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Self-Expanding Metal Stents Do Not Adversely Affect Long-term Outcomes in Acute Malignant Large-Bowel Obstruction: A Retrospective Analysis. Dis Colon Rectum 2022; 65:228-237. [PMID: 34990424 DOI: 10.1097/dcr.0000000000002084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Self-expanding metal stents as a bridge to surgery in acute malignant large-bowel obstruction has gained popularity. However, long-term oncologic outcomes have not been well established. OBJECTIVE To investigate long-term oncologic outcomes of patients undergoing curative resection after the placement of a colonic stent compared with emergency surgery for acute malignant large-bowel obstruction. DESIGN This is a retrospective study. SETTING All patients presenting at 3 tertiary care centers between April 2002 and December 2012 with a diagnosis of complete malignant large-bowel obstruction were reviewed. Patients with disease distal to the hepatic flexure were selected for analysis. PATIENTS One hundred twenty-two patients who underwent either emergency surgery or placement of a colonic stent with curative intent were included. INTERVENTIONS Patients receiving emergency surgery within 24 hours of presenting with obstructive symptoms, including those with failed stents, were included in the emergency surgery group. All patients with clinically successful stent deployment before surgery were included in the stent group. MAIN OUTCOME MEASURES Overall survival and disease-free survival were calculated using the Kaplan-Meier method. RESULTS Sixty-four patients underwent emergency surgery, and 58 patients underwent placement of a self-expanding metal stent. Groups were similar in terms of sex, tumor stage and grade, and Charlson and Charlson-Age Comorbidity Index scores. Patients in the surgery group were older than patients in the stent group. There were no differences in the number of lymph nodes harvested, positive nodes, rates of vascular and perineural invasion, or utilization of chemotherapy. Thirty-day mortality after resection was similar between groups (7.41% vs 4.41%; p > 0.05). Patients who underwent colonic stenting as a bridge to surgery had similar 10-year overall survival (40.5% vs 32.7%; p = 0.13) and 10-year disease-free survival (40.2% vs 33.8%; p = 0.26) compared with those who underwent emergency surgery. Similar results were seen on intention-to-treat analysis. LIMITATIONS This was a small retrospective study. CONCLUSIONS Stent insertion followed by oncologic resection is associated with similar overall survival and disease-free survival compared with emergency resection. Stent insertion as a bridge to surgery should be considered in patients presenting with malignant colorectal obstruction. See Video Abstract at http://links.lww.com/DCR/B714Los Stents Metálicos Autoexpandibles No Afectan Negativamente Los Resultados A Largo Plazo En La Obstrucción Maligna Aguda Del Colon: Un Análisis Retrospectivo. ANTECEDENTES Los stents metálicos autoexpandibles como puente a una cirugía en la obstrucción maligna aguda del colon han ganado popularidad. Sin embargo, no se han establecido bien los resultados oncológicos a largo plazo. OBJETIVO Investigar los resultados oncológicos a largo plazo de los pacientes sometidos a resección curativa después de la colocación de un stent colónico en comparación con la cirugía de urgencia para la obstrucción maligna aguda del colon. DISEO Estudio retrospectivo. MBITO Entre abril de 2002 y diciembre de 2012, se revisaron todos los pacientes que acudieron a tres centros de tercer nivel con un diagnóstico de obstrucción maligna completa del colon. Se seleccionaron para el análisis los pacientes con enfermedad distal al ángulo hepático. PACIENTES Se incluyeron 122 pacientes que fueron operados de urgencia o a una colocación de un stent colónico con intención curativa. PROCEDIMIENTOS Los pacientes que se sometieron a cirugía de urgencia dentro de las 24 horas posteriores a la presentación de síntomas obstructivos; se incluyeron aquellos con stents fallidos en el grupo de cirugía de urgencia. Todos los pacientes con colocación clínicamente exitosa del stent antes de la cirugía se incluyeron en el grupo de stent. PRINCIPALES VARIABLES ANALIZADAS La sobrevida global y la sobrevida libre de enfermedad se calcularon mediante el método de Kaplan-Meier. RESULTADOS Sesenta y cuatro pacientes fueron llevados a cirugía urgente y en 58 pacientes se colocó de un stent metálico autoexpandible. Los grupos fueron similares en relación a sexo, estadio y grado del tumor, puntuación de comorbilidad de Charlson y Charlson-Age. Los pacientes del grupo de cirugía eran mayores que los del grupo de stents. No hubo diferencias en el número de ganglios linfáticos recolectados, ganglios positivos, tasas de invasión vascular y perineural o utilización de quimioterapia. La mortalidad a los 30 días después de la resección fue similar entre los grupos (7,41% frente a 4,41%; p> 0,05). Los pacientes que se sometieron a la colocación de un stent colónico como puente a la cirugía tuvieron una sobrevida general a diez años similar (40,5% vs 32,7%; p = 0,13) y una sobrevida libre de enfermedad a diez años (40,2% vs 33,8%, respectivamente; p = 0,26) en comparación a los operados de urgencia. Se observaron resultados similares en el análisis por intención de tratamiento. LIMITACIONES Estudio retrospectivo reducido. CONCLUSIONES La utilización de un stent y posteriormente la resección oncológica se asocia a una sobrevida general y una sobrevida libre de enfermedad similar en comparación con la resección de urgencia. La utilización de un stent como puente a la cirugía debe considerarse en pacientes que presentan obstrucción colorrectal maligna. Consulte Video Resumen en http://links.lww.com/DCR/B714. (Traducción-Dr. Lisbeth Alarcon-Bernes).
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Khayyat YM. Therapeutic utility of percutaneous cecostomy in adults: an updated systematic review. Ther Adv Gastrointest Endosc 2022; 15:26317745211073411. [PMID: 35141521 PMCID: PMC8819810 DOI: 10.1177/26317745211073411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/24/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Yasir Mohammed Khayyat
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Al-Awali District, 24381 - 8156, Saudi Arabia
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Lam J, Chauhan V, Lam I, Kannappa L, Salama Y. Colorectal stenting in England: a cross-sectional study of practice. Ann R Coll Surg Engl 2020; 102:451-456. [PMID: 32347738 DOI: 10.1308/rcsann.2020.0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England. METHODS All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty). RESULTS Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure. CONCLUSIONS All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.
