected disease were more likely to be young (mean age of 67.1 vs. 70.3 years) and to have right-sided tumors (75.3%, 73.0%, and 45.6%, respectively, for right, left, and rectal; P < .001). In all age groups, patients undergoing resection had higher median and 1-year survival rates (colon: 11 vs. 2 months, 45% vs. 12%, P < .001; rectum: 16 vs. 6 months, 59% vs. 25%, P < .001) when compared with patients who did not undergo resection.

CONCLUSIONS

Most patients who present with stage IV colorectal cancer undergo resection of the primary tumor. The proportion of patients undergoing resection depends on patient age and race and the anatomical location of the primary tumor. The degree to which case selection explains the treatment and survival differences observed is not known. Further investigation of the role of surgery in the management of incurable stage IV colorectal cancer is warranted.