Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction

BACKGROUND: In patients with colorectal cancer, a preoperative colonoscopy is recommended to exclude synchronous lesions. Unfortunately, between 7% and 29% of patients with colorectal cancer present with acute colonic obstruction, making complete colonoscopy impossible. OBJECTIVE: The aim of our study was to evaluate the feasibility of a preoperative colonoscopy after effective stent placement in patients with acute neoplastic obstruction. DESIGN: Single-center prospective study. SETTING: All examinations were carried out at a tertiary referral center with 24-hour emergency endoscopy service. PATIENTS: Fifty-seven patients with acute neoplastic colon obstruction. INTERVENTIONS: Patients who recovered from an acute colon obstruction by an effective stent placement and who had a resectable cancer underwent a preoperative colonoscopy. MAIN OUTCOME MEASUREMENTS: Patients with a resectable cancer, complete preoperative colonoscopies, and synchronous lesions rates. RESULTS: Self-expandable metallic stents (SEMS) were placed in 50 of 57 patients (87.8%). Thirty-one of 50 patients had a resectable cancer (62%), and a complete preoperative colonoscopy was possible in 29 of 31 patients (93.4%). A synchronous cancer was detected in 3 patients (9.6%), changing the surgical plan. LIMITATIONS: Seven patients in whom the SEMS placement (12.2%) was unsuccessful underwent an urgent surgical intervention. Nineteen of 50 patients who had stent placement were not eligible for our study because of unresectable cancer. CONCLUSIONS: Our study indicates that it is feasible in a majority of patients to perform full preoperative colonoscopy after relief of acute colonic obstruction with SEMS before surgical resection.     

Preoperative Colonoscopy for Detection of Synchronous Neoplasms after Insertion of Self-Expandable Metal Stents in Occlusive Colorectal Cancer: Comparison of Covered and Uncovered Stents

Background/Aims

In patients with occlusive colorectal cancers, a complete preoperative evaluation of the colon proximal to the obstruction is often impossible. We aimed to evaluate the feasibility of preoperative colonoscopy after stent placement and to determine whether the success rate of colonoscopy differs between covered and uncovered stents.

Methods

Seventy-three patients with malignant colorectal obstruction were enrolled prospectively. In patients with a resectable cancer, a preoperative colonoscopy was performed after insertion of a self-expandable metal stent (SEMS). The success rate of complete preoperative colonoscopy was compared between covered and uncovered stents.

Results

Forty-five of 73 patients who underwent stent placement had a resectable cancer (61.6%). A complete preoperative colonoscopy was possible in 40 of 45 patients (88.9%). The success rate of complete preoperative colonoscopy was significantly lower in the covered-stent group when the obstructing mass lesion was located in the sigmoid colon (p=0.024). Synchronous cancer was detected in one patient (2.2%). Stent migration was observed in four patients with a covered stent.

Conclusions

A preoperative complete colonoscopy after SEMS placement was feasible and safe in most patients with malignant colorectal obstruction. Uncovered stents seem to have more advantages than covered stents in preoperative colonoscopy proximal to the obstruction.     

Update on the Indications and Use of Colonic Stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.     

Safety and efficacy of self-expandable metallic stents in malignant small bowel obstructions

In this report, we present 3 cases of malignant small bowel obstruction, treated with palliative care using endoscopic self-expandable metallic stent(SEMS) placement, with the aim to identify the safety and efficacy of this procedure. Baseline patient characteristics, procedure methods, procedure time, technical and clinical success rates, complications, and patient outcomes were obtained. All 3 patients had pancreatic cancer with small bowel strictures. One patient received the SEMS using colonoscopy, while the other 2 patients received SEMS placement via double balloon endoscopy using the through-the-overtube technique. The median procedure time was 104 min. The technical and clinical success rates were 100%. Post-treatment, obstructive symptoms in all patients improved, and a low-residue diet could be tolerated. All stents remained within the patients until their deaths. The median overall survival time(stent patency time) was 76 d. SEMS placement is safe and effective as a palliative treatment for malignant small bowel obstruction.     

Technique of colonic stenting

Colonic stents have been used for more than 20 years for preoperative and palliative relief of malignant colonic obstruction. Self-expandable metal stent (SEMS) placement is more technically challenging than luminal stent placement in other locations. SEMS placement is performed most commonly with fluoroscopic guidance using through-the-scope devices. Accessories used for performing pancreaticobiliary procedures facilitate colonic SEMS placement.     

Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction

AIM: To summarize our experience with the application of self-expanding metallic stent (SEMS) in the management of acute left-sided colorectal malignant obstruction. METHODS: A retrospective chart review of all patients undergoing placement of SEMS between April 2000 and January 2004 was performed. RESULTS: Insertion of SEMS was attempted in 26 patients under fluoroscopic guidance with occasional endoscopic assistance. The sites of lesions were located in splenic flexure of two patients, left colon of seven patients, sigmoid colon of eight patients and rectum of nine patients. The intended uses of SEMS were for palliation in 7 patients and as a bridge to elective surgery in 19 patients. In the latter group, placement of SEMS allowed for preoperative systemic and bowel preparation and the following one-stage anastomosis. Successful stent placement was achieved in 22 (85%) of the 26 patients. The clinical bowel obstruction resolved 24 hours after successful stent placement in 21 (95%) patients. Three SEMS-related minor complications occurred, two stents migrated and one caused anal pain. CONCLUSION: SEMS represents an effective and safe tool in the management of acute malignant colorectal obstruction. As a bridge to surgery, SEMS can provide time for systematic support and bowel preparation and obviate the need for fecal diversion or on-table lavage. As a palliative measure, SEMS can eliminate the need for emergent colostomy.     

WallFlex colonic stent placement for management of malignant colonic obstruction: a prospective study at two centers

BACKGROUND: Self-expanding metal stents (SEMSs) can alleviate malignant colonic obstruction and avoid emergency decompressive surgery. The use of colonic larger-diameter SEMSs may improve bowel function and reduce migration risk. OBJECTIVE: To evaluate the effectiveness and safety of a novel large-diameter SEMS (WallFlex) designed for delivery through the endoscope in treating malignant colonic obstruction. DESIGN: Prospective clinical cohort study. SETTING: Two Italian study centers. PATIENTS: Forty-two consecutive patients with malignant colonic obstruction: 23 requiring palliation and 19 bridging to surgery. INTERVENTIONS: Colorectal SEMS placement. MAIN OUTCOME MEASUREMENTS: Technical success, defined as accurate SEMS deployment across the stricture on the first attempt; clinical success, ie, complete relief of bowel obstruction without complications; and bridging to surgery, denoting the performance of elective one-stage surgery. RESULTS: The rate of technical success was 93% (95% CI, 81%-99%) and of initial clinical success was 95% (95% CI, 84%-99%). In 58% (95% CI, 40%-84%) of the palliation group, clinical success was maintained after 6 months. All 19 patients with operable tumors were successfully bridged to one-stage elective surgery within a median of 5 days. One perforation and one stent migration occurred. All complications could be resolved nonsurgically. LIMITATIONS: No control group was included. CONCLUSIONS: In a prospective study of through-the-scope WallFlex stent placement for malignant colonic obstruction, high rates of technical and initial clinical success, and bridging to surgery were achieved. Complications could be readily managed.     

Stents for colonic strictures: Materials,designs, and more

Colonic obstruction is one of the common manifestations of colon cancer. Historically, the treatment of malignant colonic obstruction consisted of surgical removal of the obstructing tumor, if possible, and decompression of the bowel with an ostomy. Self-expandable metal stents (SEMS) have now been used effectively for nonsurgical relief of malignant colonic obstruction, either for palliative care or as a bridge to elective surgery. Since the introduction of SEMS insertion technique in the early 1990s, multiple studies and reports have been published on the outcomes of SEMS in treating large bowel obstruction. SEMS are now recommended as an initial treatment of choice for acute left-sided colonic obstruction by surgical groups. SEMS insertion may be helpful to complete colonoscopy screening before surgery to detect any synchronous neoplasm proximal to a malignant colonic obstruction. SEMS insertion would also buy more time for a selected group of patients who may benefit from chemoradiation before surgery. This article reviews the development of colorectal stents, designs, materials, various types of colonic stents used in the treatment of colonic strictures, indications for their insertion, outcomes, limitations, complications, and future directions of the colonic stents.     

