colonic stenting: a bridge to surgery ? joint hospital surgical grand round fiona ka man chan kwong...
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COLONIC STENTING: A BRIDGE TO SURGERY ?
Joint hospital surgical grand round
Fiona Ka Man Chan
Kwong Wah Hospital
Acute malignant colonic obstruction
Occur in 8% to 29% of all colorectal malignancies
70% are left sided 5 year survival in
obstructed carcinoma of colon 20%
Right sided obstruction are dealt with by emergency right hemicolectomy with ileocolic anastomosis
No optimal treatment for left sided colonic obstruction
Deans et al. Br J Surg. 1994 ; 81:1270–1276Serpell et al. Br J Surg. 1989; 76:965-969
Phillips et al. Br J Surg. 1985; 72: 296–302Finan et al. Colorectal Disease. 2007;9:1-17
What are the options for obstructive left sided colonic cancer (OLCC) ?
Ansaloni et al. WSES guidelines 2010
Emergency surgery
High morbidity 40-50% and mortality 15-20%
Primary resection and anastomosis carried a mortality rate of 10% , wound infection 25-60%, and high clinical leakage rate of 18% compared with 6% in elective surgery
Tekkis et al. Ann Surg. 2004, 350:76-81Deans et al. Br J Surg. 1994, 39:1227-1230Phillips et al. Br J Surg. 1985, 72: 296–302
Impact of stoma
Emergency surgery resulted in high stoma rates
Stoma creation is associated with high complication of 34% and impaired quality of life
Up to 40% of stomas were not reversed Stoma closure is associated with mortality
of 7%, morbidity 37%, leakage 3%
Park et al. Dis Colon Rectum. 1999; 42:1575–1580
Nugent et al. Dis Colon Rectum. 1999; ;42:1569
Deans et al. Br J Surg. 1994, 39:1227-1230
Potential benefits of self expanding metallic stents (SEMS) Increase one stage operation with
resection and primary anastomosis Decrease stoma rate Decrease morbidity and mortality
Recent evidence
Tan et al Br J Surg. 2012; 99: 469–476
Primary anastomosis
Overall successful primary anastomosis in favour of SEMS group
Significant difference in 1 stage operation with primary anastomosis in SEMS group 67% Vs 38% in emergency surgery group
Tan et al Br J Surg. 2012; 99: 469–476Martinez et al. Dis Colon Rectum.2002; 45:401–406
Cheung et al. Arch Surg. 2009; 144:1127–1132
Stoma rates
Overall stoma rates in favour of SEMS group
Tan et al Br J Surg. 2012; 99: 469–476
Success rate
Technical success rate 92-96%, clinical 71.7-92% in previous systemic reviews on uncontrolled data
Drop in technical success rate of 47 - 83% and clinical success of 40-83% in recent randomized controlled trails
One trial terminated due to high rate of technical failure (53%)
Khot et al. Br J Surg. 2002; 89:1096–1102
Watt et al. Ann Surg. 2007; 246:24–30
Tan et al Br J Surg. 2012; 99: 469–476
Complications
Overall complication rates 5.3-5.9% Mortality 0.5-1% Early
Perforation 3-5% Bleeding 0-5% Misplacement
Late Migration 11% Reocclusion 10% Erosion
Khot et al. Br J Surg. 2002; 89:1096–1102
Fracture
Migration
Perforation
One Dutch randomized controlled trial reported a high perforation risk up to 9%, up to 20% when silent perforations were included
Another also report perforation rate of 7% with silent perforation adding on to 35% perforation rate
Potential of tumour dissemination leading to compromise of oncological safety
No survival and local recurrence data on these patients so far
Cheung et al. Arch Surg. 144:1127–1132Pirlet et al. Surg Endosc. 25(6):1814–1821
Van Hooft et al Lancet Oncol. 2011 Apr;12(4):344-52
Mortality and morbidity
One trial terminated for increased 30-day morbidity in colonic stenting group No significant difference in mortality and
morbidity in subsequent analysis In contrast, another trial terminated for high
anatomsotic leakage rates in emergency arm Mortality rate 6.9% in SEMS group Vs 5.9%
in emergency surgery No significant difference in in-hospital
mortality
Tan et al Br J Surg. 2012; 99: 469–476
Anastomotic leakage
Significantly lower rate in stenting group in the single centered RCTs 0% in stent group Vs 8-30.7% in emergency
group No significant difference in meta-analysis
Zhang et al. Surg Endosc . 2012;26:110–119
Tan et al Br J Surg 2012; 99: 469–476
Validity of this meta analysis? Small sample size in each RCT Contradicting results between studies
Endoscopist / radiologist experience Multi-center participation
Oncological safety
No difference in 3 and 5 year survival Elevated level of CK20 mRNA with
endoscopic colonic stenting 14% of silent perforations in histological
examination of resected specimens in stented group
Safety has yet to be further explored with survival studies
Saida et al. Dis Colon Rectum 2003; 46:S44–S4
Maruthachalam et al. Br J Surg 2007; 94:1151–1154
Tan et al Br J Surg 2012; 99: 469–476
Cost effectiveness
12%-20% reduction in cost in SEMS group due to shorter hospital stay, lower complication rates and operative cost
23% less surgery per patient
Osman et al. Colorectal Dis. 2000;2:233–7Binkert et al. Radiology 1998;206:199–204
Targownik et al. Gastrointest Endosc. 2004;60:865–74
Conclusion
Colonic stents can be considered as a bridge to surgery in patient with acute colonic obstruction
Stenting should be performed by high volume centers with careful patient selection
Further survival analysis is needed to evaluate the impact of silent perforations on patient survival
Reference 1. Martinez-Santos C, Lobato RF, Fradejas JM, Pinto I, Ortega-Deballon P, Moreno-Azcoita M
(2002) Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum 45:401–406
2. Tilney HS, Lovegrove RE, Purkayastha S, Sains PS, Weston-Petrides GK, Darzi AW, Tekkis PP, Heriot AG (2007) Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 21:225–233
3. Khot UP, Lang AW, Murali K, Parker MC (2002) Systematic review of the efficacy and safety of colorectal stents. Br J Surg 89:1096–1102
4. Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ (2007) Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 246:24–30
5. Cheung HY, Chung CC, Tsang WW, Wong JC, Yau KK, Li MK (2009) Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial. Arch Surg 144:1127–1132
6. Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL (2011) Emergency preoperative stenting versus surgery for acute leftsided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 25(6):1814–1821
7. van Hooft JE, Bemelman WA, Breumelhof R, Siersema PD, Kruyt PM, van der Linde K, Veenendaal RA, Verhulst ML, Marinelli AW, Gerritsen JJ, van Berkel AM, Timmer R, Grubben MJ, Scholten P, Geraedts AA, Oldenburg B, Sprangers MA, Bossuyt PM, Fockens P (2007) Colonic stenting as bridge to surgery versus emergency surgery for management of acute leftsided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study). BMC Surg 7:12
8. Sebastian S, Johnston S, Geoghegan T, TorreggianiW,Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastrenterol 2004; 99: 2051–2057.
9. Tan, C. J., Dasari, B. V. M. and Gardiner, K. (2012), Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg, 99: 469–476. doi: 10.1002/bjs.8689
10. Zhang Y , Shi J , Shi B , et al. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis . Surg Endosc . 2012;26:110–119
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