Malignant colorectal obstruction: treatment with a flexible covered stent

Therapeutic utility of percutaneous cecostomy in adults: an updated systematic review

Objective

Percutaneous cecostomy is a minimally invasive procedure that provides access to the colon for therapeutic interventions. This review aimed to update and summarize the existing information on the use and application of percutaneous endoscopic cecostomy in the field of therapeutic gastroenterology.

Data Sources

A systematic review of the literature was performed without any restrictions on the year of publication from the date of inception in 1986 to January 2021.

Methods

The review was performed using the medical subject heading keywords in the following search engines: MEDLINE, EMBASE, Cochrane, and Google Scholar.

Results

A total of 29 articles were subjected to final data extraction. The review included a total of 174 patients who underwent percutaneous cecostomy. Most of the included studies were conducted in the United States (n = 14). The most common comorbidity was cancer (n = 10) and the major indication for performing percutaneous cecostomy was colonic pseudo-obstruction or Ogilvie's syndrome (n = 15). The main technique for performing percutaneous cecostomy was endoscopy (17 studies), followed by fluoroscopy- (five studies), computed-tomography- (three studies), laparoscopy- (two studies), and ultrasound- (one study) guided procedures. The procedure was technically successful in 153 (88%) cases. The total cumulative rates of major and minor complications were 47.5%. These complications included tube malfunction, local wound site infections, and bleeding and rare complications of peritonitis and death.

Conclusion

Percutaneous cecostomy is a safe and effective option for managing acute colonic pseudo-obstruction. It leads to durable symptom relief with low to minimal risk.

Uncovered versus covered stent in management of large bowel obstruction due to colorectal malignancy: a systematic review and meta-analysis

PURPOSE

To compare outcomes of uncovered stent and covered stent in management of large bowel obstruction secondary to colorectal malignancy.

METHODS

We conducted a search of electronic databases identifying studies comparing outcomes of uncovered and covered stents in management of large bowel obstruction secondary to colorectal malignancy. The Cochrane risk-of-bias tool and the Newcastle-Ottawa scale were used to assess the included studies. Random or fixed effects modelling were applied as appropriate to calculate pooled outcome data.

RESULTS

One randomised controlled trial (RCT) and nine observational studies, enrolling 753 patients, were identified. Uncovered stent was associated with lower risks of complications (RR 0.57 95% CI 0.44-0.74, P < 0.0001), tumour overgrowth (RR 0.29 95% CI 0.09-0.93, P = 0.04), and stent migration (RR 0.29 95% CI 0.17-0.48, P < 0.00001); longer duration of patency (MD 18.47 95% CI 10.46-26.48, P < 0.00001); lower need for stent reinsertion (RR 0.38 95% CI 0.17-0.86, P = 0.02); and higher risk of tumour ingrowth (RR 4.53 95% CI 1.92-10.69, P = 0.0008). Rates of technical success (RR 1.02 95% CI 0.99-1.04, P = 0.21), clinical success (RR 1.03 95% CI 0.98-1.08, P = 0.32), perforation (RD 0.01 95% CI - 0.03-0.02, P = 0.65), bleeding (RD 0.00 95% CI - 0.03-0.03, P = 0.98), stool impaction (RR 0.56 95% CI 0.12-2.04, P = 0.38) and stent obstruction (RR 2.23 95% CI 0.94-5.34, P = 0.97) were similar.

CONCLUSIONS

Our results suggest that uncovered stents are superior as indicated by fewer complications, lower rates of stent migration, longer duration of patency and a reduced need for stent reinsertion. The best available evidence is mainly derived from non-randomised studies; there is a need for more RCTs.

Clinical effect of double coaxial self-expandable metallic stent in management of malignant colon obstruction

PURPOSE

We aimed to evaluate the clinical effectiveness and safety of double coaxial self-expandable metallic stent (DCSEMS) in management of malignant colonic obstruction as a bridge to surgery or palliation for inoperable patients.

