Metal stents for malignant colorectal obstruction

Malignant obstruction of the colon occurs in 7–25% of patients with colorectal cancer. As emergency laparotomy is reported to have relatively high morbidity and mortality rate, there is a need for alternative procedures with reduced complication rates.

Over the last decade colorectal stenting has been reported as an alternative endoscopic method to relieve acute colonic obstruction. With the availability of more sophisticated stents and stent delivery systems, this approach has been used as a palliative method and as a pre‐operative bridge to facilitate one‐stage surgical resection of primary colonic tumors. Technical and clinical successes have been reported in 80–100% of treated patients. Distal lesions are more common and theoretically easier to stent although lesions within the ascending colon have been succesfully managed. Minor complications include transient anorectal pain, tenesmus and rectal bleeding. However, stent migration and colonic perforation are also well recognized. Despite the fact that no randomized controlled studies have yet been performed, literature data show that colonic stenting is a safe and effective procedure and can reduce costs, avoiding the need for colostomy and improving the quality of life of patients with advanced disease.     

Feasibility of laparoscopic surgery after stent insertion for obstructive colorectal cancer

Introduction

A growing number of patients with obstructive colorectal cancer are being treated with self‐expanding metallic stents (SEMS) followed by laparoscopic resection. The aim of this study was to assess the feasibility of stent insertion and laparoscopic surgery for obstructive colorectal cancer and to compare these outcomes to regular laparoscopic surgery for non‐obstructive colorectal cancer.

Methods

We retrospectively analyzed the outcomes of patients with a malignant colonic obstruction who underwent SEMS placement followed by elective laparoscopic resection. The comparison was made between stent‐laparoscopy and laparoscopy alone for non‐obstructive colorectal cancer.

Results

Colonic stenting as a bridge to surgery was successful in 97.1% of all cases. Fifteen patients underwent an elective laparoscopic surgery for left‐sided colon and rectal cancer after SEMS. The mean interval from SEMS insertion to laparoscopic surgery was 21.5 days. There was no conversion to open surgery and no need for a diverting stoma. One patient (6.7%) experienced paralytic ileus. Our comparison of stent‐laparoscopy to regular laparoscopy for non‐obstructive colorectal cancer treatment showed comparable short‐term postoperative outcomes with the exception of blood loss, which was greater in the stent‐laparoscopy group.

Conclusion

Elective laparoscopic surgery after colonic stenting is a safe and feasible strategy for the treatment of an acute malignant colonic obstruction.     

Colorectal stenting

Intestinal stenting is a procedure that is rapidly coming into more widespread use. It is reported to be a safe and highly effective alternative in patients with unresectable intestinal obstruction. Recent reports show the value of this procedure in colorectal obstruction, as it is relatively safe and can avoid the need for high-risk emergency laparotomy and resection in two sessions. New stents can be inserted in a one-step procedure, with delivery through the scope during the initial diagnostic endoscopy. If examinations show that curative treatment is not possible, resection can be completely avoided, so that the initial stent already forms part of the palliative strategy. Although stents are expensive, the procedure appears to be cost-effective, since emergency surgery can be avoided in patients with acute bowel obstruction, and in those with advanced disease no resection of the colon is necessary.     

Through-the-scope double colonic stenting in the management of inoperable proximal malignant colonic obstruction: a pilot study

