SciELO - Scientific Electronic Library Online

 
vol.24 issue3Is CA 19-9 of Any Help in the Management of Cholangiocarcinoma?CA 19-9 as a Marker of Survival and a Predictor of Metastization in Cholangiocarcinoma author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

  • Have no similar articlesSimilars in SciELO

Share


GE-Portuguese Journal of Gastroenterology

Print version ISSN 2341-4545

GE Port J Gastroenterol vol.24 no.3 Lisboa June 2017

https://doi.org/10.1159/000456089 

EDITORIAL

 

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

Tratamento Paliativo da Obstrução Maligna Colo-Rectal com Próteses Metálicas: Próteses Para Todos?

 

Jorge Canena

Centro de Gastrenterologia do Hospital Cuf Infante Santo, Nova Medical School – Faculdade de Ciências Médicas da UNL, Lisbon , Serviço de Gastrenterologia do Hospital Amadora-Sintra, Amadora , and Serviço de Gastrenterologia do Hospital de Santo António dos Capuchos, CHLC, Lisbon , Portugal

* Corresponding author.

 

Keywords: Metallic stent; Malignant large bowel obstruction;·Palliative stenting

Palavras Chave: Próteses metálicas; Obstrução maligna colo-retal;·Tratamento paliativo com próteses

 

Life, like scientific knowledge, is most of the time a rollercoaster, meaning that a subject can go up and down in the course of time. This is also true with respect to the application of a self-expandable metallic stent (SEMS) as a definitive palliative treatment in obstructive colorectal cancer. In the last years of the first decade of the 21 st century, papers concerning SEMS, as a nonsurgical palliative treatment for malignant colorectal obstruction, always asked the same question in the introduction: “the question remains: are SEMS used for definitive palliation of malignant colorectal obstruction as successful as those used as a bridge to surgery?” [1–5]. It is clear that 8 years ago, the use of a stent preoperatively was considered the standard of care and highly recommended in every tertiary center [6, 7]. Furthermore, the use of a stent as a definitive palliative treatment for the remaining life of a patient was still a matter of debate.

However, today, in December 2016, everything is reversed. In 2014, the European Society of Gastrointestinal Endoscopy (ESGE) presented guidelines for the use of metallic stents in obstructive colorectal cancer [8]. The special focus is on 2 items: (a) SEMS placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction. For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, i.e., American Society of Anesthesiologists (ASA)  physical status ≥ III and/or age >70 years. In addition, to create the perfect scenario for a huge debate, the so-called poor son returned in glory: (b) SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction, except in patients treated or considered for treatment with antiangiogenic drugs (e.g., bevacizumab). How did we arrive at this conclusion?

Colorectal cancer is one of the leading malignancies worldwide [4, 9]. One of the most common complications is obstruction, which can occur in up to 20% of the patients [4, 7]. The majority of patients presenting with obstruction have advanced disease, are often elderly individuals, and have overall a poor medical condition [4, 7, 10, 11]. Curative treatment is not feasible, and therefore palliation is the primary aim in these patients [1, 4, 10, 12]. Emergency surgery in patients with an unprepared colon leads to significant morbidity and mortality [4, 13, 14]. Furthermore, surgery often involves creation of a colostomy, which is not reversed in up to 50% of the patients, leading to a profound negative impact on the quality of life [1, 4, 13, 14].

In 1990, an unknown Berlin surgeon used a metallic stent to treat a patient with obstructive rectal cancer, and without foreseeing the future, he initiated an endless debate [15]. Two recent meta-analyses have created a robust case for SEMS in the palliative scenario [16, 17] : (1) Liang et al. [16] conducted a meta-analysis of 9 studies (3 randomized controlled trials as well as 2 prospective and 4 retrospective trials) comparing SEMS to surgery for palliative treatment of colorectal obstruction. A combined analysis revealed that the SEMS group had similar shortterm complication and mortality risks as the surgical group. However, the SEMS group was associated with a shorter hospitalization time followed by a quick recovery. (2) Zhao et al. [17] conducted a new meta-analysis concerning 13 relevant articles (prospective, retrospective, and controlled), representing 837 patients (SEMS group, n = 404; surgery group, n = 433). The authors found that compared to the surgery group, the SEMS group showed lower clinical success but shorter durations of hospital stay, shorter time to initiation of chemotherapy, and a lower rate of stoma formation. Both meta-analyses reported a successful relief of obstruction when palliative SEMS placement was concerned (with a >90% rate). Additionally, the SEMS group experienced a significantly lower rate of 30-day mortality. Finally, the rate of total complications was similar between these 2 groups. Shortterm complications occurred more often in the palliative surgery group, while late complications were more frequent in the SEMS group. Stent-related complications (34%) mainly included colonic perforation (10%), stent migration (9%), and reobstruction (18%), far from the disastrous numbers that some papers reported in the past; the results were questioned due to the poor experience of the endoscopists included in the studies [11, 18]. A recent large prospective study prospectively followed 255 patients submitted to SEMS placement in the palliative setting. After 1 year of follow-up, clinical success was obtained in 96% of the patients still alive and reporting a rate of complications of 36.8%, namely a perforation rate of 5.1% [19]. 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].