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Affiliation(s)
- J Lam
- Kettering General Hospital NHS Foundation Trust, UK
| | - V Chauhan
- Kettering General Hospital NHS Foundation Trust, UK
| | - I Lam
- University of Nottingham, UK
| | - L Kannappa
- Kettering General Hospital NHS Foundation Trust, UK
| | - Y Salama
- Kettering General Hospital NHS Foundation Trust, UK
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Wallace B, Schuepbach F, Gaukel S, Marwan AI, Staerkle RF, Vuille-dit-Bille RN. Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Gastroenterol Res Pract 2020; 2020:9057963. [PMID: 32411206 PMCID: PMC7199605 DOI: 10.1155/2020/9057963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 02/08/2023] Open
Abstract
Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.
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Affiliation(s)
- Bradley Wallace
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | | | - Stefan Gaukel
- Department of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Switzerland
| | - Ahmed I. Marwan
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | - Ralph F. Staerkle
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Switzerland
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Bagdasarov VV, Bagdasarova EA, Pavlov PV, Karchevskiy EV. [Transtumoral decompression in acute left-sided colonic obstruction]. Khirurgiia (Mosk) 2018:22-29. [PMID: 29953096 DOI: 10.17116/hirurgia2018622-29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To prove an effectiveness of transtumoral decompression in patients with acute malignant left-sided colonic obstruction. MATERIAL AND METHODS 154 patients with acute left-side colonic obstruction were enrolled. Patients were divided into 4 groups. In groups 1-3 (n=120) patients underwent surgery at the moment of colonic obstruction, in 34 patients obstruction was managed with transtumoral decompression followed by radical surgery. Self-expanding metallic stents (SEMS) were used in these patients. Radical and palliative procedures at the moment of colonic obstruction are associated with high rate of postoperative complications and mortality. RESULTS Transtumoral decompression in malignant colonic obstruction resolves the main objectives of complicated colonic cancer management: absence of surgical trauma, endotracheal narcosis, reduced risk of abdominal infection, possible multidisciplinary assessment of patient's status and preparation for radical surgery.
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Affiliation(s)
- V V Bagdasarov
- Sechenov First Moscow State Medical University Moscow, Russia
| | - E A Bagdasarova
- Sechenov First Moscow State Medical University Moscow, Russia
| | - P V Pavlov
- Hertzen Moscow Oncology Research Institute, Russia
| | - E V Karchevskiy
- Sechenov First Moscow State Medical University Moscow, Russia
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Abelson JS, Yeo HL, Mao J, Milsom JW, Sedrakyan A. Long-term Postprocedural Outcomes of Palliative Emergency Stenting vs Stoma in Malignant Large-Bowel Obstruction. JAMA Surg 2017; 152:429-435. [PMID: 28097296 DOI: 10.1001/jamasurg.2016.5043] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Colonic stenting was introduced for palliation of malignant large-bowel obstruction (MLBO) more than 20 years ago but remains controversial. Objective To compare outcomes after palliative stenting vs stoma creation in patients with MLBO requiring emergency management. Design, Setting, and Participants This observational cohort study assessed 345 patients from New York State with an urgent or emergency admission to the hospital for obstruction secondary to colorectal cancer and who underwent stenting or stoma creation from October 1, 2009, through December 31, 2013. Patients were excluded if they underwent resection within 1 year of the index admission. Exposures Palliative stenting vs stoma creation. Main Outcomes and Measures Primary outcomes included subsequent operation and readmission within 90-day and 1-year follow-up. Secondary outcomes were in-hospital death, major medical and surgical complications, length of stay, total charges, and discharge dispositions. Multivariable hierarchical analyses and propensity score matching were used to compare outcomes between the exposure groups. Results The cohort included 345 patients (mean [SD] age, 69.9 [14.4] years in the stoma group and 70.9 [16.8] years in the stent group; 87 men [50.3%] in the stoma group and 90 [52.3%] in the stent group; and 114 non-Hispanic white patients [65.9%] in the stoma group and 90 [52.3%] in the stent group). Most patients undergoing stenting were treated at high-volume (104 [60.5%]) vs medium-volume (42 [24.4%]) or low-volume (26 [15.1%]) hospitals (P < .001). Patients undergoing stenting were significantly less likely to experience prolonged length of stay (odds ratio [OR], 0.50; 95% CI, 0.26-0.97; P = .04), more likely to be discharged to their usual residence (OR, 0.14; 95% CI, 0.07-0.28; P < .001), and tended to have similar or fewer complications (major events: OR, 0.81; 95% CI, 0.30-2.18; P = .68; procedural complications: OR, 0.57; 95% CI, 0.11-1.22; P = .10). There was no significant difference between the groups in terms of 90-day and 1-year readmission to the hospitals (90 days: OR, 0.93; 95% CI, 0.49-1.78; P = .83; 1 year: OR, 0.72; 95% CI, 0.38-1.37; P = .30). Subsequent operation at 90 days was also not different between the groups (OR, 1.34; 95% CI, 0.26-6.89; P = .72), but there was a higher chance of subsequent operation at 1 year after the stenting procedure (OR, 2.93; 95% CI, 1.12-7.68; P = .03), with most subsequent operations being restenting. Conclusions and Relevance In patients with MLBO and if resection is not part of the treatment plan, stenting is safe and improves the efficiency of care with obvious quality-of-life benefits. It should be offered at experienced centers, and patients should be counseled regarding increased risk of subsequent stenting within 1 year.
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Affiliation(s)
- Jonathan S Abelson
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York
| | - Heather L Yeo
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York2Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York
| | - Jialin Mao
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York
| | - Jeffrey W Milsom
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York
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Predictors of outcome for endoscopic colorectal stenting: a decade experience. Int J Colorectal Dis 2017; 32:375-382. [PMID: 27817034 DOI: 10.1007/s00384-016-2696-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various factors on the short- and long-term results of colorectal stenting. METHODS A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome. RESULTS Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90 %) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22 % of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio [AOR] 0.2 [95 % confidence interval (CI) 0.1-0.8]; p = 0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 [95 % CI 1.4-10.3]; p = 0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 [95 % CI 1.0-10.0]; p = 0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 [95 % CI 1.5-11.7]; p = 0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 [95 % CI 2.6-71.2]; p = 0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 [95 % CI 1.3-16.2]; p = 0.017). CONCLUSIONS Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.
