• Colonoscopy
• Intestinal obstruction
• Self-expandable metallic stents
• Simulation training

• Korean Gastrointestinal Endoscopy Research Foundation

• bridge-to-surgery
• colorectal cancer
• obstructive colon cancer; oncologic outcome
• self-expanding metal stent

• Humans
• Male
• Colorectal Neoplasms/surgery
• Colorectal Neoplasms/complications
• Neoplasm Recurrence, Local/complications
• Stents/adverse effects
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Intestinal Obstruction/etiology
• Treatment Outcome
• Retrospective Studies

Self-expanding metal stents placed during endoscopy are increasingly the first-line treatment for luminal obstruction caused by esophageal, gastroduodenal, and colorectal malignancies in patients who are not candidates for definitive surgical resection. In this review, we provide a practical guide for clinicians to optimise patient and procedure selection for endoscopic stenting in malignant gastrointestinal obstructions. The role of endoscopic stenting in each of the major anatomical systems (esophageal, gastroduodenal, and colorectal) is presented with regard to pre-procedural patient evaluation, procedural techniques, clinical outcomes, and potential complications, as well as post-procedure aftercare.

Self-expandable metal stents (SEMSs) can be applied to relieve colorectal obstruction secondary to incurable primary colorectal cancer or extracolonic malignancy. We aimed to identify factors associated with clinical success and the reintervention-free survival (RFS) after palliative stenting.

Cases of palliative SEMS placement between 2005 and 2019 were retrieved from the institutional database and reviewed retrospectively. Logistic regression and log-rank testing followed by Cox proportional hazard analyses were performed to investigate the predictors of the clinical success of palliative stenting and factors associated with RFS, respectively.

A total of 593 patients underwent palliative stenting for malignant colonic obstruction (MCO). The technical and clinical success rates were 92.9% and 83.5%, respectively. Peritoneal carcinomatosis was a predictor of clinical failure (odds ratio, 0.33; 95% confidence interval [CI], 0.17 to 0.65) in the multivariate analysis. Peritoneal carcinomatosis (hazard ratio [HR], 2.48; 95% CI, 1.69 to 3.64) and stent expansion >90% on day 1 (HR, 1.62; 95% CI, 1.05 to 2.50) were associated with a shorter RFS. Neither clinical success nor RFS was associated with extracolonic malignancy. Re-obstruction, stent migration, and perforation were responsible for most reinterventions after clinically successful palliative stenting.

In patients requiring palliative stenting for MCO, peritoneal carcinomatosis was associated with both clinical failure and short RFS. Stent expansion >90% on postprocedural day 1 was another predictor of a short RFS after clinically successful stenting. A large prospective study is warranted to establish factors associated with RFS after successful palliative stenting for MCO.

• Colorectal neoplasms
• Malignant colonic obstruction
• Self-expandable metal stents

• bevacizumab
• chemotherapy
• malignant large bowel obstruction
• obstructive colorectal cancer
• self-expandable metallic stent

• Colorectal cancer
• Endoscopic stenting
• Malignant colorectal obstruction

• Colectomy/methods
• Colon, Descending
• Colon, Sigmoid
• Colonoscopy/methods
• Colorectal Neoplasms/complications
• Colorectal Surgery
• Colostomy/methods
• Cooperative Behavior
• Gastroenterology
• Humans
• Intestinal Obstruction/etiology
• Intestinal Obstruction/surgery
• Mortality
• Patient Selection
• Postoperative Complications/epidemiology
• Self Expandable Metallic Stents

Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.

• Colorectal cancer
• Malignant colonic obstruction
• Self-expandable metal stent

• Metastatic
• colorectal cancer
• stenting
• treatment outcome

Self-expandable metallic stenting (SEMS) for malignant colorectal obstruction (MCO) as a bridge to elective surgery (BTS) is a widely used procedure. The aim of this study was to assess short-term outcomes of SEMS for MCO as BTS.

This study analyzed pooled data from BTS patients who were enrolled in two multicenter prospective single-arm observational clinical studies that used different stent types. Both studies were conducted by the Japan Colonic Stent Safe Procedure Research Group (JCSSPRG). The first study evaluated the WallFlex™ colonic stent for BTS or palliative treatment (PAL) from May 2012 to October 2013 and the second evaluated the Niti-S™ colonic stent from October 2013 to May 2014. Fifty-three facilities in Japan participated in the studies. Before each study started, the procedure had been shared with the participating institutions by posting details of the standard methods of SEMS placement on the JCSSPRG website. Patients were followed until discharged after surgery.

A total of 723 consecutive patients were enrolled in the two studies. After excluding nine patients, the remaining 714 patients were evaluated as a per-protocol cohort. SEMS placement was performed in 426 patients (312 WallFlex and 114 Niti-S) as BTS and in 288 as PAL. In the 426 BTS patients, the technical success rate was 98.1% (418/426). The clinical success rate was 93.8% (392/418). SEMS-related preoperative complications occurred in 8.5% of patients (36/426), perforations in 1.9% (8/426), and stent migration in 1.2% (5/426). Primary anastomosis was possible in 91.8% of patients (391/426), 3.8% of whom (15/393) had anastomosis leakage. The overall stoma creation rate was 10.6% (45/426). The postoperative complication rate was 16.9% (72/426) and mortality rate was 0.5% (2/426).

