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

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

3. Introduction

4. Colorectal cancer
Hong Kong cancer registry 2011

5. 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

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

7. 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

8. 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

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

10. Colonic stenting

11. 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

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

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

14. 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

15. 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

16. Evidence

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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?

27. Thank you