One important issue in delivering SEMS in the palliative scenario is the evaluation of risk factors for complications. In a large retrospective series, Small et al. [12] identified complete obstruction, operator experience (<20 procedures), stricture dilatation, stent diameter ≤ 22 mm, and bevacizumab as predictors of complications. In a retrospective series of 39 patients, Jung et al. [2] found that the location of the obstruction and the length of the stent were significant factors associated with a good outcome. Shorter stents (<10 cm) had better outcomes than longer stents ( ≥ 10 cm), and patients with a distal colorectal obstruction had better outcomes than those with a proximal colorectal obstruction. Interestingly, some authors affirm that when the placement of a stent in the proximal colon (i.e., proximal to the splenic flexure) is compared to a stent placed in the left colon, there were no differences in the technical and clinical success rates for both procedures, suggesting that the through-the-scope techniquemakes all tumor locations accessible from a technical perspective [4, 12, 22].

Another study retrospectively analyzed 201 consecutive patients undergoing stenting for incurable malignant obstruction [3]. Extrinsic and long colorectal stenoses were associated with higher rates of technical and clinical failures, migration was associated with a stent diameter <25 mm, and bevacizumab therapy increased the risk of perforation by 19.6-fold. Concerning factors associated with survival, a Karnofsky performance status of ≤ 50 was associated with shorter survival and a 3.7-fold higher risk of death within 6 months after the stent was placed. One important issue is the success of stenting extrinsic malignant stenosis. The technical and clinical success rates of placing SEMS in extracolonic malignancies have been reported to range from 67 to 96% and from 20 to 96%, respectively [23–27], which are poor results when compared to those reported for stenting of colorectal cancer [28, 29]. One retrospective study comparing SEMS placement for primary colonic tumor versus extracolonic malignancies reported an increased complication rate in the extracolonic malignancy group (33 vs. 9%) [27]. However, other studies did not report extrinsic obstruction as a risk factor for complications [28, 29]. The recent ESGE guidelines suggest that it is generally advisable to attempt palliative stenting of extracolonic malignancies in order to avoid surgery in these patients who have a relatively short survival [8].

In this issue of the GE Portuguese Journal of Gastroenterology, Sousa et al. [30] retrospectively analyzed 45 patients submitted to SEMS for palliation of obstructing malignant colorectal cancer over a 10-year period. As expected, experienced endoscopists (>20 procedures) reported a technical and clinical success rate of >90%. Additionally, relief of obstruction without intervention was maintained until death in 77.8% of the patients, and this rate was improved with reintervention, namely placing another stent in obstructed patients previously submitted to palliative stenting. In line with the literature, they reported a 17.8% rate of complications including a 8.9% rate of perforations. The authors also analyzed possible predictors of complications, namely gender, age, location of tumor, presence of metastasis, and the Eastern Cooperative Oncology Group (ECOG) stage, which were not statistically significant predictors of complications. This is no surprise, as most of these factors have not emerged in the literature as predictors of complications, except the location of the tumor, namely a proximal location, which is a conflicting predictive factor as discussed before. However, in the study by Sousa et al. [30] only 4 patients had their strictures located in the proximal colon, and therefore, it was impossible to draw conclusions from this low number of patients. Interestingly, the above-mentioned study identified the length of stenosis as an independent predictor of complications. This has been previously debated in several studies with conflicting results: (1) 3 studies reported that stenting of a long obstructed segment was not associated with clinical failures [31–33] ; (2) however, in 2 retrospective studies, a better outcome was observed in short colon strictures [2, 3]. One of these retrospective studies reported more technical failures in strictures >4 cm (OR 5.33) and even clinical failures (OR 2.40) [3].