METHODS

Between April 2006 and December 2012, 49 patients (27 males and 22 females; median age, 68 years; age range, 38-91 years) were selected to receive decompressive therapy for malignant colonic obstruction by implanting a DCSEMS. Application of DCSEMS was attempted in 49 patients under fluoroscopic guidance. The obstruction was located in the transverse colon (n=2), descending colon (n=7), sigmoid colon (n=24), rectosigmoid junction (n=6), and the rectum (n=10). The intended use of DCSEMS was as a bridge to elective surgery in 23 patients and palliation in 26 patients.

RESULTS

Clinical success, defined as >50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 48 of 49 patients (98%). The stent was properly inserted in all patients. No immediate major procedure-related complications occurred. One patient in the bridge-to-surgery group had colon perforation three days after DCSEMS application. Four patients had late migrations of the double stent.

CONCLUSION

Application of DCSEMS is safe and effective in management of malignant colonic obstruction; it prevents stent migration and tumor ingrowth and lowers perforation rate during the stent application.

A novel, ring-connected stent versus conventional GI stents: comparative study of physical properties and migration rates in a canine colon obstruction model

BACKGROUND

Migration of stents is one of the most common adverse events in covered stent placement in GI tract obstruction.

OBJECTIVE

To compare physical property and migration rates in a canine colon obstruction model among a novel stent and conventional stents.

DESIGN

Comparative physical test and animal study.

SETTING

Medical device testing laboratory and animal laboratory.

SUBJECTS

Mongrel dogs (N=26).

INTERVENTIONS

Surgical colon obstruction followed by placement of a novel (n=13) or conventional (n=13) stent.

MAIN OUTCOME MEASUREMENTS

Physical properties, migration, and adverse events.

RESULTS

The novel stent showed better flexibility, as in a physical test of longitudinal compressibility and axial force, than did conventional stents, and it withstood the fatigue test for 10 days. In terms of radial force and tensile strength, the novel stent showed the same or better results than conventional stents. In a canine colon obstruction model, the migration rate of a novel stent was significantly lower than that of a conventional stent (2/13, 15.4% vs 8/13, 61.5%; P=.008).

LIMITATIONS

Animal study of limited size.

CONCLUSION

The novel, ring-connected stent is more flexible and more resistant to migration than the conventional stents.

A Novel Foam Contrast Agent Suitable for Fluoroscopic Interventional Procedure: Comparative Study of Physical Properties and Experimental Intervention in Animal Model

In fluoroscopic contrast study for interventional procedure, liquid contrast agent may be diluted in body fluid, losing its contrast effect. We developed a novel contrast agent of “foam state” to maintain contrast effect for enough time and performed a comparative study of physical properties and its usefulness in experimental intervention in animal model. The mean size of microbubble of foam contrast was 13.8 ± 3.6 µm. The viscosity was 201.0 ± 0.624 cP (centipoise) and the specific gravity was 0.616. The foam decayed slowly and it had 97.5 minutes of half-life. In terms of the sustainability in a slow flow environment, foam contrast washed out much more slowly than a conventional contrast. In experimental colonic stent placement, foam contrast revealed significantly better results than conventional contrast in procedure time, total amount of contrast usage, and the number of injections (p < 0.05). Our foam contrast has high viscosity and low specific gravity and maintains foam state for a sufficient time. Foam contrast with these properties was useful in experimental intervention in animal model. We anticipate that foam contrast may be applied to various kinds of interventional procedures.

Conformable covered versus uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction: a randomized prospective study

BACKGROUND

A conformable self-expandable metallic stent was developed to overcome the limitation of previous self-expandable metallic stents. The aim of this study was to evaluate outcomes after placement of conformable covered and uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction.

METHODS

A single-blind, randomized, parallel-group, prospective study were conducted in 4 medical centres between March 2009 and July 2012. 134 patients with unresectable malignant gastroduodenal obstruction were assigned to a covered double-layered (n=66) or uncovered unfixed-cell braided (n=68) stent placement group. Primary analysis was performed to compare re-intervention rates between two groups.

