Angular positioning of stent increases bowel perforation after self-expandable metal stent placement for malignant colorectal obstruction

Danish guidelines for treating acute colonic obstruction caused by colorectal cancer-a review

Acute onset of colonic obstruction caused by colorectal cancer occurs in approximately 14% of Danish patients with colon cancer(1). Given that colorectal cancer is a common cancer with about 4,500 new cases annually, acute onset will occur in a reasonably large number of patients in Danish emergency departments, and all surgeons should be familiar with the treatment principles. A revised guideline from the Danish Colorectal Cancer Group is currently underway, and this status article reviews the latest knowledge and recommendations.

Comparison of different types of covered self-expandable metal stents for malignant colorectal obstruction

BACKGROUND

Stent migration is one of the main drawbacks of covered self-expandable metal stent (SEMSs), occurring in up to 40% of malignant colorectal obstruction management cases. Various types of covered SEMSs have been developed to reduce this risk. We aimed to compare the effectiveness and complication rates of the flare-type covered SEMS (Flare) with those of the double-layered covered SEMS (ComVi).

METHODS

We performed a prospective, randomized study in four tertiary referral centers between July 2016 and April 2018. Patients with malignant colorectal obstruction were eligible for the study. The primary outcome was migration rate as observed within the first month. Rates of technical success, clinical success, and complications within the first month were also assessed.

RESULTS

A total of 60 patients were included (mean age, 70.5 ± 12.5 years; male, 31 [51.7%]). Flare and ComVi stents were applied in 30 patients each. The Flare and ComVi groups showed comparable technical success rates (90% [27/30] vs. 96.7% [29/30], p = 0.605) and clinical success rates (85.2% [23/27] vs. 75.9% [22/29], p = 0.589). Migration occurred in three (11.1%) and four (13.8%) cases in the Flare and ComVi groups, respectively, without significant difference (p = 0.99), and the risk of other complications, including perforation and re-obstruction, did not differ between the two groups.

CONCLUSIONS

Our study indicates that both flare-shape and double-layered covered SEMSs are equally effective options for the management of malignant colorectal obstruction with low migration rates when compared with previously reported migration risk of covered SEMS.

Self-expandable Metal Stent as a Bridge to Surgery for Colorectal Cancer: Safety and Oncological Outcomes

BACKGROUND/AIM

Self-expandable metal stent (SEMS) as a bridge to surgery (BTS) for obstructive colorectal cancer (CRC) raises concerns regarding the short-term as well as oncological outcome. The present study aimed to investigate the safety of SEMS placement and risk factors of worse short-term and oncological outcomes as BTS.

PATIENTS AND METHODS

Twenty-four patients with obstructive CRC who underwent SEMS placement as BTS were included. Success rate of SEMS placement and 2-year relapse-free survival (RFS) rates in stage II/III BTS patients were assessed.

RESULTS

Technical and clinical success rates for SEMS placement were 100% and 87.5%, respectively. In Multivariate analyses, longer tumour length, longer interval to surgery, and angular positioning were risk factors related with the complication of stent placement. Two-year RFS rates were significantly higher in the no-complication than in the complication group (100% vs. 75%, log-rank test, p<0.01).

CONCLUSION

A long tumour length, long interval between SEMS insertion and surgery, and angular positioning of the SEMS were identified as risk factors for SEMS-related complications. Moreover, SEMS insertion and/or surgery complications were associated with worse oncological outcome in CRC patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of through-the-scope stent insertion with standard stent insertion for the management of malignant colorectal obstruction: a prospective study

BACKGROUND

The aim of the present study was to compare the feasibility, safety and efficacy of the through-the-scope (TTS) stent technique to that of the standard metallic stent technique for the management of malignant colorectal obstruction.

METHODS

Fifty-two patients scheduled to receive stent insertion for the management of acute obstructive colorectal cancer were enrolled in our study and divided into a TTS stent group (n = 24) and a standard stent group (n = 28). The stent insertion procedure was performed under endoscopic and fluoroscopic guidance in all patients. The success rate, complications, fluoroscopic time, and clinical remission rate were recorded and compared.