SEMS placement for MCO as BTS is safe and effective with respect to peri-procedural outcomes. Further investigations are needed to confirm long-term oncological outcomes.

The online version of this article (10.1007/s00464-018-6324-8) contains supplementary material, which is available to authorized users.

• Bridge to surgery
• Colon and rectal cancer
• Intestinal obstruction
• Multicenter study
• Prospective cohort study
• Self-expandable metallic stent

• Aged
• Colorectal Neoplasms/complications
• Colorectal Neoplasms/surgery
• Elective Surgical Procedures/adverse effects
• Feasibility Studies
• Female
• Humans
• Intestinal Obstruction/etiology
• Intestinal Obstruction/mortality
• Intestinal Obstruction/surgery
• Japan
• Male
• Middle Aged
• Palliative Care
• Postoperative Complications/epidemiology
• Prospective Studies
• Self Expandable Metallic Stents/adverse effects

• Japan Gastroenterological Endoscopy Society
• JFE(The Japanese Foundation for Research and Promotion of Endoscopy)

• Advanced endoscopy
• Gastrointestinal endoscopy
• Performance
• Training

• Balloon Enteroscopy/education
• Cholangiopancreatography, Endoscopic Retrograde
• Clinical Competence/standards
• Colonoscopy/education
• Education, Medical, Graduate/standards
• Educational Measurement
• Endoscopy/education
• Endosonography
• Humans
• Pulsed Radiofrequency Treatment
• Reproducibility of Results

Colonic stenting has been used in the setting of malignant obstruction to avoid an emergent colectomy. We sought to determine whether preoperative placement of a colonic stent decreases morbidity and the rate of colostomy formation.

Cases of obstructing sigmoid, rectosigmoid, and rectal cancer from January 1, 2010, to December 31, 2011, were identified in the Nationwide Inpatient Sample (NIS) database. All patients were treated at hospitals in the United States, and the database generated national estimates. Postoperative complications, mortality, and the rate of colostomy formation were analyzed.

Of the estimated 7891 patients who presented with obstructing sigmoid, rectosigmoid, or rectal cancer necessitating intervention, 12.1% (n = 956) underwent placement of a colonic stent, and the remainder underwent surgery without stent placement. Of the patients who underwent stenting, 19.9% went on to have colon resection or stoma creation during the same admission. Patients who underwent preoperative colonic stent placement had a lower rate of total postoperative complications (10.5% vs 21.7%; P < .01). There was no significant difference in mortality (4.7% vs 4.2%; P = .69). The rate of colostomy formation was more than 2-fold higher in patients who did not undergo preoperative stenting (42.5% vs 19.5%; P < .01). Preoperative stenting was associated with increased use of laparoscopy (32.6% vs 9.7%; P < .01).

Our study characterizes the national incidence of preoperative placement of a colonic stent in the setting of malignant obstruction. Preoperative stent placement is associated with lower postoperative complications and a lower rate of colostomy formation. The results support the hypothesis that stenting as a bridge to surgery may benefit patients by converting an emergent surgery into an elective one.

• Colonic obstruction
• Malignant bowel obstruction
• Obstructing colon cancer

• Cancer
• Colorectal
• Emergency
• Stent
• Surgery

• Colonoscopy
• cadaver model
• colonic strictures
• simulated colonoscopy
• stents

• Abdominal Neoplasms/complications
• Colon/diagnostic imaging
• Colon/surgery
• Colonic Diseases/diagnostic imaging
• Colonic Diseases/etiology
• Colonic Diseases/surgery
• Colonic Neoplasms/complications
• Colonography, Computed Tomographic
• Colonoscopy/methods
• Humans
• Intestinal Obstruction/diagnostic imaging
• Intestinal Obstruction/etiology
• Intestinal Obstruction/surgery
• Stents
• Tomography, X-Ray Computed

Tumoral obstructions in almost the entire gastrointestinal tract can be resolved with interventional digestive endoscopy techniques. Self-expanding metal stent (SEMS) insertion in the obstructed colon is a minimally invasive and relatively simple procedure providing an effective first-line treatment for relief of acute malignant obstruction symptoms and serving either as a preoperative or “bridge to surgery” procedure or as palliative definitive care. This technique was introduced in the early 1990s. Although there is still debate about its real value, a lot of reports have been published since then and the procedure is advocated by many surgical groups as the method of choice for the initial treatment of left-sided tumoral colonic obstruction. Before the procedure, colonic obstruction has to be diagnosed by abdominal radiographs, water contrast enema and/or a computed tomography scan. The greatest information is provided by the latter and it is perhaps the method of choice prior to stenting. Skills and training are mandatory, as in all interventional procedures. The key step for success is to cross the malignant stricture with a guidewire. Care must be taken not to over insufflate an obstructed colon during the procedure. SEMS slide over the guidewire through the endoscope working channel or in parallel, outside the endoscope. An average 7% perforation rate has been reported during the procedure and other minor complications can appear in the follow up. However, as a whole, this technique seems to compare favorably with surgery.

• Self-expanding metal stent
• Malignant colorectal obstruction
• Emergency surgery
• Interventional endoscopy