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Annals of Surgical Oncology 9:574-579 (2002)
© 2002 Society of Surgical Oncology

ORIGINAL ARTICLES

Placement of Self-Expanding Metal Stents for Acute Malignant Large-Bowel Obstruction: A Collective Review

Christine E. Dauphine, MD, Patrick Tan, MD, Robert W. Beart, Jr., MD, Petar Vukasin, MD, Hartley Cohen, MD and Marvin L. Corman, MD

From the Division of Colon and Rectal Surgery (CED, PT, RWB, PV, MLC) and the Department of Gastroenterology (HC), Keck School of Medicine, University of Southern California/Los Angeles County Medical Center, Los Angeles, California.

Correspondence: Address correspondence and reprint requests to: Marvin L. Corman, MD, Department of Surgery, Long Island Jewish Medical Center, 269–11 76th Ave., Suite FP 417, New Hyde Park, NY 11040; Fax: 718-470-1265; E-mail: mcorman{at}lij.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background: The purpose of this study was to review our experience with self-expanding metal stents as the initial interventional approach in the management of acute malignant large-bowel obstruction.

Methods: Twenty-six patients who underwent placement of colonic stents at our institution between June 1994 and June 2000 were identified and reviewed.

Results: In 14 patients, the stents were placed for palliation, whereas in 12, they were placed as a bridge to surgery. In 22 patients (85%), stent placement was successful on the first occasion. In the remaining four individuals, one was successfully stented at the second occasion, and three required emergency surgery. Nine of the 12 patients (75%) in the bridge-to-surgery group underwent elective colon resection. In the palliative group, four patients (29%) had reobstruction of the stents, and in one (9%), the stent migrated. In the remaining nine patients (64%), the stent was patent until the patient died or until the time of last follow-up (median, 156 days).

Conclusions: In our experience with 26 patients who developed a complete bowel obstruction as a consequence of a malignant tumor, placement of colonic stents to achieve immediate nonoperative decompression proved to be both safe and effective. Subsequent elective resection was accomplished in the majority of resectable cases.

Key Words: Colonic obstruction • Stent • Endoprosthesis • Cancer • Colon and rectum


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The concept of using a self-expandable metal stent to relieve obstruction in an occluded lumen was first introduced in 1985, when Wright et al.1 successfully placed stents in the canine jugular vein and abdominal aorta. Over the years, stent placement has been attempted in multiple sites: coronary arteries, major vessels, urethra, trachea, esophagus, and biliary tract.2–5 In 1991, Dohmoto6 published the initial experience with a metallic stent placed in the colon. This was undertaken as a palliative measure. In 1994, Tejero et al.7 published a preliminary report of two patients with colonic obstruction who had metallic stents placed before surgery. Since then, a number of publications have appeared that suggest that colonic stent placement is a relatively simple and safe alternative to standard surgical management of acute malignant obstruction of the left colon, thereby obviating the need for emergency surgery or colostomy.8–11 This article represents our experience with 26 patients, all of whom underwent placement of self-expanding metal stents as the initial interventional approach in the management of acute colonic obstruction during the period June 1994 to June 2000.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
All patients who had self-expandable metal stents placed for the treatment of complete mechanical large-bowel obstruction (LBO) at the Los Angeles County/University of Southern California Medical Center were identified. The charts of 26 patients were retrospectively reviewed. All patients were seen from June 1994 through June 2000. Acute LBO was diagnosed by the presence of one or more of the following criteria: (1) symptoms of abdominal pain or fullness, nausea, vomiting, or constipation; (2) signs of abdominal distention or tympani; or (3) radiographical evidence of complete or partial LBO confirmed by water-soluble contrast enema. Patients were not considered candidates for stent placement if they exhibited peritonitis, volvulus of a bowel segment, or obstruction that was proximal to the splenic flexure.

The endoprosthesis used was Wallstent (Boston Scientific/Microvasive, Natick, MA). The technique of stent placement varied somewhat. Initially, a procedure similar to that described by Tejero et al.7 and Mainar et al.10 was used, with fluoroscopic guidance alone. Subsequently, we added the use of an endoscope to fluoroscopy for direct visualization of the lesion, as described by Soonawalla et al.12 A new technique using an endoscope alone (without fluoroscopy) was developed as well. In this circumstance, the colonoscope is inserted first, and the guide wire is placed through its channel and then through the lesion. The instrument is then removed and reinserted adjacent to the wire. The stent is then deployed over the guide wire in the usual fashion (Fig. 1). Further details of this procedure, along with its advantages and disadvantages, have previously been published.13



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  		FIG. 1. Stent deployed in the sigmoid colon with residual gas and contrast remaining in the proximal colon. Minimal distension of the bowel is evident.

