How to decide on stent insertion or surgery in colorectal obstruction?

Development and validation of a nomogram for preoperative prediction of tumor deposits in colorectal cancer

BACKGROUND

Based on the clinical data of colorectal cancer (CRC) patients who underwent surgery at our institution, a model for predicting the formation of tumor deposits (TDs) in this patient population was established.

AIM

To establish an effective model for predicting TD formation, thus enabling clinicians to identify CRC patients at high risk for TDs and implement personalized treatment strategies.

METHODS

CRC patients (n = 645) who met the inclusion criteria were randomly divided into training (n = 452) and validation (n = 193) cohorts using a 7:3 ratio in this retrospective analysis. Least absolute shrinkage and selection operator regression was employed to screen potential risk factors, and multivariable logistic regression analysis was used to identify independent risk factors. Subsequently, a predictive model for TD formation in CRC patients was constructed based on the independent risk factors. The discrimination ability of the model, its consistency with actual results, and its clinical applicability were evaluated using receiver-operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

Thirty-four (7.5%) patients with TDs were identified in the training cohort based on postoperative pathological specimens. Multivariate logistic regression analysis identified female sex, preoperative intestinal obstruction, left-sided CRC, and lymph node metastasis as independent risk factors for TD formation. The AUCs of the nomogram models constructed using these variables were 0.839 and 0.853 in the training and validation cohorts, respectively. The calibration curve demonstrated good consistency, and the training cohort DCA yielded a threshold probability of 7%-78%.

CONCLUSION

This study developed and validated a nomogram with good predictive performance for identifying TDs in CRC patients. Our predictive model can assist surgeons in making optimal treatment decisions.

Stenting versus surgery in obstructed malignant colorectal cancer-a review of short and long-term results

Obstructed colorectal cancers (CRCs) continue to be challenging to manage. Apart from surgical resection, the use of self-expanding metallic stents (SEMS) has become increasingly popular. SEMS could potentially allow for the conversion of an emergency operation into a semi-elective procedure, allow for the optimization of the patient's physiology, avoid the requirement for a stoma, as well as allow for a minimally-invasive approach to be adopted. This review article therefore highlights the evidence available in the literature pertaining to the use of SEMS in obstructed CRCs.

COMPARATIVE EVALUATION OF THE USE OF COATED AND UNCOATED SELF-EXPANDABLE METALLIC STENTS IN MALIGNANT COLORECTAL OBSTRUCTION

THE OBJECTIVE was to compare the efficacy and rate of complications in patients of groups with uncovered and covered colorectal stents.

METHODS AND MATERIALS. The study included 102 patients who were admitted for emergency with symptoms of malignant colon obstruction, who were randomly installed covered and uncovered SEMS from December 2012 to September 2017.

RESULTS. Clinical success was achieved with uncovered stents in 98 % of cases and 96 % with covered stents (relative risk (RR) 1.02). 95 % confidence interval (CI) 0.954–1.092). The incidence of complications in the group of uncovered stents was 9.8 %, in the group of covered stents – 3.9 % (RR 0.938, CI 0.841–1.046); the frequency of recurrences of obstruction did not significantly different between groups. The median duration of cumulative stent patency was 181 days in the group of uncovered stents and 218 days in the group of covered stents (p=0.427), the difference was statistically insignificant.

CONCLUSION. The use of double covered and double uncovered stents is equally effectively and safely for patients with malignant colorectal obstruction. The frequency of reobstructions did not exceed 4 % and did not differ in the groups of covered and uncovered stents. The choice of the type of stent should be determined individually depending on the clinical situation.

Endoscopic stenting in colorectal cancer

Acute malignant large bowel obstruction presents as one of the few emergencies of colorectal cancer (CRC). Management of this condition can either be by (I) upfront surgery or (II) the use of self-expanding metallic stent (SEMS) as a bridge to elective surgery. For patients with metastasis, the use of SEMS is reported to enable earlier commencement of chemotherapy. Although the use of SEMS in patients with acute malignant large bowel obstruction looks promising, it is plagued by its own set of complications and divided opinion over its long-term outcomes. Conflicting data are present, and definitive indication requires further evaluation and debate. This article will describe the typical presentation of patients with acute malignant large bowel obstruction. An introduction to the SEMS insertion procedural steps will be undertaken. Following which the article aims to review the safety profile of SEMS and the short- and long-term outcomes of SEMS in both the curative and palliative setting.

Bowel obstruction in advanced cancer

Purpose:

Assessment of treatment of cancer patients with bowel obstruction, identification of prognostic factors, and assessment of reference to palliative care.

Methods:

Records of patients with a diagnosis of bowel obstruction over a 6-month (January–June 2013) period were reviewed.