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Safety and efficacy of palliative colorectal stent placement using a nasal endoscope technique. Surg Laparosc Endosc Percutan Tech 2016; 25:262-5. [PMID: 26018052 PMCID: PMC4454541 DOI: 10.1097/sle.0000000000000159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to evaluate the safety and efficacy of palliative self-expanding metallic stent (SEMS) placement using a nasal endoscope technique in the context of colorectal malignant obstruction. Eighteen patients with malignant colorectal obstruction who underwent palliative SEMS insertion using a nasal endoscope technique at the Toyonaka Municipal Hospital from August 2005 to August 2011 were enrolled and retrospectively analyzed. In all cases, a guidewire could be inserted on the oral side of the tumor. The placement success rate was 94.4% (17/18), and the complication rate was 23.5% (4 cases). The stent migrated in 3 cases, and perforation occurred in 1 case following bevacizumab chemotherapy. These outcomes indicate that stenting is useful for terminal patients and that nasal endoscopy is useful in cases of difficult guidewire placement.
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Takahashi H, Okabayashi K, Tsuruta M, Hasegawa H, Yahagi M, Kitagawa Y. Self-Expanding Metallic Stents Versus Surgical Intervention as Palliative Therapy for Obstructive Colorectal Cancer: A Meta-analysis. World J Surg 2016; 39:2037-44. [PMID: 25894403 DOI: 10.1007/s00268-015-3068-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although self-expanding metallic stents (SEMS) are useful tools for relieving large bowel obstructions in patients with colorectal cancer (CRC), their efficacy in a palliative setting has not been validated. This meta-analysis aimed to evaluate the feasibility of SEMS as a palliation for unresectable CRC patients with bowel obstructions and to determine their contribution to the prognosis of CRC, compared with surgical intervention. METHODS We conducted a literature search of the PubMed and Cochrane Library databases. We selected all controlled trials that compared SEMS with surgical interventions as palliative treatments in unresectable obstructive CRC patients. The primary outcome was early complications, and the secondary outcomes were mortality, other morbidities, and long-term survival rates. RESULTS Ten studies met our inclusion criteria. SEMS significantly reduced the risk of early complications (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.20-0.58%; P<0.01), mortality (OR 0.31; 95% CI 0.15%-0.64%; P<0.01), and stoma creation (OR 0.19; 95% CI 0.12-0.28%; P<0.01). Although SEMS placement was significantly associated with a higher risk of perforation of the large bowel (OR 5.25 95% CI 2.00-13.78%; P<0.01) and late complications (OR 1.94; 95% CI 0.90-4.19%; P=0.03), it also contributed significantly to better long-term survival (hazard ratio 0.46; 95% CI 0.31-0.68%; P<0.01). CONCLUSIONS Compared with surgical intervention, SEMS could provide feasible palliation for patients with bowel obstructions and unresectable CRC, because of their acceptable morbidity rates and better patient prognoses.
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Affiliation(s)
- Hidena Takahashi
- Department of Surgery, Keio University School of Medicine, 35 Shinanotmachi, Shinjuku-ku, Tokyo, Japan,
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“The Role of Primary Tumor Resection (PTR) in Metastatic Colorectal Cancer”. CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0281-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hong SP, Kim TI. Colorectal stenting: An advanced approach to malignant colorectal obstruction. World J Gastroenterol 2014; 20:16020-16028. [PMID: 25473154 PMCID: PMC4239488 DOI: 10.3748/wjg.v20.i43.16020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 06/12/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
Some colorectal cancer (CRC) patients present symptoms of bowel obstruction, which is considered a surgical emergency. Because of poor medical condition and high incidence of post-surgical complications, there has been increasing use of self-expanding metal stents (SEMS) for the purpose of palliation or as a bridge to surgery with some benefits, including shorter hospital stays, lower rates of adverse events, and one-stage surgery. However, with increasing survival of CRC patients, there have been controversial data on clinical outcomes and complications, compared between SEMS use and surgery for treatment of malignant bowel obstruction. We review recent clinical data on clinical outcomes of SEMS use compared to surgery, including complications.
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Köhler G, Antoniou SA, Lechner M, Mayer F, Mair J, Emmanuel K. Stenting for Emergency Colorectal Obstruction: An Analysis of 204 Patients in Relation to Predictors of Failure and Complications. Scand J Surg 2014; 104:146-53. [DOI: 10.1177/1457496914552342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 07/03/2014] [Indexed: 12/19/2022]
Abstract
Background and Aims: Self-expanding metallic stents are increasingly used in the management of malignant and benign colorectal obstructions. We aimed to identify relevant predictive factors for stent failure and stent-related complications. Material and Methods: We conducted a retrospective single-center analysis of 204 consecutive patients who underwent emergency colorectal stenting procedures because of symptomatic bowel obstructions from 1996 to 2011 at the Sisters of Charity Hospital Linz, Austria. Results: A total of 204 patients (median age 74 years) with 36 (17.7%) benign and 168 (82.3%) malignant obstructions were included in the study. Technical success was achieved in 92.5% and clinical success in 86.8% of the cases. Major complications occurred in 2.9% and minor ones in 19.6%. Overall mortality during a median follow-up period of 4.3 years was 73% (149 patients). Relevant predictors of increased risk of complications were extracolonic obstruction (p = 0.001), complete obstruction (p = 0.066), and inflammatory bowel disease (p = 0.05). Stent localization at the splenic flexure, a stenosis of >8 cm in length, and the need for endoscopic guidance were associated with higher rates of technical and/or clinical stenting failure. Conclusion: Colorectal stenting is less invasive than other means of emergency treatment for large bowel obstruction; it is generally safe and effective in different types of colorectal obstruction. However, relevant rates of failure and complications were recorded and predictors could be determined.