 
A second stent is placed if immediate decompression does not occur after insertion of the first. In instances in which fluoroscopy was not used, the second stent was placed more proximally (through the first). This differs from the fluoroscopic-guided procedure in that placement of the stent is initially accomplished proximally, and then a second stent is placed more distally if required.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The 26 patients (Table 1) ranged in age from 39 to 90 years, with a median of 58 years. Fifteen patients (58%) were men, and 11 (42%) were women. The median duration of obstructive symptoms reported by the patients was 6 days (range, 3 to 30 days). Twenty patients (77%) had primary colonic adenocarcinomas, three of which harbored recurrent cancers. Six patients (23%) had extracolonic tumors compressing or involving the colon. Fourteen patients (54%) had stents placed for palliation with no intent of future operation or stent removal. Twelve patients (46%) had placement as a bridge to surgery, with plans to undergo an elective procedure within 2 weeks of stent placement. The site of obstruction was found between the splenic flexure and the rectosigmoid junction; the majority of lesions were located in the sigmoid colon. Placement of the stents was accomplished under fluoroscopic guidance (with or without colonoscopy) in 18 patients (69%) and with colonoscopy alone in the remaining 8 (31%). Seven patients (27%) required the placement of two stents to achieve complete decompression. The median time required for stent placement was 23 minutes (range, 12 to 150 minutes).


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  		TABLE 1. TABLE 1. Case summary of patients from this series with malignant colonic obstruction
 
Twenty-two patients (85%) had stents placed successfully on the first attempt and without complication. In the remaining four (15%), decompression was not achieved. In one (patient 17), the guide wire could not be passed through the obstruction, and the patient was taken to the operating room for an emergency total colectomy. In another (patient 26), the first stent that was placed did not decompress the obstruction completely. Placement of a second stent resulted in perforation of the bowel wall; this necessitated the performance of an emergency Hartmann procedure. Perforation also occurred in patient 25; this, too, led to the need for a Hartmann procedure. All three patients were part of the bridge-to-surgery group. Despite the above-mentioned complications, each individual made an uneventful recovery. One person (patient 12) required balloon dilation of the stent because of inadequate decompression after placement.

Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no deaths or anastomotic complications (Fig. 2). The median length of time between stent placement and subsequent surgery was 7 days (range, 2 to 11 days). Of the 14 stenting procedures performed successfully for palliation, 9 (64%) remained patent and in place until the patient died or until the end of the follow-up period. In one individual (patient 3), stent migration occurred, resulting in elimination of the stent 5 days after placement. The stent was not replaced, but there was no reobstruction; the patient died of metastases a few months later.



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  		FIG. 2. High anterior resection opened specimen with mesh incised. The procedure was undertaken electively.

 
Reobstruction ultimately occurred in four patients as a consequence of tumor ingrowth. This was recognized at 14, 60, 100, and 130 days. Three of these individuals underwent exploratory laparotomy. A colostomy was created in two, and a gastrostomy alone was accomplished in the third because of carcinomatosis. Re-stenting was successfully performed in the fourth (patient 12). Another individual (patient 6) was lost to follow-up after stent placement.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Between 7% and 29% of patients with colorectal cancers present with acute intestinal obstruction, of which almost 90% are located at or distal to the splenic flexure.14–17 The management of these generally mandates emergency surgical intervention and, at the minimum, decompression. The operative mortality, however, for obstruction secondary to colon carcinoma has been reported to be from 23% to 45%.14 If the ileocecal valve is competent, with no evidence of small-bowel dilatation, the patient is considered to be at an increased risk for the development of a perforation. Furthermore, electrolyte imbalance, bowel ischemia, and sepsis caused by bacterial translocation are particular concerns in this situation.18 Additionally, cancer patients, especially those with bowel obstruction, are typically malnourished, older, and dehydrated and may have widely disseminated disease at the time of presentation.9,10,18 In short, these are clearly individuals who are at an increased risk for emergency surgery. Still, resection of the tumor-bearing segment with primary anastomosis in a single operative procedure would seem to be the ideal approach in a patient with an obstructing cancer. Realistically, however, in such individuals, in addition to the risk factors previously mentioned, the lack of bowel preparation and the severe dilatation of proximal bowel segments often lead the surgeon to performing multiple procedures, with operative mortality rates as high as 60%.10,14