RESULTS

120 patients were analysed (59 in the covered group and 61 in the uncovered group). Overall rates of re-intervention were not significantly different between the two groups: 13/59 (22.0%) in the covered group vs. 13/61 (21.3%) in the uncovered group, p=0.999. Stent migration was more frequent in the covered group than in the uncovered group (p=0.003). The tumour ingrowth rate was higher in the uncovered group than in the covered group (p=0.016).

CONCLUSIONS

The rates of re-intervention did not significantly differ between the two stents. Conformable covered double-layered and uncovered unfixed-cell braided stents were associated with different patterns of stent malfunction.

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.

A novel animal model of gastrointestinal obstruction for the development of stent

BACKGROUND

The need for newer gastrointestinal (GI) stents has been continuously raised. Newly developed stents are generally tested for physical properties in vitro and directly introduced to clinical practice because there is no reliable animal model of GI obstruction. The aim of this study was to establish an animal model both that can represent obstruction of the GI tract and be used to develop new stents.

MATERIAL AND METHODS

Surgical obstruction of the descending colon by wrapping with a nonabsorbable synthetic mesh and rubber bands was made in 17 healthy mongrel dogs. Four days later, a covered self-expanding metallic stent was placed for the obstructed segment in each dog under fluoroscopic guidance. Patency and migration of the inserted stents were evaluated clinically on a daily basis and fluoroscopically on a weekly basis. After sacrifice of the dogs, the degree and extent of residual colonic obstruction were assessed fluoroscopically. The specimen of the colonic obstructed segment was examined microscopically.

RESULTS

In all 17 mongrel dogs, segmental obstruction in the descending colon was successfully created and confirmed with fluoroscopic examination using a contrast medium. The percentage of luminal narrowing ranged from 99%-100%. Stent placement was technically successful in all 17 dogs. During the follow-up period, stent migration occurred in 12 dogs and indwelling time of a stent ranged from 0-95 d (mean 29.2 ± 38.8 d). On postmortem pathologic examination, it was found that fibrosis had newly formed outside the colonic longitudinal muscle layer in all dogs.

CONCLUSIONS

Our canine colonic obstruction model is the first animal model that can be feasible for developing a new design of stent and provide in vivo data on complications, particularly stent migration.

Clinical outcomes following secondary self-expandable metal stent (SEMS) insertion due to previous stent migration in malignant colorectal obstruction

BACKGROUND

There has been no research on the clinical outcomes of secondary self-expandable metal stent (SEMS) placement after initial stent migration. Therefore, this study aimed to assess the clinical outcomes of secondary SEMS placement after initial stent migration compared to the outcomes of secondary SEMS placement done for reasons other than migration and identify factors predictive of long-term outcomes.

METHODS

Between January 2005 and February 2011, a total of 422 patients underwent SEMS insertion for malignant colorectal obstruction at Severance Hospital. Of these, there were 98 cases of secondary SEMS placement, 38 of which were due to previous stent migration. We compared the clinical outcomes of secondary SEMS between stent migration and nonmigration groups. We also sought to identify risk factors for long-term outcomes of secondary SEMS after initial stent migration.

RESULTS

The baseline clinical characteristics were similar between the two groups. The technical and clinical success rates of secondary SEMS insertion in the migration and nonmigration groups were 94.7% and 83.3% (p = 0.09) and 73.7% and 53.3% (p = 0.122), respectively. In the migration group, sustained clinical success after secondary SEMS was associated with the absence of complications after insertion of the first stent (p < 0.001) and a longer time interval (more than 100 days) between the first and second stent insertion (p = 0.011).

CONCLUSIONS

Our data showed that secondary colorectal SEMS after stent migration is safe and effective. Moreover, the sustained clinical success of the secondary stent following migration was dependent on the outcomes of the first stent.

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.

Insertion of self expandable metal stent for malignant stomal obstruction in a patient with advanced colon cancer

Self expandable metal stent can be used both as palliative treatment for malignant colorectal obstruction and as a bridge to surgery in patients with potentially resectable colorectal cancer. Here, we report a case of successful relief of malignant stomal obstruction using a metal stent. A 56-year-old man underwent loop ileostomy and was given palliative chemotherapy for ascending colon cancer with peritoneal carcinomatosis. Eight months after the surgery, he complained of abdominal pain and decreased fecal output. Computed tomography and endoscopy revealed malignant stomal obstruction. Due to his poor clinical condition, we inserted the stent at the stomal orifice, instead of additional surgery, and his obstructive symptoms were successfully relieved. Stent insertion is thought to be a good alternative treatment for malignant stomal obstruction, instead of surgery.