The usefulness of clip application in preventing migration of self-expandable metal stent in patients with malignant gastrointestinal obstruction]

BACKGROUND/AIMS: Management of malignant gastrointestinal obstruction presents a significant challenge. Recently, self-expandable metal stent (SEMS) has emerged as an effective, safe, and less invasive alternative for the treatment of malignant intestinal obstruction. Accordingly, we reviewed our experience in SEMS insertion with hemoclip placement. METHODS: Between June 2004 and December 2005, a total of 40 SEMS were tried to place in 38 patients with malignant intestinal obstruction. Two stents were placed again due to recurrent obstruction and delayed stent migration after initial stent placement. We analyzed the technical and clinical success rates and complications. RESULTS: Total stent placement was successful in 38/40 (95%). In 2 cases, stent placement was failed due to complete obstruction. Twenty-eight stents for palliation of malignant intestinal stenosis, 9 stents for one-staged operation for malignant colonic obstruction, and 1 stent for management of tracheoesophageal fistula were placed. Stent migration occurred in 6/38 (15.8%). Early stent migration rate was significantly lower in the clipping group (0/19, 0%) than in the non-clipping group (5/19, 26.3%, p=0.04). Recurrent obstruction occurred in 2/38 (6.1%) due to tumor ingrowth and in 1/38 (2.6%) due to hard food materials. CONCLUSIONS: Application of the clips reduce early stent migration in patients with malignant gastrointestinal obstruction.     

A temporary self-expanding metallic stent for malignant colorectal obstruction

AIM:To investigate the clinical safety and efficacy of a temporary self-expanding metallic stent(SEMS) for malignant colorectal obstruction.METHODS:From September 2007 to June 2012,33 patients with malignant colorectal obstruction were treated with a temporary SEMS.The stent had a tubular configuration with a retrieval lasso attached inside the proximal end of the stent to facilitate its removal.The SEMS was removed one week after placement.Clinical examination,abdominal X-ray and a contrast study were prospectively performed and both initial and follow-up data before and at 1 d,1 wk,and 1 mo,3 mo,6 mo and 12 mo after stent placement were obtained.Data collected on the technical and clinical success of the procedures,complications,need for reinsertion and survival were analyzed.RESULTS:Stent placement and removal were technically successful in all patients with no procedurerelated complications.Post-procedural complications included stent migration(n = 2) and anal pain(n = 2).Clinical success was achieved in 31(93.9%) of 33 patients with resolution of bowel obstruction within 3 d of stent removal.Eleven of the 33 patients died 73.81 ± 23.66 d(range 42-121 d) after removal of the stent without colonic re-obstruction.Clinical success was achieved in another 8 patients without symptoms of obstruction during the follow-up period.Reinsertion of the stent was performed in the remaining 12 patients with re-obstruction after 84.33 ± 51.80 d of follow-up.The mean and median periods of relief of obstructive symptoms were 97.25 ± 9.56 d and 105 ± 17.43 d,respectively,using Kaplan-Meier analysis.CONCLUSION:Temporary SEMS is a safe and effective approach in patients with malignant colorectal obstruction due to low complication rates and good medium-term outcomes.     

Surgical failure after colonic stenting as a bridge to surgery

AIM: To identify risk factors for surgical failure after colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction.METHODS: The medical records of patients who underwent stent insertion for malignant colonic obstruction between February 2004 and August 2012 were retrospectively reviewed. Patients with malignant colonic obstruction had overt clinical symptoms and signs of obstruction. Malignant colonic obstruction was diagnosed by computed tomography and colonoscopy. A total of 181 patients underwent stent insertion during the study period; of these, 68 consecutive patients were included in our study when they had undergone stent placement as a bridge to surgery in acute left-sided malignant colonic obstruction due to primary colon cancer.RESULTS: Out of 68 patients, forty-eight (70.6%) were male, and the mean age was 64.9 (range, 38-89) years. The technical and clinical success rates were 97.1% (66/68) and 88.2% (60/68), respectively. Overall, 85.3% (58/68) of patients underwent primary tumor resection and primary anastomosis. Surgically successful preoperative colonic stenting was achieved in 77.9% (53/68). The mean duration, defined as the time between the SEMS attempt and surgery, was 11.3 d (range, 0-26 d). The mean hospital stay after surgery was 12.5 d (range, 6-55 d). On multivariate analysis, the use of multiple self-expanding metal stents (OR = 28.872; 95%CI: 1.939-429.956, P = 0.015) was a significant independent risk factor for surgical failure of preoperative stenting as a bridge to surgery. Morbidity and mortality rates in surgery after stent insertion were 4.4% (3/68) and 1.5% (1/68), respectively.CONCLUSION: The use of multiple self-expanding metal stents appears to be a risk factor for surgical failure.     

