Colonic Stenting VS Surgery as the initial
management of obstruction in patients with
colonic carcinoma.
Talal Al-Jabri *, Rohit Ghurye, Irshad Shaikh, Mokthar Uheba.
Department of Surgery
Brighton & Sussex University Hospitals NHS Trust
East and North Hertfordshire NHS Trust *
XIV ANNUAL CONFERENCE OF EUROPEAN SOCIETY of
SURGERY AND FIRST MEETING OF ITALIAN AND
EUROPEAN CHAPTER OF AMERICAN COLLEGE of
SURGEONS, Turin, Italy, Friday November 26, 2010
Introduction
•
Colonic obstruction secondary to malignancy is a surgical emergency!
•
Emergency procedures such as a Loop Colostomy, Hartmanns or
Subtotal Colectomy are well established option for obstructive Colonic
Carcinoma (CCa).
•
However these patients (pts) are usually poor surgical candidates.
-↑ Incidence of post-op complications
- ↑ Mortality rate (10-30%)
- ↓ Health-related quality of life
•
Self-Expanding Metallic Stents (SEMS) is an option.
- resuscitation and optimisation of patents relief of obstruction
- allows for staging
- relief of obstruction
- ↓hospital/ITU stay and costs
- avoidance of stoma.
•
SEMS is not perfect:
- Surgery tends to require much less re-intervention.
- risks of SEMS include: colonic perforation, bleeding, stent migration and occlusion .
- SEMS are expensive (~$1000) and may not be technically possible to deploy.
•
Objective:
To audit our experience of emergency surgery versus colonic stenting in the
initial treatment of pts with colonic malignancy. To compare our outcomes to a
measurable standard that being the results published by:
- Vemulapalli R et al. A comparison of palliative stenting or emergent surgery for
obstructing incurable colon cancer. Dig Dis Sci. 2010 Jun;55(6):1732-7.
- Vemulapalli R, Lara LF, Sreenarasimhaiah J, Harford WV, Siddiqui AA. A comparison of palliative stenting or
emergent surgery for obstructing incurable colon cancer. Dig Dis Sci. 2010 Jun;55(6):1732-7. Epub 2009 Aug 2
-Riedl S, Wiebelt H, Bergmann U, Hermanek P Jr. Postoperative complications and fatalities in surgical
therapy of colon carcinoma.Results of the German multicenter study by the ColorectalCarcinoma Study
Group. Chirurg. 1995;66:597–606.
- Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following
colostomy. Dis ColonRectum. 1994;37:916–920. 0
Material and Methods
•
The Colo-Rectal Multidisciplinary Team Co-ordinator and the Clinical
Informations Unit provided a list of pts from 2005 to 2010 who presented to
Royal Sussex County Hospital (RSCH) and undergone:
1) emergency/elective surgery (current standard treatment)
2) emergency/elective colonic stenting
•
The study population consists of pts with acute left-sided malignant colonic
obstruction. The pt notes were retrieved and reviewed retrospectively.
•
SEMS or Surgery was offered to pts at the discretion of the surgeon oncall.
Materials and Methods
•
Inclusion/Exclusion criteria:
- non-operable and metastatic colorectal cancer defined by typical abnormalities on a
gastrografin enema study or CT-abdomen with contrast compatible with a malignant
colonic stricture.
- Pts with evidence of perforation at initial presentation were excluded.
•
Clinical success was defined by relief of symptoms<24hrs after stenting.
•
Early complications included those presenting <30 days post-op.
•
Late complications included those presenting >30 days post-op.
•
We took the outcomes of the following published paper from the University of Texas
Southwestern Medical School to be the standard to which we audited against:
Vemulapalli R, Lara LF, Sreenarasimhaiah J, Harford WV, Siddiqui AA. A comparison of
palliative stenting or emergent surgery for obstructing incurable colon cancer. Dig Dis
Sci. 2010 Jun;55(6):1732-7. Epub 2009 Aug 2
Results
•
33 pts met the inclusion criteria. These patients were comparable by
tumour site and age/gender.
- 19 pts were in the Stent group.
- 14 pts were in the Surgery group.
•
The Stent Group (n=19):
- 8 months Median time before stent occlusion in our results
(standard/UTSW 8 months also).
- Median hospital stay 2 days, range 1-11 (Standard median 2 days
range 1-24).
- 0 days ITU stay.
- 0% hospital mortality (Standard 0%).
- 2.2 procedures on avg per patient.
- 5% pts required a stoma.
Our Stenting results compared to the
standard we audited against (UTSW Paper)
Surgery Group (n=14)
• Hospital stay median 10 days, range 3-31 (standard: median 8 days,
range 2-43)
•93% pts required a stoma.
•1.2 procedures per pt (avg).
•ITU stay 0.5 days (avg).
Surgery VS Stenting
Surgery
Stenting
Acute Complications
(HAP/wound infection
and perf/migration)
36%
10%
Late complications
(obstruction in surgery
and stent
occlusion/migration)
7%
15%
Relief of obstruction
100%
100%
Avg No. Procedures
per pt
1.2 procedures
2.2 procedures
Avg No pts requiring
Stoma
93%
5%
Hospital Stay (median
and range)
10 (3-31)
2 (1-11)
Avg ITU stay
0.5 days
0 days
Post-op mortality
0%
0%
Discussion
•
This study showed:
- Stenting is a safe option to treat incurable CCa.
- Stenting can be as effective as surgery at palliating obstruction 2nd to CCa
•
Stenting resulted in:
- less overall complications compared to surgery.
- fewer pts having to endure life with a stoma.
 better quality of life.
- shorter hospital stays and in our study no ITU stays.
•
However there were a higher number of procedures per pt (re-stenting) and more
late complications in the stenting group
 due to migration following tumour shrinkage in chemotherapy and also stent
occlusion following tumour progression.
•
Stenting is technically successful in 78-100% cases and clinically successful in 84100%.  Our results showed a 100% clinical/technical success rate..
Keymling M. Colorectal stenting. Endoscopy. 2003;35:234–238.
•
Surgery requires 6-12 weeks recovery time which in pts with reduced life
expectancies is substantial!
Stenting = short recovery time.
•
10% stents in general migrate according to the literature.
Our results are in keeping with this.
As technique and design evolves this may improve.
•
Perforation is greatest risk only 5% suffered this in our study. Though the standard
measured against suffered only 4%.
 possibly due to different stent design standard used Wallflex (Boston)
 We used Nitinol Stents.
Us compared to standard:
Less stent occlusion
More perforation and Migration  ? Due to stent design ?chemotherapy ?other
Less complications overall (us 25%, standard 34% due to stent occlusion).
Discussion
•
Limitations:
- size of groups not very large
- retrospective
- population groups may be different which may effect results.
- different Stent used from standard
- surgical notes did not always say whether stents were passed 2cm
beyond tumour margin as in paper
- other factors such as chemotherapy which can increase risk of
perforation should be looked at
- as retrospective can not be certain all pts captured for study
Conclusions
•
Stenting is a suitable option for the management of pts with end
stage CCa.
•
Recommendations from audit:
- If technical expertise present to consider stenting as first line for
obstruction in end stage CCa.
-Surgery is recommended only in those who are unsuitable for
SEMS.
- To compare Wallflex VS Nitinol. To otherwise use a suitable
alternative that has flares which may help prevent migration.
- To assess risk of perforation in pts undergoing chemotherapy and
stenting.