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Affiliation(s)
- G. Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Linz, Austria
- Academic Teaching Hospital of the Universities Graz and Innsbruck, Linz, Austria
| | - S. A. Antoniou
- Center for Minimally Invasive Surgery, Hospital Neuwerk, Moenchengladbach, Germany
| | - M. Lechner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - F. Mayer
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - J. Mair
- Department of Diagnostic and Interventional Radiology, Sisters of Charity Hospital, Linz, Austria
| | - K. Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Linz, Austria
- Academic Teaching Hospital of the Universities Graz and Innsbruck, Linz, Austria
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Srinivasan N, Kozarek RA. Stents for colonic strictures: Materials, designs, and more. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Lee KJ, Kim SW, Kim TI, Lee JH, Lee BI, Keum B, Cheung DY, Yang CH. Evidence-based recommendations on colorectal stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy. Clin Endosc 2013; 46:355-67. [PMID: 23964332 PMCID: PMC3746140 DOI: 10.5946/ce.2013.46.4.355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/13/2012] [Accepted: 10/29/2012] [Indexed: 12/11/2022] Open
Abstract
Recently, placement of self-expandable metallic stents has been used for the treatment of colorectal obstruction. As domestic awareness of colorectal cancer has increased, the number of colorectal stenting procedures performed has also increased. We aimed to provide evidence-based recommendations for colorectal stenting to aid gastroenterologists in making informed decisions regarding the management of patients who present with colorectal obstruction. The working group consisted of eight gastroenterologists who actively practice and conduct research in the field of colorectal stenting and are the members of the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy. A literature search was conducted using the PubMed, Embase, KoreaMed, and the Cochrane Library databases to identify relevant articles published between January 2001 and June 2012. Based on the modified Delphi process, 10 recommendation statements regarding indications, usefulness, methodology and complications of colorectal stenting, and alternative treatments for malignant colorectal obstruction were determined. The contents will be widely distributed, and periodically revised to reflect the latest knowledge. These evidence-based recommendations for colorectal stenting will provide gastroenterologists and patients with appropriate and balanced information, and will improve the quality of care.
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Affiliation(s)
- Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Phase II clinical study on stent therapy for unresectable malignant colorectal obstruction (JIVROSG-0206). Am J Clin Oncol 2012; 35:73-6. [PMID: 21293242 DOI: 10.1097/coc.0b013e318201a10d] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Chou SQH, Song HY, Kim JH, Park JH, Fan Y, Lee H, Yoon YS, Kim JC. Dual-design expandable colorectal stent for a malignant colorectal obstruction: preliminary prospective study using new 20-mm diameter stents. Korean J Radiol 2011; 13:66-72. [PMID: 22247638 PMCID: PMC3253405 DOI: 10.3348/kjr.2012.13.1.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 09/01/2011] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Sandas Qi Hua Chou
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
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Foo CC, Poon JTC, Law WL. Self-expanding metallic stents for acute left-sided large-bowel obstruction: a review of 130 patients. Colorectal Dis 2011; 13:549-54. [PMID: 20082633 DOI: 10.1111/j.1463-1318.2010.02216.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- C C Foo
- Division of Colorectal Surgery, Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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de Gregorio MA, Laborda A, Tejero E, Miguelena JM, Carnevale FC, de Blas I, Gimenez M, Maynar M, D'Agostino H. Ten-year retrospective study of treatment of malignant colonic obstructions with self-expandable stents. J Vasc Interv Radiol 2011; 22:870-8. [PMID: 21514839 DOI: 10.1016/j.jvir.2011.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 01/07/2011] [Accepted: 02/04/2011] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Miguel A de Gregorio
- Research Group in Minimally Invasive Techniques, University of Zaragoza, Avda Miguel Servet 177, Zaragoza 50013, Spain
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Saida Y, Enomoto T, Takabayashi K, Otsuji A, Nakamura Y, Nagao J, Kusachi S. Outcome of 141 cases of self-expandable metallic stent placements for malignant and benign colorectal strictures in a single center. Surg Endosc 2011; 25:1748-52. [PMID: 21437740 DOI: 10.1007/s00464-010-1310-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 07/26/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND The use of a self-expandable metallic stent (SEMS) has emerged as an alternative treatment option for malignant colorectal obstruction. Although the technical success rate of SEMS has been widely reported, outcome data are limited. METHODS This retrospective study evaluated the short- and long-term outcomes of colorectal SEMS for malignant and benign disease in patients who underwent SEMS at a single center. RESULTS One surgeon inserted all stents under endoscopic and fluoroscopic guidance; 141 SEMS procedures were performed in 133 patients (82 males, mean age 69 years). The SEMS procedure was undertaken for: palliation of malignant obstruction in 30 patients (36 cases), and the technical success rate was 94%; a bridge to surgery for colorectal cancers in 98 patients/cases, and the technical success rate was 91%; benign stricture in 5 patients (7 cases), and the technical success rate was 100%. Due to anatomical differences, the success rate was lower at the cecum, descending colon, and sigmoid than in the rectosigmoid and rectum. In 11 cases of technical failures, the failures were due to technical problems in 9 cases (82%) and due to the state of the stricture in 2 cases (18%). Procedure-related complications occurred in 6 patients (4%): perforation in 3 and migration in 3. All perforation cases and one migration case underwent emergency surgery. There was no mortality. In the bridge to surgery group, postoperative complications were much lower in the clinical success cases (6%) than in the failure group (36%). In the palliation treatment group, long-term SEMS migration occurred in 4 patients (14%), and re-obstruction occurred in 5 patients (18%); the mean insertion period was 201 (range: 10-576) days. CONCLUSIONS Colorectal SEMS had feasible short and long-term results and low morbidity, making it a viable option for various types of colorectal obstruction with careful attention to the indications.
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Affiliation(s)
- Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan.
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Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc 2011; 73:535-42. [PMID: 21257165 DOI: 10.1016/j.gie.2010.10.052] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 10/27/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) provide a promising alternative for initial palliation of malignant bowel obstruction. However, data on the long-term outcomes of SEMSs are limited. OBJECTIVE The aim of this study was to compare the long-term outcomes of endoscopic stenting with those of surgery for palliation in patients with incurable obstructive colorectal cancer. DESIGNS AND SETTING: A retrospective study. PATIENTS From January 2000 to December 2008, patients with incurable obstructive colorectal cancer who were treated with SEMSs (n = 71) or palliative surgery (n = 73) were reviewed. INTERVENTIONS SEMS placement by using through-the-endoscope methods or surgery. MAIN OUTCOME MEASUREMENTS Success rates and complication rates. RESULTS Early success rates in the SEMS group and those in the surgery group were not different (95.8% vs 100%, P = .12), and the SEMS group had fewer early complications than the surgery group (15.5% vs 32.9%, P = .015). Although the patency duration of the first stent in the SEMS group was shorter than that in the surgery group (P < .001), the median patency duration after a second stenting was comparable to that of the surgery group (P = .239). There were more late complications in the SEMS group than in the surgery group (P = .028), but the rates of major complications did not differ between the 2 groups (P = .074). LIMITATIONS Retrospective and single-center study. CONCLUSIONS SEMSs were not only an effective and acceptable therapy for initial palliation of malignant colorectal obstruction, but they also showed long-term efficacy comparable to that with surgery.
