Self-expanding metallic stent insertion in the proximal colon

Objective Colonic obstruction may be relieved by the insertion of a self‐expanding metallic stent (SEMS), either for permanent palliative relief or as a bridge to surgery. Lesions proximal to the descending colon can be more difficult to intubate and stent [ 1 ]. SEMS placement in the more proximal colon lesions has been reported in only a few cases [ 2 , 4 ]. The aim of this study was to review the outcome of SEMS for obstruction at the splenic flexure and above. Method A study of all colonic stents inserted in one specialist unit was undertaken. Patients’ demographics, site and aetiology of the underlying obstruction, success or other outcome of the procedures were collected. Thirty‐day morbidity and mortality were documented. Results Seven patients had proximal lesions: four in the transverse colon and three at the splenic flexure. Six patients had colorectal carcinoma and one had extrinsic compression from a gastric carcinoma. Six of the SEMS were inserted for permanent palliation, and one as a bridge to surgery. Stent placement was technically successful in six of the seven patients. In the seventh patient, there was a failure of expansion of the stent, after successful intubation of the lesion, which was in the distal transverse colon. One patient suffered from minor self‐limiting abdominal pain in the first 24 h after the procedure. There was no other SEMS related morbidity or mortality. All of the successfully stented patients were discharged from the surgical ward within 3 days after the procedure. Median survival time was 4.3 months (range 3–12 months). Three patients are still alive. Conclusion The SEMS is a useful tool in managing acute bowel obstruction. Placement of colonic stents proximal to the descending colon is safe, feasible and effective.     

Management of acute malignant large-bowel obstruction with self-expanding metal stent

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.     

Safety and efficacy of metallic stents in the management of colorectal obstruction.

BACKGROUND: The use of self-expandable metallic stents in the management of obstructing colorectal cancer has been described with increasing frequency in the literature. Our goal was to evaluate the efficacy and associated morbidity of the use of self-expandable metallic stents to relieve colorectal obstruction at our institution. METHODS: A retrospective chart review of patients who underwent colorectal stent placement between December 2001 and December 2003 in a tertiary referral center was performed. RESULTS: Stents were placed successfully in 17 of 21 patients (81%) with colorectal obstruction. Placement was achieved endoscopically in 13 patients and radiologically in 4. Ten self-expandable metallic stents were used as a bridge to surgery, and 7 were used for palliation. The obstructions were located in the sigmoid colon (11 patients), the rectosigmoid (3), the splenic flexure, the hepatic flexure, and the rectum. Malignant obstruction was noted in 14 patients. One patient with malignancy experienced a sigmoid perforation, and 2 patients with benign disease had complications (1 stent migration and 1 re-obstruction). Stent patency in obstruction secondary to colonic adenocarcinoma was 100% in our follow-up period (range, 5 to 15 months). CONCLUSIONS: The use of stents as a bridge to surgery is associated with low morbidity, allows for bowel preparation, and thus avoids the need for a temporary colostomy. Long-term patency suggests that stents may allow for the avoidance of an operation in patients with metastatic disease and further defines their role in the palliation of malignant obstruction. Further prospective randomized studies are necessary to fully elucidate the use of stents in the management of colorectal cancer.     

结肠镜非透视下金属支架置人术在梗阻性结直肠癌患者急诊处理中的应用

目的探讨结肠镜非透视下金属支架置入术应用于梗阻性结直肠癌患者急诊处理的安全性和有效性。方法回顾性分析2010年1月至2012年6月间在第二军医大学长海医院接受结肠镜非透视下金属支架置入术治疗42例梗阻性结直肠癌患者的临床资料。手术采用改良双人肠镜操作法,结肠镜进镜至肿瘤部位,暴露肿瘤狭窄孔,经活检孔插入黄斑马导丝,沿导丝将选择好的金属支架及置人器置人并通过狭窄段,释放支架并调整输送器使支架置于目的位置。结果42例梗阻性结直肠癌患者中直肠癌19例,乙状结肠癌9例,降结肠癌8例,结肠脾曲癌1例,结肠肝曲癌3例,升结肠癌2例。支架置入成功率100％,支架置入操作时间1．1～51．0（11．8~10．4）min。除l例患者因心力衰竭于术后第2天死亡外,其余4l例患者术后第1天即可进流质饮食,术后2~3d出院,术后临床症状缓解率为100％。术中无一例患者发生穿孔,术后3例患者有轻微出血,经药物治疗后好转。结论肠镜镜非透视下金属支架置入术在梗阻性结直肠癌患者急诊处理中安全、有效、省时。     

Clinical use of the self-expanding metallic stent in the management of colorectal cancer

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.     

Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction

Background

The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications.

Methods

Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy.

Results

A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100 % and the clinical success rate 94.1 %. Overall complications were observed in 49 patients (32.2 %) during the follow-up period (median, 98 days; interquartile range, 19–302 days). Obstruction (17.1 %), migration (7.9 %), perforation (5.2 %), bleeding (1.3 %), and tenesmus (0.7 %) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan–Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group.

Conclusions

Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.     

Palliative therapy of colorectal carcinoma: stent or surgery?

“Surgical” palliation of obstructing colorectal carcinomas may involve resection with or without stoma formation, formation of a stoma alone, a colonic bypass procedure, or no procedure at all. Palliative surgical procedures confer a significant morbidity and mortality. Factors associated with increased mortality for colorectal cancer include advancing age of patient, advancing stage of the disease and the necessity for an emergency procedure. Advanced obstructing malignant lesions pose a clinical dilemma as the risks and time of recovery from surgery have to be balanced against providing a dignified quality of remaining life. Self expanding metal stents (SEMS) for acutely obstructing advanced colorectal carcinomas provide a cost effective option that avoids surgery in a usually frail group of patients. They can be inserted under sedation, rapidly decompress the colon and lead to an early return of colonic function. The procedure is carried out endoscopically with radiological assistance to determine a lumen and to confirm adequate stent placement. SEMS are not suitable for low rectal lesions and are more difficult to place in those that traverse colonic flexures. Complications from successful SEMS placement include migration and stent occlusion. The morbidity associated with SEMS is associated with migration or perforation of the colon during placement, pain and less commonly haemorrhage. Despite these problems most patients can be successfully decompressed without further endoscopic or surgical reintervention and allow satisfactory palliation.     

Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases

Background Self-expanding metal stents (SEMS) are an established treatment for palliation of malignant colorectal strictures and as a bridge to surgery for acute malignant colonic obstruction. Patients with benign colonic strictures may benefit from stent placement, but little data exist for this indication. Methods All cases of colonic stent placement identified from a prospectively collected gastrointestinal database from April 1999 to August 2006 were reviewed. During the study period, 23 patients with benign obstructive disease underwent endoscopic SEMS placement. The etiologies of the stricture were diverticular/inflammatory (n = 16), postsurgical anastomotic (n = 3), radiation-induced (n = 3), and Crohn’s (n = 1) disease. All strictures were located in the left colon. Five patients had an associated colonic fistula. Uncovered Enteral Wallstents or Ultraflex Precision Colonic stents (Boston Scientific) were endoscopically placed in all but one patient. Results Stent placement was technically successful for all 23 patients, and obstruction was relieved for 22 patients (95%). Major complications occurred in 38% of the patients including migration (n = 2), reobstruction (n = 4), and perforation (n = 2). Of these major complications, 87% occurred after 7 days. Four patients did not undergo an operation. Of the 19 patients who underwent planned surgical resection, 16 were successfully decompressed and converted from an emergent operation to an elective one with a median time to surgical resection of 12 days (range, 2 days to 18 months). Surgery was delayed more than 30 days after stent placement for six of these patients. Of the 19 patients who underwent a colectomy, 8 (42%) did not need a stoma after stent insertion. Conclusions SEMS can effectively decompress high-grade, benign colonic obstruction, thereby allowing elective surgery. The use of SEMS can offer medium-term symptom relief for benign colorectal strictures, but this approach is associated with a high rate of delayed complications. Thus, if elective surgery is planned, data from this small study suggest that it should be performed within 7 days of stent placement. Podium presentation at the annual meeting of the Society of American Gastrointestinal and Esophageal Surgeons (SAGES), 18–22 April 2007 at Las Vegas, NV, USA     

Adoption of self-expanding metallic stents in the palliative treatment of obstructive colorectal cancer-look out for perforations!

Self-expanding metallic stents (SEMSs) are increasingly used for the palliative treatment of inoperable colorectal cancer. The aim of the current study was to analyze the safety and efficacy of SEMS in the palliative treatment of obstructive colorectal cancer. Between 2003 and 2006, SEMS placement was attempted in 26 patients suffering from inoperable obstructive colorectal cancer. The recovery of the patients and the outcome of this treatment modality were analyzed prospectively. SEMS was successfully inserted in 19 (73%) of 26 patients. In 16 (84%) of these 19 cases, the placement of SEMS was the definitive treatment of colorectal obstruction and no additional surgical palliation was needed. There were 3 (16%) colonic perforations related to stent application. SEMS insertion seems to be an effective alternative in the palliative treatment of patients with malignant colorectal obstruction. However, perforation is a dangerous complication of the procedure.     