To avoid the consequences of multiple or two-stage procedures, some have suggested the placement of an intracolonic bypass tube.19 This approach, although theoretically meritorious, is technically difficult to accomplish. As of this writing it is no longer available for use in the United States. Another alternative that has been used with some success is intraoperative colonic lavage.20 Neither approach has been embraced with enthusiasm by surgeons because both are tedious and complex, require a longer operative time, and are associated with increased morbidity.21,22 A total or subtotal colectomy is strongly advocated by many surgeons, but if one is dealing with a rectal obstruction, such an operation may be associated with unacceptable, intractable diarrhea.23 For a more proximal obstruction, subtotal colectomy and ileocolonic anastomosis is generally a good choice, is well tolerated, and has a relatively low morbidity and mortality. Emergency colostomy or ileostomy, with or without resection, is still today the standard for the treatment of high-risk patients with complete malignant LBO.24 This procedure, however, also is associated with a high mortality rate.14,15,18 Furthermore, the stoma itself may be a major source of morbidity and has obvious implications for the quality of life for these individuals. In fact, for a number of reasons, 25% of patients with colostomies will never have restoration of intestinal continuity.15

Nonoperative alternatives have been attempted, with indifferent results. These include balloon dilation, placement of a plastic nonexpandable rectal tube, cryosurgical destruction, electrocoagulation, and laser ablation.25,26 As with stenting, the concept is to avoid emergency operation, allowing for either long-term palliation or for an elective resection after transanal decompression. The rigid tubes (often thoracostomy tubes are used) are generally not sufficiently flexible to permit insertion and decompression at the level of the sigmoid colon and are limited by the small diameter.25 Often, they are easily clogged. Laser treatment has been shown to be effective for palliation through destruction of the tumor and the creation of a temporary open lumen. However, patients usually must return for repeated treatments (every 5 to 9 weeks) to avoid recurrent obstruction.21,26

Certainly, there seems to be a place for a nonoperative alternative that is safe and effective in the management of rectal and colon obstruction for malignant disease. A number of reports have recommended the placement of a metallic stent for malignant LBO, either for palliation or for decompression before elective surgery. Through the use of the MEDLINE database for the years 1966 through 1999, 187 patients were identified as having undergone this procedure (Table 2).8–12,21,25,27–32 Ninety-eight stents (52.4%) were placed as palliation for nonresectable tumors, and 89 (47.6%) were placed before an elective resection was performed. Successful placement was achieved in 177 (94.6%) cases. Failure was attributed to an inability to pass the guide wire, endoscope, or both through the lesion. An emergency colostomy was necessitated in every such instance. Relief of the obstruction was observed in 170 patients (90.9%); all with an unrelieved obstruction underwent an emergency colostomy. No comparison, however, was made by any investigator between the outcomes of patients who underwent stent placement and those of a control group—that is, those who had a colostomy placed on an emergency basis. Perforation of the bowel occurred in five patients (2.7%). Three of these cases were asymptomatic, with the perforation detected at the time of elective resection. The other two underwent emergency operation. Sixteen migrations (8.6%) occurred. This complication was generally attributed to the use of a covered stent peripherally coated with polyurethane or silicone or to tumor shrinkage after chemoradiation or laser treatment.27,29,33 One third of patients with migration were asymptomatic, and another third benefited from placement of a second stent. Three other patients developed reobstruction from proximal migration of the stent; all underwent surgical removal of the stents. The final two underwent repeated laser debulking until they died. The total number of reobstructions, usually successfully managed with enemas, was 12 (6.4%). Of the 89 resectable cases, 76 (85.4%) underwent an elective, single-stage procedure. Twenty-six (13.9%) underwent emergency operation because of failed placement, perforation of the bowel, reobstruction, or the presence of synchronous disease elsewhere in the colon. Three deaths (1.6%) were reported. One occurred secondary to acute renal failure, another because of inability to relieve the initial obstruction, and the third from multiple complications.


