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Dylen MYC, Lee JWK, Ting LY, Ragupathi T, Yu NJ, Lim F, Farouk R, Seng CC. Transverse Colostomy Differs in Outcomes Compared to Sigmoid Colostomy: A Cohort Analysis. J INVEST SURG 2021; 35:783-787. [PMID: 34334098 DOI: 10.1080/08941939.2021.1956025] [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: 10/20/2022]
Abstract
PURPOSE Our aim was to identify any differences in outcomes following transverse versus sigmoid colostomy creation for management of cancer. METHODS Transverse and sigmoid colostomies are used to manage cancer-related complications including obstruction, perforation, and fistulation. The decision to use either colostomy is largely based on the surgeon's preference and the location of the cancer complication. All patients treated for cancer complications with the use of a sigmoid or transverse colostomy at National University Hospital between January 2011 and December 2016 were included. Patient characteristics and distribution frequencies were reported based on the operation performed. Post procedure morbidity and mortality was compared. Univariate and subgroup analysis were performed. RESULTS This was a single-center, retrospective cohort study of 93 patients who underwent a colostomy creation over a 5-year duration. Of the 93 patients included, 56 underwent a transverse colostomy (median age 59, 26 male, 30 female) and 37 a sigmoid colostomy (median age 64, 20 male, 17 female). According to univariate analysis, higher rates of stoma prolapse were seen patients with transverse colostomies. There were no differences in complications between a laparoscopic or open approach. There were no differences in the rate of other postoperative complications. CONCLUSION Sigmoid colostomies were associated with a lower prolapse rate compared to transverse colostomies for cancer management. The manner of surgical approach did not affect rate of postoperative complications.
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Affiliation(s)
| | - James Wai Kit Lee
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore
| | - Lim Yi Ting
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tharun Ragupathi
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore
| | - Ng Jing Yu
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Frances Lim
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore
| | - Ridzuan Farouk
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore
| | - Chong Choon Seng
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore
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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: 0.2] [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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Self-expanding metallic stent as a bridge to surgery in the treatment of left colon cancer obstruction: Cost-benefit analysis and oncologic results. Cir Esp 2017; 95:143-151. [PMID: 28336185 DOI: 10.1016/j.ciresp.2016.12.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/26/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. METHODS This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat" analysis. RESULTS There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. CONCLUSIONS The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.
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Alcántara M, Serra-Aracil X, Falcó J, Mora L, Bombardó J, Navarro S. Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer. World J Surg 2011. [PMID: 21559998 DOI: 10.1007/s00268-011-1139y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The main aim of this study was to compare short-term results and long-term outcomes of patients who underwent intraoperative colonic lavage (IOCL) with primary anastomosis with those who had stent placement prior to scheduled surgery for obstructive left-sided colonic cancer (OLCC). METHODS We conducted a prospective, controlled, randomized study of patients diagnosed with OLCC. Patients were divided into two groups: stent and deferred surgery (group 1) and emergency IOCL (group 2). Demographic variables, risk prediction models, postoperative morbidity and mortality, staging, complications due to stent placement, surgical time, clinical follow-up, health costs, and follow-up of survival were recorded. RESULTS Twenty-eight patients (15 group 1 and 13 group 1) were enrolled. The study was suspended upon detecting excess morbidity in group 2. The two groups were homogeneous in clinical and demographic terms. Overall morbidity in group 1 was 2/15 (13.3%) compared with 7/13 (53.8%) in group 2 (p = 0.042). None of the 15 patients in group 1 presented anastomotic dehiscence compared with 4/13 (30.7%) in group 2 (p = 0.035). Surgical site infection was detected in 2 (13.3%) patients in group 1 and in 6 (46.1%) in group 2 (p = 0.096). Postoperative stay was 8 days (IQR 3, group 1) and 10 days (IQR 10, group 2) (p = 0.05). The mean follow-up period was 37.6 months (SD = 16.08) with no differences in survival between the groups. CONCLUSION In our setting, the use of a stent and scheduled surgery is safer than IOCL and is associated with lower morbidity, shorter hospital stay, and equally good long-term survival.
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Affiliation(s)
- M Alcántara
- Colorectal Surgery Unit, Corporación Sanitaria y Universitaria Parc Tauli (Universitat Autónoma de Barcelona), Parc Taulí s/n, 08208 Sabadell, Barcelona, Spain.
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Alcántara M, Serra-Aracil X, Falcó J, Mora L, Bombardó J, Navarro S. Prospective, Controlled, Randomized Study of Intraoperative Colonic Lavage Versus Stent Placement in Obstructive Left-sided Colonic Cancer. World J Surg 2011; 35:1904-10. [DOI: 10.1007/s00268-011-1139-y] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 2010; 25:1814-21. [PMID: 21170659 DOI: 10.1007/s00464-010-1471-6] [Citation(s) in RCA: 219] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 11/02/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical management of left colonic cancer presenting as an acute obstruction remains controversial and still is associated with high mortality and morbidity rates. Recently, self-expandable metallic stents (SEMS) have been used as a bridge to surgery in an attempt to decompress the colon and then allow elective one-stage surgical resection without stoma placement. This study aimed to compare the outcomes of emergency surgery alone with emergency placement of colonic SEMS as a bridge to surgery in terms of efficiency and reduction of the stoma placement rate. METHODS A multicenter prospective, randomized, controlled trial was conducted according to the consolidated standards of reporting trials (CONSORT) Statement criteria. Patients eligible for the study were randomized to either emergency surgery or emergency SEMS as a bridge to surgery. The primary outcome was the need for a stoma (temporary or permanent) for any reason. The secondary end points were mortality, morbidity, and length of hospital stay. RESULTS Nine centers participated in the trial. Among the 70 patients eligible for the study, 60 were randomized and included for the final analysis, 30 patients in each group. Seven patients were randomized but did not fulfill the entry requirements, whereas three further eligible patients were not randomized for various reasons. Concerning the primary outcome, 17 patients in the surgery group sustained a stoma placement versus 13 patients in the SEMS group (p=0.30). No statistically significant difference was noted concerning the secondary outcomes. A total of 16 attempts at SEMS placement (53.3%) were technical failures. Two colonic perforations directly related to the stent placement procedure occurred among the 30 randomized patients and 1 perforation occurred among the nonrandomized patients, leading to premature closure of inclusions in the study before the expected number of 80 patients was reached. CONCLUSION This randomized trial failed to demonstrate that emergency preoperative SEMS for patients presenting with acute left-sided malignant colonic obstruction could significantly decrease the need for stoma placement.