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Placement of stents in proximal colonic obstructions using a percutaneous retroperitoneal colostomy. Surg Laparosc Endosc Percutan Tech 2011; 19:e202-5. [PMID: 19851253 DOI: 10.1097/sle.0b013e3181badb00] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In cases of proximal colonic obstruction, the long distances and the tortuosity of the distal bowel make it difficult to advance and position the stent in the target lesion. We report 2 cases of stent placement for malignant obstruction of the proximal colon in which access was obtained through percutaneous retroperitoneal colostomy. In these cases, we initially tried to place a stent through the rectum under endoscopic guidance, but it was not possible to reach the lesion. We then decided to cross the lesion through percutaneous puncture of the retroperitoneum. The procedures were completed without complications and the patients' symptoms improved. A percutaneous retroperitoneal approach for the deployment of colonic stents has not been described earlier in the literature. We suggest that our technique provides an alternative means of colonic decompression in cases in which conventional retrograde methods fail to provide acceptable palliation in nonsurgical candidates.
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Chang IS, Park SW, Hwang DY, Seong MK, Joh HK, Yoon SY, Cho YH, Choe WH. The efficacy of the coaxial technique using a 6-Fr introducer sheath in stent placement for treating the obstructions proximal to the descending colon. Korean J Radiol 2011; 12:107-12. [PMID: 21228946 PMCID: PMC3017874 DOI: 10.3348/kjr.2011.12.1.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Accepted: 10/29/2010] [Indexed: 11/15/2022] Open
Abstract
Objective We wanted to evaluate the efficacy of stent placement using the coaxial technique with a stiff, long introducer sheath in patients with technical failure using an angiographic catheter for the obstructions proximal to the descending colon. Materials and Methods Self-expandable metallic stent placement was attempted under fluoroscopy-guidance in 77 consecutive patients who had malignant colorectal obstruction. Stent placement was performed using an angiographic catheter and a guide wire. If the angiographic catheter could not be advanced over the guide wire into the obstructive lesions proximal to the descending colon, then a 6-Fr introducer sheath was used. The technical success rate, the clinical success rate and the complications were analyzed. Results Successful stent placement was achieved in 75 of 77 patients (97%). The angiographic catheter failed to advance into the obstructive lesions of 11 patients (M:F = 7:4; mean age, 65.5 years) whose lesions were at the level of the splenic flexure or transverse colon. Therefore, the coaxial technique was implemented in all these 11 patients using a 6-Fr stiff introducer sheath and then the stent placement was successful. There were no complications related to the use of a stiff introducer sheath. Clinical success, which was defined as relief of clinical obstructive bowel symptoms, was obtained within 24 hours in all of patients. Conclusion The coaxial technique using a stiff introducer sheath can increase the technical success of fluoroscopy-guided, self-expandable metallic stent placement in patients with colonic obstruction proximal to the descending colon.
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Affiliation(s)
- Il Soo Chang
- Department of Radiology, Konkuk University Hospital, Seoul 143-729, Korea
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Rezk Y, Timmins PF, Smith HS. Review article: palliative care in gynecologic oncology. Am J Hosp Palliat Care 2010; 28:356-74. [PMID: 21187291 DOI: 10.1177/1049909110392204] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.
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Affiliation(s)
- Youssef Rezk
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Albany Medical College, Albany, NY 12208, USA
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Stenting of the Lower Gastrointestinal Tract: Current Status. Cardiovasc Intervent Radiol 2010; 34:462-73. [DOI: 10.1007/s00270-010-0005-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 09/13/2010] [Indexed: 02/07/2023]
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Datye A, Hersh J. Colonic perforation after stent placement for malignant colorectal obstruction--causes and contributing factors. MINIM INVASIV THER 2010; 20:133-40. [PMID: 20929424 DOI: 10.3109/13645706.2010.518787] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Kim SY, Kwon SH, Oh JH. Radiologic Placement of Uncovered Stents for the Treatment of Malignant Colorectal Obstruction. J Vasc Interv Radiol 2010; 21:1244-9. [DOI: 10.1016/j.jvir.2010.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 02/15/2010] [Accepted: 04/03/2010] [Indexed: 01/11/2023] Open
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Rayhanabad J, Abbas MA. Long-Term Outcome of Endoscopic Colorectal Stenting for Malignant and Benign Disease. Am Surg 2009. [DOI: 10.1177/000313480907501007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Although the technical success rate of endoscopic stenting has been defined, there is a paucity of outcome data. The purpose of this study was to evaluate the long-term results of colorectal stenting for both malignant and benign disease. A retrospective review was conducted of patients who underwent stenting at a tertiary center over 4 years. One surgeon performed all stents under endoscopic and fluoroscopic guidance. A total of 49 stent procedures were performed in 36 patients (19 females, mean age 65 years). Mean follow-up was 15 months. Twenty-eight patients (78%) underwent stenting for malignant disease and eight patients (22%) for benign conditions. The most common reason for intervention was obstruction (81%). Technical success rate was 72 per cent. Carcinomatosis was associated with a higher technical failure rate. Procedural related complications occurred in two patients (6%). Long-term stent migration rate was 24 per cent and was more common in patients with benign disease and patients who received nonmetal stents or stents with diameter < 25 mm. Endoscopic reintervention was required in 33 per cent of patients with initial technical success. Long-term need for subsequent operative intervention was 14 per cent. Endoscopic stenting is a viable option for a select group of patients with colorectal disease. Patient's selection and stent choice influence outcome.
