Laparoscopic Colorectal Resection after Endoscopic Stent Insertion in Cases of Malignant Colorectal Obstruction: the Experience of a Single Center

PURPOSE: Laparoscopic surgery has been considered to be contraindicated for obstructive colorectal cancer. However, endoscopic stent insertion for obstructive colorectal cancer has recently allowed elective laparoscopic surgery. The aim of this study is to evaluate the feasibility and the short-term clinical outcomes of laparoscopic surgery following endoscopic stent insertion for management of malignant colorectal obstruction at a single center. METHODS: The medical records of patients who had undergone endoscopic stent insertion for colorectal cancer obstruction, followed by laparoscopic colorectal resections, from August 2004 to August 2008 were reviewed. To evaluate the surgical and clinical outcomes, we analyzed the clinical and pathologic data. RESULTS: Thirty-six endoscopic stent insertions were successfully performed during the study period. Of those 36, the 28 treated by laparoscopic surgery were enrolled in this study. The mean interval between stent insertion and surgery was 7.4+/-2.3 days. Two cases were converted to open surgery. The mean operative time was 185.5+/-53.1 min, and the mean blood loss was 77.0+/-72.9 mL. Flatus was passed on the mean 2nd postoperative day, and patients started to eat on the mean 4th postoperative day. The mean postoperative hospital stay was 11.2+/-4.4 days. Anastomosis leakages occurred in two cases and were treated by a secondary operation with a transient ileostomy. There were morbidities in five cases, but no mortalities. CONCLUSION: A combined endoscopic stent insertion and laparoscopic surgery is an effective and safe, minimally invasive operation for malignant colorectal obstruction.

Short-term Oncologic Outcome of Curative Resection for Obstructive Colorectal Cancer Followed by Stent Insertion: Comparative Study with Non-abstructive Colorectal Cancer

PURPOSE: Recently, a self-expandable metallic stent has allowed an elective single-stage resection avoiding the risk of emergency operation and stoma formation in patients with obstructive colorectal cancer (CRC). But, forceful expansion of stent may increase the possibility of tumor cell exfoliation and dissemination through bowel lumen, lymphatic and blood vessels. Aim of study is to evaluate the short-term outcome of curative resection for obstructive colorectal cancer followed by stent in terms of oncologic safety. METHODS: Twenty-seven patients who underwent curative resection for obstructive CRC followed by stent insertion were included in 'stent group' and control group included 87 patients who underwent surgery for non-obstructive CRC. The clinicopathologic characteristics and prognosis were compared between two groups. RESULTS: There was no significant difference in clinicopathologic characteristics between two groups. No difference was found in postoperative complications between two groups. Overall survival rate of two groups showed no statistically significant differences (P=0.1254). Stage-matched survival rates (stage II & III) were also showed no differences between two groups. CONCLUSION: Stent insertion itself does not compromise the survival of patients with obstructive CRC. Oncologic safety of stent insertion for obstructive CRC is acceptable. A further large-scaled prospective study and long-term follow-up is necessary to evaluate the oncologic safety of stent insertion in obstructive CRC.

Clinical research of the self-made subcutaneous negative pressure drainage tube to prevent postoperative incision infection of elderly patients with obstructive colorectal cancer / 中国医师进修杂志

Objective To investigate the means which can prevent postoperative incision infection of elderly patients with obstructive colorectal cancer. Methods Sixty-seven cases of elderly patients with obstructive colorectal cancer adopting surgical treatment were divided into two groups, including experimental group with 37 cases and control group with 30 cases. Put self-made negative pressure drainage tube with side-hole into subcutaneous interspace of abdominal incision of experimental group alter operation, kept continuous negative pressure drainage 7-10 d and pull out the self-made subcutaneous negative pressure drainage tubes till drainage volume decreased obviously. The abdominal wall incisions of the control group were given conventional suture. Results Incision infection occurred in only one case (2.7%) and no incision dehiscence occurred in the experimental group, and incision healing time was (9.36 ± 2.18) d. Incision infection occurred in 7 cases (23.3%) in the control group, of which there were 3 cases (10.0%) of wound dehiscence, incision healing time was (12.25 ±4.06) d. Incision infection rate of the two groups had significant difference (χ2= 6.706,P < 0.05), incision dehiscence rate of the two groups had no significant difference (P 0.05), incision healing time of the two groups had significant difference (t = 6.676, P < 0.05). Conclusion Using the self-made subcutaneous negative pressure drainage tube and keeping it continuous negative pressure drainage after operation can be effective in preventing incision infection of elderly patients with obstructive colorectal cancer, and promote wound healing.