BACKGROUND AND STUDY AIMS: Particularly in cases of proximal colonic obstruction, the long distance and tortuosity of the bowel make it difficult for gastroenterologists and radiologists to advance the stent to the point of the obstruction. The purpose of this study was to evaluate the clinical usefulness and efficacy in preventing stent migration and tumor ingrowth of a new self-expanding through-the-scope (TTS) double colonic stent in the palliative management of patients with inoperable proximal malignant colonic obstruction. PATIENTS AND METHODS: A total of seven patients (four men, three women; mean age 62 years, range 57 - 68) underwent placement of a newly developed through-the-scope self-expanding double colonic stent. The etiologies of the obstructions at the time of stent insertion were colonic adenocarcinoma (no previous surgical resection) in five cases and metastatic adenocarcinoma from gastric carcinoma in two. The locations of the obstructions were the ascending colon in three cases, the hepatic flexure in two, and the transverse colon in two. To prevent tumor ingrowth and stent migration, an uncovered Niti-S stent (Taewoong Medical Co., Ltd., Seoul, South Korea) was inserted into the stenotic area; a partly membrane-covered Niti-S stent was then again inserted into the stenotic area inside the uncovered Niti-S stent. RESULTS: The self-expanding TTS double colonic stents were placed in the colon in seven patients with acute malignant colonic obstruction. Double stenting was successful in traversing the lesion in six of the seven cases. In one patient, the stent was not successfully placed across the lesion due to a very acute angle at the hepatic flexure. There were no significant complications relating to the insertion, with no clinical or radiographic evidence of perforation or bleeding during or after the procedures, and there were no cases of stent migration or tumor ingrowth during the mean follow-up period of 13 months. CONCLUSIONS: Placement of these new self-expanding through-the-scope double colonic stents for the management of inoperable proximal malignant colonic obstruction is a feasible, effective, and safe form of palliative treatment for the prevention of stent migration and tumor ingrowth.     

Self-expandable metallic stents as palliative treatment for malignant colorectal obstruction

Background In recent years, stent placement for malignant colorectal obstruction has become an accepted alternative to surgery. The purpose of this study was to evaluate the usefulness of self-expandable metallic stents (SEMS) as palliative management for patients with unresectable malignant colorectal obstruction. Methods Twelve patients with unresectable malignant colorectal obstruction were treated with SEMS as palliative therapy. The sites of obstruction were located in the rectum (n = 9), the descending colon (n = 1), and the transverse colon (n = 2). All procedures were performed with combined endoscopic and fluoroscopic guidance. We analyzed the technical and clinical success rates of stent placement and the complications associated with the procedure. Results The stents were successfully implanted and bowel obstruction was relieved in all cases; the technical and clinical success rates were 100%. Two complications occurred, including stent migration. There was no case requiring reintervention. All patients died of initial disease or another coexisting disease between 9 and 534 days (mean 133 ± 148 days) after stent placement. None of the patients with stent in position at death had clinical or radiologic signs of bowel obstruction. Conclusions SEMS placement in patients with malignant colorectal obstruction is technically feasible and safe, making it useful as a palliative treatment.     

超细内镜引导自膨式金属支架置入术在结肠肿瘤并梗阻诊治中的临床观察

目的 探讨超细内镜引导自膨式金属支架置入术在结肠肿瘤并梗阻诊治中的临床疗效及可行性.方法 回顾性分析2019年6月-2020年12月该院22例采用超细内镜引导自膨式金属支架置入治疗结肠肿瘤并梗阻患者的临床资料.结果 超细内镜引导自膨式金属支架置入应用成功率为95.45％,手术操作时间为(26.0±7.2)min,行一期...     

Successful treatment of obstructing colonic cancer by combining self-expandable stent and neoadjuvant chemotherapy: A case report

BACKGROUND Surgery 5-10 d after stent insertion was recommended by the European Society of Gastrointestinal Endoscopy for obstructing colonic cancer. For some obstructive patients, this may be not a good choice. Here, we report the successful treatment of obstructing colonic cancer by combining self-expandable stent and neoadjuvant chemotherapy.CASE SUMMARY The patient was a 72-year-old man who was admitted with a chief complaint of abdominal pain for more than 1 mo. Computed tomography(CT) scanning revealed that there was a mass in the descending colon, which led to intestinal obstruction. On admission, a series of therapeutic measures, such as fasting and water deprivation, gastrointestinal decompression, total parenteral nutrition, and octreotide acetate, were taken to improve the obstructive symptoms. At the same time, a self-expandable metal stent was successfully placed across the stenosis,and a biopsy was obtained and diagnosed as adenocarcinoma. CT scanning 14 d after insertion of the stent revealed that the intestine was swollen significantly.Systemic chemotherapy with modified FOLFOX6(mFOLFOX6) was administered. After two courses of mFOLFOX6, CT scanning showed clearly that swelling of the intestine was improved. Subsequently, the patient underwent left hemi-colectomy without stoma placement. The postoperative course was uneventful, and he has been disease-free for 6 mo after surgery.CONCLUSION This modified treatment strategy may provide an alternative therapy for patients with obstructing colonic cancers.     

