Self‐expanding metallic stents for acute left‐sided large‐bowel obstruction: a review of 130 patients

Aim The aim of this study was to evaluate the outcomes of self‐expanding metallic stent (SEMS) placement in acute left‐sided large‐bowel obstruction. Method From 1997 to 2008, 130 patients [mean 67 (SD 14.7)] underwent SEMS insertion for acute left‐sided large‐bowel obstruction. One‐hundred and one procedures were palliative, and 29 patients underwent stent insertion as a bridge for surgery. The success rate and the outcome were analysed. Results The chief causes of obstruction were primary (67%) and recurrent (16%) colorectal carcinoma. The success rate was 88% after insertion of the first stent. In nine patients, insertion of a second stent was required. Complications occurred in 20% of the insertions, with migration (10.8%) being the most common. Perforation occurred in two patients and one developed a colovesical fistula. In patients with palliative stenting, 14 (13.9%) required subsequent surgery, with a stoma placed in all except three. Among the 29 patients who underwent SEMS insertion as a bridge to surgery, subsequent surgical resection was performed in 26 patients at a mean interval of 12 days (SD 18.0). Primary anastomosis was performed in 24 patients. The mean survival for those who underwent SEMS insertion as a bridge to surgery was 40 (95% confidence interval: 24–55) months. Conclusion SEMS placement is safe and effective in relieving acute left‐sided colonic obstruction. It allows subsequent definitive surgery on an elective setting and also serves as good palliation for advanced or disseminated disease.     

Comparison of efficacy between uncovered and covered self‐expanding metallic stents in malignant large bowel obstruction: a systematic review and meta‐analysis

Aim Insertion of a self‐expandable metallic stent (SEMS) can rapidly relieve colorectal obstruction. This study aimed to compare the efficacy between uncovered and covered SEMSs in the treatment of malignant colorectal obstruction. Method A systematic search in Medline, Embase, the Cochrane controlled trials register and bibliographies of retrieved articles was performed. Randomized controlled trials and other comparative studies comparing uncovered and covered SEMSs for treatment of malignant colorectal obstruction were selected for this systematic review and meta‐analysis. The main outcome measures were technical success, clinical success, tumour ingrowth, tumour overgrowth, early migration (≤ 7 days), late migration (> 7 days), overall complications and the duration of stent patency. Results Compared with covered SEMSs, uncovered SEMSs were associated with a lower late migration rate (relative risk 0.25; 95% CI 0.08, 0.80; P = 0.02), a higher tumour ingrowth rate (relative risk 5.99; 95% CI 2.23, 16.10; P = 0.0004) and a prolonged stent patency (weighted mean difference 15.34 days; 95% CI 4.31, 26.37; P = 0.006). There was no significant difference in technical success, clinical success, tumour overgrowth, early migration, perforation or overall complications between the two groups. Conclusion Tumour ingrowth occurred more frequently in the uncovered SEMS group, while late migration was more common in the covered SEMS group.     

Short‐term and long‐term outcomes of patients with malignant large bowel obstruction

Objective: The aim of the present study was to review our experience in the surgical management of patients with obstructing colorectal cancers over an 11‐year period, 1987–1997. Patients and methods: Retrospective review of case records of 275 patients (male: 177; female 98) who had undergone emergency surgery for obstructing colorectal cancers was performed. Tumours proximal to splenic flexure were defined as proximal tumours while those at or below the splenic flexure were defined as distal tumours. Results: The obstruction was caused by proximal tumours in 88 (32%) patients. The resection rate and the primary anastomotic rate were higher for proximal tumours compared with distal tumours (95.5%vs 85.6%, P = 0.014; 92%vs 30.5%, P < 0.001). For distal tumours, stoma rate was found to be influenced by the following factors: preoperative albumin level, duration of observation after admission, operating surgeons’ years of experience, bowel perforation and site of the obstructing tumour. Multivariate analysis disclosed that surgeons’ experience was the only independent factor predicting stoma formation. The in‐hospital mortality and the anastomotic leakage rates were 15.3% and 5.6%, respectively. Tumour stage was the only prognostic factor affecting the disease‐free survival after curative resection. The 5‐year disease‐free survival rates for Dukes’ B and C disease were 66% and 37.2%, respectively. Conclusions: Tumour stage was a significant prognostic factor for patients with obstructing colorectal cancers. Emergency surgery for distal tumours should preferentially be performed by more experienced surgeons in order to achieve a higher anastomotic rate.     

