colonic stenting for intestinal obstruction due to left colon and rectal cancer dr sherman lam

Colonic stenting for intestinal obstruction due to left colon and rectal cancer

Dr Sherman LamTKOH

JHSGR 26 April 2014

Outline of presentation

Introduction

Colonic stenting

– Indication/contra-indication

– Efficacy

– ComplicationEvidence

– Palliation

– Bridge to elective surgeryConclusion

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

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. 1992Tekkis et al. Ann Surg. 2004Deans et al. Br J Surg. 1994Phillips et al. Br J Surg. 1985

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. 1999Nugent et al. Dis Colon Rectum. 1999Deans et al. Br J Surg. 1994

Obstructed left side colonic cancer (OLCC)

Ansaloni et al. World Journal of Emergency Surgery 2010

Colonic stenting

Colonic stenting

Dohmoto, 1991

Palliative intent 19 non-resectable or metastatic rectal cancer Successful rate 84%, half alive with no recurrent

obstruction in 6 monthsTejero, 1994

Bridge to elective surgery 2 cases

M. Dohmoto et al Surgical Endoscopy 1996Tejero et al. Dis Colon Rectum 1994

Colonic stenting

Indications:

PalliationBridge to elective surgery

Contra-indications:

Evidence of perforation (clinical/radiological)

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

Complications

Severe pain 5%

Bleeding 5%

0.5% need blood transfusion

Khot et al. Br J Surg 2002Rahul et al. Abdom Imaging 2008Suzuki et al. Dis Col Rec 2004

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 2002Rahul et al. Abdom Imaging 2008Suzuki et al. Dis Col Rec 2004

Evidence

Palliation

Compared to emergency surgery

hospital stay shorter

stoma creation ? lower

same

Law et al. Br J Surg 2003Xinopulos et al. Surg Endosc 2004Fiori et al. Anticancer Res 2004Sagar et al. Cochrane 2011

Law et al. Br J Surg 2003Tilney et al. Surg Endosc 2007

Ye GY et al. World J Gastroenterol 2012

Palliation

Compared to emergency surgery

morbidity/mortality ? lower

same

Lee et al. Am J Surg 2012Dionigi G et al. Surg Oncol 2007

Ye et al. World J Gastroenterol 2012Sagar et al. Cochrane 2011

Bridge to elective surgery

Compared to emergency surgery

primary anastomosis

higher Cheung HYS et al. Arch Surg 2009Cennamo et al. Int J Colorectal Dis 2013Tan et al. Br J Surg 2012Zhang et al. Surg Endosc 2012Dastur et al. Tech Coloproctol 2008

Bridge to elective surgery

Compared to emergency surgery

stoma ?

lower

same Kavanagh et al. Dis Colon Rectum 2013Pirlet et al. Surg Endosc 2011

Cennamo et al. Int J Colorectal Dis 2013Tan et al. Br J Surg 2012

Bridge to elective surgery

Compared to emergency surgery

morbidity/mortality ?

lower

higher

Ghazal et al. J Gastrointest Surg 2013Alcantara et al. World J Surg 2011Ho et al. Int J Colorectal Dis 2012Zhang 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

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

conflicting evidence for stoma rate, morbidity/mortality

long term survival same? worse?, local reccurrence higher?

Thank you