Results:

Seventy-five patients were diagnosed with bowel obstruction. Fifty-one (68%) were female and the median age was 65 years (27–100). The most frequent cancer was colorectal, 30 (40%), followed by gynecological cancer, 20 (27%). Forty-three (57%) patients underwent conservative treatment; 26 (35%) underwent surgery; and 6 (8%) had a stent placement. In 68 (91%), the bowel obstruction was resolved. Three years after the bowel obstruction episode, 15 (20%) patients were still alive. An analysis of the possible association of variables recorded with mortality was carried out, and for death at the first admission, only the resolution of the obstruction was significant (P < .001); for the 3-year survival the significant factors were hemoglobin >10.7 g/dL (P < .001) and ascites (P = .001) at the time of obstruction. Thirty-seven (49%) patients were referred to palliative care.

Conclusions:

Although bowel obstruction in cancer patients is usually associated with a short life expectancy, some patients have relatively long survivals. Only about half of the patients were referred to palliative care.

[Standardization of surgical care for malignant colonic obstruction]

AIM

To standardize surgical care for malignant colonic obstruction.

MATERIAL AND METHODS

There were 572 patients with malignant colonic obstruction: 247 of them were hospitalized in 2011-2013 (I group); 325 - in 2014-2017 (group II). Forty-six patients underwent medication; 302 - acute resection; 141 - stoma construction; 83 - stent deployment. Elective surgery and radiation or chemotherapy was performed after 0.5-6 months in 110 patients of group II. Acute resection was more common in I group, elective resection - in group II. Early and long-term results including Kaplan-Meier 3-year overall survival were compared in both groups.

RESULTS

Complications occurred in 46.69% (group I) and 21% (group II). Postoperative mortality was significantly higher in group I compared with II group: 26.11 and 10.33%, respectively. Three-year overall survival was higher in group I compared with group II: 0.82 and 0.69, respectively.

CONCLUSION

Advisability of new two-stage surgical standard is confirmed for malignant colonic obstruction. Stoma formation and stenting may be a valid alternative in some patients with malignant colonic obstruction due to significantly lower postoperative mortality.

[The optimal terms of the second stage of treatment of patients with malignant colonic obstruction]

AIM

To determine the optimal terms of the second stage of treatment of patients with malignant colonic obstruction.

MATERIAL AND METHODS

There were 110 patients with colorectal cancer stage T_3-4N₀M₀ (groups I-III, n=69) and T_3-4N_0-2M_0-1 (group IV, n=41). Everybody has been previously treated for colonic obstruction 0,5-6 months ago: stoma in 62 cases, stenting - in 48 cases. Elective radical surgery and radiotherapy and/or chemotherapy were applied in 2 (I group, n=23), 3 (II, n=23), 4 (III, n=23) weeks or 4-6 months (IV, n=41) after colonic decompression. The optimal terms of radical surgery are determined depending on CT-data, histological examination.

RESULTS

Bowel wall thickness was significantly higher in I-II groups compared with III-IV groups: 3.7; 2.5; 1.9; 1.7, respectively (p≤0,5). The maximum number of tumor emboli was found in III-IV groups. Signs of focal colitis were absent in III-IV groups.

CONCLUSION

The expediency of the new surgical standard is confirmed. Bridging strategy (stenting and stoma) may be a valid alternative in some patients with malignant colonic obstruction due to reduced postoperative mortality. The optimal terms for resection in patients with local cancer is 4 weeks after colonic decompression, in locally advanced cancer - 4-6 months.

Randomized controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post hoc cost analysis

AIM

In view of the increasing burden on the healthcare system, this study aims to perform a cost-effectiveness analysis of the management of incurable large bowel obstruction comparing the cost of a stent vs surgery.

METHOD

A prospective randomized controlled trial was conducted at two major teaching hospitals in Australia between September 2006 and November 2011. Fifty-six patients with malignant incurable large bowel obstruction were randomized to stent insertion or surgical decompression, of whom 52 were included in the final analysis. Data were collected at all points during the patient journey and quality of life data were obtained by patient surveys. All data points were analysed and a cost-effectiveness study was performed to compare the costs between the two treatment groups.

RESULTS

Stenting as a procedure was significantly more expensive than surgery (A$4462.50 vs A$3251.50; P < 0.001). Post-procedure stay for stented patients was significantly lower (median 7 vs 11 days; P = 0.03). Combined costs of stent group ward stay, multidisciplinary team discussion and complication management were significantly lower (P = 0.013). Overall cost difference between the two treatment groups was A$3902.44 (P = 0.101). European Quality of Life - 5 Dimensions (EQ-5D) scores for the first 4 weeks gave mean area under the curve adjusted weeks of 2.411 vs 2.271 for the stent and surgery groups respectively (P = 0.603). The incremental cost-effectiveness ratio between the surgery and the stent group was $22 955.53 in favour of stenting.

CONCLUSIONS

Treatment with stenting is cheaper than open surgery and provides quicker discharge from hospital.

Benefit of Surgical Resection of the Primary Tumor in Patients Undergoing Chemotherapy for Stage IV Colorectal Cancer with Unresected Metastasis

PURPOSE

Resection of the primary tumor in patients with unresected metastatic colorectal cancer is controversial, and often performed only for palliation of symptoms. Our goal was to determine if resection of the primary tumor in this patient population is associated with improved survival.

METHODS

This is a retrospective cohort study of the National Cancer Data Base from 2004 to 2012. The study population included all patients with synchronous metastatic colorectal adenocarcinoma who were treated with systemic chemotherapy. The study groups were patients who underwent definitive surgery for the primary tumor and those who did not. Patients were excluded if they had surgical intervention on the sites of metastasis or pathology other than adenocarcinoma. Primary outcome was overall survival.

RESULTS

Of the 65,543 patients with unresected stage IV colorectal adenocarcinoma undergoing chemotherapy, 55% underwent surgical resection of the primary site. Patients who underwent surgical resection of the primary tumor had improved median survival compared to patients treated with chemotherapy alone (22 vs 13 months, p < .0001). The surgical survival benefit was present for patients who were treated with either multi-agent or single-agent chemotherapy (23 vs 14 months, p < 0.001; 19 vs 9 months, p < 0.001). Surgical resection of the primary tumor was also associated with improved survival when using multivariate analysis with propensity score matching (OR = 0.863; 95% CI [0.805-.924]; HR = 0.914; 95% CI [0.888-0.942]).

CONCLUSIONS

Our results show that in patients with synchronous unresected stage IV colorectal adenocarcinoma undergoing single- or multi-agent chemotherapy, after adjusting for confounding variables, definitive resection of the primary site was associated with improved overall survival. Large randomized controlled trials are needed to determine if there is a causal relationship between surgery and increased overall survival in this patient population.

[Managerial and methodological aspects of emergency surgery for malignant colonic obstruction]

AIM

To determine the most feasible treatment strategy for malignant colonic obstruction.

MATERIAL AND METHODS

There were 427 patients with malignant colonic obstruction who were hospitalized for emergency indications. 30 of them were treated with medical therapy; 286 - underwent acute resection; 43 - stoma construction; 68 - stents deployment. 64 out of 427 patients underwent elective restorative/radical surgery and radio- or chemotherapy in 1-8 months. 3-year Kaplan-Meier survival was assessed.

RESULTS

Complications occurred in 58% after acute resection and in 32.6% and 8.8% after stoma and stent deployment, respectively. Postoperative mortality was significantly lower after palliative surgery (stent or stoma) compared with acute resection: 2.9%, 18.6%, 29.37%, respectively. 3-year survival was higher after elective resections compared with emergency resection group: 0,81 и 0,68 respectively.

CONCLUSION

Bridging strategy (stoma/stents) may be a valid alternative in some patients with malignant colonic obstruction due to significantly reduced postoperative mortality. Acute surgery for malignant colonic obstruction should only be carried out by appropriately trained surgeons at multi-field hospital.

[The possibilities to improve the outcomes in patients with colon cancer complicated by acute obstruction]

AIM

To improve the outcomes in patients with colon cancer complicated by acute obstruction via development of combined and complex treatment strategies.

MATERIAL AND METHODS

We observed 442 patients with colon cancer complicated with acute obstruction. Original classification and diagnostic algorithm were applied.

RESULTS

Time of preoperative opening-up, volume and type of surgery were defined using obtained data. Also we are able to perform delayed radical surgery after correction of metabolic disorders and comorbidities, to create the conditions for combined and complex methods of treatment, to decrease the incidence of postoperative complications and mortality rate.

CONCLUSION

Three-stage surgery with shortened time between interventions decreases the incidence of anastomosis failure, allows to refuse Hartmann's procedure and to avoid severe reconstructive surgical stage without prolongation of rehabilitation period.

Niclosamide inhibition of STAT3 synergizes with erlotinib in human colon cancer

Niclosamide, an anthelmintic drug approved by the US Food and Drug Administration against cestodes, is used to treat tapeworm infection. In this study, we show that niclosamide can potentially inhibit signal transducer and activator of transcription 3 (STAT3) in colon cancer cell lines. Combined inhibition of epidermal growth factor receptor and STAT3 by erlotinib and niclosamide synergistically induces apoptosis and antiproliferation in colon cancer cell lines. Our findings suggest that erlotinib and niclosamide combination provides an effective therapeutic approach to improving the prognosis of colon cancer.