Taken together and in conclusion, the study by Sousa et al. [30] shows what experienced endoscopists have learned in the last 15 years, without the need of illuminating guidelines which have a lot of weak points and should be reopened for discussion. Definitive palliation of malignant large bowel obstruction using metallic stents is associated with clinical success (including restenting) until death in 80–90% of the patients; it avoids colostomies and improves quality of life. The procedure provides rapid and effective relief of obstruction and is associated with acceptable morbidity and need for reintervention, as well as minimal mortality. It should be performed by experienced endoscopists. Even in clinical situations with known risk factors (e.g., extrinsic, long, and total obstructions), stenting is an acceptable first option. So, in conclusion, for palliation of malignant large bowel obstruction the answer is: stents for all.

 

References

1 Repici A, Fregonese D, Costamagna G, Dumas R. Kähler G, Meisner S, et al: Ultraflex precision colonic stent placement for palliation of malignant colonic obstruction: a prospective multicenter study. Gastrointest Endosc 2007;66:920–927.         [ Links ]

2 Jung MK, Park SY, Jeon SW, Cho CM, Tak WY, Kweon YO, et al: Factors associated with the long-term outcome of a self-expandable colon stent used for palliation of malignant colorectal obstruction. Surg Endosc 2010;24:525–530.         [ Links ]

3 Manes G, de Bellis M, Fuccio L, Repici A, Masci E, Ardizzone S, et al: Endoscopic palliation in patients with incurable malignant colorectal obstruction by means of self-expanding metal stent: analysis of results and predictors of outcomes in a large multicenter series. Arch Surg 2011;146:1157–1162.         [ Links ]

4 Canena J, Liberato M, Marques I, Rodrigues C, Lagos A, Patrocínio S, et al: Sustained relief of obstructive symptoms for the remaining life of patients following placement of an expandable metal stent for malignant colorectal obstruction. Rev Esp Enferm Dig 2012;104:418–425.         [ Links ]

5 Ptok H, Meyer F, Marusch F, Steinert R, Gastinger I, Lippert H, et al: Palliative stent implantation in the treatment of malignant colorectal obstruction. Surg Endosc 2006;20:909–914.         [ Links ]

6 Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ: Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 2007;246:24–30.         [ Links ]

7 Repici A, Ferreira DP: Expandable metal stents for malignant colorectal strictures. Gastrointest Endoscopy Clin N Am 2011;21:511–533.         [ Links ]

8 van Hooft JE, van Helsima EJ, Vanbiervillet G, Beets-Tan RG, DeWitt JM, Donnellan F, et al: Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline Endoscopy 2014;46:990–1002.         [ Links ]

9 Lee HJ, Hong SP, Cheon JH, Kim TI, Min BS, Kim NK, et al: Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc 2011;73:535–542.         [ Links ]

10 Bittinger M, Messmann H: Self-expanding metal stents as nonsurgical palliative therapy for malignant colonic obstruction: time to change the standard of care? Gastrointest Endosc 2007;66:928–930.         [ Links ]

11 Fernández-Esparrach G, Bordas JM, Giráldez MD, Ginès A, Pelissé M, Sendino O, et al: Severe complications limit long-term clinical success of self-expanding metal stents in patients with obstructive colorectal cancer. Am J Gastroenterol 2010;105:1087–1093.         [ Links ]

12 Small AJ, Coelho-Prabhu N, Baron TH: Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560–572.         [ Links ]

13 Davila M: Self-expanding metal stents in malignant colonic obstruction: have we covered all angles? Gastrointest Endosc 2007;66:937–939.         [ Links ]

14 Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ: Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 2007;246:24–30.         [ Links ]

15 Dohmoto M, Rupp KD, Hohlbach G: Endoscopically-implanted prosthesis in rectal carcinoma (in German). Dtsch Med Wochenschr 1990;115:915.         [ Links ]

16 Liang TW, Sun Y, Wei YC, Yang DX: Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: a self-expanding metallic stent or surgery? A system review and meta-analysis. Surg Today 2014;44:22–33.         [ Links ]

17 Zhao XD, Cai BB, Cao RS, Shi RH: Palliative treatment for incurable malignant colorectal obstructions: a meta-analysis. World J Gastroenterol 2013;19:5565–5574.         [ Links ]