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Affiliation(s)
- Jessica Rayhanabad
- From the Section of Colon and Rectal Surgery, Department of Surgery, Kaiser Permanente, Los Angeles, California
| | - Maher A. Abbas
- From the Section of Colon and Rectal Surgery, Department of Surgery, Kaiser Permanente, Los Angeles, California
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Park IJ, Choi GS, Kang BM, Lim KH, Lee IT, Jeon SW, Jun SH. Comparison of one-stage managements of obstructing left-sided colon and rectal cancer: stent-laparoscopic approach vs. intraoperative colonic lavage. J Gastrointest Surg 2009; 13:960-5. [PMID: 19159986 DOI: 10.1007/s11605-008-0798-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 12/11/2008] [Indexed: 02/06/2023]
Abstract
PURPOSE We evaluated the operative outcomes of laparoscopic surgery following self-expandable metallic stent compared to one-stage emergency surgical treatment. METHODS From April 1996 to October 2007, 95 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Twenty-five patients were assigned to the preoperative stenting and elective laparoscopic surgical treatment group (SLAP) and 70 to the emergency open surgery with intraoperative colon lavage group (OLAV). RESULTS Among the 25 patients in the SLAP group, a primary anastomosis was possible in all patients and a diverting stoma was needed in one patient. The operative time was shorter in the SLAP group (198.53 vs. 262.17 min, P = 0.002). Tumor size, number of retrieved lymph nodes, and pathological stage were similar in both groups. The rate of anastomotic failure was similar and postoperative complications occurred less in the SLAP group (5.9% vs. 31.4%, P = 0.034). The passage of flatus and oral intake were resumed earlier in the SLAP group (2.88 vs. 3.68 days, P = 0.046 and 5.18 vs. 6.65 days, P < 0.001, respectively). The postoperative hospital stay was shorter in the SLAP group (10 vs. 15.4 days, P = 0.013). CONCLUSIONS In patients with left-sided malignant colon and rectal obstruction, laparoscopic surgery after SEMS could be safely performed with successful early postoperative outcomes.
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Affiliation(s)
- In Ja Park
- Division of Colorectal Surgery, Department of Surgery, School of Medicine, Kyungpook National University, 50 Samduk-dong 2ga Jung-gu, Daegu, South Korea
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Geiger TM, Miedema BW, Tsereteli Z, Sporn E, Thaler K. Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data. Int J Colorectal Dis 2008; 23:1007-12. [PMID: 18594837 DOI: 10.1007/s00384-008-0518-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Permanent metal stent placement for malignant intestinal obstruction has been proven to be efficient. Temporary stents for benign conditions of the colon and rectum are less studied. This is a case study, review of the literature, and observation from an animal model on placement of stents in the colorectum for benign disease. MATERIALS AND METHODS A 55-year-old man presented with recurrent obstructions from a benign stricture of the distal sigmoid colon. After failed balloon dilations, a polyester coated stent was placed. The purpose of the stent was to improve symptoms and avoid surgery. The stent was expelled after 5 days. We conducted a literature review of stents placed for benign colorectal strictures and an animal study to evaluate stent migration. RESULTS In the literature, there were 53 reports of uncovered metal stents, four covered metal stents, and six polyester stents. Patency rates were 71%, and migration rate was 43%. Migration occurred earlier with polyester stents (mean=8 days) versus covered (32 days) or uncovered metal stents (112 days). Severe complications were seen in 23% of patients. Four 45-kg pigs underwent rectosigmoid transection with a 21-mm anastomosis and endoscopic placement of a Polyflex stent. Two stents were secured with suture. Stents without fixation were expelled within 24 h of surgery. Stents with fixation were expelled between postoperative days 2 and 14. CONCLUSION Stents for the treatment of benign colorectal strictures are safe, with comparable patency rates between stent types. Metal stents can cause severe complications. In a pig model, covered polyester stents tend to migrate early even with fixation. Further investigation needs to focus on new stent designs and/or better fixation.
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Affiliation(s)
- Timothy M Geiger
- Division of General Surgery, University of Missouri-Columbia, Columbia, MO 65212, USA
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Malignant rectal obstruction within 5 cm of the anal verge: is there a role for expandable metallic stent placement? Gastrointest Endosc 2008; 68:713-20. [PMID: 18561924 DOI: 10.1016/j.gie.2007.12.051] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Accepted: 12/17/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Placement of expandable metallic stents (EMS) has been considered contraindicated for patients with malignant rectal obstruction within 5 cm of the anal verge because of the potential problems of anal pain. OBJECTIVE Our purpose was to investigate the technical feasibility, clinical effectiveness, and safety of EMS placement in patients with malignant rectal obstruction within 5 cm of the anal verge. DESIGN Retrospective study. SETTING Single tertiary referral university hospital. PATIENTS The sites of obstruction included the rectum within 5 cm (range, 25-50 mm) of the anal verge in 16 patients (group A) and more than 5 cm (range, 53-74 mm) in 14 patients (group B). INTERVENTIONS Placement of 3 types of EMS. MAIN OUTCOME MEASUREMENTS Complications including pain were evaluated and compared between 2 groups with the Fisher exact test. RESULTS The overall technical success rate was 100%. Colon perforation occurred in 2 patients, who underwent emergency surgery. Ten (62.5%) of group A and 1 (7.1%) of group B complained of pain (P = .011). In 3 of the 10 patients in group A, the pain disappeared spontaneously within a week or was tolerated by the patients without use of analgesics, although the remaining 7 patients of group A and the 1 patient in group B needed analgesics until death or elective surgery. LIMITATIONS Retrospective study. CONCLUSIONS Placement of EMS in patients with malignant rectal obstruction within 5 cm of the anal verge seems feasible and relatively safe and may provide adequate palliation and preoperative decompression of obstruction symptoms. Anal pain was tolerable to the patients with or without use of analgesics.
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Kim TH, Song HY, Shin JH, Park IK, Kim JH, Lim JO, Kim KR, Choi EK. Usefulness of multifunctional gastrointestinal coil catheter for colorectal stent placement. Eur Radiol 2008; 18:2530-4. [DOI: 10.1007/s00330-008-1042-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 02/12/2008] [Accepted: 03/29/2008] [Indexed: 10/22/2022]
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Abstract
OBJECTIVE Colonic obstruction may be relieved by the insertion of a self-expanding metallic stent (SEMS), either for permanent palliative relief or as a bridge to surgery. Lesions proximal to the descending colon can be more difficult to intubate and stent [1]. SEMS placement in the more proximal colon lesions has been reported in only a few cases [2,4]. The aim of this study was to review the outcome of SEMS for obstruction at the splenic flexure and above. METHOD A study of all colonic stents inserted in one specialist unit was undertaken. Patients' demographics, site and aetiology of the underlying obstruction, success or other outcome of the procedures were collected. Thirty-day morbidity and mortality were documented. RESULTS Seven patients had proximal lesions: four in the transverse colon and three at the splenic flexure. Six patients had colorectal carcinoma and one had extrinsic compression from a gastric carcinoma. Six of the SEMS were inserted for permanent palliation, and one as a bridge to surgery. Stent placement was technically successful in six of the seven patients. In the seventh patient, there was a failure of expansion of the stent, after successful intubation of the lesion, which was in the distal transverse colon. One patient suffered from minor self-limiting abdominal pain in the first 24 h after the procedure. There was no other SEMS related morbidity or mortality. All of the successfully stented patients were discharged from the surgical ward within 3 days after the procedure. Median survival time was 4.3 months (range 3-12 months). Three patients are still alive. CONCLUSION The SEMS is a useful tool in managing acute bowel obstruction. Placement of colonic stents proximal to the descending colon is safe, feasible and effective.
