Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction

doi:10.1016/j.gie.2005.12.032

Gastrointestinal Endoscopy

Volume 63, Issue 6, May 2006, Pages 814-819

https://doi.org/10.1016/j.gie.2005.12.032 Get rights and content

Background

In patients with colorectal cancer, a preoperative colonoscopy is recommended to exclude synchronous lesions. Unfortunately, between 7% and 29% of patients with colorectal cancer present with acute colonic obstruction, making complete colonoscopy impossible.

Objective

The aim of our study was to evaluate the feasibility of a preoperative colonoscopy after effective stent placement in patients with acute neoplastic obstruction.

Design

Single-center prospective study.

Setting

All examinations were carried out at a tertiary referral center with 24-hour emergency endoscopy service.

Patients

Fifty-seven patients with acute neoplastic colon obstruction.

Interventions

Patients who recovered from an acute colon obstruction by an effective stent placement and who had a resectable cancer underwent a preoperative colonoscopy.

Main Outcome Measurements

Patients with a resectable cancer, complete preoperative colonoscopies, and synchronous lesions rates.

Results

Self-expandable metallic stents (SEMS) were placed in 50 of 57 patients (87.8%). Thirty-one of 50 patients had a resectable cancer (62%), and a complete preoperative colonoscopy was possible in 29 of 31 patients (93.4%). A synchronous cancer was detected in 3 patients (9.6%), changing the surgical plan.

Limitations

Seven patients in whom the SEMS placement (12.2%) was unsuccessful underwent an urgent surgical intervention. Nineteen of 50 patients who had stent placement were not eligible for our study because of unresectable cancer.

Conclusions

Our study indicates that it is feasible in a majority of patients to perform full preoperative colonoscopy after relief of acute colonic obstruction with SEMS before surgical resection.

Section snippets

Patients and methods

From January 2002 to September 2004, 57 consecutive patients (33 men, 24 women; mean age, 69 ± 18 years) with acute neoplastic colon obstruction who were undergoing SEMS placement were prospectively included in the study. Patients were eligible for the study if they presented with clinical signs and symptoms of intestinal obstruction. Suspicion of perforation was an exclusion criterion. SEMS placement was performed under endoscopic and fluoroscopic control within 12 hours of the diagnosis. Full

Results

In 57 consecutive patients with acute neoplastic colon obstruction, the site of obstruction was the rectosigmoid junction (n = 26), sigmoid colon (n = 11), sigmoid-descending colon junction (n = 5), descending colon (n = 5), splenic flexure (n = 4), transverse colon (n = 5), and hepatic flexure (n = 1) (Table 1). The length of the obstructions ranged from 2.0 to 8.5 cm (mean, 4.0 cm). We placed 56 SEMS (Enteral Wallstent [23], Ultraflex Precision [33]), and insertion was technically successful

Discussion

In patients with colon cancer, it is recommended that a preoperative colonoscopy be performed because a synchronous cancer could change the surgical plan; in fact, in the literature, the reported rate of synchronous colon-cancer lesions ranges from 2% to 12% of patients.9, 10, 11, 12 Unfortunately, between 7% and 29% of patients with colorectal cancer present with an acute colon obstruction, making the execution of a colonoscopy impossible; in this case, the standard treatment is emergency

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Cited by (61)

