Long-term Outcomes of One Stage Surgery Using Transanal Colorectal Tube for Acute Colorectal Obstruction of Stage II/III Distal Colon Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Since oncological outcomes of transanal colorectal tube (TCT) placement, an endoscopic treatment for colorectal cancer (CRC) with acute colorectal obstruction (ACO), remain unknown, this study analyzed long-term outcomes of TCT placement for stage II/III CRC with ACO. MATERIALS AND METHODS: Data were retrospectively reviewed from consecutive patients with distal stage II/III CRC who underwent surgery between January 2007 and December 2011 at two Japanese hospitals. One hospital conducted emergency surgery and the other performed TCT placement as the standard treatment for all CRCs with ACO. Propensity score (PS) matching was used to adjust baseline characteristics between two groups. RESULTS: Among 754 patients with distal stage II/III CRC, 680 did not have ACO (non-ACO group) and 74 had ACO (ACO group). The PS matching between both hospitals identified 234 pairs in the non-ACO group and 23 pairs in the ACO group. In the non-ACO group, the surgical quality was equivalent between the two institutions, with no significant differences in overall survival (OS) and disease-free survival (DFS). In the ACO group, the rate of primary resection/anastomosis was higher in the TCT group than in the surgery group (87.0% vs. 26.1%, p < 0.001). No significant differences were noted between the surgery and the TCT groups in OS (5-year OS, 61.9% vs. 51.5%; p=0.490) and DFS (5-year DFS, 45.9% vs. 38.3%; p=0.658). CONCLUSION: TCT placement can achieve similar long-term outcomes to emergency surgery, with a high rate of primary resection/anastomosis for distal stage II/III colon cancer with ACO.

Estudio comparativo del stent colónico versus laparotomía en el tratamiento de la obstrucción intestinal aguda por cáncer colorrectal / Comparative Study of Colonic Stenting against Laparotomy for Treating Acute Intestinal Obstruction Due to Colorectal Cancer

Objetivo: la obstrucción por cáncer colorrectal (CCR) es una entidad frecuente y con importante morbilidad y mortalidad. El uso de stent colónicos aparece como una buena alternativa y pueden utilizarse con carácter paliativo o como una terapia puente para facilitar una única y definitiva cirugía. El objetivo del presente estudio es comparar el uso de los stents con la cirugía en los pacientes con obstrucción maligna colorrectal en términos de necesidad de ostomías, morbimortalidad y sobrevida. Métodos: se realizó un estudio descriptivo donde se analizaron retrospectivamente los datos recogidos de una cohorte de 103 pacientes, desde 2004 al 2012, registrada en una base de datos para tal fin y dividida en 4 grupos: un grupo al que se le colocó stent colónico y luego se llevó a cirugía electiva (SCX, n = 26), otro grupo llevado a cirugía convencional (CXC, n = 30), y los otros dos grupos con pacientes en fase avanzada de la enfermedad, unos en quienes solo se les colocó stent paliativo (SP, n = 24) y otros llevados a cirugía con intención paliativa (CP, n = 23). Se establecieron comparaciones entre los grupos y se realizó una descripción de los hallazgos más relevantes. Resultados: se registró un éxito técnico en 90,0% y éxito clínico en 82,0% en los grupos con stents. Se presentaron dos perforaciones asociadas con el stent (8,3%) en el grupo SP y ninguna en el grupo SCX. Hubo migración del stent en 3 pacientes (11,5%) del grupo SCX y en 3 (12,5%) del grupo SP. Se encontró una sobrevida global del 42,7%, siendo más baja en los grupos SP y CP con 4,2% y 34,8%, respectivamente. Se presentó una menor necesidad de ostomías en el grupo SCX con 5 pacientes (19,2%) versus 8 (26,7%) del grupo CXC, sin relevancia estadística, la cual sí se observó al comparar la necesidad de ostomías entre los grupos de CXC y CP con 8 (26,7%) y 15 (65,2%) pacientes respectivamente (P<0,05). Hubo alivio en el grupo SCX en 22 pacientes (84,6%) y solo en 18 del grupo CXC (60%), con una diferencia estadísticamente significativa (p = 0,042). La estancia hospitalaria fue menor en los grupos manejados con stent (SCX y SP), con promedio de 4 días (0-9 días) para cada uno. En el grupo CXC, 30 pacientes requirieron al menos una reintervención, 9 (39,1%) del grupo CP y 8 en el grupo de los stents. Conclusión: el uso de los stents colorrectales con intención paliativa o como terapia puente preoperatoria tiene baja morbilidad y evita en ocasiones una colostomía temporal o definitiva; también previene cirugías en pacientes con enfermedad avanzada y minimiza las ostomías en comparación con los pacientes operados paliativamente; además de que tienen menor estancia hospitalaria. Sin embargo, se necesitan estudios prospectivos que aclaren cuál es el verdadero papel de los stents en la patología obstructiva colorrectal maligna.

