Expandable metal stent placement in the treatment of a malignant anastomotic stricture of the transverse colon

Clinical efficacy of endoscopic treatment for benign colorectal stricture: balloon dilatation versus stenting

BACKGROUND/AIMS

There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes.

METHODS

Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed.

RESULTS

Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5±13.3 months vs. 2.0±0.6 months, p=0.031).

CONCLUSIONS

Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.

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.

Comparison of a newly designed double-layered combination covered stent and D-weave uncovered stent for decompression of obstructive colorectal cancer: a prospective multicenter study

PURPOSE

Stent reocclusion and migration are the most important complications after stent insertion. To overcome both problems, a double-layered combination covered stent was developed. Our purpose was to compare the efficacy and safety of the newly designed double-layered combination covered stent (Niti-S enteral colonic stent, Comvi type) and the double-wire woven uncovered stent (Niti-S enteral colonic stent, D-type) in the treatment of malignant colorectal obstructions.

METHODS

Sixty-eight patients with obstructive colorectal cancer underwent stent placement for preoperative decompression (n = 30) or palliative purpose (n = 38) at 6 medical centers. Combination covered stents were used in 31 patients and uncovered stents were used in 37 patients.

RESULTS

There were no significant differences between both stents in terms of technical and clinical success rates. Regarding complications after stent insertion, there was no significant difference in early stent occlusion and migration rate between the combination covered stents and the uncovered stents. Despite a trend toward lower rates of late stent occlusion in the combination covered stent group, there was no significant difference in the rate of late stent occlusion by tumor ingrowth between the 2 groups (0% vs 20%, respectively; P = .107), and late stent migration occurred significantly more often with the combination covered stent (22.2% vs 0%, respectively; P = .041). However, we observed no significant difference in the overall late-complication rates and stent patency duration between the 2 groups.

CONCLUSIONS

In our study, we could not prove that the newly designed double-layered combination covered stents have preventive advantages in stent migration compared with the uncovered stent.

Oncologic outcomes of self-expanding metallic stent insertion as a bridge to surgery in the management of left-sided colon cancer obstruction: comparison with nonobstructing elective surgery

BACKGROUND

Self-expanding metallic stents (SEMS) have been used as a bridge to surgery in patients with obstruction by colorectal cancer, but the oncologic safety of this technique has not yet been established. The aim of the present study was to compare the outcomes of bridge to surgery after SEMS insertion and nonobstructing elective surgery.

METHODS

Between October 1999 and July 2007, 35 patients who had left-sided colon malignancy obstruction and underwent surgical resection after SEMS insertion (group A) were matched to 350 patients who underwent elective surgery for nonobstructing left-sided colon cancer based on stage II, III, and IV malignancies according to the 2001 American Joint Committee on Cancer (group B). Group B was randomly extracted from the colorectal database of our institute. The two groups were compared for clinicopathologic variables, complications, and survival rate.

RESULTS

There were no significant differences in clinicopathologic variables between group A and group B. However, the stoma formation rate was statistically different between the two groups (p = 0.003). Self-expanding metallic stent insertion had an adverse effect on the 5-year overall survival rate (A vs. B, 38.4% vs. 65.6%, respectively; p = 0.025) and the 5-year disease-free survival rate (A vs. B, 48.3% vs. 75.5%, respectively; p = 0.024).

CONCLUSIONS

These data show that insertion of SEMS as a bridge to surgery in the management of left-sided colon cancer obstruction is possibly associated with adverse oncologic outcomes compared with nonobstructing elective surgery, but it is unclear what magnitude of this effect is related to the underlying obstruction rather than to the SEMS.

Self-expandable metallic stents as palliative treatment for malignant colorectal obstruction

BACKGROUND

In recent years, stent placement for malignant colorectal obstruction has become an accepted alternative to surgery. The purpose of this study was to evaluate the usefulness of self-expandable metallic stents (SEMS) as palliative management for patients with unresectable malignant colorectal obstruction.

METHODS

Twelve patients with unresectable malignant colorectal obstruction were treated with SEMS as palliative therapy. The sites of obstruction were located in the rectum (n = 9), the descending colon (n = 1), and the transverse colon (n = 2). All procedures were performed with combined endoscopic and fluoroscopic guidance. We analyzed the technical and clinical success rates of stent placement and the complications associated with the procedure.

RESULTS

The stents were successfully implanted and bowel obstruction was relieved in all cases; the technical and clinical success rates were 100%. Two complications occurred, including stent migration. There was no case requiring reintervention. All patients died of initial disease or another coexisting disease between 9 and 534 days (mean 133 +/- 148 days) after stent placement. None of the patients with stent in position at death had clinical or radiologic signs of bowel obstruction.

CONCLUSIONS

SEMS placement in patients with malignant colorectal obstruction is technically feasible and safe, making it useful as a palliative treatment.

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.

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.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

METHODS

Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

RESULTS

Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

CONCLUSIONS

Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complications of stent placement for benign stricture of gastrointestinal tract

AIM

To observe the frequent complications of stent placement for stricture of the gastrointestinal tract and to find proper treatment.

METHODS

A total number of 140 stents were inserted in 138 patients with benign stricture of the gastrointestinal tract. The procedure was completed under fluoroscopy in all of the patients.

RESULTS

Stents were successfully placed in all the 138 patients. Pains occurred in 23 patients (16.7%), slight or dull pains were found in 21 patients and severe chest pain in 2 respectively. For the former type of pain, the patients received only analgesia or even no treatment, while peridural anesthesia was conducted for the latter condition. Reflux occurred in 16 of these patients (11.6%) after stent placement. It was managed by common antireflux procedures. Gastrointestinal bleeding occurred in 13 patients (9.4%), and was treated by hemostat. Restenosis of the gastrointestinal tract occurred in 8 patients (5.8%), and was apparently associated with hyperplasia of granulation tissue. In 2 patients, the second stent was placed under X-ray guidance. The granulation tissue was removed by cauterization through hot-node therapy under gastroscope guidance in 3 patients, and surgical reconstruction was performed in another 3 patients. Stent migration occurred in 5 patients (3.6%), and were extracted with the aid of a gastroscope. Food-bolus obstruction was encountered in 2 patients (1.4%) and was treated by endoscope removal. No perforation occurred in all patients.

CONCLUSION

Frequent complications after stent placement for benign stricture of the gastrointestinal tract include pain, reflux, bleeding, restenosis, stent migration and food-bolus obstruction. They can be treated by drugs, the second stent placement or gastroscopic procedures according to the specific conditions.