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Affiliation(s)
- B Elsberger
- Colorectal Unit, Western General Hospital, Edinburgh, UK.
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Surgical Emergencies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Siddiqui A, Khandelwal N, Anthony T, Huerta S. Colonic stent versus surgery for the management of acute malignant colonic obstruction: a decision analysis. Aliment Pharmacol Ther 2007; 26:1379-86. [PMID: 17848183 DOI: 10.1111/j.1365-2036.2007.03513.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute colonic obstruction because of advanced colonic malignancy is a surgical emergency. AIM To compare the clinical outcomes and cost-effectiveness of endoscopic self-expanding metal stent (SEMS) vs. surgery for emergent management of acute malignant colonic obstruction in patients with metastatic colorectal cancer over a 6-month period. METHODS Decision analysis was used to calculate the cost-effectiveness and success of two competing strategies in a hypothetical patient with metastatic colon cancer presenting with acute, malignant colonic obstruction: (i) emergent colonic stent (SEMS cohort); (ii) emergent surgical resection followed by diversion (surgery cohort). RESULTS Self-expanding metal stent resulted in a success and a lower mortality rate when compared to surgery over a 6-month period. Colonic SEMS was also associated with a lower mean cost per patient (USD 27,225 vs. USD 57,398). Mortality in the surgery group was 25 times that of the SEMS cohort. One- and two-way sensitivity analyses identified SEMS as the dominant strategy. CONCLUSION Colonic stent insertion is more effective and less costly than surgery for the management of colonic obstruction in patients with metastatic colon cancer.
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Affiliation(s)
- A Siddiqui
- Division of Gastroenterology, VA North Texas Health Care System and University of Texas Southwestern Medical School, Dallas, TX, USA.
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Jost RS, Jost R, Schoch E, Brunner B, Decurtins M, Zollikofer CL. Colorectal stenting: an effective therapy for preoperative and palliative treatment. Cardiovasc Intervent Radiol 2007; 30:433-40. [PMID: 17225973 DOI: 10.1007/s00270-006-0012-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Rahel S Jost
- Department of Surgery, Kantonsspital Winterthur, Brauersstrasse 15, 8401 Winterthur, Switzerland.
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Abstract
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.
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Affiliation(s)
- Rahul Dharmadhikari
- Department of Radiology, Queen Elizabeth Hospital, Queen Elizabeth Avenue Sheriff Hill, Gateshead, Tyne and Wear, NE9 6SX, UK.
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Choi JS, Choo SW, Park KB, Shin SW, Yoo SY, Kim JH, Do YS. Interventional management of malignant colorectal obstruction: use of covered and uncovered stents. Korean J Radiol 2007; 8:57-63. [PMID: 17277564 PMCID: PMC2626692 DOI: 10.3348/kjr.2007.8.1.57] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jin Soo Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
- Department of Radiology, Dongsan Medical Center, Keimyung University, School of Medicine, Taegu 700-712, Korea
| | - Sung Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
| | - So-Young Yoo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 135-710, Korea
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Gmeiner M, Pfeifer J. Management of complications in surgery of the colon. Eur Surg 2007; 39:15-32. [PMID: 32288768 PMCID: PMC7102154 DOI: 10.1007/s10353-007-0311-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/23/2007] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- M. Gmeiner
- />Department of Pulmology, General Hospital Graz-West, Graz, Austria
| | - J. Pfeifer
- />Department of General Surgery, Medical University of Graz, Graz, Austria
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Abe T, Maetani I, Kakemura T, Fujinuma S, Sakai Y. SUCCESSFUL PLACEMENT OF SELF-EXPANDABLE METALLIC STENTS FOR DOUBLE COLORECTAL CANCERS. Dig Endosc 2006. [DOI: 10.1111/j.1443-1661.2006.00662.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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40
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Rullán R, Danielson P, Hirsh M, Kim D, Eckardt A, Bhattacharya K. Self-expanding silicone stent for treatment of postoperative colorectal stricture in an infant with Hirschsprung's disease: a case report. J Pediatr Surg 2006; 41:1613-5. [PMID: 16952603 DOI: 10.1016/j.jpedsurg.2006.05.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Benign colorectal strictures can be a complication of intestinal surgery, with limited options for endoscopic intervention. In this report, we describe a case where a removable silicone stent was temporarily placed to successfully treat a benign post operative stricture in an infant with Hirschsprung's disease.
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Affiliation(s)
- Ramón Rullán
- Division of Gastroenterology, University of Massachusetts Medical School/Memorial Medical Center, Worcester, MA 01655, USA
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41
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Ptok H, Marusch F, Steinert R, Meyer L, Lippert H, Gastinger I. Incurable Stenosing Colorectal Carcinoma: Endoscopic Stent Implantation or Palliative Surgery? World J Surg 2006; 30:1481-7. [PMID: 16850152 DOI: 10.1007/s00268-005-0513-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Palliative surgery for the treatment of incurable obstructive colorectal carcinoma is associated with a considerable perioperative morbidity and mortality but no substantial improvement of the prognosis. The aim of the present study was to study the effectiveness of colorectal stenting compared with palliative surgery in incurable obstructive colorectal carcinoma. PATIENTS AND METHODS From April 1999 to April 2005, data of consecutive patients with incurable stenosing colorectal carcinoma, either treated with stent implantation or palliative surgical intervention, were prospectively recorded with respect to age, sex, tumor location (including metastases), ASA-score, peri-interventional morbidity, mortality, rates of complications, and re-interventions as well as survival. RESULTS Of 40 patients, 38 (95%) were successfully treated with a stent. Two patients (5%) underwent surgical intervention after stent dislocation. In contrast, 38 patients primarily underwent palliative surgical intervention. Stent patients were significantly older (P=0.020), had a higher ASA-score (P=0.012), and had more frequently distant metastases (P=0.011). After successful stent implantation, no early complications were observed, but late complications occurred in 11 subjects (29%). Following palliative surgical intervention, postoperative complications occurred in 12 individuals (32%) . Postoperative mortality was 5% in the surgery group, whereas no patient died following stent implantation. There was no significant differences in the survival of both groups (9.9 vs. 7.8 months, respectively; log rank: 0.506). CONCLUSIONS Palliative treatment of incurable obstructive colorectal carcinoma using stents is an effective and suitable alternative to palliative surgery with no negative impact on the survival but less peri-interventional morbidity and mortality as well as comparable overall morbidity.