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Affiliation(s)
- Isabelle A Pirlet
- Digestive Surgery Unit, Hôpital Saint Eloi, Montpellier University Hospital, Montpellier Cedex 5, France
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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: 37] [Impact Index Per Article: 2.5] [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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Scabini S, Rimini E, Romairone E, Scordamaglia R, Damiani G, Pertile D, Ferrando V. Colon and rectal surgery for cancer without mechanical bowel preparation: one-center randomized prospective trial. World J Surg Oncol 2010; 8:35. [PMID: 20433721 PMCID: PMC2873340 DOI: 10.1186/1477-7819-8-35] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Accepted: 04/30/2010] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. The aim of the study was to assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. METHODS Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. RESULTS Two hundred forty four patients were included in the study, 120 in group A and 124 in group B. Demographic characteristics, type of surgical procedure and type of anastomosis did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups but the overall infectious complications rate was 20.0% in group A and 11.3% in group B (p .05). Wound infection (p = 0.18), anastomotic leak (p = 0.52), and intra-abdominal abscess (p = 0.36) occurred in 9.2%, 5.8%, and 5.0% versus 4.8%, 4.0%, and 2.4%, respectively. No mechanical bowel preparation seems to be safe also in rectal surgery. CONCLUSIONS These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.
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Affiliation(s)
- Stefano Scabini
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
| | - Edoardo Rimini
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
| | - Emanuele Romairone
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
| | - Renato Scordamaglia
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
| | - Giampiero Damiani
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
| | - Davide Pertile
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
| | - Valter Ferrando
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy
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Palliation of malignant rectal obstruction from invasive prostate cancer with multiple overlapping self-expanding metal stents. South Med J 2010; 102:1257-9. [PMID: 20016435 DOI: 10.1097/smj.0b013e3181bf69a4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Self-expandable metal stents (SEMS) are used for colonic neoplastic and extracolonic metastatic obstruction relief. Limited data exists on their use for locally invasive prostate cancer. We describe a unique approach using overlapping SEMS to alleviate a rectosigmoid obstruction from locally invasive prostate cancer. A patient with locally advanced prostate cancer presented with obstipation and lymphedema. Placement of overlapping rectosigmoid SEMS was performed, relieving the visualized rectosigmoid obstruction.
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Keswani RN, Azar RR, Edmundowicz SA, Zhang Q, Ammar T, Banerjee B, Early DS, Jonnalagadda SS. Stenting for malignant colonic obstruction: a comparison of efficacy and complications in colonic versus extracolonic malignancy. Gastrointest Endosc 2009; 69:675-80. [PMID: 19251009 DOI: 10.1016/j.gie.2008.09.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 09/05/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Self-expandable metal stent placement for palliation of malignant colonic obstruction for colorectal cancer (CRC) is safe and efficacious. In contrast, outcomes of stent placement for extracolonic malignancy (ECM) are unclear. OBJECTIVE To compare the success and complication rates of colorectal stenting in patients with CRC versus those with ECM. DESIGN Retrospective chart review. SETTING Tertiary-care academic medical center. PATIENTS AND INTERVENTIONS Between September 2000 and December 2007, all patients with malignant colon obstruction in whom endoscopy was performed with the intention of placing a colonic metal stent. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates, surgical interventions, and procedure-related complications. RESULTS Colonic stenting was performed for CRC in 34 patients and for ECM in 15 patients. Patients with CRC were more likely to have clinical success after all endoscopic therapy (94.1%) than those with ECM (20.0%) (P < .0001). Surgical diversion to relieve persistent obstructive symptoms was required in significantly more patients with ECM. Five patients with ECM (33.3%) had at least one complication, including 2 deaths, compared with 3 patients with CRC (8.8%) (P = .046). Only underlying ECM was predictive of failed colon stent placement by multivariate analysis (hazard ratio 21.0, P = .0013). A history of radiation therapy was the sole predictor of complications (hazard ratio 7.8, P = .048). LIMITATIONS Single institution, retrospective analysis, relatively small sample size. CONCLUSIONS Colon stenting for large-bowel obstruction from ECM is infrequently successful and is associated with a significantly higher risk of complications in comparison with patients with CRC.
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Affiliation(s)
- Rajesh N Keswani
- Interventional and Pancreatobiliary Endoscopy Section, Section of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA.
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A dilemma in geriatric oncology: malignant bowel obstruction in an 81-year-old man. Cancer Treat Rev 2008; 34 Suppl 2:S17-22. [PMID: 19101404 DOI: 10.1016/s0305-7372(08)70005-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An 81-year-old male presenting with bowel obstruction was found upon examination to have bilobar liver metastases. In light of the patient's advanced age, bowel resection was foregone in favor of stent deployment, which led to rapid resolution of symptoms. The multidisciplinary team assembled to coordinate further care advised the use of chemotherapy with irinotecan, oxaliplatin, and 5-FU, which was well tolerated and led to an objective response. The special considerations relevant to the patient's advanced age, including the choice of stent deployment rather than resection and the decision to employ 5-FU-based chemotherapy in spite of limited trial data with this approach in patients of advanced age, are explained in detail.
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Clinical application of self-expandable metallic stent for treatment of colorectal obstruction caused by extrinsic invasive tumors. Dis Colon Rectum 2008; 51:578-83. [PMID: 18259816 DOI: 10.1007/s10350-008-9207-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Revised: 09/01/2007] [Accepted: 10/17/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this study was to extend the application of self-expandable metallic stents by investigating their usefulness in treating colorectal obstructions caused by unresectable extrinsic tumors. METHODS From January 2000 to November 2005, a total of 60 colorectal stenting procedures were performed, and 57 stents were deployed in 39 patients with extrinsic tumors. The success rate and complications were analyzed retrospectively. RESULTS The most common etiology and location of obstruction were advanced gastric cancer and transverse colon. Technical success was 34 of 39 patients (87.2 percent). The causes of technical failure were immediate stent migration (n = 1), technical problems (n = 1), and access failure because of bowel immobilization (n = 3). Clinical success was 32 of 34 technical successes (82.1 percent). The two patients without clinical success had multifocal strictures of the bowel. Complications occurred in 22 of 57 stents (38.6 percent), including stent reobstruction (n = 14) and stent migration (n = 5). All of stent migrations except one developed with covered stents. CONCLUSIONS In patients with colonic obstruction caused by extrinsic tumors, stent insertion provided effective symptom relief and can be a reasonable alternative choice to a colostomy. An uncovered stent might be more preferable, considering less migration and remaining short life expectancy, compared with a covered stent.
