Colonic cancer: The current role of stent insertion

Abstract

Acute colonic obstruction secondary to left-colonic malignancy remains a common emergency condition. Traditional management is emergency surgery and has high morbidity and mortality. Self expandable metallic stents (SEMS) promised to improve morbidity and mortality, stoma rates and hospital stay. SEMS use in the potentially curative setting, as a bridge to surgery, is associated with an improved stoma rate and morbidity, but has no mortality benefit. There are concerns about oncological safety with higher local recurrence rates, thus SEMS is not recommended in this setting unless the patient has increased surgical risk and would benefit from a period of recovery prior to surgery. SEMS has a definite role in the palliative setting, for both patients with incurable disease or those with a high surgical risk. SEMS is associated with improved morbidity, mortality, and stoma rates. The technique for SEMS insertion is now well established but it is still unclear whether covered or uncovered stents are better.

Metallic Stent for Malignant Colorectal Obstruction

“…The objectives of SEMS placement are shorter stay in a hospital, reduction in morbidity as well as mortality, and an improved quality of life. 7 A large meta-analysis comparing palliative SEMS placement (n ¼ 404) with palliative surgery (n ¼ 433) for incurable MCRO showed that SEMS group had a lower clinical success rate (93.1 vs 99.8%, p ¼ 0.0009) but a shorter duration of hospital stay (10 days vs 19 days, p < 0.00001), shorter time for initiation of chemotherapy (16 days vs 33 days, p < 0.00001), and a significantly lower rate of 30-day mortality (4.2 vs 10.5%, p ¼ 0.01). Although stent-related complications including perforation (10.1%), stent migration (9.2%), and reobstruction (18.3%) were not uncommon, the rate of total complications was similar between these two groups (SEMS: 34.0 vs surgery: 38.1%, p ¼ 0.60).…”

“…21,22 Systemic chemotherapy during stenting could induce stent-related complications, such as perforation due to tissue necrosis and/or stent migration due to tumor shrinkage. 7,20 According to a recent large meta-analysis searching for risk factors of stent-related perforation, bevacizumab-based therapy was identified as a risk factor for perforation with a perforation rate of 12.5%, whereas the risk for chemotherapy without bevacizumab was 7.0%. 17 On the basis of these observations, palliative SEMS placement is not recommended in patients who are considered for treatment with antiangiogenic agents, such as bevacizumab.…”

“…5,6 Self-expandable metallic stent (SEMS) has been used in MCRO since the early 1990s. 7 Fluoroscopic or endoscopic SEMS placement showed a significant rise in its application as a bridge to elective surgery and palliative treatment. 8 A meta-analysis of 54 studies analyzed the clinical outcomes of 1,198 patients who underwent SEMS placement for MCRO.…”

Endoscopic Stenting for Colorectal Cancer. The Importance of Collaboration between Specialists

“…Operative endoscopy has become a common therapeutic advancement in clinical practice [1,2,3,4,5] New techniques generate comparisons with established techniques. The positive aspects of these comparisons can get lost in a field of mere competition when different medical specialties are involved.…”