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Affiliation(s)
- Henry Ptok
- Department of Surgery, Carl-Thiem Hospital, Thiemstrasse 111, Cottbus, 03048, and Department of General, Visceral and Vascular Surgery, University Hospital, Germany.
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Athreya S, Moss J, Urquhart G, Edwards R, Downie A, Poon FW. Colorectal stenting for colonic obstruction: the indications, complications, effectiveness and outcome--5 year review. Eur J Radiol 2006; 60:91-4. [PMID: 16806783 DOI: 10.1016/j.ejrad.2006.05.017] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Revised: 04/11/2006] [Accepted: 05/24/2006] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- S Athreya
- Department of Radiology, Gartnavel General Hospital, Glasgow, UK.
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Sherazi Z, Otti C, Jang O, Kamal T, Patel M. Deployment of stents in two separate colorectal strictures in a patient with extracolonic pelvic metastases. Cardiovasc Intervent Radiol 2006; 29:924-7. [PMID: 16718426 DOI: 10.1007/s00270-004-0322-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fan YB, Cheng YS, Chen NW, Xu HM, Yang Z, Wang Y, Huang YY, Zheng Q. Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction. World J Gastroenterol 2006; 12:755-9. [PMID: 16521189 PMCID: PMC4066126 DOI: 10.3748/wjg.v12.i5.755] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- You-Ben Fan
- Department of Surgery, Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, China
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45
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Bhardwaj R, Parker M. Colorectal obstruction. EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80276-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pothuri B, Guirguis A, Gerdes H, Barakat RR, Chi DS. The use of colorectal stents for palliation of large-bowel obstruction due to recurrent gynecologic cancer. Gynecol Oncol 2005; 95:513-7. [PMID: 15581955 DOI: 10.1016/j.ygyno.2004.07.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2004] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Acute large-bowel obstruction (LBO) is considered a surgical emergency. In gynecologic oncology patients with LBO due to recurrent tumor, surgery has been the standard treatment. However, operative intervention has significant associated morbidity and mortality. Recent reports have addressed the use of colorectal stents for the treatment of colonic malignancies. We are reporting our experience with colorectal stents in gynecologic oncology patients. METHODS We reviewed the records of all patients who underwent colorectal stent placement for palliation of LBO due to recurrent gynecologic malignancy from August 2001 to January 2003. RESULTS Six patients were identified; five patients had recurrent ovarian cancer and one had recurrent endometrial cancer. The mean age of the six patients at the time of stent placement was 51.5 years (range, 22-83 years). The length of LBO ranged from 2 to 10 cm. Two patients had a lumen of 1 to 2 mm before stent placement, while the other four had a complete obstruction and needed balloon dilatation before the deployment of the stent. Four (67%) of six patients had immediate relief, with passage of stool and flatus noted at the time of the colorectal stent placement. Stent placement failed to relieve the LBO in two patients (33%); these patients went on to receive colostomies. Of the four patients who had successful stent placement, the mean survival after stent placement was 120 days. One patient had a contained sigmoid bowel perforation noted 12 days after stent placement, which resolved with conservative measures. CONCLUSION Colonic stents appear to be a useful option in the management of patients with LBO due to recurrent gynecologic malignancy.
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Affiliation(s)
- Bhavana Pothuri
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Abstract
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.
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Affiliation(s)
- Wing-Kin Syn
- Gastroenterology Department, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
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48
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Lewis R, Flynn A, Dean ME, Melville A, Eastwood A, Booth A. Management of colorectal cancers. Qual Saf Health Care 2004; 13:400-4. [PMID: 15465947 PMCID: PMC1743890 DOI: 10.1136/qhc.13.5.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The management of colorectal cancers, published in a recent issue of Effective Health Care, is reviewed.
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Affiliation(s)
- R Lewis
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
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Targownik LE, Spiegel BM, Sack J, Hines OJ, Dulai GS, Gralnek IM, Farrell JJ. Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004; 60:865-74. [PMID: 15604999 DOI: 10.1016/s0016-5107(04)02225-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Laura E Targownik
- Division of Digestive Diseases, School of Medicine, UCLA Center for the Health Sciences, University of California-Los Angeles, Los Angeles, CA 90095, USA
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50
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Tomiki Y, Watanabe T, Ishibiki Y, Tanaka M, Suda S, Yamamoto T, Sakamoto K, Kamano T. Comparison of stent placement and colostomy as palliative treatment for inoperable malignant colorectal obstruction. Surg Endosc 2004; 18:1572-7. [PMID: 15931483 DOI: 10.1007/s00464-004-8106-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2004] [Accepted: 05/12/2004] [Indexed: 12/16/2022]
Abstract
BACKGROUND Stent placement is a useful palliative treatment for inoperable acute malignant colorectal obstruction. However, data comparing stent placement with colostomy are scarce. METHODS We compared the clinical outcome of 18 patients who had stent placement and 17 patients who underwent only colostomy. RESULTS The postoperative hospital stay was 22.3 days for stent placement compared with 47.4 days for colostomy (p = 0.016). The duration to readmission was 129.2 days for stent placement and 188.4 days for colostomy. The estimated duration of primary stent patency was 106 days. Mean survival period was 134 days in patients with stent placement and 191 days in patients with colostomy. CONCLUSION Postoperative hospital stay was shorter in patients with stent placement but duration to readmission and survival were longer in patients with colostomy. However, stent placement increases the option of palliative treatment and is an effective treatment contributing to improving quality of life.
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Affiliation(s)
- Y Tomiki
- Department of Coloproctological Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Tokyo 113-8421, Japan.
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