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Fregonese D, Naspetti R, Ferrer S, Gallego J, Costamagna G, Dumas R, Campaioli M, Morante AL, Mambrini P, Meisner S, Repici A, Andreo L, Masci E, Mingo A, Barcenilla J, Petruzziello L. Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction. Gastrointest Endosc 2008; 67:68-73. [PMID: 18028916 DOI: 10.1016/j.gie.2007.05.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2007] [Accepted: 05/09/2007] [Indexed: 01/12/2023]
Abstract
BACKGROUND Emergency surgery for malignant colon obstruction entails relatively high morbidity and mortality rates and typically necessitates a 2-step resection. These problems might be potentially mitigated by placement of a self-expanding metal stent (SEMS) as a bridge to surgery. A nitinol colorectal SEMS may offer several advantages, but available evidence on the utility of this SEMS type remains highly limited. OBJECTIVE Our purpose was to evaluate the effectiveness and safety as a bridge to surgery of a nitinol SEMS designed for colorectal use. DESIGN Prospective and retrospective multicenter clinical study. SETTING Sixteen European study centers. PATIENTS Thirty-six patients with malignant colonic obstruction. INTERVENTIONS Nitinol colorectal SEMS placement. MAIN OUTCOME MEASURES Technical success in accurate SEMS placement with coverage of the entire stricture length, clinical success in alleviating colonic obstructive symptoms, and bridging to elective surgery. RESULTS Technical success was achieved in 97% of patients with a 95% CI of 85% to 100% and clinical success in 81% (95% CI, 64%-92%). Elective surgery was performed in 94% (95% CI, 81%-99%) of patients at a median of 11 days (95% CI, 7-15 days) after SEMS placement. SEMS-related perforation occurred in 3 patients. LIMITATIONS No control group was included in this nonrandomized cohort study. CONCLUSIONS In this first comparatively large clinical study of a nitinol colorectal SEMS as a bridge to surgery, a high proportion of patients successfully proceeded to elective surgery after prior decompression by SEMS placement.
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Affiliation(s)
- Diego Fregonese
- Camposampiero, Firenze, Rome, Prato, Torino, Milan, Italy, Valencia, Madrid, Burgos, Alicante, Palencia, Spain, Nice, Ajaccio, France, Copenhagen, Denmark
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Alcantara M, Serra X, Bombardó J, Falcó J, Perandreu J, Ayguavives I, Mora L, Hernando R, Navarro S. Colorectal stenting as an effective therapy for preoperative and palliative treatment of large bowel obstruction: 9 years' experience. Tech Coloproctol 2007; 11:316-22. [PMID: 18060531 DOI: 10.1007/s10151-007-0372-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Accepted: 09/20/2007] [Indexed: 01/02/2023]
Abstract
BACKGROUND Since their introduction, selfextending metal stents (SEMS) have established themselves as an option in the treatment of obstructive colorectal cancer. Thanks to stenting, patients traditionally treated with emergency surgery can now be converted to scheduled surgery with mechanical preparation of the colon and primary anastomosis. Stenting represents a valid one-step surgical alternative for intestinal obstruction of the colon. METHODS We performed a prospective study of 95 patients (mean age, 68 years; range 48-94) with large bowel obstruction due to colorectal cancer treated with SEMS placed under fluoroscopic guidance, some as a bridge to surgery (group A) and others with palliative intent (group B). Computed tomography was performed for diagnostic purposes and to study the extent of disease. RESULTS Treatment was palliative in 28 cases (group B) and as a bridge to surgery in 67 (group A). The latter group underwent mechanical preparation of the colon and elective surgery. No patients died as a result of the procedure. In 90 cases (95%), treatment was effective and the obstruction resolved. Complications were 4 cases of perforation, 1 of tenesmus, 4 obstructions and 4 migrations. In 7 cases, a second stent was inserted to allow subsequent scheduled surgery. CONCLUSIONS Self-extending stents resolve colorectal cancer obstruction and allow optimal patient staging and scheduled surgical treatment. Stenting is also a useful option in advanced or irresectable tumors, avoiding the need for surgery and offering good palliation.
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Affiliation(s)
- M Alcantara
- Coloproctology Unit, Sabadell Hospital, Parc Taulí S/N 08208, Sabadell Barcelona, Spain.
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Abstract
OBJECTIVE To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature. SUMMARY BACKGROUND DATA Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers. METHODS A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review. RESULTS Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates. CONCLUSIONS Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.
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Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 2007; 246:24-30. [PMID: 17592286 PMCID: PMC1899207 DOI: 10.1097/01.sla.0000261124.72687.72] [Citation(s) in RCA: 297] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature. SUMMARY BACKGROUND DATA Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers. METHODS A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review. RESULTS Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates. CONCLUSIONS Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.
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Affiliation(s)
- Amber M Watt
- ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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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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Roig JV, García-Armengol J, Alós R, Solana A, Rodríguez-Carrillo R, Galindo P, Fabra MI, López-Delgado A, García-Romero J. Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición? Cir Esp 2007; 81:240-6. [PMID: 17498451 DOI: 10.1016/s0009-739x(07)71312-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required.
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Affiliation(s)
- José V Roig
- Servicio de Cirugía General y Digestiva, Consorcio Hospital General Universitario de Valencia, Valencia, España.
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Mucci-Hennekinne S, Kervegant AG, Regenet N, Beaulieu A, Barbieux JP, Dehni N, Casa C, Arnaud JP. Management of acute malignant large-bowel obstruction with self-expanding metal stent. Surg Endosc 2007; 21:1101-3. [PMID: 17356934 DOI: 10.1007/s00464-007-9258-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 11/20/2006] [Accepted: 12/18/2006] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction. METHODS Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. RESULTS In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication. CONCLUSIONS Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.
