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

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(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

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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.

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