Management of malignant left-sided large bowel obstruction: a comparison between colonic stents and surgery

Background: Management of distal malignant large bowel obstruction (LBO) remains challenging. Acute surgical intervention is often associated with poorer clinical outcome compared to an elective procedure. Self‐expandable metallic stents (SEMS) as a bridge to surgery (BTS) or palliation remain controversial and are not yet widely available. Methods: From 1998 to 2008, a retrospective analysis of the patients presenting with an acute malignant LBO to The Tweed Public and John Flynn Private Hospitals was performed. Results: Fifty‐six admissions with malignant distal colonic obstruction were reviewed. On an intention to treat, patients underwent either stent 30 or surgery 26. American Association of Anaesthetists (ASA) scores, obesity rates and palliative procedures were all higher in the stent group. Inpatient deaths numbered four (two stent group, two surgery group). The technical success of inserted stents was 29/30, while clinical success was 27/30. Complications both medical, surgical and intensive care unit admissions were more common in the surgical group. Length of stay was 8.5 days for stent and 17.7 days for surgery. Of the 25 successful stent survivors, 14 were palliative and 11 were BTS. Conclusions: SEMS are effective in treatment of LBO either as palliation or BTS. They are associated with an overall better outcome and improved quality of life of patients. Surgery is indicated where SEMS are unavailable or have failed.     

肠道支架减压在左侧大肠癌梗阻一期切除吻合中的应用

目的 探讨术前肠道支架减压在左侧大肠癌梗阻一期切除吻合中运用的安全性和有效性.方法 回顾性分析2005年5月至2008年9月浙江中医药大学附属第一医院收治的97例左侧大肠癌患者临床资料.支架联合手术组46例,为左侧大肠癌合并肠梗阻的患者,成功放置肠道支架减压后行手术一期切除吻合治疗.单纯手术组51例,为无梗阻的左侧大肠癌而限期手术治疗的患者.观察两组患者术后胃肠功能恢复、术后住院时间、并发症发生情况.采用t检验、χ~2检验对数据进行分析.结果 支架联合手术组46例中,1例乙状结肠癌患者于肠道支架植入术后第4天出现肠道穿孔致弥漫性腹膜炎,急诊行乙状结肠癌根治术.45例均顺利完成一期手术治疗,术后11～16 d痊愈出院,1例患者术后10 d死于呼吸道感染及心功能衰竭.术后随访4～48个月.两组患者在术后肛门排气时间、住院时间、围手术期并发症发生率、复发转移率、随访期内生存率方面比较差异无统计学意义(t=0.164,1.358,χ~2=0.252,1.200,0.580,P>0.05).结论 术前肠道支架减压是治疗左侧大肠癌梗阻患者安全、有效的方法.     

Large bowel obstruction due to colorectal carcinoma can be safely treated by colonic stent insertion – case series from a UK district general hospital

Aim The aim of this study is to audit our outcomes and experience of colonic stent insertion for malignant bowel obstruction. Method Retrospective audit of all stent insertions in a single district general hospital between August 2003 and December 2009. All patients had presented with acute bowel obstruction caused by malignant colorectal disease and details were collected prospectively and contemporaneously onto a database. Stent insertion was a combined endoscopic and fluoroscopic procedure involving a colorectal surgeon and consultant radiologist. Results Stenting was attempted on 62 occasions in 54 patients. The technical success rate was 86% and the clinical success rate 84%. The indications for stenting were for relief of acute bowel obstruction, palliation and as a bridge to surgery. There were complications in 14 cases (22.5%) including three perforations and one perioperative mortality. There were three cases of stent migration, six cases of re‐stenosis and two stents became impacted with stool. There were no incidents of acute or delayed haemorrhage in any patients. Conclusion Our experience shows that stenting for obstructing colorectal cancer is a safe and effective method of alleviating acute and impending bowel obstruction and can be provided safely and effectively in a district general hospital.     