Preoperative diagnosis of obstructive colitis in colorectal cancer patients who underwent self-expandable metallic stent insertion as a bridge to surgery
2022, Asian Journal of Surgery
Citation Excerpt :
In recent years, SEMS insertion for obstructive CRC as a “bridge to surgery” (BTS) has become common.7–9 When SEMS is placed, preoperative colonoscopy can be performed by passing through the stent after decompression of the colon.10–12 Total colonoscopy through a stent is useful in diagnosing synchronous cancer; however, preoperative diagnosis of OC by colonoscopy has not been reported.
Obstructive colitis (OC) is a risk factor of anastomotic leakage in colorectal cancer resection. We aimed to clarify the relationship between the severity of OC and clinicopathological findings and to detect predictive factors of OC.
We retrospectively reviewed 43 cases of colectomy after self-expandable metallic stent placement for left-sided colorectal cancer. Preoperative diagnosis of OC was made by multiple modalities (initial computed tomography (CT), presurgical CT, and colonoscopy). We classified OC macroscopically in resected specimens into five groups (Grade 0: none, 1: mild [mild edema], 2: moderate [severe edema, redness, erosion], 3: severe [ulceration, bleeding], 4: very severe [necrosis, perforation]), and investigated the relationship between the preoperative assessment, surgical findings and the severity of OC.
OC of Grade 2 or more (53.5%) was significantly correlated with severe edema in initial CT. There was no significant correlation between OC and anastomosis rate. The creation of covering stoma was significantly higher in the Grade 2 or more OC group. No leakage was observed in either group.
Initial CT may be most useful for prediction of OC. It is important to make a preoperative diagnosis of OC by combining multiple modalities, which enables to determine the appropriate location for resection, anastomosis, and construction of a covering stoma.
Critical appraisal of oncological safety of stent as bridge to surgery in left-sided obstructing colon cancer; a systematic review and meta-analysis
2018, Critical Reviews in Oncology/Hematology
Citation Excerpt :
Traditionally, acute malignant colonic obstruction has been managed with emergency surgery (ES), either consisting of acute resection or decompressing stoma construction. Resection in the emergency setting might be associated with a substantial risk of mortality and morbidity rates, especially in patients with high operativerisk (Tanis et al., 2015; Dohmoto, 1991; Vitale et al., 2006). This resulted in the search for alternative treatment approaches.
This meta-analysis aims to determine the long-term oncological outcomes of SEMS as bridge to surgery (BTS) versus emergency surgery (ES). A systematic search without restrictions was conducted, and all studies comparing SEMS with ES reporting on long-term outcomes were included. Methodological quality was assessed using the appropriate tools. Twenty-one comparative studies were selected, reporting on 1919 patients. Meta-analysis showed no significant difference regarding three- and five-year overall survival (OR = 0·85 (0·68-1·08) and OR = 1·04 (0·68-1·57), respectively), disease-free survival (OR = 0·96 (0·73-1·26) and OR = 0·86 (0·54-1·36), respectively) and local recurrence rate (OR = 1·32 (0·78-2·23)). Permanent stomas were significantly lower in the SEMS group (OR 0·49 (0·32-0·74)). Sensitivity analysis on three-year survival showed opposite outcomes, with a trend towards worse survival in the SEMS group when only RCTs are taken into account. In conclusion, when in experienced hands, SEMS placement as BTS seems oncologically safe.
Comparison between metallic stent and transanal decompression tube for malignant large-bowel obstruction
2016, Journal of Surgical Research
Citation Excerpt :
A considerable number of meta-analyses have shown more favorable short-term outcomes of SEMS insertion followed by surgery (i.e., “bridge to surgery,” [BTS]) than of emergency surgery alone in terms of morbidity, stoma creation, primary anastomosis, and length of postoperative hospital stay (LOS).8-10 The BTS strategy can prevent high-risk emergency surgery and may allow for elective one-stage radical surgery after full preoperative staging, screening for synchronous proximal lesions, and appropriate bowel preparation.11-13 Another endoscopic decompression technique, placement of a transanal decompression tube (TDT), also helps to avoid two-stage surgery for MLBO.
The short-term safety and efficacy of a self-expandable metallic colonic stent (SEMS) insertion followed by elective surgery, “bridge to surgery (BTS)”, for malignant large-bowel obstruction (MLBO) have been well described comparing with emergency surgery. The aim of this study was to compare short-term outcomes of endoscopic decompression using a SEMS versus a transanal decompression tube (TDT).
From January 2005 to November 2014, a total of 101 patients with MLBO underwent surgery at our single institution were retrospectively identified. Among them, 73 patients who underwent preoperative complete insertion of a decompression device (TDT, n = 45; SEMS, n = 28) were finally included in this study. Six patients with incomplete insertion of a decompression device (TDT, n = 5; SEMS, n = 1) were also excluded. The primary endpoints of this study were the postoperative morbidity and mortality rates. The secondary endpoints were decompression-related outcomes. Additionally, propensity score matched (PSM) analysis was conducted in short-term outcomes between the groups.
The SEMS group had significantly higher proportion of right-sided tumor and bigger tumor size compared with those of the TDT group. The SEMS group had a significantly higher proportion of patients who underwent laparoscopic surgery, and consequently, a longer surgical duration than did the TDT group. Higher rates of insertion failure and perforation were recognized in the TDT group than in the SEMS group (10.0% versus 3.6% and 8.9% versus 0.0%, respectively), although these differences were not statistically significant (P = 0.406 and 0.291, respectively). The two groups showed similar occurrences of anastomotic leakage, bowel obstruction, overall complications, and mortality. Compared with the TDT group, the SEMS group had a significantly lower rate of surgical site infection (24.4% versus 3.6%, respectively; P = 0.023 and P = 0.025 after PSM) and a shorter length of hospital stay (median, 21 d [interquartile range, 18-29 d] versus 38 d [interquartile range, 28-45 d], respectively; P = 0.015 and P = 0.003 after PSM). Solid food intake after decompression and preoperative temporary discharge occurred only in the SEMS group.
Preoperative SEMS insertion for MLBO is effective with at least equivalent short-term outcomes and superior preoperative quality of life compared with decompression using TDT.
Perforation in colorectal stenting: A meta-analysis and a search for risk factors
2014, Gastrointestinal Endoscopy
Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement.
To identify risk factors for perforation from colonic stenting.
A meta-analysis of 86 studies published between 2005 and 2011.
Multicenter review.
All patients who underwent colorectal stent placement.
Colorectal stent placement.
The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab.
A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%).
Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis.
The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.
Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline
2014, Gastrointestinal Endoscopy
Citation Excerpt :
Current evidence does not justify routine preoperative assessment for synchronous tumors in obstructed patients by CTC or colonoscopy through the stent. However, preoperative CTC and colonoscopy through the stent appear feasible and safe in these patients and there are presently no data to discourage their use in this population.25–28 The role of positron emission tomography (PET)/CT in the diagnosis of synchronous lesions remains to be elucidated.29
The optimal surgery timing after stenting in colorectal cancer patients with malignant obstruction: additionally compared with emergency surgery
2023, World Journal of Surgical Oncology

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Original ArticlePreoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Patients and methods

Results

Discussion

Am J Surg

Am J Surg

Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathologic variables

Am J Surg

Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents

Radiology

Preoperative evaluation: medical obstacles to surgery

Cancer

Colorectal stenting

Endoscopy

Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction

Am J Gastroenterol

Metal stents for palliation of rectal carcinoma: a preliminary reports on 12 patients

Endoscopy

Acute colorectal obstruction—treatment with self-expandable metallic stents before scheduled surgery: results of a multicenter study

Radiology

Original Article
Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction