Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial

doi:10.1016/j.amjsurg.2011.11.013

The American Journal of Surgery

Volume 204, Issue 3, September 2012, Pages 321-326

https://doi.org/10.1016/j.amjsurg.2011.11.013 Get rights and content

Abstract

Background

Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction.

Methods

In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death.

Results

There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125–612 days) in patients who had stents and 280 days (range, 135–591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure.

Conclusions

Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

Section snippets

Study design

After adequate experience with >40 patients who had SEMS placement for obstructing colorectal cancer, it was decided to perform a prospective randomized trial to compare SEMS placement with proximal diverting colostomy in patients with stage IV unresectable colorectal cancer. Inclusion criteria were (1) patients with obstructing cancer of the rectum or of the sigmoid colon at preoperative sigmoidoscopy, (2) the presence of distant metastases (stage IV), (3) symptoms of chronic subacute

Early results: endoscopic stent placement

There were no major difficulties in positioning the stents. The median time required was 36 ± 15 minutes (range, 15–55 minutes). None of the patients complained of any major discomfort. All patients resumed bowel function within 24 hours. Oral feeding was started the day after the procedure without any discomfort for the patients or need for infusion support. Hospital stays ranged from 2 to 4 days (mean, 2.6 ± .8 days).

Early results: colostomy

No mortality was observed. In 1 patient (9.1%), there was a partial prolapse

Comments

Colorectal cancer is the most common cause of large bowel obstruction, and almost 90% of the tumors that cause obstruction are located at or distal to the splenic flexure. The distal location of most of the lesions allows a relatively easy insertion and deployment of the stent.

The placement of a metallic stent in the colon was first reported by in 1991 by Dohmoto.⁸ Tejero et al⁹ introduced the technique of placing the stent under fluoroscopic control before surgery. Since then, many reports

Conclusions

Our results show that SEMS placement can represent the treatment of choice in patients with nonresectable stage IV colorectal cancer and symptoms of chronic obstruction, provided that the procedure is performed by highly trained teams and in elective and favorable conditions.

Recently, 2 prospective randomized trials18, 19 showed that SEMS placement in patients with acute colorectal obstruction followed by elective surgery resulted in higher mortality rates than in patients who underwent

References (19)

D.J. Schoetz
Evolving practice patterns in colon and rectal surgery
J Am Coll Surg
(2006)
S. Nagula et al.
Quality of life and symptom control after stent placement or surgical palliation of malignant colorectal obstructions
J Am Coll Surg
(2010)
S.J. Winawer et al.
Prevention of colorectal cancer by colonoscopy polypectomy
N Engl J Med
(1993)
D.A. Licherman et al.
One-time screening for colorectal cancer with combined fecal occult blood testing and examination of the distal colonVeterans Affairs Cooperative Study 380
N Engl J Med
(2001)
A. Jemal et al.
Cancer statistics 2003
CA Cancer J Clin
(2003)
Evidence based reviews in surgery: colorectal surgery
Dis Colon Rectum
(2011)
T. Sammour et al.
Laparoscopic colorectal surgery is associated with a higher complication rate than open surgery
Ann Surg
(2011)
K.F. Schultz et al.
CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials
Ann Intern Med
(2010)
M. Dohmoto
New method; endoscopic implantation of rectal stent in palliative treatment of malignant stenosis
Endosc Digest
(1991)

There are more references available in the full text version of this article.

Cited by (64)