18 van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM, Bossuyt PM, et al: Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer . Endoscopy 2008;40:184–191.         [ Links ]

19 Meisner S, Gonzálex-Huix F, Vandervoort JG, Repici A, Xinopoulos D, Grund K, et al: Self-expanding metal stenting for palliation of patients with malignant colonic obstruction: effectiveness and efficacy on 255 patients with 12-month’s follow-up. Gastroenterol Res Pract 2012;2012:296347.         [ Links ]

20 Yoon JY, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH: Outcomes of secondary self-expandable metal stents versus surgery after delayed initial palliative stent failure in malignant colorectal obstruction. Digestion 2013;88:46–55.         [ Links ]

21 Yoon JY, Jung YS, Hong SP, Kim TI, Kim WH, Cheon JH: Outcomes of secondary stent-in-stent self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011;74:625–633.         [ Links ]

22 Repici A, Adler DG, Gibbs CM, Malesci A, Preatoni P, Baron TH: Stenting of the proximal colon in patients with malignant large bowel obstruction: techniques and outcomes. Gastrointest Endosc 2007;66:940–944.         [ Links ]

23 Kim JY, Kim SG, Im JP, et al: Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction. Surg Endosc 2013;27:272–277.         [ Links ]

24 Moon SJ, Kim SW, Lee B, Lim CH, Kim JS, Soo J, et al: Palliative stent for malignant colonic obstruction by extracolonic malignancy: a comparison with colorectal cancer. Dig Dis Sci 2014;59:1891–1897.         [ Links ]

25 Kim BK, Hong SP, Heo HM, Kim JY, Hur H, Lee KY, et al: Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery. Gastrointest Endosc 2012;75:294–301.         [ Links ]

26 Kim JH, Song HY, Park JH, Ye BD, Yoon YS, Kim JC: Metallic stent placement in the palliative treatment of malignant colonic obstructions: primary colonic versus extracolonic malignancies. J Vasc Interv Radiol 2011;22:1727–1732.         [ Links ]

27 Keswani RN, Azar RR, Edmundowicz SA, Zhang Q, Ammar T, Banerjee B, et al: Stenting for malignant colonic obstruction: a comparison of efficacy and complications in colonic versus extracolonic malignancy. Gastrointest Endosc 2009;69:675–680.         [ Links ]

28 Abbott S, Eglinton TW, Ma Y, Stevenson C, Robertson GM, Frizelle FA: Predictors of outcome in palliative colonic stent placement for malignant obstruction. Br J Surg 2014;101:121–126.         [ Links ]

29 Keranen I, Lepisto A, Udd M, Halttunen J, Kylänpää L: Stenting for malignant colorectal obstruction: a single-center experience with 101 patients. Surg Endosc 2012; 26:423–430.         [ Links ]

30 Sousa M, Pinho R, Proença L, Silva J, Ponte A, Rodrigues J, et al: Predictors of complications and mortality in self-expanding metal stents for the palliation of malignant colonic obstruction. GE Port J Gastroenterol 2017, DOI: 10.1159/000452697.         [ Links ]

31 Cheung DY, Kim JY, Hong SP, Jung MK, Ye BD, Kim SG, et al: Outcome and safety of selfexpandable metallic stents for malignant colon obstruction: a Korean multicenter randomized prospective study. Surg Endosc 2012;26:3106–3113.         [ Links ]

32 Luigiano C, Ferrara F, Fabbri C, Ghersi S, Bassi M, Billi P, et al: Through-the-scope large diameter self-expanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: a single center experience with a long-term follow-up. Scand J Gastroenterol 2011;46:591–596.         [ Links ]

33 Almadi MA, Azzam N, Alharbi O, Mohammed AH, Sadaf N, Aljebreen AM: Complications and survival in patients undergoing colonic stenting for malignant obstruction. World J Gastroenterol 2013;19:7138–7145.         [ Links ]

 

Disclosure Statement

Jorge Canena is a consultant for Boston Scientific but did not receive any financial arrangements for this research or any assistance with manuscript preparation.

 

* Corresponding author.

Prof. Jorge Canena

Centro de Gastrenterologia do Hospital Cuf Infante Santo, Nova Medical School – Faculdade de Ciências Médicas da UNL

Travessa do Castro 3

PT–1350-070 Lisbon (Portugal)

E-Mail jmtcanena@live.com.pt

 

Received: December 13, 2016; Accepted after revision: December 16, 2016

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License