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 Poor prognosis in obstructive compared with non obstructive patients with OS 5 yr 20% There were fewer Dukes' A tumours in those with complete obstruction (P less than 0.005) and greater numbers of advanced tumours (P less than 0.0005) compared with those without obstruction The main reason for this is that emergency surgery for obstruction of the right colon carries the same mortality as that for elective surgery as shown in the Large Bowel Cancer Project, right sided obstruction are dealt with by emergency Deans et al. Br J Surg. 1994 ; 81:1270–1276 Serpell et al. Br J Surg. 1989; 76:965-969 Phillips et al. Br J Surg. 1985; 72: 296–302 Finan et al. Colorectal Disease. 2007;9:1-17

What are the options for obstructive left sided colonic cancer (OLCC) ? 40% will undergo one stage resection and anastomosis Most frequently used is hartmanns procedure The advocates of SC note the safety of ileocolic anastomoses, which eliminate possible metachronous tumors and treat possible synchronous tumors [12]. The main drawback is the increased surgical time, the scale of the surgery and the loss of physiological functions of the colon such as absorption and storage. The advocates of IOCL also consider primary colocolic anastomoses to be safe, with morbidity (2-37%) and mortality rates (0-17%) [13] similar to those reported with the Hartmann procedure (9-33% and 6-18%, respectively). IOCL avoids the disadvantages of the reconstruction of the intestinal transit and thus has better survival rates than the Hartmann procedure Until recently the use of colonic stenting for relieve of obstruction to allow definitive elective surgery at optimal conditions 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 High risk patients with poor general condition underlying tumour disease , dehydration and electrolyte imbalance . Mortality 3.5% morbidity 23% Tekkis et al. Ann Surg. 2004, 350:76-81 Deans et al. Br J Surg. 1994, 39:1227-1230 Phillips 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% 34% of complication : ileostomies and colostomy; early and late; improper site, retraction, skin irritation, peristomal infection/hernia Unable to reverse due to advanced age or comorbidity, leading to higher health costs in terms of psychological well being, and reducing quality of life Cost of stoma care shouldn’t be over looked, enterostomal supplies, lost of work, decrease QOL Represents a significant burden on the enconomical and psychological well being 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 Convert the procedure to an election condition adequate resuscitation bowel preparation staging optimization of comorbidities neoadjuvant chemoradiotherapy possibility of laparoscopic colectomy with primary anastomosis single stage operation

Recent evidence Recent RCTs demonstrates variability in their results from stenting against emergency syrgery. ITT Tan et al Br J Surg. 2012; 99: 469–476

234 ppl 116 sems 118

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 This echoes with previous studies of Primary anastomosis 84.6% Vs 41.4% (martinez) Converting an emergency procedure to an elective one thus creating optimal condition for susccessful primary anastomosis Tan et al Br J Surg. 2012; 99: 469–476 Martinez 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 Decrease stoma requirement (7% Vs 43%) Targownik 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%) Pirlet 40% technical and clincial success Van hooft 70% 70% of complete obstruction rates compare with previous published data with 53.8% , in which degree of obstruction is considered one important factor for complications Multicentered 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 Perforation: esp after balloon dilatation or laser cannalization 3-5% , 10% mortality rate Migration 11%: small stent diameter, short length, cover stent, angulation, chemo/radiotherapy Reocclusion: ingrowth, migration, fecal impaction, distortion Perforation: death and tumour dissemniation Tan: silent perforation 14% Higher perforation rates in recent RCT : 13%-66% Van Hooft, chemo. Short interval between stenting and OT, patient with poor risk 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. 144:1127–1132 Pirlet 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 In contrast to previous comparative ies and metaanalysis which showed a decrease mortality in elective surgery group studDecrease in mortality, decrease medical complications Tilney et al. Surg Endosc. 2007; 21:225-233 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 Decrease leakage 11 % Vs 3% saida 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 Variability in outcomes, experience of endoscopist, single and multicentered

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 Questioned by many studies Saida: Long term prognosis: 3 and 5 yr OS didn’t differ ( 50 Vs 48%), 44Vs 40% CK20 epithelial cells in GI tract, but is no expression seen in controls. Indication tumour cell dissemination in peripheral circulation Law, Carne : palliative Jin: pairing obstructive Vs non obstructive , so obstructive patients should be poorer colonic obstruction secondary to tumour is known to adversely impact outcome regardless of pathological staging Silent perforations could have oncological significance as it could potentially result in tumour cells seedling and peritoneal dissemination 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: cost analysis (total hospital stay inclusive of reversal of colostomy, cost of radiology suite/OT, running cost, stents ) more cost effective due to shorter hospital stay and expenditure cos Targownik : Decision analysis: quantitative method of estimating cost effectiveness of alternative management. Difference in cost: secondary hospitalization for restoration of bowel continuity Additional surgeries and ICU care Decision model of colonic stent placement and emergency surgery for obstructing cancer of left side of colon, decrease operative procedure by 23%, reduce need for stoma from 43 to 73% (83%) STOMA COST Osman et al. Colorectal Dis. 2000;2:233–7 Binkert 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 Patients: probably those with high predicted preoperative mobidity and mortality , further studies are need to definite subgroups who benefits precisely.

Reference Martinez-Santos C, Lobato RF, Fradejas JM, Pinto I, Ortega-Deballon P, Moreno-Azcoita M (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 Tilney HS, Lovegrove RE, Purkayastha S, Sains PS, Weston-Petrides GK, Darzi AW, Tekkis PP, Heriot AG (2007) Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 21:225– 233 Khot UP, Lang AW, Murali K, Parker MC (2002) Systematic review of the efficacy and safety of colorectal stents. Br J Surg 89:1096–1102 Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ (2007) Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 246:24–30 Cheung HY, Chung CC, Tsang WW, Wong JC, Yau KK, Li MK (2009) Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial. Arch Surg 144:1127–1132 Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL (2011) Emergency preoperative stenting versus surgery for acute leftsided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 25(6):1814–1821 van Hooft JE, Bemelman WA, Breumelhof R, Siersema PD, Kruyt PM, van der Linde K, Veenendaal RA, Verhulst ML, Marinelli AW, Gerritsen JJ, van Berkel AM, Timmer R, Grubben MJ, Scholten P, Geraedts AA, Oldenburg B, Sprangers MA, Bossuyt PM, Fockens P (2007) Colonic stenting as bridge to surgery versus emergency surgery for management of acute leftsided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study). BMC Surg 7:12 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. Tan, C. J., Dasari, B. V. M. and Gardiner, K. (2012), Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg, 99: 469–476. doi: 10.1002/bjs.8689 Zhang Y , Shi J , Shi B , et al.  Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis . Surg Endosc . 2012;26:110–119

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