Endoscopic stenting of colonic tumours

Self-expandable metal stents (SEMS) are useful for the non-surgical relief of malignant colonic obstruction. They may be used both as a palliative measure and as a pre-operative bridge to facilitate a one-stage surgical resection of primary colonic tumours. SEMS may be placed endoscopically or by interventional radiologists without the use of endoscopy. In experienced centres SEMS can be successfully placed in approximately 90% of cases. Although it is known that the placement of these devices is feasible, there are no prospective trials comparing stent placement for colonic obstruction to routine surgical care. Additionally, there are no studies comparing the outcome of the method of placement (endoscopic versus radiological). This chapter reviews the types of expandable metal stent used for treatment of colonic obstruction, the indications for their insertion, their methods of insertion, and outcomes following insertion. Future research directions using expandable stents for colonic tumours are also addressed.     

Comparison of short-and long-term outcomes following either insertion of self-expanding metallic stents or emergency surgery in malignant large bowel obstruction

BACKGROUND: Self-expanding metallic stents (SEMS) are now regarded as a safe and effective treatment for an acute obstructing colorectal cancer. SEMS insertion is an invasive procedure that could potentially worsen prognosis. This study assessed the short-and long-term outcomes in patients stented for acute large bowel obstruction and in patients who underwent primary emergency surgery. METHODS: We retrospectively identified 19 patients who underwent SEMS insertion and 23 patients who had primary emergency surgery for left-sided large bowel obstruction as the first presentation of colorectal cancer. RESULTS: There were no significant differences between the 19 patients in the SEMS group and the 23 patients in the primary emergency surgery group in terms of demographics and tumour location and stage. Stent insertion was successful in 16 patients (84%). One patient died from a stent-related perforation and another had a stoma fashioned for stent migration. Stents were a definitive procedure in 2 patients with advanced disease and acted as a "bridge to surgery" in the remaining 12 patients. Compared to the primary surgery group, there was a trend towards a higher primary anastomosis rate in the SEMS group (p=0.08); there were no significant differences in length of hospital stay, 30-day mortality or complication rates between the groups. Long-term prognosis (estimated 3-year survival) did not differ significantly between the groups (p=0.54); this persisted when only curative resections were considered (p=0.80). CONCLUSIONS: Preoperative stent insertion is a safe and effective treatment for large bowel obstruction, and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.     

SEMS vs cSEMS in duodenal and small bowel obstruction:High risk of migration in the covered stent group

AIM:To compare clinical success and complications of uncovered self-expanding metal stents(SEMS)vs covered SEMS(cSEMS)in obstruction of the small bowel.METHODS:Technical success,complications and outcome of endoscopic SEMS or cSEMS placement in tumor related obstruction of the duodenum or jejunum were retrospectively assessed.The primary end points were rates of stent migration and overgrowth.Secondary end points were the effect of concomitant biliary drainage on migration rate and overall survival.The data was analyzed according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.RESULTS:Thirty-two SEMS were implanted in 20 patients.In all patients,endoscopic stent implantation was successful.Stent migration was observed in 9 of16 cSEMS(56%)in comparison to 0/16 SEMS(0%)implantations(P=0.002).Stent overgrowth did not significantly differ between the two stent types(SEMS:3/16,19%;cSEMS:2/16,13%).One cSEMS dislodged and had to be recovered from the jejunum by way of laparotomy.Time until migration between SEMS and cSEMS in patients with and without concomitant biliary stents did not significantly differ(HR=1.530,95%CI0.731-6.306;P=0.556).The mean follow-up was 57±71 d(range:1-275 d).CONCLUSION:SEMS and cSEMS placement is safe in small bowel tumor obstruction.However,cSEMS is accompanied with a high rate of migration in comparison to uncovered SEMS.     

TECHNICAL TIPS FOR STENT PLACEMENT IN THE PROXIMAL COLON USING KNITTED NITINOL ESOPHAGEAL STENT

Self‐expandable metallic stents (SEMS) have recently become widely used. A dedicated stent such as the through‐the‐scope (TTS) stent has enabled easier placement of SEMS by endoscopists for colorectal obstructions. In Japan, however, the TTS stent is not yet available. Therefore, we have to perform non‐TTS placement using esophageal, tracheal or vascular stents for colorectal obstructions. We have developed some modifications which aid the placement of esophageal stents, including increasing the length of the delivery system, and the use of a splinting tube or a double splinting tube. These technical modifications allow markedly better placement of a knitted nitinol Ultraflex esophageal stent for a colorectal obstruction. They allowed us to even place SEMS in the proximal colon without difficulty, and in all patients we treated. Therefore, with some technical modifications, it is feasible to use an esophageal stent for proximal colonic obstruction.     