Objective: Obstructions due to colorectal cancer (CRC) are common and carry significant risks of morbidity and mortality. The use of colonic stents appears to be a good alternative and can be used with palliative therapy or as a bridge to facilitate definitive one-time-only surgery. The aim of this study is to compare the use of stents with surgery in patients with malignant colorectal obstructions in terms of morbidity, survival and the need for ostomies. Methods: This is a descriptive study based on data collected from a cohort of 103 patients from 2004 to 2012. Data were recorded in a database designed for this purpose. Patients were retrospectively divided into four groups for purposes of analysis. One group, which was labelled SCX, had had colonic stents placed and later underwent elective surgery (n = 26). A second group labelled CXC had undergone conventional surgery (n = 30). The other two groups consisted of patients in advanced stages of the disease. One of these groups, labelled SP received palliative stents (n = 24). The final group, labelled CP, underwent palliative surgery (n = 23). Comparisons among groups were made and then descriptions of the most important findings were developed. Results: The technical success rate was 90.0% and the clinical success rate was 82.0% in the groups of patients who received stents. There were two perforations in the SP group (8.3%) and none in the other group (SP) which received stents. Stent migration occurred in three patients (11.5%) in the SCX group and three (12.5%) in the SP group. The overall survival rate was 42.7%, but was only 4.2% in the SP group and 34.8% in the CP group. Fewer ostomies were required in the SCX group (five patients, 19.2%) than in the CXC group (eight patients, 26.7%) although the difference was not statistically significant. Similarly eight patients (26.7%) in the CXC group and 15 patients (65.2%) in the CP group required ostomies (P <0.05). Obstructions were ...

Evidence-Based Recommendations on Colorectal Stenting: A Report from the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy

Recently, placement of self-expandable metallic stents has been used for the treatment of colorectal obstruction. As domestic awareness of colorectal cancer has increased, the number of colorectal stenting procedures performed has also increased. We aimed to provide evidence-based recommendations for colorectal stenting to aid gastroenterologists in making informed decisions regarding the management of patients who present with colorectal obstruction. The working group consisted of eight gastroenterologists who actively practice and conduct research in the field of colorectal stenting and are the members of the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy. A literature search was conducted using the PubMed, Embase, KoreaMed, and the Cochrane Library databases to identify relevant articles published between January 2001 and June 2012. Based on the modified Delphi process, 10 recommendation statements regarding indications, usefulness, methodology and complications of colorectal stenting, and alternative treatments for malignant colorectal obstruction were determined. The contents will be widely distributed, and periodically revised to reflect the latest knowledge. These evidence-based recommendations for colorectal stenting will provide gastroenterologists and patients with appropriate and balanced information, and will improve the quality of care.

The Learning Curve for Colorectal Stent Insertion for the Treatment of Malignant Colorectal Obstruction

BACKGROUND/AIMS: We aimed to assess the effectiveness of self-expanding metal stent (SEMS) insertion by evaluating the learning curve in relation to the experience of an endoscopist. METHODS: We retrospectively analyzed the outcomes of 120 SEMS insertion procedures performed by one endoscopist in patients with malignant colorectal obstruction. We compared the technical and clinical success rates, complication rates, and duration of the procedures by quartiles. RESULTS: The mean age of the patients (76 men and 44 women) was 64.6 years. The overall technical success rate was 95.0% (114/120), and the clinical success rate was 90.0% (108/120). The median procedure duration was 16.2 minutes (range, 3.4 to 96.5 minutes). From the first to the last quartile, the technical success rates were 90.0%, 96.7%, 96.7%, and 96.7% (p=0.263), and the clinical success rates were 90.0%, 90.0%, 96.7%, and 83.3% (p=0.588), respectively. Procedure-related complications were observed in 28 patients (23.3%). The complication rates for SEMS insertion when patients were divided by quartiles were 26.7%, 23.3%, 10.0%, and 33.3% (p=0.184), respectively. Moreover, the number of stents per procedure was 1.13, 1.03, 1.00, and 1.00 (p=0.029), respectively. The median duration of SEMS insertion decreased significantly, 20.9 to 14.8 minutes after the first 30 procedures (p=0.005). CONCLUSIONS: An experienced endoscopist was able to perform the SEMS insertion procedure easily and effectively after performing 30 SEMS insertions.