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Affiliation(s)
- S Mucci-Hennekinne
- Department of Visceral Surgery, CHU-Angers, 4 rue Larrey, Angers-49100, France
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20
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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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Beham A, Rentsch M, Püllmann K, Mantouvalou L, Spatz H, Schlitt HJ, Obed A. Survival benefit in patients after palliative resection vs non-resection colon cancer surgery. World J Gastroenterol 2006; 12:6634-8. [PMID: 17075976 PMCID: PMC4125668 DOI: 10.3748/wjg.v12.i41.6634] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [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 evaluate survival in patients undergoing palliative resection versus non-resection surgery for primary colorectal cancer in a retrospective analysis.
METHODS: Demographics, TNM status, operating details and survival were reviewed for 67 patients undergoing surgery for incurable colorectal cancer. Palliative resection of the primary tumor was performed in 46 cases in contrast to 21 patients with non-resection of the primary tumor and bypass surgery. Risk factors for postoperative mortality and poor survival were analyzed with univariate and multivariate analyses.
RESULTS: The two groups were comparable in terms of age, gender, preoperative presence of ileus and tumor stage. Multivariate analysis showed that median survival was significantly higher in patients with palliative resection surgery (544 vs 233 d). Differentiation of the tumor and tumor size were additional independent factors that were associated with a significantly poorer survival rate.
CONCLUSION: Palliative resection surgery for primary colorectal cancer is associated with a higher median survival rate. Also, the presence of liver metastasis and tumor size are associated with poor survival. Therefore, resection of the primary tumor should be considered in patients with non-curable colon cancer.
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Affiliation(s)
- A Beham
- Department of Surgery, The University of Regensburg, Franz-Josef-Strauss Allee 11, 93053 Regensburg, Germany.
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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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Abstract
Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.
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Affiliation(s)
- Heather Rossi
- Department of Surgery, University of Minnesota Cancer Center, 420 Delaware Street SE, Mayo Mail Code 195, Minneapolis, MN 55455, USA
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24
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OKI E, OKUYAMA T, HIGASHI H, YOSHIDA M, BABA H, MAEHARA Y. Preoperative insertion of transanal ileus tubes for treatment of acute obstruction in cancer of the colon and rectum. Asia Pac J Clin Oncol 2005. [DOI: 10.1111/j.1743-7563.2005.00012.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Watson AJM, Shanmugam V, Mackay I, Chaturvedi S, Loudon MA, Duddalwar V, Hussey JK. Outcomes after placement of colorectal stents. Colorectal Dis 2005; 7:70-3. [PMID: 15606589 DOI: 10.1111/j.1463-1318.2004.00727.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonic stents are increasingly used to palliate or alleviate large bowel obstruction in patients with colon cancer and other obstructing lesions in whom a definitive surgical procedure is inappropriate. We report on the outcomes of a large group of patients who underwent deployment of a colon stent in a single institution by a single operator. PATIENTS AND METHODS This was a retrospective observational cohort study of all patients undergoing colonic stenting between September 1995 and May 2002. Data collected included nature of pathology, type of stent used, procedure morbidity, patient survival and details of any definitive procedures performed after stenting. RESULTS One hundred and seven patients were evaluated (58 male) with a median age of 75 years (range 36-99 years). A total of 112 stents were successfully deployed (46 as an emergency). Twelve patients had double stents inserted coaxially and overlapping. In 7 patients the stent could not be safely deployed. Eighty-seven patients had colorectal cancer, 13 patients had an extra-luminal malignancy, 5 had diverticular strictures and in 2 patients the pathology was unknown. At last review (May 2002) 18 patients were alive, 82 patients had died and 7 patients had been lost to follow-up. Of those patients who died, the median survival after stenting alone was 6 weeks (range 4 days-36 weeks). Ten patients underwent subsequent definitive surgery. Stent complications included, 2 colonic perforations, 3 stent occlusions and 4 stent migrations. CONCLUSION Colonic stenting can be used effectively, with acceptable morbidity, to manage patients presenting with large bowel obstruction. In a smaller number of patients colon stents may safely temporize symptoms while definitive surgery is planned.
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Affiliation(s)
- A J M Watson
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.
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26
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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: 6.3] [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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Biondo S, Parés D, Frago R, Martí-Ragué J, Kreisler E, De Oca J, Jaurrieta E. Large bowel obstruction: predictive factors for postoperative mortality. Dis Colon Rectum 2004; 47:1889-97. [PMID: 15622582 DOI: 10.1007/s10350-004-0688-7] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction. METHODS Two-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmann's procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit < or = 30 percent, hemoglobin < or = 10 g/dl, and leukocyte count >15,000/mm3). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality. RESULTS One or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III-IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression. CONCLUSION Large bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.
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Affiliation(s)
- Sebastiano Biondo
- Department of Surgery, Hospital Universitario de Bellvitge, University of Barcelona, Barcelona, Spain.
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Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004; 99:2051-2057. [PMID: 15447772 DOI: 10.1111/j.1572-0241.2004.40017.x] [Citation(s) in RCA: 411] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expanding metal stents have been used in the management of colorectal obstruction as an alternative to emergency surgery. Our aim was to systematically review the efficacy and safety of these stents in the setting of malignant colorectal obstruction. METHODS Both English and foreign language reports were identified from Medline, Embase, Cancerlit, Science Citation Index, Cochrane Library, and proceedings of relevant meetings. Data were collected on technical success, clinical success, and safety parameters. RESULTS Fifty-four studies reported the use of stents in a total of 1,198 patients. The median technical and clinical success rates were 94% (i.q.r. 90-100) and 91% (i.q.r. 84-94), respectively. The clinical success when used as a bridge to surgery was 71.7%. Major complications related to stent placement included perforation (3.76%), stent migration (11.81%), and reobstruction (7.34%). Factors related to an increased complication risk were identified. Stent-related mortality was 0.58%. Limited available data suggest that this approach may be cost effective in the preoperative setting. CONCLUSION Placement of self-expanding metal stents is an effective and safe definitive procedure in the palliation of malignant colorectal obstruction. In operable patients, it provides a useful option to avoid colostomy, by facilitating safer single-stage surgery.