Usefulness of biodegradable polydioxanone stents in the treatment of postsurgical colorectal strictures and fistulas

Benign colonic strictures and fistulas are a growing problem presenting most commonly after bowel resection. Standard treatment is with endoscopic bougies or, more usually, balloon dilation. When these approaches are not successful, other solutions are available and different endoscopic and surgical approaches have been used to treat fistulas. We present an additional option--biodegradable stents--for the treatment of colonic strictures and fistulas that have proven refractory to other endoscopic interventions. We analyzed the results from 10 patients with either a postsurgical colorectal stricture (n =7) or rectocutaneous fistula (n =3) treated with the biodegradable SX-ELLA esophageal stent (covered or uncovered). Stents were successfully placed in nine patients, although early migration subsequently occurred in one. Placement was impossible in one patient due to deformity of the area and the fact that the stricture was approximately 30cm from the anus. The fistulas were successfully closed in all patients, although symptoms reappeared in one patient. In the six patients who received stents for strictures, symptoms resolved in five; in the remaining patient, the stent migrated shortly after the endoscopy. Treatment of colonic strictures and rectocutaneous fistulas with biodegradable stents is an effective alternative in the short-to-medium term. The stent does not have to be removed and is subject to very few complications. The drawbacks of this approach are the need to repeat the procedure in some patients and the lack of published series on efficacy.     

自膨式金属支架及手术解除晚期结直肠癌肠梗阻的疗效比较

背景:对于发生梗阻的晚期结直肠癌患者,置入金属支架的治疗效果尤其是远期疗效知之甚少。目的:比较自膨式金属支架和姑息性手术解除晚期结直肠癌患者肠梗阻的疗效。方法:纳入采用自膨式金属支架和姑息性手术两种治疗方式的186例患者,回顾性分析两组患者性别、年龄、梗阻部位、转移部位、支架类型、支架直径、术后并发症、住院时间、化疗、手术至初次化疗时间和晚期梗阻等资料。结果与结论:支架组的技术成功率低于手术组(P=0.030),临床成功率无差异。与手术组比较,支架组并发症发生率较低,但是主要并发症发生率比较,差异无显著性意义(P=0.839)。支架组住院时间、手术到化疗时间均比较短,但其晚期梗阻的发生率明显高于手术组(P=0.028)。Logistic多元回归分析发现,支架直径和化疗是影响晚期梗阻的独立危险因素。说明对于无法切除并发梗阻的结直肠癌患者支架置入治疗具有更好的早期疗效,但是长期疗效较差,尤其是放置支架直径较小的化疗患者,可能需要再次放置支架或手术以解除晚期梗阻。     

老年低位结直肠癌并急性肠梗阻急诊一期切除临床效果分析

目的探讨老年低位结直肠癌合并急性肠梗阻急诊行一期切除吻合的可行性。方法 76例老年低位结直肠癌并发急性肠梗阻患者全部行急诊一期左半结肠或乙状结肠、直肠癌切除吻合手术。结果本组76例患者均经急诊术中结肠灌洗后行一期切除吻合。术后发生吻合口瘘3例,2例保守治疗痊愈,1例行横结肠造瘘;11例出现不同程度的炎性肠梗阻,经保守治疗后痊愈;无死亡病例;切口感染10例。结论老年低位结直肠癌并急性肠梗阻需要围手术期的综合整体治疗,急诊经术中结肠灌洗后行一期切除吻合是安全、可行的。     

Endoscopic retrograde cholangiopancreatography for distal malignant biliary stricture

Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.     

The role of barium enema in detecting colorectal disease. A radiologist's perspective.

The single-contrast barium enema examination remains useful for patients with acute diseases such as bowel obstruction, diverticulitis, appendicitis, and fistulas. It is also the procedure of choice for those patients who are too elderly, debilitated, or ill to cooperate with the maneuvers necessary for a double-contrast examination. The double-contrast technique is more sensitive than the single-contrast technique for detection of polyps, early inflammatory bowel disease, and lesions of the rectum. In the older population, there has been an increase in the incidence of colonic polyps and carcinomas in the right side of the colon. This emphasizes the need to examine the entire colon in these patients. The double-contrast barium enema is a safe, accurate, and cost-effective tool for accomplishing this. It is also recommended as the initial procedure in the examination of patients with positive results on fecal occult blood testing.     