Phase II clinical study on stent therapy for unresectable malignant colorectal obstruction (JIVROSG-0206)

PURPOSE

A phase II study of stent therapy for unresectable malignant colorectal obstruction was conducted to ascertain the clinical efficacy, safety, and procedural feasibility.

METHODS

Inclusion criteria comprised unresectable obstruction of the rectum or sigmoid colon; no other apparent stenosis; performance status by Eastern Cooperative Oncology Group ≤3; and maintained major organ function. The treatment protocol was to place an uncovered metal stent through the anus in an obstructive portion under x-ray fluoroscopic guidance. The patients were followed for 4 weeks after therapy, and the degree of improvement in subjective symptoms lasting ≥2 weeks was assessed as effective when the patient was decompressed with stent, or ineffective when not decompressed. Rate of clinical efficacy was defined as the proportion of effective cases.

RESULTS

The participants of the study comprised 33 patients (13 men and 20 women; mean age, 60 y). Rate of procedure completion was 97.0% (32/33). Treatment was effective in 27 patients, ineffective in 4, and unassessable in 1, yielding a clinical efficacy rate of 81.8% (27/33). Death owing to underlying disease (n=3), stent removal owing to anal pain (n=1), and occlusion at another location (n=1) were noted. No recurrences were seen among clinically effective cases. Adverse reactions included grades 2 to 3 diarrhea (n=12), pain (n=5), bleeding (n=1), and dysuria (n=1), but no grade 4 adverse reactions or treatment-related deaths were identified.

CONCLUSIONS

Stent therapy for unresectable malignant colorectal obstruction is effective, safe, and feasible.

Dual-design expandable colorectal stent for a malignant colorectal obstruction: preliminary prospective study using new 20-mm diameter stents

Objective

To evaluate the safety and effectiveness of a 20-mm diameter dual-design expandable colorectal stent for malignant colorectal obstruction.

Materials and Methods

The study series included 34 patients with malignant colorectal obstruction who underwent implantation of a 20-mm dual-design expandable colorectal stent in our department between March 2009 and June 2010. The 20-mm dual-design expandable colorectal stent was placed by using a 3.8-mm delivery system that had 28-mm diameter proximal and distal ends. Among the 34 patients, stent placement for palliation was performed in 20 patients, while stent placement for bridge to surgery was performed in 14 patients.

Results

A 97% (33 of 34) success rate was achieved for the stent placement. The perforation rate in the bridge to surgery group was 7% (1 of 14), compared to 0% (0 of 19) in palliative group. Migration occurred in one of 33 patients (3%) at 30 days after stent placement.

Conclusion

The placement of a 20-mm diameter dual-design stent appears to be clinically safe and effective for the management of colorectal obstruction, with low perforation and migration rates.

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.

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.

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.

Self-expanding metallic stents for acute left-sided large-bowel obstruction: a review of 130 patients

AIM

The aim of this study was to evaluate the outcomes of self-expanding metallic stent (SEMS) placement in acute left-sided large-bowel obstruction.

METHOD

From 1997 to 2008, 130 patients [mean 67 (SD 14.7)] underwent SEMS insertion for acute left-sided large-bowel obstruction. One-hundred and one procedures were palliative, and 29 patients underwent stent insertion as a bridge for surgery. The success rate and the outcome were analysed.

RESULTS

The chief causes of obstruction were primary (67%) and recurrent (16%) colorectal carcinoma. The success rate was 88% after insertion of the first stent. In nine patients, insertion of a second stent was required. Complications occurred in 20% of the insertions, with migration (10.8%) being the most common. Perforation occurred in two patients and one developed a colovesical fistula. In patients with palliative stenting, 14 (13.9%) required subsequent surgery, with a stoma placed in all except three. Among the 29 patients who underwent SEMS insertion as a bridge to surgery, subsequent surgical resection was performed in 26 patients at a mean interval of 12 days (SD 18.0). Primary anastomosis was performed in 24 patients. The mean survival for those who underwent SEMS insertion as a bridge to surgery was 40 (95% confidence interval: 24-55) months.