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Affiliation(s)
- Shaji Sebastian
- Department of Gastroenterology, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland
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29
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Saida Y, Sumiyama Y, Nagao J, Nakamura Y, Nakamura Y. EXPERIENCES OF SELF-EXPANDABLE METALLIC STENT FOR COLORECTAL OBSTRUCTIONS: 70 CASES. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00371.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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Law WL, Chan WF, Lee YM, Chu KW. Non-curative surgery for colorectal cancer: critical appraisal of outcomes. Int J Colorectal Dis 2004; 19:197-202. [PMID: 14618348 DOI: 10.1007/s00384-003-0551-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2003] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The value of surgery for patients with incurable colorectal cancer is controversial. This study evaluated outcomes in patients undergoing non-curative surgery for colorectal cancer and aimed to identify patients who would benefit from palliative surgery. PATIENTS AND METHODS Demographics, tumour characteristics, operating details and outcomes were reviewed for 180 patients undergoing surgery for incurable colorectal cancer; palliative resection was performed in 150 cases. Seventeen patients died in the postoperative period. Risk factors for postoperative mortality and poor survival were analysed with univariate and multivariate analysis. RESULTS Multivariate analysis showed that operative mortality was significantly higher in patients with non-resection surgery and in those with ascites. Median survival of patients with resection was significantly longer than in those without resection (30 vs. 17 weeks). Other independent factors that were significantly associated poor survival were the presence of ascites, presence of bilobar liver metastasis and absence of chemotherapy and/or radiation therapy. CONCLUSION Non-curative surgery is associated with high mortality in patients without resection and in the presence of ascites. These two factors, together with the presence of bilobar liver metastasis and the absence of chemotherapy and/or radiation therapy, are associated with poor survival. In the presence of these factors the balance between the benefit and risk of surgery should be carefully considered before decision for operative treatment.
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Affiliation(s)
- Wai Lun Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Pokfulam Road, Hong Kong, China.
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Piccinni G, Angrisano A, Testini M, Bonomo GM. Definitive palliation for neoplastic colonic obstruction using enteral stents: Personal case-series with literature review. World J Gastroenterol 2004; 10:758-64. [PMID: 14991956 PMCID: PMC4716927 DOI: 10.3748/wjg.v10.i5.758] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute colonic obstruction due to malignancies is an emergency that requires surgical treatment. Elderly patients or inoperable tumors require intestinal decompression that is a simple colostomy in almost all cases. This “manoeuvre” leads the patient to a percentage of mortality/morbidity and to a bad quality of life due to acceptance of stoma. The introduction of enteral metal stent inserted endoscopically has, in our opinion, provided a new way to obtaining the definitive palliation of inoperable colo-rectal cancer with a simple method. We reported our case-series and we analyzed the current literature and costs of treatments.
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Affiliation(s)
- Giuseppe Piccinni
- Sezione di Chirurgia Generale, Vascolare ed Oncologia Clinica, Dipartimento per le Applicazioni in Chirurgia delle Tecnologie Innovative Universita di Bari, Policlinico, Piazza G. Cesare 11, 70124 Bari, Italy.
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Dauphine CE, Tan PY, Beart RW, Corman ML, Vukasin P. Self-expanding metallic stents in the management of lower gastrointestinal hemorrhage. J Laparoendosc Adv Surg Tech A 2004; 13:407-9. [PMID: 14733707 DOI: 10.1089/109264203322656504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A case of an 82-year-old woman is reported who developed a lower gastrointestinal hemorrhage secondary to metastatic ovarian carcinoma to the colon. The bleeding, associated with an incomplete obstruction of the large bowel, was successfully treated with the endoscopic insertion of two self-expanding metal stents. A technique of stent placement is presented which differs from that previously reported, where both stents were via colonoscopy and without the use of fluoroscopy.
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Affiliation(s)
- Christine E Dauphine
- Division of Colon and Rectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles County/USC Medical Center, Los Angeles, California, USA
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Law WL, Choi HK, Chu KW. Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer. Br J Surg 2003; 90:1429-33. [PMID: 14598426 DOI: 10.1002/bjs.4311] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Self-expanding metallic stents provide an alternative to surgery as definitive palliation in patients with obstructing colorectal cancer. This study aimed to compare the outcome of patients with obstruction due to primary left-sided colorectal cancer treated by palliative stenting with outcome in patients who had undergone surgery. METHODS Patients with incurable obstructing primary colorectal cancer distal to the splenic flexure treated with emergency surgery (n = 31) or placement of a metallic stent (n = 30) from November 1997 to June 2002 were included. Data on the mortality, morbidity, necessity of intensive care and hospital stay for the two groups were compared. The subsequent outcomes, including the incidence of stoma creation and survival, were also analysed. RESULTS The two groups were similar in terms of age, sex distribution and presence of co-morbidity. Insertion of metallic stents was successful in 29 of 30 patients. Hospital death occurred in four and eight patients in the study and control groups respectively (P = 0.335). Fewer patients with placement of a stent required intensive care (1 versus 11; P = 0.001) and the median hospital stay was shorter in patients with stenting (4 versus 8 days; P = 0.008). A stoma was subsequently created in four patients with stenting, whereas 15 patients who had emergency operation required a stoma (P = 0.005). The difference in median survival between the two groups was not statistically significant (107 versus 119 days; P = 0.088). CONCLUSION Self-expanding metallic stents are effective in the palliation of obstructing colorectal cancer. Placement of stents is associated with a shorter hospital stay, less likelihood of intensive care and a lower incidence of stoma creation, when compared with emergency surgery. Thus insertion of a metallic stent should be considered in patients with incurable obstructing colorectal cancer.
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Affiliation(s)
- W L Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Pokfulam Road, Hong Kong, China.
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Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Foundation, Rochester, Minnesota, USA
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35
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Scurtu R, Barrier A, André T, Houry S, Huguier M. [Self-expandable metallic stent for palliative treatment of colorectal malignant obstructions: risk of perforation]. ANNALES DE CHIRURGIE 2003; 128:359-63. [PMID: 12943830 DOI: 10.1016/s0003-3944(03)00118-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The self-expandable metallic stents are a good alternative to surgery for the palliative treatment of malignant colonic obstructions. The aim of this paper was to emphasize the causes which could increase the risk of perforation. PATIENTS AND METHODS From November 2000 to November 2001, 6 patients with malignant colonic obstruction, to whom surgery was denied due to tumor extension and/or poor general condition, have had a palliative treatment (N = 5) or an attempt (N = 1) with self-expandable metallic stents placed by endoscopy. RESULTS Only one patient did not developed any complication and died 5 months later of cancer. Five out of the 6 patients (83%) developed a colonic perforation following stenting (N = 4) or the attempt to place the stent (N = 1), two into the first 24 h after the procedure, and three 3, 5, and 10 months later. Subsequent colostomy was done in 2 patients while the 3 others have had an external drainage of the perforation and died postoperatively. CONCLUSION The self-expandable metallic stents seems to be a less aggressive alternative therapy to surgery for malignant colonic obstructions. Nevertheless, the high rate of colonic perforations, suggests reconsidering the indications in the definitive palliation of malignant colonic obstructions.