Endolaparoscopic left hemicolectomy and synchronous laparoscopic radical nephrectomy for obstructive carcinoma of the descending colon and renal cell carcinoma

Colorectal self-expandable metal stents (SEMS) have been used successfully as preoperative bridges to surgery for obstructive left-sided colorectal carcinoma. Endoscopic relief of the obstruction allows for full bowel preparation and accurate preoperative staging. A laparoscopic approach, considered by many to be contraindicated in the presence of obstruction, becomes feasible after endoscopic decompression. We present a case of obstructive carcinoma of the descending colon successfully treated with endoscopic decompression with colorectal SEMS. Subsequent staging with computed tomography revealed a renal cell carcinoma in the left kidney. Synchronous laparoscopic resection of the two carcinomas was performed, with no morbidity. To the best of our knowledge, this is the first report of endolaparoscopic left hemicolectomy and synchronous laparoscopic radical nephrectomy for obstructive carcinoma of the descending colon and renal cell carcinoma. The advantages of colorectal SEMS and the endolaparoscopic approach in managing obstructive colorectal carcinoma are discussed.     

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

Background

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

Methods

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

Results

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p?=?ns) and 100 and 96.6% (p?>?0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p?=?0.274) and 13.7 and 16.7% (p?=?0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p?=?0.761) and 25.9, 15, and 0% (p?=?0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

Conclusions

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.     

Treatment of acute malignant colorectal obstruction with self-expandable metallic stents

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.     

超细内镜联合腹腔镜在急性左半结肠恶性梗阻中的应用

目的:评价超细内镜联合腹腔镜在急性左半结肠恶性梗阻应用中的安全性和有效性。方法:回顾性分析2013年1—9月收治的11例急性左半结肠恶性梗阻患者临床资料。先通过超细内镜引导下置入肠道支架,解除梗阻,再行腹腔镜结直肠癌根治一期吻合术。结果:11例患者均成功置入结肠支架,病变部位包括结肠脾区1例、降结肠2例、乙降结肠交界4例、乙状结肠2例、直乙状结肠交界2例。9例患者在支架置入后接受了根治性手术,2例因肝转移实施姑息性手术。术后1例切口感染,1例肺部感染,1例吻合口出血,均经保守治疗后好转。结论:术前肠道支架减压联合腹腔镜一期吻合手术是治疗急性左半结肠恶性梗阻安全有效的方法。     

Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer

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.     

Elective (planned) colectomy in patients with colorectal obstruction after placement of a self-expanding metallic stent as a bridge to surgery: the results of a prospective study

Introduction  Acute malignant colorectal obstruction (CRO) can be satisfactorily dealt by the placement of a self-expanding metallic stent (SEMS). The aim of this prospective study was to evaluate the rate of elective (planned) colectomy (EPC) in patients with CRO after SEMS placement as a bridge to surgery on an intention-to-treat (ITT) basis.
Method  From 2002 to 2007, 30 SEMS were placed as a bridge to surgery in 30 CRO patients (median age 73 ± 12 years). The obstructing lesions were located in the right ( n  = 1), transverse ( n  = 1) or left colon ( n  = 24) or the upper third of the rectum ( n  = 4).
Results  The SEMS was placed successfully in 25 (83%) patients. Five patients underwent Hartmann's procedure ( n  = 2) or a diverting colostomy ( n  = 3). The SEMS was functionally operational in 23 (92%) of the 25 patients. A diverting colostomy was avoided in 23 (77%) of the 30 patients (placement failure n  = 5, clinical failure n  = 2). There were no complications in 17 (80%) patients. On an ITT basis, 70% of the patients (21 out of 30) underwent an EPC.
Conclusion  On an ITT basis, SEMS placement in CRO patients enabled EPC in 70% of patients.     

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE: Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study. PATIENTS AND METHODS: In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma. RESULTS: The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction. CONCLUSION: Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.     

Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction

Background

Self-expandable metal stents (SEMS) have been used as a bridging or palliative treatment for malignant colorectal obstruction. Colonic obstruction also may arise from advanced extracolonic malignancy, but the clinical outcomes of stent placement for extracolonic malignancy are unclear. This study compared the clinical outcomes of SEMS between patients with colorectal cancer and those with extracolonic malignancy.

Methods

Patients who underwent endoscopic SEMS placement for a malignant colorectal obstruction were enrolled at Seoul National University Hospital from April 2005 and August 2011. Their medical records were retrospectively reviewed in terms of success rate, complications, and duration of stent patency.

