Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction

Transanal drainage tubes vs metallic stents for acute malignant left-sided bowel obstruction: A systematic review and meta-analysis

BACKGROUND

The surgical management of acute malignant left-sided bowel obstruction is associated with high morbidity and mortality. Recently, transanal drainage tubes (DTs) and metallic stents (MSs) used as a "bridge to surgery" have become widely used decompression methods compared with emergency surgery. This study aims to evaluate the efficacy and safety of DTs and MSs for the decompression of acute left-sided malignant colorectal obstruction.

METHODS

All studies were acquired from PubMed, Medline, Embase, CNKI and the Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed with RevMan5.3. Mean differences (MDs), odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa scale were used to assess the risk of bias.

RESULTS

Eleven studies, which included three randomized controlled trials (RCTs) and 8 observational studies, were assessed. The methodological quality of the trials ranged from low to moderate. The pooled results of the technical success rate showed that the difference was not statistically significant between the2 devises. The differences in clinical success rate, operative time and complications were statistically significant between MSs and DTs, and MSs were associated with a better clinical success rate, increased operative time and fewer complications. Sensitivity analysis proved the stability of the pooled results, and the publication bias was low.

CONCLUSION

MS insertion for acute left-sided malignant bowel obstruction is effective and safe with a better technical success rate and with fewer complications than decompression using a DT, and MS insertion can avoid stoma formation. Moreover, MS insertion appears to be a useful treatment strategy for malignant colonic obstruction even if the lesion is located in the right colon. More large-sample, multicenter, high-quality RCTs are needed to verify the outcomes of this meta-analysis.

Management of Colorectal Cancer Patients Undergoing a Colonic Stenting: A Multidisciplinary Team Approach

Colonic stent procedure is one of the best therapeutic medical interventions for managing a colorectal cancer patient with large bowel obstruction. This is a retrospective study that evaluated data from the past 10 years; it examined the epidemiological and clinical data of patients with colorectal cancer undergoing a colonic stent procedure. In addition, this study prospectively evaluated the nurse's roles during a colonic stent procedure, and at the same time, it explored the patient's satisfaction with the procedure at the Hospital Universitario Central de Asturias (Spain). The results revealed that for the last 10 years, a total of 102 patients underwent a colonic stent procedure. Male patients outnumbered female patients by 2:1. The palliative group consisted of patients with multiple cancer metastases, elderly patients, and patients with other comorbidities, whereas the preoperative group comprised those patients with fewer comorbidities and no multiple cancer metastases. Survival time in the palliative group was 3 months without any aggressive treatment, whereas patients with a favorable condition and fit for surgery after a colonic stent procedure had a survival time of 28 months. In the prospective study, nurses implemented care in terms of a multidisciplinary team approach of safety culture that included patient safety, equipment safety, and environment and procedure safety. Therefore, the level of patient satisfaction was high. In conclusion, management of a colorectal cancer patient undergoing colonic stenting performed at the Hospital Universitario Central de Asturias has high technical and clinical success, and it is a quality procedure that includes a multidisciplinary team approach.

The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine

PURPOSE

Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine.

METHODS

We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65-99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction.

RESULTS

The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20-1377 days). On multivariate analysis, shorter stents (< 10 cm) yielded better outcomes than longer stents (≥ 10 cm) (P = 0.041), and the Cox proportional hazard model also indicated that shorter stents (P = 0.036) predicted longer event-free survival.

CONCLUSIONS

Elderly patients with malignant bowel obstruction receiving shorter stents had longer event-free survival after stenting with better general condition.

[Colonic stenting: an opportunity with a risk : A critical evaluation]

BACKGROUND

Frequently, the first clinical sign of colorectal cancer is complete obstruction, which has to be considered an emergency situation. The treatment goal is to overcome ileus including reduction of the associated high morbidity and mortality. Therefore, alternative therapeutic options to emergency surgery have been sought in order to allow adequate preparation for elective surgery or stabilization of palliative patients and avoid colostoma. Therapeutic results of the placement of self-expanding metal stents (SEMS) are discussed in terms of a single-center, retrospective observational study.

