Outcomes of Secondary Self-Expandable Metal Stents versus Surgery after Delayed Initial Palliative Stent Failure in Malignant Colorectal Obstruction

Abstract

Background/Aims: When re-intervention is required due to an occluded first colorectal self-expanding metal stent for malignant colorectal obstruction, serious controversies exist regarding whether to use endoscopic re-stenting or surgery. To compare the clinical outcomes in patients who underwent stent re-insertion versus palliative surgery as a second intervention. Methods: A total of 115 patients who received either self-expandable metal stent (SEMS) insertion or palliative surgery for treatment of a second occurrence of malignant colorectal obstruction after the first SEMS placement were retrospectively studied between July 2005 and December 2009. Results: The median overall survival (8.2 vs. 15.5 months) and progression-free survival (4.0 vs. 2.7 months) were not significantly different between the stent and surgery groups (p = 0.895 and 0.650, respectively). The median lumen patency in the stent group was 3.4 months and that in the surgery group was 7.9 months (p = 0.003). The immediate complication rate after second stent insertion was 13.9% and late complication rate was observed in 12 of 79 (15.2%) patients. There was no mortality related to the SEMS procedure. The complication and mortality rates associated with palliative surgery were 3.5% (2/57) and 12.3% (7/57), respectively. Conclusions: Although there is no significant difference in the overall survival between stenting and surgery, a secondary stent insertion had a lower mortality rate despite a shorter duration of temporary colorectal decompression compared to that of palliative surgery.

Colonic cancer: The current role of stent insertion

“…15 It is suggested that dilatation may adversely affect patient outcomes following SEMS. [21][22][23] Systematic review and meta-analysis of retrospective data suggests an increased risk of perforation colonic perforation with stricture dilatation. 24,25 Enteral SEMS may be covered or uncovered.…”

“…Stent diameter of less than 24 mm increases the risk of stent related complications (perforation, re-obstruction and migration), especially stent migration. 21,22 Whilst stent length per se does not seem to be important, the ESGE guidance is that the stent should traverse the stricture such that it extends 20 mm either side (after deployment). 15 As with all technical procedures, there is a learning curve for colonic SEMS placement.…”

“…Stentin-stent placement has reported success rates of 75% to 86% but there is a lack of data on long-term outcomes. 21 Chemotherapy is known to prolong survival in palliative colorectal cancer. Shorter hospitalization and better 30-day mortality rate in SEMS use allows earlier start of chemotherapy treatment.…”

“…Shorter hospitalization and better 30-day mortality rate in SEMS use allows earlier start of chemotherapy treatment. Early evidence regarding chemotherapy use in stented patients was contradictory 21,58 but there was concern that chemotherapy use may increase perforation rate. Retrospective series suggested an increased perforation rate in those treated with bevacizumab (an angiogenesis inhibitor) (17%-50%).…”

Palliative Stenting for Malignant Large Bowel Obstruction: Stents for All?

“…In previous retrospective series, we observed that sustained relief of obstruction without reintervention was obtained in approximately 75% of the patients until death, and this result could be further enlarged to 80-90% of the cases using a second stent [2,4,12] . Furthermore, other recent studies suggested that placing a second stent in patients previously submitted to palliative stenting was a viable option [20,21] .…”