colonic stenting for intestinal obstruction due to left colon and rectal cancer dr sherman lam
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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. - PowerPoint PPT PresentationTRANSCRIPT
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