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Affiliation(s)
- R Scurtu
- Service de chirurgie générale et digestive, CHU Tenon, 4, rue de la Chine, 75970 Paris 20, France
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36
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Zmora O, Mahajna A, Bar-Zakai B, Rosin D, Hershko D, Shabtai M, Krausz MM, Ayalon A. Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg 2003; 237:363-7. [PMID: 12616120 PMCID: PMC1514315 DOI: 10.1097/01.sla.0000055222.90581.59] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. SUMMARY BACKGROUND DATA Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. METHODS Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. RESULTS Three hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. CONCLUSIONS These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.
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Affiliation(s)
- Oded Zmora
- Department of Surgery, Sheba Medical Center and Sackler School of Medicine, Tel Aviv, Israel.
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Abstract
BACKGROUND Colorectal stents are being used for palliation and as a 'bridge to surgery' in obstructing colorectal cancers. METHODS A systematic review of the published data on stenting for the treatment of colorectal obstruction was carried out by searching Medline and other online databases for the period from January 1990 to December 2000. A total of 58 publications (case series, single case reports and reviews) was found, of which 29 case series were included in the analysis. Technical and clinical success, complications and reobstruction, both in palliation and as a 'bridge to surgery', were assessed. Both descriptive statistics and pooled analyses were carried out. RESULTS Pooled results showed that stent insertion was attempted in 598 instances. Technical success was achieved in 551 (92 per cent) and clinical success in 525 (88 per cent). Palliation was achieved in 302 (90 per cent) of 336 cases, while 223 (85 per cent) of 262 insertions succeeded as a 'bridge to surgery' (95 per cent had a one-stage surgical procedure). There were three deaths (1 per cent). Perforation occurred 22 times (4 per cent). Stent migration was reported in 54 (10 per cent) of 551 technically successful cases. The rate of stent reobstruction was 52 (10 per cent) of 525, mainly in the palliative group. CONCLUSION Evidence suggests that colorectal stents offer good palliation, and are safe and effective as a 'bridge to surgery'. Stent usage can avoid the need for a stoma, and is associated with low rates of mortality and morbidity. Dilatation of malignant strictures at the time of stent placement appears to be dangerous and should be avoided.
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Affiliation(s)
- U P Khot
- Department of Surgery, Darent Valley Hospital, Dartford, UK
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Dauphine CE, Tan P, Beart RW, Vukasin P, Cohen H, Corman ML. Placement of self-expanding metal stents for acute malignant large-bowel obstruction: a collective review. Ann Surg Oncol 2002; 9:574-9. [PMID: 12095974 DOI: 10.1007/bf02573894] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this study was to review our experience with self-expanding metal stents as the initial interventional approach in the management of acute malignant large-bowel obstruction. METHODS Twenty-six patients who underwent placement of colonic stents at our institution between June 1994 and June 2000 were identified and reviewed. RESULTS In 14 patients, the stents were placed for palliation, whereas in 12, they were placed as a bridge to surgery. In 22 patients (85%), stent placement was successful on the first occasion. In the remaining four individuals, one was successfully stented at the second occasion, and three required emergency surgery. Nine of the 12 patients (75%) in the bridge-to-surgery group underwent elective colon resection. In the palliative group, four patients (29%) had reobstruction of the stents, and in one (9%), the stent migrated. In the remaining nine patients (64%), the stent was patent until the patient died or until the time of last follow-up (median, 156 days). CONCLUSIONS In our experience with 26 patients who developed a complete bowel obstruction as a consequence of a malignant tumor, placement of colonic stents to achieve immediate nonoperative decompression proved to be both safe and effective. Subsequent elective resection was accomplished in the majority of resectable cases.
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Affiliation(s)
- Christine E Dauphine
- Division of Colon and Rectal Surgery, Keck School of Medicine, University of Southern California/Los Angeles County Medical Center, USA
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Wong KS, Cheong DMO, Wong D. Treatment of acute malignant colorectal obstruction with self-expandable metallic stents. ANZ J Surg 2002; 72:385-8. [PMID: 12121153 DOI: 10.1046/j.1445-2197.2002.02431.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Malignant left-sided large bowel obstruction from intraluminal and extrinsic causes constitutes a surgical emergency. When conservative measures fail, emergent surgery is usually required, which carries increased morbidity and mortality compared with elective resections. In many situations, a stoma is created and further surgery may be required later to re-establish bowel continuity. We present an initial series of patients in whom self-expandable metallic stents (SEMS) were deployed to allow bowel decompression in place of emergency surgery for acute left-sided colorectal obstruction. METHODS From April 1999 to January 2001, patients who were admitted to the colorectal unit with clinical and radiological features of intestinal obstruction were considered for endolumenal stenting. Stenting was performed under radiological guidance. RESULTS Sixteen patients underwent endolumenal stenting (age range: 23-90 years, eight men and eight women). There were two technical failures, two delayed perforations and one sealed perforation related to the stent. Three patients underwent elective resection and anastomosis after successful bowel decompression and mechanical bowel preparation. Eight patients with advanced malignancy or multiple medical disease had good bowel decompression after stent deployment and did not undergo any surgery. CONCLUSION SEMS is a useful alternative in the management of acute left-sided colorectal obstruction for a select group of patients. An algorithm for management of acute left-sided large bowel obstruction incorporating the use of SEMS is proposed.
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Affiliation(s)
- Kutt Sing Wong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore.
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40
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Abstract
Radical surgery remains the only potentially curative treatment for colorectal cancer. Major changes in the principles of rectal cancer resection have been recently described (total mesorectum excision) whereas there have been few changes in the principles of colonic cancer resection. This chapter presents surgical procedures for curative treatment of colorectal cancer in both the elective and emergency settings.