Results

Endoscopic SEMS placements were performed for colorectal cancer in 149 patients and for extracolonic malignancy in 60 patients. The causes of obstruction in extracolonic malignancy were advanced gastric cancer in 39 patients (65 %), pancreatic cancer in nine patients (15 %), ovarian cancer in three patients (5 %) and other causes in nine patients (15 %). The clinical success rates were similar between the two groups (92.6 vs 86.7 %; p = 0.688), and multivariate analysis showed no significant risk factor for unsuccessful endoscopic SEMS placement. Reobstruction in palliative endoscopic SEMS placement occurred for 16 patients with colorectal cancer (21.9 %) and 18 patients with extracolonic malignancy (30 %) during a median follow-up period of 90 days (p = 0.288). The rates did not differ significantly between the two groups (4.1 vs 8.3 %; p = 0.467). The median duration of stent patency was 193 ± 42 days for the patients with colorectal cancer and 186 ± 31 days for the patients with extracolonic malignancy (p = 0.253). The duration of stent patency was not affected by underlying malignancy, previous surgery, or palliative chemotherapy.

Conclusions

Endoscopic SEMS placement is highly effective and comparable for palliation of obstruction in extracolonic malignancy and colorectal cancer in terms of clinical success, complications, and duration of patency.     

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

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.     

Self expanding wall stents in malignant colorectal cancer: is complete obstruction a contraindication to stent placement?

Objective  Technical failures have previously been associated with complete clinical obstruction and complete block to the retrograde flow of gastrograffin is considered by some to be a contraindication to the procedure. We report on the technical and clinical success rates of self-expanding metallic stents (SEMS) in both complete and incomplete obstruction in a prospective series of malignant colorectal obstructions.
Method  A prospective study of all patients undergoing attempted palliative and bridge to surgery SEMS placement for malignant colorectal obstruction over a 7-year period (April 1999–October 2006) was undertaken.
Results  Seventy-two patients (49 males) with a mean age of 71 years (range 49–98) were included. Technical success was achieved in 27 of 32 patients (84%) with complete obstruction and 33 of 36 patients (92%) with incomplete obstruction, P  < 0.46, Fishers exact test. Clinical success was achieved in 17 of 26 patients (65%) with complete obstruction and 24 of 33 patients (73%) with incomplete obstruction, P  < 0.58, Fishers exact test. Although placed correctly in 89% cases, relief of symptoms occurred in only 71%, P  = 0.002, matched pairs test. There were two colonic perforations in the series with one procedure related death.
Conclusion  Placement of SEMS for obstructing colorectal cancer is technically successful in a high proportion of cases. Complete radiological obstruction is not a contraindication to stent placement. The relief of obstructive symptoms following successful placement of a wall stent is less predictable.     

Management of obstructive colorectal cancer with endoscopic stenting followed by single-stage surgery: open or laparoscopic resection?

BACKGROUND: About one-third of patients with colorectal carcinoma present with acute colonic obstruction requiring emergency surgery. Current surgical options are intraoperative lavage and resection of the colonic segment involved with primary anastomosis, subtotal colectomy with primary anastomosis, colostomy followed by resection, and resection of the colonic segment involved with end colostomy (Hartmann's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and a poor quality of life. Endoscopic colonic stent insertion can effectively decompress the obstructed colon, allowing bowel preparation and elective resection. METHODS: The authors present their experience managing 31 patients with obstructing colorectal cancer who underwent endoscopic colonic decompression with self-expanding metallic stents. A total of 16 patients were treated with open resection, and 6 underwent a laparoscopic resection. The remaining 9 patients were managed with endoscopic palliation and adjuvant therapy. Of the 31 patients, 17 were treated with postoperative chemotherapy. RESULTS: The mean interval between stenting and surgery was 11 days (range, 1-21 days). There was no intraoperative morbidity. The incidence of postoperative morbidity was 20% for open surgery and 0% for laparoscopic surgery. The mean postoperative hospital stay was 13 days for the open surgery group, and 7 days for the laparoscopic group (p = 0.003). The hospital mortality rate was 3.2%. Follow-up evaluation was completed for 96% of the patients. The minimum follow-up period was 15 months. All the patients in the palliative group died of disease, with a median survival of 3 months. Of the 22 surgically treated patients, 17 (77%) are alive at this writing. CONCLUSION: This initial experience shows that after successful endoscopic stenting of malignant colorectal obstruction, elective surgical resection can be performed safely. The presence of the endoluminal stent does not prevent a laparoscopic approach. The combined endoscopic and laparoscopic procedures are a less invasive alternative to the multistage open operations and offer a faster recovery.