Stenting of the proximal colon in patients with malignant large bowel obstruction: techniques and outcomes

BACKGROUND: Self-expandable metal stents are used throughout the GI tract to relieve malignant obstructions. OBJECTIVE: Our purpose was to determine the outcome after colonic stent placement into the proximal colon. DESIGN: Medical records of patients from 3 institutions who underwent attempts at placement of self-expandable metal stents for malignant obstructions of the proximal colon were retrospectively reviewed. Extracted data included patient characteristics, obstruction location, and goal of procedure (palliation vs bridge to surgery). SETTING: Academic medial centers. PATIENTS: Those with right-sided malignant colonic obstruction. INTERVENTIONS: Placement of colonic stent. MAIN OUTCOME MEASUREMENTS: Initial technical success, relief of obstruction, and early and long-term complications. RESULTS: Twenty-one patients (15 men, 6 women; mean age 67 years) were included. Tumor type was colonic adenocarcinoma in 19 patients. Obstruction was complete in 8 patients and subtotal in 13 patients. Stenting was attempted as a bridge to surgery in 8 patients and as palliation in 13 patients. Initial technical success was achieved in 20 of 21 patients (95%). Complete relief of obstruction was achieved in 17 of 20 patients who had technical success (85%), unachieved in 2 patients (No. 14 and 17), and unknown in 1 patient (No. 6). There were no procedure-related complications (bleeding, perforation, etc). The only long-term complication was stent reocclusion from tumor ingrowth. LIMITATIONS: Retrospective, single-arm analysis. CONCLUSIONS: Self-expandable metal stents appear to be safe and effective in the treatment of malignant obstruction of the proximal colon. Technical and clinical success rates are comparable to those seen with distal colonic stenting.     

Stone extraction balloon-guided repeat self-expanding metal stent placement

Self-expanding metal stent (SEMS) placement offers safe and effective palliation in patients with upper gastrointestinal obstruction due to a malignancy. Well described complications of SEMS placement include tumor growth, obstruction, and stent migration. SEMS occlusions are treated by SEMS redeployment, argon plasma coagulation application, balloon dilation, and surgical bypass. At our center, we usually place the second SEMS into the first SEMS if there is complete occlusion by the tumor. We discovered a...     

SUCCESSFUL TREATMENT USING A SELF‐EXPANDABLE METALLIC STENT IN THE PALLIATION FOR UNRESECTABLE MALIGNANT OBSTRUCTION OF THE COLON AND RECTUM

Background: We attempted the placement of a self‐expandable metallic stent (SEMS) for unresectable malignant obstruction of the proximal colon as well as obstruction of the distal colon and rectum, using a technical device. Patients and methods: Thirty patients were selected to place SEMS. The procedure was performed under endoscopic and fluoroscopic guidance. As a technical device, we used an angiographic introducer to straighten the rectosigmoid region. Moreover, we used a transparent hood to easily obtain a front view of the stricture. Results: Of 30 cases of attempted SEMS placement, SEMS was successfully placed in 26 (87%). The technical success rate was 82% (9/11) in strictures of the proximal colon, while it was 89% (17/19) in those of the distal colon or rectum. According to complications, stent migration occurred in one patient (3%) and restenosis was also observed in one patient (3%). Conclusion: Placement of SEMS is a feasible and effective adjunct and alternative to stoma in malignant large bowel obstruction.     

Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction

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.     

Using stents in the management of malignant bowel obstruction: the current situation and future progress

Introduction: The use of self-expanding metal stents (SEMS) has been considered an effective and safe alternative to emergency surgery as bridge to surgery or for palliation in advanced colorectal cancer even though more recent data have raised concerns on both early and long-term outcomes when patients are treated with bridge to surgery indications.

Areas covered: A comprehensive literature review of articles on endoscopic management of malignant bowel obstruction was performed. Indication, technique, outcomes, benefits and risks of these treatments in acute malignant colonic obstruction were reviewed. The clinical effectiveness and safety of SEMS in obstructive colorectal cancer, as bridge to surgery or for palliation compared to surgery, is discussed.

Expert commentary: SEMS placement, when performed in tertiary level center with appropriate expertise in colorectal stenting, may have several advantages over surgery avoiding the potential for surgical morbidity in a typically frail group of patients even though these advantages are to be carefully balanced over the risk of life-threatening, stent-related complications.