CONCLUSION

SEMS placement is safe and effective in relieving acute left-sided colonic obstruction. It allows subsequent definitive surgery on an elective setting and also serves as good palliation for advanced or disseminated disease.

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.

Gastrointestinal stent update

The use of self-expanding metallic stents in the upper gastrointestinal tract, placed under radiologic imaging or endoscopic guidance, is the current treatment of choice for the palliation of malignant gastrointestinal outlet obstructions. Advances in metallic stent design and delivery systems have progressed to the stage where this treatment is now considered a minimally invasive therapy. Metallic stent placement will broaden further into the field of nonsurgical therapy for the gastrointestinal tract. To date, metallic stents placed in the esophagus, gastric outlet, colorectum, and bile ducts are not intended to be curative, but rather to provide a palliative treatment for obstructions. The evolution of metallic stent technology will render such procedures not only palliative but also therapeutic, by enabling local drug delivery, and the use of biodegradable materials will reduce procedure-related complications.

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.

Dual-design expandable colorectal stent for malignant colorectal obstruction: comparison of flared ends and bent ends

OBJECTIVE

The purpose of this study was to compare, focusing on colonic perforation and stent migration, the clinical safety and efficacy of dual-design expandable colorectal stents with flared ends with those of stents with bent ends in the treatment of patients with malignant colorectal obstruction.

SUBJECTS AND METHODS

A total of 122 patients with malignant colorectal obstruction underwent implantation of dual-design stents with flared (n = 69) or bent (n = 53) ends.

RESULTS

Stent placement was technically successful in 116 of 122 patients (95.1%), 65 of 69 patients (94.2%) with flared-end stents and 51 of 53 patients (96.2%) with bent-end stents (p > 0.05). Clinical success was achieved within 2 days in 61 of 65 patients (93.8%) with bent-end stents and in 46 of 51 patients (90.2%) with flared-end stents (p > 0.05). Complications included seven cases of colonic perforation (6%), seven cases of stent migration (6%), three cases of tumor overgrowth (2.6%), four cases of severe rectal pain (3.4%), and four cases of bleeding (3.4%). There were no significant differences between the rates of colonic perforation and stent migration in the two groups (6.2% vs 5.9%), and the overall complication rates were similar (p > 0.05).

CONCLUSION

Dual-design expandable colorectal stents with flared ends and those with bent ends are equally safe and effective, having similar perforation and migration rates.

Factors associated with the long-term outcome of a self-expandable colon stent used for palliation of malignant colorectal obstruction

BACKGROUND

The placement of self-expanding metal stents (SEMS) is a safe and effective definitive procedure for the palliation of malignant colorectal obstruction. In this study, the clinical outcomes, including the technical and clinical success rates, and the risk factors associated with the long-term outcomes of palliative SEMS were evaluated.

METHODS

From February 2002 to April 2008, 39 patients (18 men and 21 women) with malignant colorectal obstruction underwent placement of uncovered or covered stents under fluoroscopic or endoscopic guidance. The mean age of the patients was 64.5 +/- 14.6 years (range, 37-96 years).

RESULTS

The technical success rate was 100% (39/39), and the clinical success rate was 87.2% (34/39). Five cases had failed relief of the obstruction due to the development of migration in two patients, two malfunctions, and one perforation. Four patients experienced late complications: migration managed with a palliative colostomy in two patients, tumor ingrowth managed successfully with a second stent in one patient, perforation with an intraabdominal abscess at the upper margin of the stent 4 months after stenting in one patient. The location of the obstruction and the length of the stent were significant factors associated with a good outcome. Shorter stents (<10 cm) had better outcomes than longer stents (>or=10 cm; p = 0.008), and patients with a distal colorectal obstruction had better outcomes than those with a proximal colorectal obstruction (p = 0.015).