RESULTS

The technique success rate was 100 % (24/24) in the TTS stent group and 78.6 % (22/28) in the standard stent group (p = 0.03). In five patients in the standard stent group, the stent failed to pass through occlusive lesions because of the stiffness of the stent system. Serious bleeding occurred in one patient in the standard stent group. The fluoroscopy time in the TTS stent group was significantly reduced (12.9 ± 6.6 min) compared with that of the standard stent group (24.8 ± 9.8 min; p < 0.01). Silent perforation occurred in 17.9 % (5/28) of the cases in the standard stent group compared with none in the TTS (p = 0.03). Clinical remission was achieved in 97.1 % (23/24) and 78.6 % (22/28) of patients in the TTS and standard stent groups, respectively (p = 0.11).

CONCLUSIONS

The TTS stent is safer and more feasible for the management of malignant colorectal obstructions than the standard stent, and the TTS technique provides a higher success rate, a similar clinical remission rate, and a markedly reduced fluoroscopic time.

Self-expanding metallic stent improves histopathologic edema compared with transanal drainage tube for malignant colorectal obstruction

AIMS

To compare the usefulness of the self-expanding metallic stent (SEMS) with that of the transanal drainage tube (TDT) and emergency surgery after failure of decompression (ESFD) in patients with malignant colonic obstruction (MCO), and to evaluate post-decompression histopathologic changes.

METHODS

From January 2010 to June 2015, 39 patients with MCO received SEMS, TDT, and ESFD. We evaluated the outcomes including success rates of placement, clinical outcomes after decompression, and histopathologic findings of the resected specimens.

RESULTS

Technical success rates were 100% for SEMS and 78.9% for TDT. Clinical success rates were 100% for SEMS and 80.0% for TDT. Postoperative ileus was significantly less frequent after SEMS than after TDT (p = 0.014). Histopathologic edema grade was significantly lower for SEMS than for TDT and ESFD (p < 0.0001). There was no significant difference between edema grade and duration of decompression in the TDT group (p = 0.629), while all patients with SEMS were classified in a low edema grade (grade 0-2). The rate of stoma creation was significantly higher in patients with a high edema grade (grade 3) than in those with a low edema grade (grade 0-2) (p = 0.003). There was no microscopic perforation in any group.

CONCLUSION

Significantly greater resolution of histopathologic edema was achieved after placement of SEMS than after placement of TDT. These findings provide an indication of favorable clinical outcomes of SEMS in comparison with TDT and ESFD. This article is protected by copyright. All rights reserved.

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.

Intestinal stricture in Crohn's disease

Crohn's disease (CD) is a disease with chronic inflammation of unknown etiology involving any part of the gastrointestinal tract. The incidence and prevalence of CD are increasing recently in Asia. Half of the CD patients will have intestinal complications, such as strictures or fistulas, within 20 years after diagnosis. Twenty-five percentage of CD patients have had at least one small bowel stricture and 10% have had at least one colonic stricture and lead to significant complications. Most of these patients will require at least one surgery during their lifetime. Early diagnosis and evaluation with adequate managements for the patients can prevent disability and mortality of these patient. Here, we reviewed the current incidence of CD with stricture, the etiology of stricture, and how to diagnose and manage the stricture.

Patients who failed endoscopic stenting for left-sided malignant colorectal obstruction suffered the worst outcomes

BACKGROUND

Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking.

OBJECTIVES

This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting.

METHODS

A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed.

RESULTS

From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25-96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61-48.8; p < 0.001) times more likely to develop severe adverse events than those who were successfully stented. The group of patients who failed stenting was also 3.3 (95 % CI, 1.19-9.20; p = 0.026) times more likely to develop severe adverse events than those operated immediately. The only factor that predicted failure of stenting was a more acute angulation between the tumour and the distal lumen.

CONCLUSIONS

Patients who failed endoscopic stenting fared worse than those who were successfully stented and also those who underwent emergency surgery upfront. Identification of factors that predict failures may be vital to minimise morbidity in these high-risk patients.

Analysis of risk factors associated with complications of colonic stenting for malignant obstruction

Self expanding metalic stent (SEMS) application can cause serious problems up to one third of the patients and some studies reported negative effect of SEMSs on survival in patients with malignancy. The SEMS type especially the rigid one like Wall-stent rather than more flexible type Ultraflex was also reported to have bad impact on the risk of perforation we believe that stent based management protocol for patients with non-perforating left sided obstructing colorectal cancer is a complex method that needs qualified medical and technical team.