肠道支架置入联合腹腔镜手术治疗结直肠癌并梗阻的临床研究

目的探讨肠道支架置入联合腹腔镜手术治疗结直肠癌并梗阻的临床价值。方法回顾性分析2014年1月-2016年9月在九江市第一人民医院住院的72例确诊为急性左半结肠及直肠癌并梗阻的患者,其中35例行肠道支架置入联合腹腔镜手术治疗(联合组),37例行传统开腹手术加术中肠腔冲洗(传统组),比较两组患者的临床指标。结果两组术前资料具有可比性,肠镜下支架置入成功率100.0%,临床缓解率100.0%。与传统组相比,联合组在手术时间(145.42 vs 200.25 min)、切口长度(4.52 vs 16.21 cm)、术中出血量(51.41 vs 215.24ml)、清扫淋巴结数(17.24 vs 13.41枚)、术后住院时间(8.52 vs 11.50 d)和二期手术率(2.9%vs 24.3%)方面均有明显优势,差异均有统计学意义(P 0.05)。两组术中肿瘤切除率、术后肛门排气时间、治疗费用和手术并发症比较,差异均无统计学意义(P0.05)。结论肠道支架在治疗结直肠癌并梗阻中具有放置成功率高、临床缓解率高等优点;肠道支架置入联合腹腔镜手术治疗结直肠癌并梗阻是一种安全、可行、效果好的方法,能降低二期手术率,值得临床推广。     

急性结直肠恶性梗阻的金属支架置入治疗

目的:探讨内镜引导下金属支架置入术治疗结直肠癌并发急性肠梗阻的可行性及临床效果。方法:对20例结直肠癌并发急性肠梗阻的患者,在内镜引导下行金属支架置入术,然后观察其临床效果。其中乙状结肠癌11例,降结肠癌4例,直肠癌5例,术前评估可切除的结直肠癌15例,结肠癌并腹腔转移5例。结果:20例患者金属支架置入一次成功19例,1～2d后梗阻症状均消除或缓解,7～10d后15例可切除的结直肠癌行肠管Ⅰ期切除吻合术,术后恢复顺利,无感染及吻合口漏等并发症;4例因肿瘤转移行永久性支架植入术。随访90～180d,1例于术后51d肠梗阻症状复发,再行外科手术死于心功能衰竭;1例因癌细胞转移,术后83d死于全身衰竭。1例患者在术后42d出现内支架移位,置入了第2根支架后症状缓解。结论:经内镜引导下置入金属内支架治疗结直肠癌并发肠梗阻成功率高,安全、经济,明显减轻患者痛苦,提高患者的生活质量。     

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.     

CT colonography: examination prerequisites

CT colonography is likely to play an important role in colorectal cancer screening. The ability of this new technique to detect colorectal polyps and cancer is predicated on an optimally cleansed and distended colon. Whereas the most common reported colonic cleansing regimen employed for CT colonography is polyethylene glycol lavage solution, saline cathartics such as sodium phosphate and magnesium citrate offer the advantage of a drier cleansed colon. Positive labeling of residual stool and fluid combined with electronic substraction of tagged material is under investigation. This new technique would eliminate purgative bowel cleansing and increase patient acceptance of CT colonography. Colonic distention is easily and reliably achieved with atmospheric air, although carbon dioxide is being evaluated as a more comfortable alternative. The use of antispasmodics for CT colonography is controversial. Glucagon is no longer used at centers where a clear benefit has not been found. Intravenous contrast may be useful in a specific subset of patients undergoing CT colonography, although it is doubtful that it will be used routinely for CT colonography.     