CONCLUSION

Patients with bowel obstruction involving a short segment and those with a distal obstruction had better stent outcomes.

Combination endo-radiological colorectal stenting: a prospective 5-year clinical evaluation

OBJECTIVE

Self-expanding metallic stents have found increasing use in the palliation of malignant large-bowel obstruction or as a 'bridge to surgery' to facilitate a planned operative procedure. We describe a 5-year experience of using the combined endoscopic/fluoroscopic through-the-scope method of stent placement in a tertiary referral centre.

METHOD

A prospective database of patients referred for colorectal stenting was compiled. Technical success, clinical success (decompression) and procedure-related complications were measured as end-points.

RESULTS

Sixty-three patients underwent 71 stenting procedures; 39 (62%) patients were male and the median age of patients was 78 years; 32 patients had metastatic disease and seven strictures were due to extrinsic compression. The indication for stenting was palliation in 56 patients and preoperative in seven patients. There was a technical success rate of 91% and a clinical success rate of 89%. Complications occurred in 24% of the cohort: overgrowth, (8%), migration (6%), fistulation (4%), stent fracture (3%), tenesmus (3%) and faecal urgency (1%). There was no procedure-related death within the cohort and no technical failures proximal to the descending colon.

CONCLUSION

Combination endoscopic/fluoroscopic colorectal stenting is effective and safe. It may be particularly useful in the stenting of more proximal colonic strictures.

Endoscopic stenting-Where are we now and where can we go?

Self expanding metal stents (SEMS) play an important role in the management of malignant obstructing lesions in the gastrointestinal tract. Traditionally, they have been used for palliation in malignant gastric outlet and colonic obstruction and esophageal malignancy. The development of the polyflex stent, which is a removable self expanding plastic stent, allows temporary stent insertion for benign esophageal disease and possibly for patients undergoing neoadjuvant chemotherapy prior to esophagectomy. Potential complications of SEMS insertion include perforation, tumour overgrowth or ingrowth, and stent migration. Newer stents are being developed with the aim of increasing technical and clinical success rates, while reducing complication rates. Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease. It is hoped that, in the future, newer stents will improve our management of these difficult conditions and, possibly, provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.

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.

Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction

BACKGROUND

Emergency surgery for malignant colon obstruction entails relatively high morbidity and mortality rates and typically necessitates a 2-step resection. These problems might be potentially mitigated by placement of a self-expanding metal stent (SEMS) as a bridge to surgery. A nitinol colorectal SEMS may offer several advantages, but available evidence on the utility of this SEMS type remains highly limited.

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety as a bridge to surgery of a nitinol SEMS designed for colorectal use.

DESIGN

Prospective and retrospective multicenter clinical study.

SETTING

Sixteen European study centers.

PATIENTS

Thirty-six patients with malignant colonic obstruction.

INTERVENTIONS

Nitinol colorectal SEMS placement.

MAIN OUTCOME MEASURES

Technical success in accurate SEMS placement with coverage of the entire stricture length, clinical success in alleviating colonic obstructive symptoms, and bridging to elective surgery.

RESULTS

Technical success was achieved in 97% of patients with a 95% CI of 85% to 100% and clinical success in 81% (95% CI, 64%-92%). Elective surgery was performed in 94% (95% CI, 81%-99%) of patients at a median of 11 days (95% CI, 7-15 days) after SEMS placement. SEMS-related perforation occurred in 3 patients.

LIMITATIONS

No control group was included in this nonrandomized cohort study.

CONCLUSIONS

In this first comparatively large clinical study of a nitinol colorectal SEMS as a bridge to surgery, a high proportion of patients successfully proceeded to elective surgery after prior decompression by SEMS placement.

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.

Colorectal stenting: an effective therapy for preoperative and palliative treatment

PURPOSE

To demonstrate the effectiveness of preoperative and palliative colorectal stent placement in acute colonic obstruction.