Outcomes After Surgical Palliation of Patients With Gastric Cancer
2022, Journal of Surgical Research
Surgery is an option for symptom palliation in patients with metastatic gastric cancer. Operative outcomes after palliative interventions are largely unknown. Herein, we assess the trends of surgical palliation use for patients with gastric cancer and describe outcomes of patients undergoing surgical palliation compared to nonsurgical palliation.
Patients with clinical Stage IV gastric cancer in the National Cancer Database (2004-2015) who received surgical or nonsurgical palliation were selected. We identified factors associated with palliative surgery. Survival differences were assessed by Kaplan–Meier estimate, Cox proportional hazard regression, and log rank test.
Six thousand eight hundred twenty nine patients received palliative care for gastric cancer. Most patients (87%, n = 5944) received nonsurgical palliation: 29% radiation therapy, 57% systemic treatment, and 14% pain management. The number of patients receiving palliative care increased between 2004 and 2015; however, use of surgical palliation declined significantly (22% in 2004, 8% in 2015; P < 0.001). Median overall survival (OS) for the cohort was 5.65 mo (95% confidence interval 5.45-5.85); 1-year and 2-year OS were 24% and 9%, respectively. Older age at diagnosis and diagnosis between 2004 and 2006 were significantly associated with undergoing surgical palliation. Patients who underwent surgical palliation had significantly shorter median OS and a 20% higher hazard of mortality than those who received nonsurgical palliation.
Patients with metastatic gastric cancer experience very short survival. While palliative surgery is used infrequently, the observed association with shorter median OS underscores the importance of careful patient selection. Palliative surgery should be offered judiciously and expectations about outcomes clearly established.
Colonic stenting for malignant obstructions-A review of current indications and outcomes
2022, American Journal of Surgery
Colonic stenting has emerged as preferred palliative treatment for left sided malignant obstructions. It shortens hospital stays, decreases healthcare cost, reduces permanent stoma rates, and expedites the start of chemotherapy. The role of stenting as a bridge-to-surgery remains unsettled.
For this paper the recommendations of the American and European society of gastroenterology and colorectal surgery were reviewed. We will discuss the benefits and risks of stenting in palliative setting and as bridge-to-surgery. Quality of life, hospital stay, and health care cost will also be considered.
Non-traversable colon masses during endoscopy are considered a risk factor of development of intestinal obstruction but preventive stent placement in patients without obstructive symptoms is not recommended. The risk of technical or clinical failure is significant at 25%. If stent placement allows neoadjuvant chemotherapy, it may increase the rate of R0 resections. Perforations may raise local recurrence and mortality rates.
Management of Synchronous Colorectal Cancer Metastases
2022, Surgical Oncology Clinics of North America
Citation Excerpt :
In the stable patient without signs/symptoms of proximal perforation, ASCRS guidelines prioritize endoscopic stenting over surgery in the setting of incurable metastatic disease. Compared with surgery, stenting is associated with reduced short-term morbidity and time to chemotherapy initiation.6,15–18 This depends on local capabilities and experience with colonic stenting, which anecdotally varies between institutions.
Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: A systematic review and meta-analysis of high quality prospective and randomised controlled trials
2020, European Journal of Surgical Oncology
Self-expanding metallic stent placement as a bridge to surgery has been reported as an alternative to emergency surgery for acute malignant colorectal obstruction. However, results from clinical trials and previous meta-analyses are conflicting. We carried out a meta-analysis to compare the surgical and oncological outcomes between emergency surgery and self-expanding metallic stents for malignant large bowel obstruction. Pubmed, Embase, CINAHL, Web of Science and Cochrane were searched for prospective and randomised controlled trials. The outcomes of focus included 3- and 5-year overall and disease-free survival, overall tumour recurrence, overall complication and 30-day mortality rate, length of hospital and ICU stay, overall blood loss, number of patients requiring transfusion, total number of lymph nodes harvested, stoma and primary anastomosis rate. Twenty-seven studies were included with a total of 3894 patients. There was no significant difference in terms of 3-year and 5-year disease-free and overall survival. Stenting resulted in less blood loss (mean difference −234.72, P < 0.00001) and higher primary anastomosis rate (RR 1.25, P < 0.00001). For curative cases, bridge to surgery groups had lower 30-day mortality rate (RR 0.65, P = 0.01), lower overall complication rate (RR 0.65, P < 0.0001), more lymph nodes harvested (mean difference 2.51, P = 0.005), shorter ICU stay (mean difference −2.27, P = 0.02) and hospital stay (mean difference −7.24, 95% P < 0.0001). Compared to emergency surgery, self-expanding metallic stent interventions improve short-term surgical outcomes, especially in the curative setting, but have similar long-term oncological and survival outcomes.