Comparison of Effects of Preoperative Stenting for Obstructing Colorectal Cancers according to the Location of the Obstructing Lesion / 대한소화기학회지

BACKGROUND/AIMS: With the development of self-expanding metallic stents, colonic obstruction can be relieved without the need for surgery. The results of preoperative placement of stents for malignant colorectal obstruction might be different according to the obstructing lesion. The objective of this study was to compare clinical improvement rates and operative results after preoperative placement of stents for malignant colorectal obstruction according to the location of the obstructing lesion. METHODS: This is a retrospective study including 57 patients who underwent self-expanding metallic stent insertion for obstructing resectable colorectal cancers. Patients were classified into three groups according to the location of the lesion as follows: proximal to the sigmoid colon (Group A), sigmoid colon (Group B), and rectum (Group C). RESULTS: The number of patients in A, B, and C groups was 13, 22, and 22, respectively. No significant differences in age, gender, stent type, and accompanying diseases among the three groups were observed. There were no significant differences in stent-related complications, clinical improvement rates, and one-stage resection rates among the three groups. The postoperative complications, the requirement rate of ICU care, the period of ICU stay, postoperative hospital stay, and hospital mortality did not significantly differ among the three groups. CONCLUSIONS: Clinical improvement rates and operative results after successful placement of stents for obstructing resectable colorectal cancers are not different according to the location of the obstructing lesion, suggesting that preoperative stenting for one-stage curative resection is useful, irrespective of the location of lesion.

Usefulness and Cost-effectiveness of Colorectal Stent Followed by Curative Resection for Left-sided Malignant Colorectal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: We aimed to evaluate the cost-effectiveness of preoperative stent insertion for treating left-sided malignant colorectal obstruction. METHODS: Patients with left-sided malignant colorectal obstruction were included in this study. The stent group (ST, n=24) included those patients who were treated with preoperative stent insertion followed by curative surgical resection. The clinical course and management cost of the ST group was compared to those of the emergency operation group (EO, n=22). RESULTS: The patients' age (60.6+/-3.1 yrs vs. 62.1+/-3.2 yrs, p=0.74) and the male to female ratio (12:12 vs. 15:7, p=0.25) were not different between the ST and EO groups. The distribution of the postoperative pathologic stages was also not different. All the patients in the ST group underwent only one surgical operation, while 6 patients (27.3%) in the EO group underwent 2 or more surgeries (p<0.01). The mean hospital stay in the ST group was 22.0+/-0.8 days compared to 26.3+/-2.4 days in the EO group (p=0.09). Postoperative care in the intensive care unit was necessary for one patient (4.2%) in the ST group, while 7 patients (31.8%) in EO group needed postoperative care (p=0.02). Postoperative complications developed in one patient in the ST group, while 6 patients in the EO experienced postoperative complications (p=0.04). The mean total cost per patient was 7,974,236 won for the ST group while this was 9,271,630 won for the EO group (p=0.06). CONCLUSIONS: Preopreative stent insertion for treating left-sided malignant colorectal obstruction is more cost-effective than an emergency operation.

Usefulness of a Self-expandable Nitinol Stent Through an Endoscope for the Treatment of a Malignant Colorectal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Expandable stents were inserted for temporary decompression of the colorectum before single-stage surgery or for palliation. The aim of this study was to evaluate the usefulness of a self-expandable nitinol stent, which can be placed through the working channel of an endoscope, for treatment of malignant colorectal obstructions. METHODS: From May 2000 to April 2001, twenty patients (eleven female, nine male, aged 39~81 years) with malignant colorectal obstructions were treated for relief from the obstructions with endoscopically guided intubation of an expandable nitinol stent through the working channel of an endoscope. Of twenty patients, thirteen underwent placement of the stent for presurgical decompression; seven, for palliative decompression. RESULTS: The site of obstructions were on the rectum (n=8), sigmoid colon (n=6), descending colon (n=2), transverse colon (n=3) and ascending colon (n=1). Stent placement was successful in 18 (90%) of the 20 patients. Failure occurred in two patients with long and tortuous lesions involving hepatic flexure or splenic flexure. All patients tolerated placement of the stent well, with no procedure-related complications. In patients with successful placement of the stent, symptoms of obstruction resolved within 72 hours. Twelve patients underwent the formal bowel preparation and elective single-stage surgery without complications 4~7 days after stent placement. In six patients, the stents provided palliative decompression of the colorectum. There was stent migration in two patients during follow-up. CONCLUSIONS: Placement of a self-expandable nitinol stent through the working channel of an endoscope is technically feasible and safe. Stent placement allowed patients with malignant colorectal obstruction to undergo single-stage surgery in cases of operable disease and to provide palliative decompression in cases of inoperable disease.

Stent treatment for the benign or malignant colorectal obstruction / 介入放射学杂志

Objective To discuss the clinical efficacy of stent treatment for the benign or malignant colorectal obstruction. Methods Under fluoroscopic and / or endoscopic guidance stent implantation was performed in 30 patients with colonic or rectal obstruction. The obstruction sites were located at rectum (n = 20), recto-sigmoid juncture (n = 2), sigmoid colon (n = 3), descending colon (n = 3) and transverse colon (n = 2). Results Thirty-one colorectal stents were implanted in total 30 patients, the technical success rate was 92% by once-through operation. The patients were immediately relieved of the symptoms of intestinal obstruction. No complications related to stent implantation occurred. The average survival time in patients with malignant obstruction was 271 days. Conclusion For colorectal obstruction, stent implantation through anus is a minimally-invasive, safe and effective treatment with few complications. The procedure can effectively relieve the patients of the intestinal obstruction symptoms and, thus, improve their living quality.