Acute Treatment of Malignant Colorectal Occlusion: Real Life Practice

Abstract

IntroductionColorectal cancer presents itself as acute bowel occlusion in 10–40% of patients. There are two main therapeutic approaches: urgent surgery and endoluminal placement self-expandable metallic stents (SEMS).Aims and MethodsThis study intended to better clarify the risk/benefit ratio of the above-mentioned approaches. We conducted a retrospective longitudinal multicenter study, including 189 patients with acute malignant colorectal occlusion, diagnosed between January 2005 and March 2013.ResultsGlobally (85 patients – 35 bridge-to-surgery and 50 palliative), SEMS's technical success was of 94%. Palliative SEMS had limited clinical success (60%) and were associated with 40% of complications. SEMS occlusion (19%) was the most frequent complication, followed by migration (9%) and bowel perforation (7%). Elective surgery after stenting was associated with a higher frequency of primary anastomosis (94% vs. 76%; p = 0.038), and a lower rate of colostomy (26% vs. 55%; p = 0.004) and overall mortality (31% vs. 57%; p = 0.02). However, no significant differences were identified concerning postoperative complications. Regarding palliative treatment, no difference was found in the complications rate and overall mortality between SEMS and decompressive colostomy/ileostomy. In this SEMS subgroup, we found a higher rate of reinterventions (40% vs. 5%; p = 0.004) and a longer hospital stay (14, nine vs. seven, three days; p = 0.004).ConclusionSEMS placement as a bridge-to-surgery should be considered in the acute treatment of colorectal malignant occlusion, since it displays advantages regarding primary anastomosis, colostomy rate and overall mortality. In contrast, in this study, palliative SEMS did not appear to present significant advantages when compared to decompressive colostomy.

Self-expandable metal stent (SEMS) placement or emergency surgery as palliative treatment for obstructive colorectal cancer: A systematic review and meta-analysis

“…On request, (Suarez et al (2010)) delivered separate data for emergency procedures from a combined dataset with elective surgery. The 18 studies included 3 RCTs (van Hooft et al, 2008;Fiori et al, 2012Fiori et al, , 2019, two prospective observational studies (Law et al, 2003;Ptok et al, 2006), and 13 retrospective studies (Suarez et al (2010); Faragher et al, 2008;Fernandes et al, 2016;Abelson et al, 2017;Tomiki et al, 2004). Within two of the included studies, 64 patients were excluded due to elective procedures (Suarez et al (2010)) and six patients because of extracolonic cancer (Tomiki et al, 2004), leaving 1518 patients for final analyses.…”

“…As an alternative to emergency surgery, self-expandable metal stent (SEMS) placement has been introduced as a minimally invasive decompressing intervention in patients with bowel obstruction. It has been suggested that SEMS placement results in lower mortality and morbidity rates and a lower chance of having a stoma compared to emergency surgery in the palliative setting (Faragher et al, 2008;Fernandes et al, 2016). In contrast to the curative setting, the oncological concerns about SEMS with a potentially increased risk of recurrent disease are not relevant if performed as a palliative procedure (Amelung et al, 2018).…”

Predictors of Complications and Mortality in Patients with Self-Expanding Metallic Stents for the Palliation of Malignant Colonic Obstruction

“…This is mainly due to late complications, suggesting that patients with incurable obstructing colorectal cancer should be offered other treatments different from SEMS, especially if eligible for chemotherapy [17,18] . On the other hand, others demonstrate shorter hospital stay, comparable risk of short-term complications and mortality, and cost-effectiveness [8,12] .…”

To Stent or Not to Stent in Colorectal Cancer: That is Still the Question in Gastroenterology!

“…Fernandes et al 7 included patients with malignant colonic obstruction irrespective of the site of obstruction, and compared not only those two groups with curative intent (101 patients) but also two groups of palliative patients (71) submitted either to SEMS for palliation or to decompressive surgery. In the curative-intent groups they found statistically significant differences favoring the SEMS group: higher primary anastomosis rate (93.8% vs 76.4%), lower stoma rate (25.7% vs 54.9%) and lower overall mortality (31.3% vs 56.7%).…”

“…These two observational studies resemble the real-life practice and despite the differences between them and the eventual weaknesses of retrospective analysis they both seem to support that maybe there is still a role for SEMS as a bridge to surgery in patients other than those with high risk for emergent surgery. Moreover, for palliation the observational study of Fernandes et al 7 suggests that colostomy may have advantages over stents.…”