Colonic perforation with intraluminal stents and bevacizumab in advanced colorectal cancer: retrospective case series and literature review

Abstract

Background: Self-expanding metal stents (SEMS) are increasingly used in the treatment of malignant large bowel obstruction in the setting of inoperable colorectal cancer. Perforation is a well-known complication associated with these devices. The addition of the vascular endothelial growth factor inhibitor bevacizumab is suspected to increase the rate, but the extent of the increase is not known. Methods:We retrospectively reviewed the records of patients receiving SEMS in tertiary hospitals in Calgary, Alta., between October 2001 and January 2012. Results:We reviewed the records of 87 patients with inoperable colorectal cancer who received SEMS during our study period. Nine perforations occurred in total: 4 of 30 (13%) patients who received no chemotherapy, 3 of 47 (6%) who received chemotherapy but no bevacizumab, and 2 of 10 (20%) who received chemotherapy and bevacizumab. These two patients received bevacizumab with FOLFIRI after SEMS placement, and they had peritoneal disease. Conclusion:Our case series and other studies suggest that bevacizumab may increase the risk of colonic perforation in the setting of SEMS. Caution should be used when combining these therapies.

Endoscopic colostomy with percutaneous colopexy: an animal feasibility study

“…Based on these unfavorable long-term oncological outcomes, the recent SEMS guidelines by the European Society of Gastrointestinal Endoscopy (ESGE) do not recommend routine SEMS insertion as a bridge to surgery in potentially curable left-sided obstructive colorectal cancer (CRC) obstruction (14). Additionally, a higher risk of perforation in patients treated with SEMS that were receiving antiangiogenic agents such as bevacizumab has been reported (15). Therefore, endoscopic colostomy can emerge as a minimally invasive alternative that can serve as a bridge to oncologic treatment, potentially overcoming present limitations of SEMS without the additional morbidity of general anesthesia and surgery for fecal diversion.…”

Enteral stents: Complications and their management

“…Minor complications related to colon stent placement such as mild to moderate rectal bleeding, transient anorectal pain, temporary incontinence, and fecal impaction are common in many reports (Table 1). [16][17][18][19][20][21][22][23][24][25][26] Late complications related to SEMS mainly include re-obstruction and migration of the stent, and rarely perforation. Migration incidence varies from 4% to 26% and is one of the more frequent complications observed at early follow-up.…”

“…Migration incidence varies from 4% to 26% and is one of the more frequent complications observed at early follow-up. [20][21][22][23][24][25][26] Obstruction can recur as a result of fecal impaction or tumor ingrowth. 21 Growth of the tumor through the mesh is the main disadvantage of uncovered stents, and its incidence varies from 2% to 20%.…”

“…A higher incidence of perforations is seen in patients receiving chemotherapy, especially in patients on bevacizumab. 26 As the overall long-term survival of patients with colon cancer improves with newer chemotherapy regimens improves, the incidence of stent-related complications is likely to increase. …”

Colonic Stenting in the Management of Acute Left-sided Malignant Colonic Obstruction is Oncologically Safe?

“…Van Halsema identified as risk factors for perforation, benign etiology of the stricture, and chemotherapy with bevacizumab [27,32,33] . Type of stent: Selection of the appropriate stent is very important for outcomes, considering material, design, diameter, length, radial force, flexibility, foreshortening ratio, and delivery system but there is no evidence to indicate which stent type is superior.…”