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Affiliation(s)
- Emmanuel Mitry
- Fédération des spécialités digestives, Hôpital Ambroise Paré, Boulogne, France
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41
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Abstract
Advances in technology continue at a rapid pace and affect all aspects of life, including surgery. We have reviewed some of these advances and the impact they are having on the investigation and management of colorectal cancer. Modern endoscopes, with magnifying, variable stiffness and localisation capabilities are making the primary investigation of colonic cancer easier and more acceptable for patients. Imaging investigations looking at primary, metastatic and recurrent disease are shifting to digital data sets, which can be stored, reviewed remotely, potentially fused with other modalities and reconstructed as 3 dimensional (3D) images for the purposes of advanced diagnostic interpretation and computer assisted surgery. They include virtual colonoscopy, trans-rectal ultrasound, magnetic resonance imaging, positron emission tomography and radioimmunoscintigraphy. Once a colorectal carcinoma is diagnosed, the treatment options available are expanding. Colonic stents are being used to relieve large bowel obstruction, either as a palliative measure or to improve the patient’s overall condition before definitive surgery. Transanal endoscopic microsurgery and minimally invasive techniques are being used with similar outcomes and a lower mortality, morbidity and hospital stay than open trans-abdominal surgery. Transanal endoscopic microsurgery allows precise excision of both benign and early malignant lesions in the mid and upper rectum. Survival of patients with inoperable hepatic metastases following radiofrequency ablation is encouraging. Robotics and telemedicine are taking surgery well into the 21st century. Artificial neural networks are being developed to enable us to predict the outcome for individual patients. New technology has a major impact on the way we practice surgery for colorectal cancer.
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Affiliation(s)
- G B Makin
- University of Hull Academic Surgical Unit, Castle Hill Hospital, Castle Road, Cottingham HU16 5JQ, United Kingdom
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Schlegel RD, Dehni N, Parc R, Caplin S, Tiret E. Results of reoperations in colorectal anastomotic strictures. Dis Colon Rectum 2001; 44:1464-8. [PMID: 11598475 DOI: 10.1007/bf02234598] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The incidence of colorectal anastomotic strictures varies from 3 to 30 percent. Most of these anastomotic strictures are simple narrowings shorter than 1 cm that can be successfully treated by dilation or endoscopic alternatives. However, up to 28 percent of patients will require surgical correction. This can be technically difficult, with the possibility of a permanent colostomy. This study reports the outcomes after operative treatment of severe strictures of colorectal anastomoses. METHODS From August 1992 to October 1996, 27 patients were referred for surgical treatment of severe rectal anastomotic strictures. The reasons for the initial surgery were as follows: rectal cancer (13), diverticular disease (7), Hirschsprung's disease (2), rectal endometriosis (2), uterine carcinoma with rectal invasion (1), ruptured abdominal aortic aneurysm with rectosigmoid necrosis (1), and rectovaginal fistula (1). There were 15 (56 percent) stapled anastomoses, and 21 (78 percent) patients had developed a postoperative leak. RESULTS The median time between initial surgery and diagnosis of the stenosis was 7.2 (range, 1-24) months and between the last operation and referral was 15.1 (range, 1-44) months. Stenosis was located at a mean distance of 9.5 (range, 4-15) cm from the anal verge. Eleven patients (41 percent) had been unsuccessfully dilated before referral. Surgical correction of the stenosis required 7 colorectal anastomoses for upper rectal anastomotic strictures and 20 coloanal anastomoses for middle and lower rectal strictures (19 Soave's procedures and 1 colon J-pouch-anal anastomosis). Intestinal continuity was restored in all cases. After a mean follow-up of 28.7 +/- 14 months, no recurrences were detected and functional results were satisfactory. CONCLUSIONS Resection of the stenosis and construction of a new colorectal anastomosis can be performed successfully for upper rectal anastomotic stricture. For a stenosis located in the middle and lower rectum, Soave's procedure offers a good alternative, with satisfactory long-term functional results. Whichever technique is used, a permanent colostomy should rarely be required.
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Affiliation(s)
- R D Schlegel
- Department of Digestive Surgery, Hôpital Saint-Antoine AP-HP, University of Paris VI (Pierre et Marie Curie), Paris, France
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Harris GJ, Senagore AJ, Lavery IC, Fazio VW. The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices. Am J Surg 2001; 181:499-506. [PMID: 11513773 DOI: 10.1016/s0002-9610(01)00622-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Colonic endolumenal stenting (CELS) to treat obstructing colorectal neoplasms was first described in 1991. The aim of this study was to review the published world literature and make recommendations for its use in current clinical practice. METHODS Suitable English language reports were identified using a Medline search. RESULTS CELS can been successfully accomplished in 64% to 100% of obstructing malignant colonic lesions. Distal lesions are more common and theoretically more easy to stent although lesions within the ascending colon have been successfully managed. Minor complications include transient anorectal pain and rectal bleeding, however, significant complications of stent dislocation and colonic perforation are also well recognized. CONCLUSION CELS can aid the palliative management of malignant colorectal obstruction. Its role in relieving obstruction prior to resection remains to be defined. Increasing experience has allowed the safe placement of stents and relief of obstruction of virtually any lesion throughout the large bowel.
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Affiliation(s)
- G J Harris
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Tominaga K, Yoshida M, Maetani I, Sakai Y. Expandable metal stent placement in the treatment of a malignant anastomotic stricture of the transverse colon. Gastrointest Endosc 2001; 53:524-7. [PMID: 11275904 DOI: 10.1067/mge.2001.112184] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- K Tominaga
- Third Department of Internal Medicine and the Division of Digestive Endoscopy, Toho University School of Medicine, Ohashi Hospital, Tokyo, Japan
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45
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Yahanda AM. Surgical Emergencies in the Cancer Patient. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Liberman H, Adams DR, Blatchford GJ, Ternent CA, Christensen MA, Thorson AG. Clinical use of the self-expanding metallic stent in the management of colorectal cancer. Am J Surg 2000; 180:407-11; discussion 412. [PMID: 11182388 DOI: 10.1016/s0002-9610(00)00492-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE This report describes our experience with the use of self-expanding metallic stents (SEMS) in the management of obstructing colorectal cancer. METHODS A retrospective chart review of all patients undergoing placement of SEMS between May 1997 and January 2000 was performed. RESULTS Insertion of SEMS was attempted in 12 patients. Successful stent placement was achieved in 10 of the 12 patients. The locations of lesions were hepatic flexure (2), splenic flexure (1), left colon (1), sigmoid colon (4) and rectum (4). The intended uses of SEMS were for palliation in 3 patients and as a bridge to elective surgery in 9. In the latter group, SEMS placement allowed for preoperative bowel preparation in 4 patients and administration of neoadjuvant therapy prior to elective surgery in 2 patients. One patient died prior to definitive surgery. Stent placement was unsuccessful in 2 patients. Three SEMS-related complications occurred; 1 stent migrated and 1 stent obstructed secondary to tumor ingrowth. One patient died 13 days after stent placement and colonic decompression. CONCLUSION SEMS represent a useful tool in the management of obstructing colorectal neoplasms. As a bridge to surgery, SEMS provide time for a complete preoperative evaluation and a mechanical bowel preparation and may obviate the need for fecal diversion or on-table lavage. It may also allow for time to administer neoadjuvant therapy when indicated. As a palliative measure, SEMS can eliminate the need for an operation.