老年患者应用自膨式金属支架作为结肠癌急性恶性肠梗阻择期手术的临时处理手段的短期评价

目的 评估自膨式金属支架（SEMS）在恶性肠梗阻患者应用价值和分析。方法 选择2014年至2017年作者收治的结肠癌伴急性肠梗阻患者的临床资料。包括接受SEMS处理23例（SEMS组）,未使用SEMS的急诊手术患者31例（no-SEMS组）,所有患者获得根治性切除。结果 所有患者均获得手术后30天的随访。SEMS组16例采用腔镜下结肠癌根治手术,7例实施开放手术;no-SEMS组均为开放手术。SEMS组术后恢复总体较no-SEMS组良好,如较短的肠功能恢复时间、较短的肠外营养时间、较短的住院时间和较少的术后并发症总数（均P<0.05）。但SEMS组术前发生1例肠穿孔、2例SEMS移位需要紧急处理。结论 针对结肠癌导致的恶性肠梗阻,SEMS内镜结肠支架置入术作为择期手术的桥梁,具有良好的短期效果,但是应该尽量避免SEMS操作并发症。     

Water soluble contrast follow‐through in the management of adhesive small bowel obstruction: A prospective randomized trial

Objective: Postoperative adhesive intestinal obstruction is the most common cause of small bowel obstructions in adults. The use of water‐soluble contrast follow‐through has been shown to be safe with a high predictive value for surgery. This study aims to evaluate the impact of contrast follow‐through on clinical outcomes of patients with adhesive small bowel obstructions. Methods: From July 1994 to June 1998, 150 patients were recruited into the study and randomized into two groups. One group (n = 75) received water‐soluble contrast follow‐through within 24 h of admission, whereas the control group (n = 75) did not. Both groups were put on conservative management and the outcomes measured included operative rate, postoperative morbidities, length of hospital stay and mortality. Results: The operative rate of both groups was similar (33.3 vs 38.7%, P = 0.496). The preoperative observation period (42 vs 65 h. P = 0.014) and the total median hospital stay (5 vs 7 days, P = 0.025) of the contrast group were significantly shorter than those of the control group. No significant difference could be found between the two groups in terms of postoperative morbidities and mortalities. Conclusions: In managing patients suspected to have adhesive small bowel obstruction, water‐soluble contrast follow‐through expedites the decision process for surgical intervention, which translates into a shorter hospital stay.      

Feasibility of a self‐assembling peptide hydrogel scaffold for meniscal defect: An in vivo study in a rabbit model

The inner avascular zone of the meniscus has limited healing capacity as the area is poorly vascularized. Although peptide hydrogels have been reported to regenerate bone and cartilage, their effect on meniscus regeneration remains unknown. We tested whether the self‐assembling peptide hydrogel scaffold KI24RGDS stays in the meniscal lesion and facilitates meniscal repair and regeneration in an induced rabbit meniscal defect model. Full‐thickness (2.0 mm diameter) cylindrical defects were introduced into the inner avascular zones of the anterior portions of the medial menisci of rabbit knees (n = 40). Right knee defects were left empty (control group) while the left knee defects were transplanted with peptide hydrogel (KI24RGDS group). Macroscopic meniscus scores were significantly higher in the KI24RGDS group than in the control group at 2, 4, and 8 weeks after surgery. Histological examinations including quantitative and qualitative scores indicated that compared with the control group, the reparative tissue in the meniscus was significantly enhanced in the KI24RGDS group at 2, 4, 8, and 12 weeks after surgery. Immunohistochemical staining showed that the reparative tissue induced by KI24RGDS at 12 weeks postimplantation was positive for Type I and II collagen. KI24RGDS is highly biocompatible and biodegradable, with strong stiffness, and a three dimensional structure mimicking native extracellular matrix and RGDS sequences that enhance cell adhesion and proliferation. This in vivo study demonstrated that KI24RGDS remained in the meniscal lesion and facilitated the repair and regeneration in a rabbit meniscal defect model.     

The association between stress,self‐esteem and childhood acceptance in nursing and pharmacy students: a comparative cross‐cultural analysis

The proposition that stress level is affected by self‐esteem development, for which acceptance from others in childhood is a key issue, was tested in two health care professions. The sample was 131 from nursing studies and 91 from pharmacy studies at a university in London, and 344 from nursing and 976 from pharmacy in Tokyo. Levels of stress were measured with the Perceived Stress Scale, self‐esteem with the Rosenberg Self‐Esteem Scale and childhood acceptance with the Parental Nurturance Scale. The data were analysed in terms of levels of and causal path between stress, self‐esteem and childhood acceptance. The proposed mechanism was supported among the nursing and pharmacy students in both British and Japanese cultures. The sample was also found to be substantially high on stress and low on self‐esteem and childhood acceptance. The results suggested that those entering the health care profession, such as nursing and pharmacy, have some additional vulnerability to stress compared with the general population. Enhancing self‐esteem was strongly recommended in stress management for health care professions. Copyright © 2008 John Wiley & Sons, Ltd.