METHODS

In 35 patients with a clinically manifest stenosis of colonic cancer, it was attempted to insert SEMS to treat ileus as the first therapeutic step. Therapeutic results were investigated with regard to technical and clinical success, spectrum and rate of complications, and survival time, differentiating between a palliative and curative group of patients.

RESULTS

Primary placement of a stent was achieved in 29 of 35 patients (82.9 %); 14 underwent the procedure with palliative and 15 with curative intention. Stent location was mainly the left hemicolon. In 2 of 15 patients (13.3 %), emergency surgery within 48 h was required because of complications, whereby in 13 patients (86.7 %), 6 patients (46.2 %) underwent elective open surgery and 7 patients (53.8 %) underwent a laparoscopic procedure. In all patients treated with curative intent, primary anastomosis was achieved, thus, avoiding a colostoma. Survival times of the palliative and curative patient groups were on average 7 and 28 months, respectively.

CONCLUSION

In carefully selected cases, placement of SEMS in malignant stenosis of the left hemicolon with ileus can be considered a reasonable therapeutic alternative to emergency surgery since it allows surgical intervention with curative intention under more favorable conditions and also avoids a colostoma.

Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis

BACKGROUND

Colonic stenting has failed to show an improvement in mortality rates in comparison with emergency surgery for acute large-bowel obstruction. However, it remains unclear which patients are more likely to benefit from this procedure.

OBJECTIVE

The aim of this study is to identify factors that may be predictive of successful outcome of colonic stenting in acute large-bowel obstruction.

DESIGN

All patients undergoing colonic stenting for acute large-bowel obstruction between 1999 and 2013 were studied. The demographics and characteristics of the obstructing lesion were analyzed.

SETTINGS

This investigation was conducted at a district general hospital.

PATIENTS

A total of 126 (76 men; median age, 76 y; range, 42-94 y) with acute large-bowel obstruction were included in the analysis.

INTERVENTION

The insertion of a self-expanding metal stent was attempted for each patient to relieve the obstruction.

MAIN OUTCOME MEASURES

The primary outcomes measured were technical success in the deployment of the stent, clinical decompression, and perforation rates.

RESULTS

Technical deployment of the stent was accomplished in 108 of 126 (86%) patients; however, only 89 (70%) achieved clinical decompression. Successful deployment and clinical decompression was associated with colorectal cancer (p = 0.03), shorter strictures (p = 0.01), and wider angulation distal to the obstruction (p = 0.049). Perforation was associated with longer strictures (p = 0.03).

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSION

Colonic stenting in acute large-bowel obstruction is more likely to be successful in shorter, malignant strictures with less angulation distal to the obstruction. Longer benign strictures are less likely to be successful and may be associated with an increased risk of perforation.

Transanal ileus tube decompression for treatment of bowel obstruction due to colorectal cancer

AIM: To assess the clinical effect of transanal ileus tube decompression in the treatment of bowel obstruction due to colorectal cancer, and to analyze the differences between emergency surgery and elective surgery after transanal ileus tube decompression.

METHODS: Fifty-four patients with bowel obstruction due to colorectal cancer treated at our hospital between October 2009 and October 2012 were included, of whom 25 underwent transanal ileus tube decompression. After this treatment, 20 cases received first-stage resection and anastomosis. A case-control study was used to compare the rate of first-stage resection and anastomosis, perioperative recovery and complications rate between patients undergoing transanal ileus tube decompression (observation group) and those undergoing emergency surgery (control group).

RESULTS: In the observation group, 25 cases were successfully treated by transanal ileus tube decompression, of whom 20 underwent laparoscopic first-stage resection and anastomosis. The rate of first-stage anastomosis was significantly higher in the observation group than in the control group (80% vs 37.9%, P < 0.05). In the perioperative period, the differences in hospital stay and operative time between the two groups were not statistically significant. The amount of bleeding was less and the time to intestinal function recovery was shorter in the observation group. The number of resected lymph nodes in the observation group was significantly more than that in the control group. The overall incidence of complications in the observation group was significantly lower than that in the control group (12.0% vs 37.9%, P < 0.05).

CONCLUSION: Transanal ileus tube decompression can improve the rate of first-stage anastomosis and reduce perioperative morbidity and mortality in the treatment of bowel obstruction due to colorectal cancer.