内镜下肠道金属支架治疗结直肠恶性梗阻的临床疗效

目的探讨内镜下肠道金属支架安置术(SEMs)治疗结直肠恶性肿瘤梗阻的疗效和安全性。方法纳入2011年1月-2014年5月南华大学附属第一医院消化内科和胃肠外科收治的因结直肠恶性梗阻行SEMs的患者108例,回顾分析该技术的临床成功率及短期并发症发生情况。结果 108例患者中,金属支架安置成功率92.59%(100/108)。术后并发症以腹痛、穿孔及出血为主,发生率分别为16.67%(18/108)、7.41%(8/108)及6.48%(7/108),穿孔均行急诊手术治疗,其他均自行缓解。结论肠道SEMs成功率高,可以有效缓解结直肠恶性梗阻,不仅可以作为姑息性治疗的手段,还可以作为外科手术的桥梁,提高患者生存质量,临床上值得推广。     

Coronary stents

Since the introduction of coronary stents into clinical practice in the late 1980s, the number of stent implantations has increased so rapidly that stents are currently used in over 80 percent of all percutaneous coronary interventions. Although stent implantation was initially limited to large vessels with proximal and discrete lesions, improvements in stent design and implantation technique now allow their deployment in more complex lesions in smaller and diffusely diseased vessels. The overall acceptance of stents by interventional cardiologists can be attributed to favorable acute and longterm results compared to balloon angioplasty alone. Interventionalists have also been quick to embrace the smoother and larger lumen after stenting, in a shorter procedure time and with no additional risk, especially since the risk of stent thrombosis has been overcome by the introduction of dual antiplatelet therapy with Aspirin and Ticlopidine or Clopidogrel. Although restenosis and the need for reinterventions is lower after stenting compared to balloon angioplasty it still remains significant with about 15 percent of all patients returning for an other revascularization procedure. Meanwhile, a completely new generation of stents promises to eliminate the problem of restenosis. Drug-eluting stents, coated with antiproliferative substances have been successfully tested in small randomized trials. The restenosis rates at 6 and 12 months were extremely low ranging between zero and nine percent, with no clinical drawbacks so far. If these results hold up in longer follow up and in real life practice with more complex lesions stented the treatment of symptomatic coronary artery disease will change even more dramatically.     

Role of self-expanding metal stents in patients with malignant colorectal obstruction: A systematic review and meta-analysis

AIM: To assess the safety and efficacy of self-expandable metal stents(SEMSs) for malignant colorectal obstruction. METHODS: Data regarding technical success, clinical success, and procedure related complications were collected from included studies. Der Simonian-Laird random effects model was used to generate the overall outcome. Thirty international studies with a total of 2058 patients with malignant colorectal obstruction were included. RESULTS: The technical and clinical success rates for SEMS placement were 94%(95%CI: 92-96) and 91%(95%CI: 88-93), respectively. Overall complication rate for SEMS was 23%(95%CI: 18-29). Stent migration8%(95%CI: 6-10) and stent obstruction 8%(95%CI: 6-11) were the most common complications, followed by perforation 5%(95%CI: 4%-7%). Surgical or endoscopic re-interventions were needed in 14%(95%CI: 10-18) of patients. Endoscopic repeat stent placement was required in 8%(95%CI: 6-10), while surgical intervention was needed in 6%(95%CI: 4-8).CONCLUSION: SEMS are effective when used as palliation or bridge to surgery for malignant colorectal obstruction with high technical and clinical success. About 14% of patients require repeat endoscopic or surgical intervention for stent failure or to manage stent related complications.     

Colonoscopy, tumors, and inflammatory bowel disease - new diagnostic methods

Accurate detection of premalignant lesions and early cancers in the colon is essential for curative endoscopic or surgical therapy, since the prognosis for the affected patients is closely related to the size and stage of the neoplastic lesion. Total colonoscopy is the accepted gold standard for screening and surveillance of colorectal cancer. This review summarizes recently published diagnostic developments and key findings in the areas of colonoscopy, colonic tumors, and inflammatory bowel diseases. Relevant findings have been reported for chromo-endoscopy in the diagnosis of colitis-associated neoplasia, as well as flat and depressed adenomas. Real-time Doppler capabilities have now been added to endoscopic optical coherence tomography; the results of large-scale testing of narrow-band imaging endoscopy in the colon are being awaited; and fluorescence imaging has recently been added to the facilities available in video endoscopy. Most importantly, endomicroscopy now for the first time allows single-cell subsurface imaging during ongoing colonoscopy procedures, opening the way to in-vivo molecular and functional imaging.