Oncological Safety of Flexible Rectal Stent Insertion in Obstructive Colorectal Cancer: Short Term Result

PURPOSE: Flexible rectal stent for obstructive colorectal cancer has an advantage of elective one stage operation after decompression. But, forceful expansion of stent may increase the possibility of tumor cell dissemination through lymph nodes and blood vessels. We studied the oncological safety of stent insertion in obstructive colorectal cancer. METHODS: From June 1996 to August 2001, the patients with stent insertion for obstructive colorectal cancer at Samsung Medical Center were retrospectively evaluated. Seventy- one patients had stent insertion for palliation or curative resection. Among these patients 15 patients underwent curative surgery after stent insertion (stent group). During the same period 25 patients underwent multi-staged operation after the decompressing colostomy or Hartman operation. (staged operation group). Statistical methods such as Fisher's exact test, 2-test, Kaplan-Meier method were used. RESULTS: There was no significant difference between two groups in terms of age, gender, tumor location, and stage. The median follow-up period was 21 months in stent insertion group and 29 months in staged operation group. Overall recurrence rate was 33.3% in stent insertion group and 32.0% in staged operation group. The 5-year survival rate in stent insertion group was higher than in staged operation group (75.8% vs. 48.3%). But there was no statistical significance (P>0.05 ). Disease free survival was 22.4 (6~51) months in stent insertion group and 27.8 (5~71) months in staged operation group. There was no significant difference either. CONCLUSIONS: There was no significant difference between two groups in survival rate, recurrence rate in short term result. Flexible rectal stent insertion can be considered as oncologically safe and useful treatment of obstructive colorectal cancer. But we think long term follow up and much more cases will be necessary to make a conclusion more definitively.

The Conservative Treatment of Rectal Perforation after Insertion of A Stent and Chemo-Radiotherephy in the Patient with Obstructive Rectal Cancer

The use of self-expanding metal stent has been widely reported that its utility can make a palliative decompression treatment and one stage operation without doing colostomy in the patient with unresectable and resectable obstructive colorectal cancer, respectively. It, however, can sometimes cause complications such as intestinal perforation. We report that the conservative treantment could be possible without removing stent or performing laparotomy in case of intestinal perforation during chemoradiotheraphy after insert of stent for relieving colonic obstruction in the 53 years old female patient with stage IV rectal cancer.

Treatment of Obstructive Colorectal Cancer

The occurrence of the colonic obstruction secondary to colorectal carcinoma (CRC) has been reported in 7~30% of the CRC patients. It is generally believed that obstructive CRC is associated with a poor prognosis with respect to operative mortality and five-year survival. A series of 1064 cases of the CRC treated surgically at Asan Medical Center from June 1989 to December 1996 has been analyzed to compare clinicopathological findings between obstructive and non-obstructive CRC and to evaluate surgical treatment options in obstructive CRC. Complete obstruction was present in 49 cases (4.6%). There were no differences between obstructive and non-obstructive CRC in tumor location, size, Dukes' stage, and differentiation. In forty-nine obstructive CRC cases, primary resections were performed in 29 cases after peri-operative bowel decompression. In this group, right colon cancer was more prevalent than staged operation group (45% vs. 5%, P<0.05) and hospital stay was significantly short (16 days vs. 38 days, P<0.05). Postoperative complication rate was higher in staged operation group (65% vs. 28%, P=0.01). It may be due to stoma related wound complication. In obstructive left colon cancer, there was a significant difference in complication rate between primary resection and staged operation (P<0.05). Overall 5-year survival rate were 66% and 53% in non-obstructive and obstructive group, respectively. Survival rate according to the Dukes' B and C stages did not show statistical differences, either. Conclusively, primary resection is preferred to the obstructive CRC when supportive care, preoperative bowel decompression, and intraoperative colonic irrigation were performed adequately.