Colonic stenting for intestinal obstruction due to left colon and rectal cancer Dr Sherman Lam TKOH JHSGR 26 April 2014

Outline of presentation Introduction Colonic stenting Indication/contra-indication Efficacy Complication Evidence Palliation Bridge to elective surgery Conclusion

Introduction

Colorectal cancer Hong Kong cancer registry 2011

Acute malignant colonic obstruction 7-30% of all colorectal carcinoma 70% left side right side: emergency (extended) right hemicolectomy with ileo-colic anastomosis left side: (at or distal to splenic flexure) no optimal treatment Waldron. et al. Br J Surg 1986

Obstructed left side colonic cancer (OLCC) Ansaloni et al. World Journal of Emergency Surgery 2010

Morbidity: 39% vs 23% Mortality: 12% vs 3.5% Emergency operation Higher morbidity and mortality than elective operation: Morbidity: 39% vs 23% Mortality: 12% vs 3.5% Primary resection and anastomosis carried high clinical leakage rate of 18% compared with 6% in elective surgery High stoma rate (up to 50%) Leitman IM et. al. Surg Gynecol Obstet. 1992 Tekkis et al. Ann Surg. 2004 Deans et al. Br J Surg. 1994 Phillips et al. Br J Surg. 1985

Stoma creation is associated with high complication of 34% Impact of stoma Stoma creation is associated with high complication of 34% impaired quality of life Up to 30% of stomas were not reversed Stoma closure is associated with mortality of 7%, morbidity 37%, leakage 3% Park et al. Dis Colon Rectum. 1999 Nugent et al. Dis Colon Rectum. 1999 Deans et al. Br J Surg. 1994

Obstructed left side colonic cancer (OLCC) Ansaloni et al. World Journal of Emergency Surgery 2010

Colonic stenting

19 non-resectable or metastatic rectal cancer Colonic stenting Dohmoto, 1991 Palliative intent 19 non-resectable or metastatic rectal cancer Successful rate 84%, half alive with no recurrent obstruction in 6 months Tejero, 1994 Bridge to elective surgery 2 cases M. Dohmoto et al Surgical Endoscopy 1996 Tejero et al. Dis Colon Rectum 1994

Bridge to elective surgery Colonic stenting Indications: Palliation Bridge to elective surgery Contra-indications: Evidence of perforation (clinical/radiological)

Technical success rate: 96% Clinical success rate: 92% Efficacy Technical success rate: 96% Clinical success rate: 92% Median duration of stent patency: 106 days (68-288 days) Watt et al. Ann Surg 2007

0.5% need blood transfusion Complications Severe pain 5% Bleeding 5% 0.5% need blood transfusion Khot et al. Br J Surg 2002 Rahul et al. Abdom Imaging 2008 Suzuki et al. Dis Col Rec 2004

2% in non-balloon dilatation vs 10% in balloon dilatation Complications Perforation 4% 2% in non-balloon dilatation vs 10% in balloon dilatation Stent migration 10% most frequent within 1st week technical factors, chemotherapy Re-obstruction 10% tumour overgrowth, tumour ingrowth, migration, fecal impaction Mortality 1% Khot et al. Br J Surg 2002 Rahul et al. Abdom Imaging 2008 Suzuki et al. Dis Col Rec 2004

Evidence

hospital stay stoma creation ? Palliation Compared to emergency surgery hospital stay shorter stoma creation ? lower same Law et al. Br J Surg 2003 Xinopulos et al. Surg Endosc 2004 Fiori et al. Anticancer Res 2004 Sagar et al. Cochrane 2011 Law et al. Br J Surg 2003 Tilney et al. Surg Endosc 2007 Ye GY et al. World J Gastroenterol 2012

morbidity/mortality ? Palliation Compared to emergency surgery lower same Lee et al. Am J Surg 2012 Dionigi G et al. Surg Oncol 2007 Ye et al. World J Gastroenterol 2012 Sagar et al. Cochrane 2011

Bridge to elective surgery Compared to emergency surgery primary anastomosis higher Cheung HYS et al. Arch Surg 2009 Cennamo et al. Int J Colorectal Dis 2013 Tan et al. Br J Surg 2012 Zhang et al. Surg Endosc 2012 Dastur et al. Tech Coloproctol 2008

Bridge to elective surgery Compared to emergency surgery stoma ? lower same Cennamo et al. Int J Colorectal Dis 2013 Tan et al. Br J Surg 2012 Kavanagh et al. Dis Colon Rectum 2013 Pirlet et al. Surg Endosc 2011

Bridge to elective surgery Compared to emergency surgery morbidity/mortality ? lower higher Ghazal et al. J Gastrointest Surg 2013 Alcantara et al. World J Surg 2011 Ho et al. Int J Colorectal Dis 2012 Zhang et al. Surg Endosc 2012 Tan et al. Br J Surg 2012

Bridge to elective surgery Compared to emergency surgery Survival no significant difference in 3-yr survival (50% vs. 48%) or 5-yr survival (44% vs. 40%) no significant difference in 3-yr survival (48% vs. 46%) no significant difference in 5-yr survival (60% vs 58%) Martinez C et al. Dis Colon Rectum 2002 J.K. Dastur et al. Tech Coloproctol 2008 Knight AL et al. Int J Colorectal Dis. 2012

Bridge to elective surgery Compared to emergency surgery Survival significant lower in 5-yr survival (30% vs 67%) Sabbagh C et al. Ann Surg 2013

Bridge to elective surgery Compared to emergency surgery Local recurrence higher local recurrence rate 32% vs 8% (median follow up 2.7 years) K. J. Gorissen et al. Br J Surg 2013

Ongoing RCT trial CReST (ColoRectal Stenting Trial) UK trial aims to recruit 400 patients over 3 years

conflicting evidence for stoma rate, morbidity/mortality Conclusion colonic stenting is safe and effective to relieve obstruction in left colon and rectal cancer in terms of short term outcome for palliation shorter hospital stay conflicting evidence for stoma rate, morbidity/mortality for bridge to elective surgery more primary anastomosis long term survival same? worse?, local reccurrence higher?

Thank you