METHODS

Sixty-seven consecutive patients (mean age 67.3 years, range 25-93 years) with clinical and radiological signs of colonic obstruction were treated: 45 (67%) preoperatively and 22 (33%) with a palliative intent. In 59 patients (88%) the obstruction was malignant, while in 8 (12%) it was benign. A total of 73 enteric Wallstents were implanted under combined fluoroscopic/endoscopic guidance.

RESULTS

Forty-five patients were treated preoperatively with a technical success rate of 84%, a clinical success rate of 83%, and a complication rate of 16%. Of the 38 patients who were successfully stented preoperatively, 36 (95%) underwent surgery 2-22 days (mean 7.2 days) after stent insertion. The improved general condition and adequate bowel cleansing allowed single-stage tumor resection and primary end-to-end anastomosis without complications in 31 cases (86% of all operations), while only 5 patients had colostomies. Stent placement was used as the final palliative treatment in 22 patients. The technical success rate was 95%, the clinical success rate 72%, and the complication rate relatively high at 67%, caused by reocclusion in most cases. After noninvasive secondary interventions (e.g., tube placement, second stenting, balloon dilatation) the secondary patency of stents was 71% and mean reported survival time after stent insertion was 92 days (range 10-285 days).

CONCLUSION

Preoperative stent placement in acute colonic obstruction is minimally invasive and allows an elective one-stage surgery in most cases. Stent placement also proved a valuable alternative to avoid colostomy in palliation.

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.

Acute colonic obstruction: endoscopic stenting and laparoscopic resection

INTRODUCTION

Acute colonic obstruction is a frequent emergency condition in a general surgical setting. The use of an endoscopic self-expanding stent can relieve obstruction and eventually prepare the patient for elective laparoscopic or open surgery.

MATERIALS AND METHODS

From September 2001 to March 2006 we treated 25 patients with acute left or transverse colonic obstruction. In 23 patients stents were positioned planning an elective procedure to be performed. In two patients with multiple liver metastases and malignant ascites only a palliation was intended (2 of 25 patients).

RESULTS

Mean age was 66.6 years. The 23 patients who underwent resection, 14 females and nine males, had a mean age of 65.5 years. Obstructions were located in the rectum (five), in the sigmoid (16) and in the transverse colon (two). In one patient stricture was due to radiotherapy, in twenty four cases it was due to primary cancer. Stents were successfully placed in 24 patients. In one of them two stents had to be placed due to the slippage of the first one beyond the stricture. Excellent resumption of colonic transit was achieved in all the patients. No complications were observed. In 23 patients resection was performed (19 laparoscopy; four open). Complications occurred in one patient in open group (pancreatic fistula after splenectomy) and was treated conservatively. Mean postoperative stay was 18.5 (range 9-35) days for the open group and 12 (range 9-20) for the laparoscopic group. Mean follow-up was 36 months.

CONCLUSIONS

Use of self expanding endoscopic colonic stents can provide excellent palliation in acute obstruction, aiming both to prepare the colon to elective surgery after adequate preparation or to palliate the stricture in case of unresectable advanced tumors.

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.

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.

Surgical Treatment of Colon Cancer

Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.

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.

Metallic stents in large bowel obstruction: experience in a District General Hospital

INTRODUCTION

Metallic stents are used increasingly in the palliation of malignant large bowel obstruction. Stenting has also been used in the setting of acute obstruction, allowing appropriate patient preparation for an elective colectomy.

METHODS

Uncovered metallic stents were inserted using a combined endoscopic/radiological technique in patients presenting with large bowel obstruction.

RESULTS

Seventeen patients (10 female, mean age 75.2 years) presented with large bowel obstruction, 14 due to malignancy and 3 secondary to diverticular stricture. Technical success was achieved in 13/17 with clinical success in 12 of these 13. There were no perforations or procedure related deaths. One stented patient had elective surgery. The five patients with clinical/technical failure required emergency surgery.

CONCLUSION

The result of our preliminary experience in the use of metallic stents is encouraging. Metallic stents should be available in all hospitals as part of a multimodality approach in treating large bowel obstruction.

Management of colorectal cancers

The management of colorectal cancers, published in a recent issue of Effective Health Care, is reviewed.

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.