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Affiliation(s)
- H Liberman
- Department of Surgery, Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska 68114, USA
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Law WL, Chu KW, Ho JW, Tung HM, Law SY, Chu KM. Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies. Dis Colon Rectum 2000; 43:1522-7. [PMID: 11089586 DOI: 10.1007/bf02236731] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The treatment of malignant obstruction of the left colon or rectum usually requires emergency surgery on poor-risk patients, and the creation of a stoma is usually inevitable. With the use of self-expanding metallic stents, the prompt relief of large-bowel obstruction without surgery has become possible. This report describes our results in the use of self-expanding metallic stents in the treatment of left-sided colonic obstruction resulting from advanced malignancies. METHODS From November 1997 to March 1999, insertion of self-expanding metallic stents was attempted in 24 patients with acute left-sided colonic obstruction caused by primary or recurrent malignancies. All the procedures were performed by colorectal surgeons. The guidewire was inserted through the channel of the endoscope, and its position was confirmed with fluoroscopy. Uncovered Wallstent esophageal endoprostheses were used in all except the first case. The insertion and deployment of the stents were under both endoscopic and fluoroscopic guidance. RESULTS There were 24 patients (15 males) with a mean age of 63.6 (range, 36-98) years. Thirteen patients had primary colorectal cancer and 11 had recurrent cancers (colorectal cancer, 5; gastric cancer, 5; other, 1). In the treatment of primary colorectal cancer, seven procedures were palliative, and no subsequent surgery was planned because of extensive liver metastasis or poor medical risk. The other six patients underwent elective resection after mechanical bowel preparation. There was no mortality related to the procedure. Stenting was successful in the relief of obstruction in 23 patients. Perforation of the colon occurred in one patient, and an emergency Hartmann's operation was performed. Migration of the stents occurred in three patients. Only 3 of the 18 patients in the palliation group required the subsequent creation of stomas. CONCLUSION The use of the self-expanding metallic stents can achieve rapid and effective nonsurgical means to relieve left-sided colonic obstruction. It provides good palliation for unresectable advanced tumors that cause colonic obstruction. It may also have a role in the temporary relief of obstruction so that subsequent colonic resection can be performed under elective conditions.
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Affiliation(s)
- W L Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong
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Nozoe T, Matsumata T. Usefulness of preoperative colonic lavage using transanal ileus tube for obstructing carcinoma of left colon: device to perform one-stage operation safely. J Clin Gastroenterol 2000; 31:156-8. [PMID: 10993434 DOI: 10.1097/00004836-200009000-00014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgical treatments for patients with obstructing carcinoma of the left colon still remain controversial, and many devices to perform a one-stage operation for such cases have been reported. The aim of the current study was to demonstrate the usefulness of preoperative colonic lavage using a transanal ileus tube to perform a one-stage operation for patients with obstructing carcinoma of the left colon. Five patients with intestinal obstruction due to advanced carcinoma of the left colon were investigated. An ileus tube was transanally inserted and placed in the colon proximal to the tumor under the guidance of a colonoscope and guidewire. Preoperative colonic lavage was done with oral administration of an irrigating solution over several days. By using a transanal ileus tube, preoperative colonic lavage can be done, which enables us to safely perform a one-stage operation for patients with obstructing carcinoma of the left colon with no increase in complications or anastomotic leakage.
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Affiliation(s)
- T Nozoe
- Department of Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
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Camúñez F, Echenagusia A, Simó G, Turégano F, Vázquez J, Barreiro-Meiro I. Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology 2000; 216:492-7. [PMID: 10924576 DOI: 10.1148/radiology.216.2.r00au12492] [Citation(s) in RCA: 189] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To determine the effectiveness and safety of metallic stents in the treatment of malignant colorectal obstruction before surgery and for palliation. MATERIALS AND METHODS Eighty patients with acute malignant colorectal obstruction presumed to be malignant were treated by means of implanting self-expanding metallic stents. RESULTS Stent placement was successful in 70 of the 80 patients and resolved bowel obstruction in 67 patients (96%). Two patients had colonic perforation and developed peritonitis 18 and 24 hours after stent placement; one patient died as a consequence. Thirty-three patients underwent elective surgery after 7 days +/- 3 (SD; range, 4-10 days), and adequate tumoral coverage and cleansing of the colon were observed in all patients. Stent placement was used as final palliative treatment in another 35 patients. Patient follow-up lasted a mean of 138 days +/- 93 (range, 36-334 days). The survival rate for the palliative group was 55% at 3 months, 44% at 6 months, and 25% at 9 months. The estimated primary stent patency rate was 91% at 3 and 6 months. CONCLUSION Management of colorectal obstruction by using metallic stents was effective and safe, although colonic perforation is a potential complication. In cases of palliation, the method may obviate palliative colostomy.
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Affiliation(s)
- F Camúñez
- Departments of Radiology and Surgery, Hospital General Universitario "Gregorio Marañón," Madrid, Spain
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50
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Abstract
This article discusses multimodal treatment of noncomplicated colon and rectal cancer, considerations for specific types of colon cancer, considerations that may modify the extent and technique of surgery, the role of adjuvant chemotherapy for colon adenocarcinoma and rectal cancer, and surgical treatment of complicated colorectal cancer.
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Affiliation(s)
- I C Lavery
- Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Ohio, USA
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