The treatment of rectal cancer with synchronous liver metastases: A matter of strategy
2019, Critical Reviews in Oncology/Hematology
Around one fifth of patients with rectal cancer (RC) have synchronous metastatic disease at the diagnosis. The optimal treatment sequence for patients with RC and synchronous liver metastases (LM) is complex and unclear, missing strong, evidence-based recommendations. From a clinical point of view, this situation is highly heterogeneous and the treatment strategy is generally determined by a number of factors, such as the potential resectability of primary tumor and LM, patients’ characteristics, the presence of primary tumor-related symptoms and the response to therapies. Treatment options for these patients include systemic therapy, short-course radiotherapy (SC-RT), long-course chemoradiotherapy (LC-CRT) and surgery of the primary tumor and LM. The principal goal is to render the patients eligible to radical surgery, thus offering a chance of cure at least for some of them. This review summarizes the most appropriate treatment strategies which should be recommended in the different clinical scenarios of this heterogeneous condition.
Comparison between endoscopic stenting and colostomy in the management of obstructing cancer of the left colon: Literature review
2019, Presse Medicale
L’occlusion colique est le mode de révélation de 8 à 29 % des cancers du côlon. L’objectif de notre travail est de comparer la mise en place du stent versus colostomie de décharge dans la prise en charge du cancer du côlon gauche en occlusion.
Nous avons réalisé une recherche systématique de la littérature à partir de l’interrogation de la base de données MEDLINE, EMBASE et Cochrane Library, pour identifier les articles relatifs à la comparaison du stent vs colostomie publiés entre 2000 et 2016.
La recherche électronique nous a permis d’identifier 6 études. Une seule étude était prospective comparative. Trois études étaient dans un but curatif. Le nombre total était 7205 malades. Dans le groupe « stent », il y avait une diminution de la durée moyenne de séjour par rapport au groupe « stomie » et une diminution du coût avec une relation statistiquement significative. Par ailleurs, il n’y avait pas de différence entre les deux groupes en termes de mortalité hospitalière et de morbidité précoce.
Devant une occlusion néoplasique du colon gauche, le choix entre colostomie ou stent colique dépend de la stratégie thérapeutique. En effet, en cas d’une stratégie curative ou d’administration d’anti-angiogéniques il est recommandé de pratiquer une colostomie. Cependant en cas de traitement palliatif, la prothèse colique est le traitement de choix.
Colonic occlusion is the mode of discovery of 8 to 29% of colonic neoplasms. Our objective is to compare the placement of stent versus colostomy in the management of obstructing cancer of the left colon.
We have carried out a systematic search of literature from MEDLINE, EMBASE and Cochrane Library database to identify articles related to the comparison of stent versus colostomy published between 2000 and 2016.
We have identified 6 studies. Only one study was prospective comparative. Three studies were for curative purposes. The total number of patients was 7205. In the “stent” group, there was a decrease in the average length of hospital stay compared to the “stoma” group and there was a decrease in cost with a statistically significant relationship. There was no difference between the two groups in terms of 4 hospital mortality and early morbidity.
In case of neoplastic occlusion of the left colon, the choice between colostomy or colonic stent depends on the therapeutic strategy. Indeed, for curative strategy or administration of anti-angiogenics, it is recommended to practice a colostomy. However, for palliative treatment, colonic stenting is the treatment to follow.

View all citing articles on Scopus

View full text

Clinical sciencePalliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study design

Early results: endoscopic stent placement

Early results: colostomy

Comments

Conclusions

J Am Coll Surg

J Am Coll Surg

Prevention of colorectal cancer by colonoscopy polypectomy

N Engl J Med

One-time screening for colorectal cancer with combined fecal occult blood testing and examination of the distal colonVeterans Affairs Cooperative Study 380

N Engl J Med

Cancer statistics 2003

CA Cancer J Clin

Evidence based reviews in surgery: colorectal surgery

Dis Colon Rectum

Laparoscopic colorectal surgery is associated with a higher complication rate than open surgery

Ann Surg

CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials

Ann Intern Med

New method; endoscopic implantation of rectal stent in palliative treatment of malignant stenosis

Endosc Digest

Clinical science
Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial