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Colorectal Stenting in Malignant Large Bowel Obstruction: The Learning Curve

Colorectal Stenting in Malignant Large Bowel Obstruction: The Learning Curve Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 917848, 4 pages doi:10.1155/2011/917848 Clinical Study Colorectal Stenting in Malignant Large Bowel Obstruction: The Learning Curve 1 2 1 D. Williams, R. Law, and A. M. Pullyblank Department of Surgery, North Bristol NHS Trust, Frenchay Hospital, Frenchay Park Road, Bristol, BS16 1LE, UK Department of Radiology, North Bristol NHS Trust, Frenchay Hospital, Frenchay Park Road, Bristol, BS16 1LE, UK Correspondence should be addressed to D. Williams, williams-dan@doctors.org.uk Received 1 August 2010; Accepted 22 September 2010 Academic Editor: Michael Huner ¨ bein Copyright © 2011 D. Williams et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aim. Self-expanding metal stents (SEMSs) are increasingly used for the palliation of metastatic colorectal cancer and as a bridge to surgery for obstructing tumours. This case series analyses the learning curve and changes in practice of colorectal stenting over a three year period. Methods. A study of 40 patients who underwent placement of SEMS for the management of colorectal cancer. Patients spanned the learning curve of a single surgeon endoscopist. Results. Technical success rates increased from 82% initially, using an average of 1.7 stents per procedure, to a 94% success rate where all patients were stented using a single stent. There has been a change in practice from elective palliative stenting toward emergency preoperative stenting. Conclusion. There is a steep learning curve for the use of SEMS in the management of malignant colorectal bowel obstruction. We suggest that at least 20 cases are required for an operator to be considered experienced. 1. Introduction in the left colon who were experiencing obstructing symp- toms were considered. The decision to attempt insertion of Up to 29% of the 40 000 new diagnoses of colorectal cancer SMES was taken in the MDT. These cases with subacute large bowel obstruction were stented for palliation only. each year in the UK present with obstructive symptoms [1, 2]. Self-expanding metal stents (SEMSs) are being used with The second indication for stenting was acute left-sided large increasing success for the palliation of metastatic colorectal bowel obstruction. Stenting was indicated in this cohort cancer and as a bridge to surgery for obstructing tumours if the patient was at high risk for emergency surgery or despite the absence of high level evidence for their safety and had disseminated disease. Consecutive eligible patients were efficacy. With the advent of the ColoRectal Stenting Trial selected over a three-year period (2006–2008). (CReST trial), a multicentred RCT, there has been debate The procedures were performed by a single surgeon as to the learning curve for colorectal stenting. This case endoscopist and a consultant radiographer in one cen- series investigated the first three years of a single surgeon tre. Stents were performed under combined endoscopic endoscopist stenting experience analysing the change in and radiological guidance (Figure 1). Technical success was practice over time and the learning curve. defined as successful placement of the SEMS across the obstructing lesion with good passage of contrast post stenting. In this series, technical success equated to clinical success and all patients who achieved a technical success had 2. Patients and Methods symptomatic relief. Data was collected prospectively on 40 patients presenting Three patients were excluded at the time of the procedure with acute or subacute large bowel obstruction that subse- as stenting was thought inappropriate (stenting was not quently underwent the insertion of an SEMS. There were attempted). One patient had a pre-existing perforation 2 indications for insertions of an SEMS in this case series. demonstrated with contrast and preceded with operative Firstly, patients with disseminated malignancy from a lesion intervention. Endoscopy and radiological studies failed to 2 International Journal of Surgical Oncology (a) (b) (c) Figure 1: A series of images demonstrating the stages involved in endoscopically guided colorectal stenting. (a) The tumour is directly visualised with the endoscope, and the guide wire is passed through the end of the scope. (b) The deployment system is passed through the stricture. (c) The stent has been successfully deployed. The stent boundaries can be clearly identified. detect an obstructing malignant lesion in the other two disease and were stented as a bridge to surgery. The other 19 patients, and stenting was not performed. patients presented with subacute bowel obstruction and were electively stented. All of these patients were later managed This paper analysed the resulting 37-patient case series. with palliation for disseminated disease. Over 80% of the To aid with analysis and to show a change in practice over patients in this series were managed with palliation. As a time, the series was divided chronologically in half (1st 18 result of this they did not undergo surgical resection and patient were stented in 2006 and 2nd 19 patients stented formal histological (TNM) staging. in 2007 and 2008). The site of the lesions stented were The site of lesion and stenting varied: 6 descending colon, 6 descending colon, 9 sigmoid colon, 12 rectosigmoid, 8 9 sigmoid colon, 12 rectosigmoid, 8 rectum, 1 extrinsic rectum, 1 extrinsic compression, and 1 at the splenic flexure. compression, and 1 at the splenic flexure. Complications included 4 failures (11%), 4 tumour overgrowths (11%), and 1 stent migration (3%). Three of the tumour overgrowth 3. Results cases were restented at day 22, 130, and 146 after the original Thirty seven patients underwent stent placement (22 male, procedure. One patient had a late tumour overgrowth which 15 Female) with an average age of 74 (55–95). 18 (49%) was managed with a defunctioning loop ileostomy. There was 1 early perforation and 1 late (2 weeks) perforation in 2 of the patients presented as an emergency with acute large bowel obstruction. Of these patients, the staging investigation patients that were restented. Both these patients died as they demonstrated disseminated disease in 11 cases. After discus- were not fit for surgery. Figure 2 demonstrates the difference between the sion in the MDT all these patient were subsequently managed palliatively (nonoperatively). The remaining 7 had localised patients in the first and second half of the case series. International Journal of Surgical Oncology 3 1990s [3, 4] and subsequently has been used to avoid surgery in patients with metastatic disease and as a bridge to surgery in those with localised disease. SEMS have many advantages for patients with acute bowel obstruction. An SEMS can be used to control an 40 emergency presentation allowing patient optimisation. A study of 8000 patients found that emergency surgery has a mortality of 19.3% compared to 5.6% for elective surgery [5]. Elective surgery also reduces morbidity, with higher rates of primary anastomosis and lower rates of severe complications. Elective Emergency Palliative Bridge to surgery Martinez-Santos et al. found that patients undergoing emer- (%) gency surgery for acute malignant large bowel obstruction had a primary anastomosis rate of 41% compared with 87% 1st 18 patients (2006) in patients operated on following insertion of an SEMS [6], 2nd 19 patients (2007 and 2008) thus saving a significant amount of stoma-related morbidity. Figure 2: A comparison between the first and second half of the In the long term, only 60% of patients with a colostomy pro- case series showing the change in practice over time. ceed to stoma reversal [7]. In patients having curative surgery following a bridge to surgery SEMS, up to 95% go onto having a single staged procedure avoiding a colostomy [8]. Table 1: The learning curve for SEMS. There are also health economic advantages [8]with reduced hospital stay [9, 10] and length of time in critical Percentage success N of stents per Stenting group care beds [6, 11]. Importantly, stenting can buy time for stag- (%) procedure ing, treatment planning, neoadjuvant therapies and patient 1–11 82 1.7 optimisation. In this case series 18 patients presented with 12–21 90 1.1 acute bowel obstruction and underwent emergency stenting. 22–37 94 1.0 Of these patients, 11 (61%) were found to have disseminated disease at staging and hence avoided unnecessary major surgery. The early patients were predominantly palliative patients Colorectal stenting itself has disadvantages. The majority electively admitted with subacute large bowel obstruction. of the published literature is limited by having a small sample 67% in the first 18 patients and 37% in the subsequent 19 size and being nonrandomised; consequently there is a large patients were electively stented for this indication. In the range in quoted complication rates. A review by Watt et al. second half of the series, more SEMS are deployed acutely found median complication rates of stent migration 11%, as a bridge to surgery or to palliate emergency large bowel perforation 4.5%, and tumour overgrowth 12% [12]. Clini- obstruction. Of the first 18 patients only 11% of patients cal success is usually quoted at a rate of 85–100% [1, 8, 12, 13] were stented following emergency presentation with acute with mortality between 0 and 2%. This study had a primary large bowel obstruction, in comparison to 26% in the perforation rate of 0% in line with the literature, but we had subsequent 19 patients. an overall mortality of 2/37 (5%) when restented patients The first 11 stents performed had an 82% technical were taken into account. Successful treatment of acute left- success rate andrequiredanaverage of 1.7stentsper sided colorectal obstruction depends on a number of opera- procedure. The subsequent 10 stents performed had a 90% tor and patient factors. A Cochrane review in 2002 concluded technical success rate and required average of 1.1 stents that the limited number of randomised control trials into the per procedure. The final 16 stents performed had a 94% management of obstructing left-sided colorectal carcinoma technical success rate. All of these patients were stented using together with methodological weaknesses does not allow a single stent. This is shown in Table 1 demonstrating how reliable assessment of the best treatment strategy [14]. There technical success increased and number of stents decreased is a clear need for further large randomised studies. with experience. The only prospective multicentred RCT to date, the Stent-in 1 study [15, 16], was stopped early following a high rate of stent-related complications. In the proposed followup 4. Discussion Stent-in 2 study [17], it is suggested that SEMS should be Colorectal cancer commonly presents with large bowel placed by an experienced gastroenterologist. They defined obstruction, often at an advanced stage with only 50% an experienced gastroenterologist as one who has placed of patients being suitable candidates for curative surgery. 20 enteral stents of which at least 10 were colonic, without Emergency surgery in these patients has a high mortality giving evidence why these figures have been suggested. This study found that there was a definite learning curve and morbidity when compared to elective surgery. Over time, several techniques such as balloon dilatation and laser for the insertion of SEMS, the first 11 stents having only ablation have been attempted with the aim of decompressing an 82% success rate, the next 10 having a 90% success rate, and the subsequent SEMS having a 94% success rate. the bowel. These techniques had limited success. The use of stents in colorectal obstruction was first reported in the early In this case series, it was also noted that the number of SEMS Percentage of patients in each cohort (%) 4 International Journal of Surgical Oncology required to relieve an obstruction decreased with experience. [6] C. Martinez-Santos, R. F. Lobato, J. M. Fradejas, I. Pinto, P. Ortega-Deballon, ´ and M. Moreno-Azcoita, “Self-expandable Initially an average of 1.7 stents were used per successful stent before elective surgery vs. emergency surgery for the procedure whereas towards the end of the series strictures treatment of malignant colorectal obstructions: comparison were consistently requiring only one stent. This increased of primary anastomosis and morbidity rates,” Diseases of the stent usage early in the series reflected inexperience and Colon and Rectum, vol. 45, no. 3, pp. 401–406, 2002. technical difficulty rather than length of stricture. There was [7] G. T. Deans, Z. H. Krukowski, and S. T. Irwin, “Malignant no significant difference between complications and length obstruction of the left colon,” British Journal of Surgery, vol. of stricture between the groups. This evidence suggests that 81, no. 9, pp. 1270–1276, 1994. operators should have a minimal experience of 20 colonic [8] U. P. Khot, A. Wenk Lang, K. Murali, and M. C. Parker, SEMS to be eligible for inclusion in future RCTs. “Systematic review of the efficacy and safety of colorectal Not being a randomised study, there is inevitable bias in stents,” British Journal of Surgery, vol. 89, no. 9, pp. 1096–1102, the selection of patient and treatment options. Experience 2002. [9] E. Fiori, A. Lamazza, A. De Cesare et al., “Palliative Manage- in colorectal stenting resulted in changes in practice over ment of Malignant Rectosigmoidal Obstruction. Colostomy time. As the study progressed, more stents were performed vs. Endoscopic Stenting. A Randomized Prospective Trial,” on an emergency basis (33% of the first 18 patients and Anticancer Research, vol. 24, no. 1, pp. 265–268, 2004. 63% of the second 19 patients) in a patient demographic [10] R. Vemulapalli, L. F. Lara, J. Sreenarasimhaiah, W. V. Harford, who were likely to be more unwell. More stents were also and A. A. Siddiqui, “A comparison of palliative stenting or performed as a bridge to surgery in the second half of the emergent surgery for obstructing incurable colon cancer,” study (26% compared with 11%). This change in practice is Digestive Diseases and Sciences, vol. 55, no. 6, pp. 1732–1737, likely to reflect an increase in operator confidence in their technical ability and knowledge of when stenting is and is not [11] W. L. Law, H. K. Choi, and K. W. Chu, “Comparison appropriate. The fact that the clinical success rates increased of stenting with emergency surgery as palliative treatment along this learning curve despite more technically difficult for obstructing primary left-sided colorectal cancer,” British patients suggests that there may also be a significant learning Journal of Surgery, vol. 90, no. 11, pp. 1429–1433, 2003. [12] A. M. Watt,I.G.Faragher, T. T. Griffin, N. A. Rieger, and curve in patient selection. G. J. Maddern, “Self-expanding metallic stents for relieving There has also been a change in practice with regard malignant colorectal obstruction: a systematic review,” Annals to restenting. The 2 mortalities in this series were patients of Surgery, vol. 246, no. 1, pp. 24–30, 2007. who died following the restenting of a multilevel obstruc- [13] C. E. Dauphine, P. Tan, R. W. Beart Jr., P. Vukasin, H. tion. Both these patients required 2-3 stents to relieve the Cohen, and M. L. Corman, “Placement of self-expanding obstruction caused by a long stricture, which in retrospect metal stents for acute malignant large-bowel obstruction: a was a mistake. If a reobstruction cannot be solved with a collective review,” Annals of Surgical Oncology, vol. 9, no. 6, single stent, practice has changed and a further stent would pp. 574–579, 2002. not be attempted. [14] G. L. De Salvo, C. Gava, S. Pucciarelli, and M. Lise, “Curative surgery for obstruction from primary left colorectal carci- In conclusion this case series suggests that initially there noma: primary or staged resection?” Cochrane Database of is a steep learning curve for the use of SEMS in the Systematic Reviews, no. 1, p. CD002101, 2002. management of malignant colorectal bowel obstruction of [15] J. E. van Hooft, P. Fockens, A. W. Marinelli et al., “Early closure about 11 cases. We suggest that at least twenty cases are of a multicenter randomized clinical trial of endoscopic required foranoperatortobeconsideredexperienced. stenting versus surgery for stage IV left-sided colorectal cancer,” Endoscopy, vol. 40, no. 3, pp. 184–191, 2008. [16] J. van Hooft, P. Fockens, A. Marinelli, P. Bossuyt, and W. References Bemelman, “Premature closure of the Dutch Stent-in I study,” Lancet, vol. 368, no. 9547, pp. 1573–1574, 2006. [1] Y.-B. Fan, Y.-S. Cheng, N.-W. Chen et al., “Clinical application of self-expanding metallic stent in the management of acute [17] J. E. Van Hooft, W. A. Bemelman, R. Breumelhof et al., “Colonic stenting as bridge to surgery versus emergency left-sided colorectal malignant obstruction,” World Journal of Gastroenterology, vol. 12, no. 5, pp. 755–759, 2006. surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 [2] P. G. Setti Carraro, M. Segala, B. M. Cesana, and G. Tiberio, “Obstructing colonic cancer: failure and survival patterns over study),” BMC Surgery, vol. 7, article 12, 2007. a ten-year follow-up after one-stage curative surgery,” Diseases of the Colon and Rectum, vol. 44, no. 2, pp. 243–250, 2001. [3] M. Dohmoto, “New method—endoscopic implantation of rectal stent in palliative treatment of malignant stenosis,” Endoscopy Digest, vol. 3, pp. 1507–1512, 1991. [4] E. Tejero, A. Mainar, L. Fernandez, R. Tobio, and M. A. De Gregorio, “New procedure for the treatment of colorectal neoplastic obstructions,” Diseases of the Colon and Rectum, vol. 37, no. 11, pp. 1158–1159, 1994. [5] P. P. Tekkis, J. D. Poloniecki, M. R. Thompson, and J. D. Stamatakis, “Operative mortality in colorectal cancer: prospective national study,” British Medical Journal, vol. 327, no. 7425, pp. 1196–1199, 2003. 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Colorectal Stenting in Malignant Large Bowel Obstruction: The Learning Curve

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Hindawi Publishing Corporation
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Copyright © 2011 D. Williams et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2090-1402
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2090-1410
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10.1155/2011/917848
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Abstract

Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 917848, 4 pages doi:10.1155/2011/917848 Clinical Study Colorectal Stenting in Malignant Large Bowel Obstruction: The Learning Curve 1 2 1 D. Williams, R. Law, and A. M. Pullyblank Department of Surgery, North Bristol NHS Trust, Frenchay Hospital, Frenchay Park Road, Bristol, BS16 1LE, UK Department of Radiology, North Bristol NHS Trust, Frenchay Hospital, Frenchay Park Road, Bristol, BS16 1LE, UK Correspondence should be addressed to D. Williams, williams-dan@doctors.org.uk Received 1 August 2010; Accepted 22 September 2010 Academic Editor: Michael Huner ¨ bein Copyright © 2011 D. Williams et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aim. Self-expanding metal stents (SEMSs) are increasingly used for the palliation of metastatic colorectal cancer and as a bridge to surgery for obstructing tumours. This case series analyses the learning curve and changes in practice of colorectal stenting over a three year period. Methods. A study of 40 patients who underwent placement of SEMS for the management of colorectal cancer. Patients spanned the learning curve of a single surgeon endoscopist. Results. Technical success rates increased from 82% initially, using an average of 1.7 stents per procedure, to a 94% success rate where all patients were stented using a single stent. There has been a change in practice from elective palliative stenting toward emergency preoperative stenting. Conclusion. There is a steep learning curve for the use of SEMS in the management of malignant colorectal bowel obstruction. We suggest that at least 20 cases are required for an operator to be considered experienced. 1. Introduction in the left colon who were experiencing obstructing symp- toms were considered. The decision to attempt insertion of Up to 29% of the 40 000 new diagnoses of colorectal cancer SMES was taken in the MDT. These cases with subacute large bowel obstruction were stented for palliation only. each year in the UK present with obstructive symptoms [1, 2]. Self-expanding metal stents (SEMSs) are being used with The second indication for stenting was acute left-sided large increasing success for the palliation of metastatic colorectal bowel obstruction. Stenting was indicated in this cohort cancer and as a bridge to surgery for obstructing tumours if the patient was at high risk for emergency surgery or despite the absence of high level evidence for their safety and had disseminated disease. Consecutive eligible patients were efficacy. With the advent of the ColoRectal Stenting Trial selected over a three-year period (2006–2008). (CReST trial), a multicentred RCT, there has been debate The procedures were performed by a single surgeon as to the learning curve for colorectal stenting. This case endoscopist and a consultant radiographer in one cen- series investigated the first three years of a single surgeon tre. Stents were performed under combined endoscopic endoscopist stenting experience analysing the change in and radiological guidance (Figure 1). Technical success was practice over time and the learning curve. defined as successful placement of the SEMS across the obstructing lesion with good passage of contrast post stenting. In this series, technical success equated to clinical success and all patients who achieved a technical success had 2. Patients and Methods symptomatic relief. Data was collected prospectively on 40 patients presenting Three patients were excluded at the time of the procedure with acute or subacute large bowel obstruction that subse- as stenting was thought inappropriate (stenting was not quently underwent the insertion of an SEMS. There were attempted). One patient had a pre-existing perforation 2 indications for insertions of an SEMS in this case series. demonstrated with contrast and preceded with operative Firstly, patients with disseminated malignancy from a lesion intervention. Endoscopy and radiological studies failed to 2 International Journal of Surgical Oncology (a) (b) (c) Figure 1: A series of images demonstrating the stages involved in endoscopically guided colorectal stenting. (a) The tumour is directly visualised with the endoscope, and the guide wire is passed through the end of the scope. (b) The deployment system is passed through the stricture. (c) The stent has been successfully deployed. The stent boundaries can be clearly identified. detect an obstructing malignant lesion in the other two disease and were stented as a bridge to surgery. The other 19 patients, and stenting was not performed. patients presented with subacute bowel obstruction and were electively stented. All of these patients were later managed This paper analysed the resulting 37-patient case series. with palliation for disseminated disease. Over 80% of the To aid with analysis and to show a change in practice over patients in this series were managed with palliation. As a time, the series was divided chronologically in half (1st 18 result of this they did not undergo surgical resection and patient were stented in 2006 and 2nd 19 patients stented formal histological (TNM) staging. in 2007 and 2008). The site of the lesions stented were The site of lesion and stenting varied: 6 descending colon, 6 descending colon, 9 sigmoid colon, 12 rectosigmoid, 8 9 sigmoid colon, 12 rectosigmoid, 8 rectum, 1 extrinsic rectum, 1 extrinsic compression, and 1 at the splenic flexure. compression, and 1 at the splenic flexure. Complications included 4 failures (11%), 4 tumour overgrowths (11%), and 1 stent migration (3%). Three of the tumour overgrowth 3. Results cases were restented at day 22, 130, and 146 after the original Thirty seven patients underwent stent placement (22 male, procedure. One patient had a late tumour overgrowth which 15 Female) with an average age of 74 (55–95). 18 (49%) was managed with a defunctioning loop ileostomy. There was 1 early perforation and 1 late (2 weeks) perforation in 2 of the patients presented as an emergency with acute large bowel obstruction. Of these patients, the staging investigation patients that were restented. Both these patients died as they demonstrated disseminated disease in 11 cases. After discus- were not fit for surgery. Figure 2 demonstrates the difference between the sion in the MDT all these patient were subsequently managed palliatively (nonoperatively). The remaining 7 had localised patients in the first and second half of the case series. International Journal of Surgical Oncology 3 1990s [3, 4] and subsequently has been used to avoid surgery in patients with metastatic disease and as a bridge to surgery in those with localised disease. SEMS have many advantages for patients with acute bowel obstruction. An SEMS can be used to control an 40 emergency presentation allowing patient optimisation. A study of 8000 patients found that emergency surgery has a mortality of 19.3% compared to 5.6% for elective surgery [5]. Elective surgery also reduces morbidity, with higher rates of primary anastomosis and lower rates of severe complications. Elective Emergency Palliative Bridge to surgery Martinez-Santos et al. found that patients undergoing emer- (%) gency surgery for acute malignant large bowel obstruction had a primary anastomosis rate of 41% compared with 87% 1st 18 patients (2006) in patients operated on following insertion of an SEMS [6], 2nd 19 patients (2007 and 2008) thus saving a significant amount of stoma-related morbidity. Figure 2: A comparison between the first and second half of the In the long term, only 60% of patients with a colostomy pro- case series showing the change in practice over time. ceed to stoma reversal [7]. In patients having curative surgery following a bridge to surgery SEMS, up to 95% go onto having a single staged procedure avoiding a colostomy [8]. Table 1: The learning curve for SEMS. There are also health economic advantages [8]with reduced hospital stay [9, 10] and length of time in critical Percentage success N of stents per Stenting group care beds [6, 11]. Importantly, stenting can buy time for stag- (%) procedure ing, treatment planning, neoadjuvant therapies and patient 1–11 82 1.7 optimisation. In this case series 18 patients presented with 12–21 90 1.1 acute bowel obstruction and underwent emergency stenting. 22–37 94 1.0 Of these patients, 11 (61%) were found to have disseminated disease at staging and hence avoided unnecessary major surgery. The early patients were predominantly palliative patients Colorectal stenting itself has disadvantages. The majority electively admitted with subacute large bowel obstruction. of the published literature is limited by having a small sample 67% in the first 18 patients and 37% in the subsequent 19 size and being nonrandomised; consequently there is a large patients were electively stented for this indication. In the range in quoted complication rates. A review by Watt et al. second half of the series, more SEMS are deployed acutely found median complication rates of stent migration 11%, as a bridge to surgery or to palliate emergency large bowel perforation 4.5%, and tumour overgrowth 12% [12]. Clini- obstruction. Of the first 18 patients only 11% of patients cal success is usually quoted at a rate of 85–100% [1, 8, 12, 13] were stented following emergency presentation with acute with mortality between 0 and 2%. This study had a primary large bowel obstruction, in comparison to 26% in the perforation rate of 0% in line with the literature, but we had subsequent 19 patients. an overall mortality of 2/37 (5%) when restented patients The first 11 stents performed had an 82% technical were taken into account. Successful treatment of acute left- success rate andrequiredanaverage of 1.7stentsper sided colorectal obstruction depends on a number of opera- procedure. The subsequent 10 stents performed had a 90% tor and patient factors. A Cochrane review in 2002 concluded technical success rate and required average of 1.1 stents that the limited number of randomised control trials into the per procedure. The final 16 stents performed had a 94% management of obstructing left-sided colorectal carcinoma technical success rate. All of these patients were stented using together with methodological weaknesses does not allow a single stent. This is shown in Table 1 demonstrating how reliable assessment of the best treatment strategy [14]. There technical success increased and number of stents decreased is a clear need for further large randomised studies. with experience. The only prospective multicentred RCT to date, the Stent-in 1 study [15, 16], was stopped early following a high rate of stent-related complications. In the proposed followup 4. Discussion Stent-in 2 study [17], it is suggested that SEMS should be Colorectal cancer commonly presents with large bowel placed by an experienced gastroenterologist. They defined obstruction, often at an advanced stage with only 50% an experienced gastroenterologist as one who has placed of patients being suitable candidates for curative surgery. 20 enteral stents of which at least 10 were colonic, without Emergency surgery in these patients has a high mortality giving evidence why these figures have been suggested. This study found that there was a definite learning curve and morbidity when compared to elective surgery. Over time, several techniques such as balloon dilatation and laser for the insertion of SEMS, the first 11 stents having only ablation have been attempted with the aim of decompressing an 82% success rate, the next 10 having a 90% success rate, and the subsequent SEMS having a 94% success rate. the bowel. These techniques had limited success. The use of stents in colorectal obstruction was first reported in the early In this case series, it was also noted that the number of SEMS Percentage of patients in each cohort (%) 4 International Journal of Surgical Oncology required to relieve an obstruction decreased with experience. [6] C. Martinez-Santos, R. F. Lobato, J. M. Fradejas, I. Pinto, P. Ortega-Deballon, ´ and M. Moreno-Azcoita, “Self-expandable Initially an average of 1.7 stents were used per successful stent before elective surgery vs. emergency surgery for the procedure whereas towards the end of the series strictures treatment of malignant colorectal obstructions: comparison were consistently requiring only one stent. This increased of primary anastomosis and morbidity rates,” Diseases of the stent usage early in the series reflected inexperience and Colon and Rectum, vol. 45, no. 3, pp. 401–406, 2002. technical difficulty rather than length of stricture. There was [7] G. T. Deans, Z. H. Krukowski, and S. T. Irwin, “Malignant no significant difference between complications and length obstruction of the left colon,” British Journal of Surgery, vol. of stricture between the groups. This evidence suggests that 81, no. 9, pp. 1270–1276, 1994. operators should have a minimal experience of 20 colonic [8] U. P. Khot, A. Wenk Lang, K. Murali, and M. C. Parker, SEMS to be eligible for inclusion in future RCTs. “Systematic review of the efficacy and safety of colorectal Not being a randomised study, there is inevitable bias in stents,” British Journal of Surgery, vol. 89, no. 9, pp. 1096–1102, the selection of patient and treatment options. Experience 2002. [9] E. Fiori, A. Lamazza, A. De Cesare et al., “Palliative Manage- in colorectal stenting resulted in changes in practice over ment of Malignant Rectosigmoidal Obstruction. Colostomy time. As the study progressed, more stents were performed vs. Endoscopic Stenting. A Randomized Prospective Trial,” on an emergency basis (33% of the first 18 patients and Anticancer Research, vol. 24, no. 1, pp. 265–268, 2004. 63% of the second 19 patients) in a patient demographic [10] R. Vemulapalli, L. F. Lara, J. Sreenarasimhaiah, W. V. Harford, who were likely to be more unwell. More stents were also and A. A. Siddiqui, “A comparison of palliative stenting or performed as a bridge to surgery in the second half of the emergent surgery for obstructing incurable colon cancer,” study (26% compared with 11%). This change in practice is Digestive Diseases and Sciences, vol. 55, no. 6, pp. 1732–1737, likely to reflect an increase in operator confidence in their technical ability and knowledge of when stenting is and is not [11] W. L. Law, H. K. Choi, and K. W. Chu, “Comparison appropriate. The fact that the clinical success rates increased of stenting with emergency surgery as palliative treatment along this learning curve despite more technically difficult for obstructing primary left-sided colorectal cancer,” British patients suggests that there may also be a significant learning Journal of Surgery, vol. 90, no. 11, pp. 1429–1433, 2003. [12] A. M. Watt,I.G.Faragher, T. T. Griffin, N. A. Rieger, and curve in patient selection. G. J. Maddern, “Self-expanding metallic stents for relieving There has also been a change in practice with regard malignant colorectal obstruction: a systematic review,” Annals to restenting. The 2 mortalities in this series were patients of Surgery, vol. 246, no. 1, pp. 24–30, 2007. who died following the restenting of a multilevel obstruc- [13] C. E. Dauphine, P. Tan, R. W. Beart Jr., P. Vukasin, H. tion. Both these patients required 2-3 stents to relieve the Cohen, and M. L. Corman, “Placement of self-expanding obstruction caused by a long stricture, which in retrospect metal stents for acute malignant large-bowel obstruction: a was a mistake. If a reobstruction cannot be solved with a collective review,” Annals of Surgical Oncology, vol. 9, no. 6, single stent, practice has changed and a further stent would pp. 574–579, 2002. not be attempted. [14] G. L. De Salvo, C. Gava, S. Pucciarelli, and M. Lise, “Curative surgery for obstruction from primary left colorectal carci- In conclusion this case series suggests that initially there noma: primary or staged resection?” Cochrane Database of is a steep learning curve for the use of SEMS in the Systematic Reviews, no. 1, p. CD002101, 2002. management of malignant colorectal bowel obstruction of [15] J. E. van Hooft, P. Fockens, A. W. Marinelli et al., “Early closure about 11 cases. We suggest that at least twenty cases are of a multicenter randomized clinical trial of endoscopic required foranoperatortobeconsideredexperienced. stenting versus surgery for stage IV left-sided colorectal cancer,” Endoscopy, vol. 40, no. 3, pp. 184–191, 2008. [16] J. van Hooft, P. Fockens, A. Marinelli, P. Bossuyt, and W. References Bemelman, “Premature closure of the Dutch Stent-in I study,” Lancet, vol. 368, no. 9547, pp. 1573–1574, 2006. [1] Y.-B. Fan, Y.-S. Cheng, N.-W. Chen et al., “Clinical application of self-expanding metallic stent in the management of acute [17] J. E. Van Hooft, W. A. Bemelman, R. Breumelhof et al., “Colonic stenting as bridge to surgery versus emergency left-sided colorectal malignant obstruction,” World Journal of Gastroenterology, vol. 12, no. 5, pp. 755–759, 2006. surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 [2] P. G. Setti Carraro, M. Segala, B. M. Cesana, and G. Tiberio, “Obstructing colonic cancer: failure and survival patterns over study),” BMC Surgery, vol. 7, article 12, 2007. a ten-year follow-up after one-stage curative surgery,” Diseases of the Colon and Rectum, vol. 44, no. 2, pp. 243–250, 2001. [3] M. Dohmoto, “New method—endoscopic implantation of rectal stent in palliative treatment of malignant stenosis,” Endoscopy Digest, vol. 3, pp. 1507–1512, 1991. [4] E. Tejero, A. Mainar, L. Fernandez, R. Tobio, and M. A. De Gregorio, “New procedure for the treatment of colorectal neoplastic obstructions,” Diseases of the Colon and Rectum, vol. 37, no. 11, pp. 1158–1159, 1994. [5] P. P. Tekkis, J. D. Poloniecki, M. R. Thompson, and J. D. Stamatakis, “Operative mortality in colorectal cancer: prospective national study,” British Medical Journal, vol. 327, no. 7425, pp. 1196–1199, 2003. 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