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  		TABLE 2. TABLE 2. Summary of literature reviews of stents in the management of malignant colonic obstruction
 

   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
There have been promising results with the use of self-expanding metal stents in the initial treatment of acute obstruction of the left colon and rectum from cancer. In the combined reported series, as well as our own experience, it has been demonstrated that stent placement is highly successful in relieving acute obstruction and is associated with minimal complications. In patients with resectable disease, successful stenting will convert an emergency procedure to an elective one. In those individuals with unresectable tumors, long-term relief of obstruction can be achieved in the vast majority of patients, thereby avoiding the inconvenience and consequences of a stoma.

Received for publication July 23, 2001. Accepted for publication March 29, 2002.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Wright KC, Walace S, Charnsangavej C, Carrasco CH, Gianturco C. Percutaneous endovascular stents: an experimental evaluation. Radiology 1985; 156: 69–72.[Abstract/Free Full Text]
  2. Kimura T, Yokoi H, Nakagawa, et al. Three-year follow-up after implantation of metallic coronary-artery stents. N Engl J Med 1996; 334: 561–6.[Abstract/Free Full Text]
  3. Badlani G. Role of permanent stents. J Endourol 1997; 11: 473–5.[Medline]
  4. Stohr S, Bollinger C. Stents in the management of malignant airway obstruction. Monaldi Arch Chest Dis 1999; 54: 264–8.[Medline]
  5. Kozarek RA. Expandable endoprostheses for gastrointestinal stenoses. Gastrointest Endosc Clin North Am 1994; 4: 279–95.[Medline]
  6. Dohmoto M. New method—endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endosc Digest 1991; 3: 1507–12.
  7. Tejero E, Mainar A, Fernandez L, Tobio R, DeGregorio MA. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum 1994; 37: 1158–9.[CrossRef][Medline]
  8. Tejero E, Fernandez-Lobato R, Mainar A, et al. Initial results of a new procedure for treatment of malignant obstruction of the left colon. Dis Colon Rectum 1997; 40: 432–6.[CrossRef][Medline]
  9. Wholey MH, Levine EA, Ferral H, Castaneda-Zuniga W. Initial clinical experience with colonic stent placement. Am J Surg 1998; 175: 194–7.[CrossRef][Medline]
  10. Mainar A, Tejero E, Maynar M, Ferral H, Castaneda-Zuniga W. Colorectal obstruction: treatment with metallic stents. Radiology 1996; 198: 761–4.[Abstract/Free Full Text]
  11. DeGregorio MA, Mainar A, Tejero E, et al. Acute colorectal obstruction: stent placement for palliative treatment—results of a multicenter study. Radiology 1998; 209: 117–20.[Abstract/Free Full Text]
  12. Soonawalla Z, Thakur K, Boorman P, et al. Use of self-expanding metallic stents in the management of obstruction of the sigmoid colon. AJR Am J Roentgenol 1998; 171: 633–6.[Abstract/Free Full Text]
  13. Dauphine CE, Tan PY, Beart RW Jr, Corman ML, Vukasin P. Self-expanding metallic stents in the management of lower gastrointestinal hemorrhage. Dis Colon Rectum (in press).
  14. Buechter KJ, Boustany C, Caillouette R. Surgical management of the acutely obstructed colon. Am J Surg 1988; 156: 163–8.[CrossRef][Medline]
  15. Deans GT, Krukowski ZH, Irwin ST. Malignant obstructions of the left colon. Br J Surg 1994; 81: 1270–6.[Medline]
  16. Serpell JW, McDermott FT, Katrivessus H, Hughes ESR. Carcinomas of the colon causing intestinal occlusion. Br J Surg 1989; 2: 549–54.
  17. Ohman U. Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982; 143: 742–7.[CrossRef][Medline]
  18. Gandrup P, Lund L, Balslev I. Management of acute malignant large bowel obstruction. Eur J Surg 1992; 158: 427–30.[Medline]
  19. Ravo B, Ger R. Temporary colostomy—an outmoded procedure? A report on the intracolonic bypass. Dis Colon Rectum 1985; 28: 904–7.[Medline]
  20. Murray JJ, Schoetz DJ, Coller JA, Roberts PL, Veidenheimer MC. Intraoperative colonic lavage and primary anastomosis in nonelective colon resection. Dis Colon Rectum 1991; 34: 527–31.[CrossRef][Medline]
  21. Wallis F, Campbell KL, Eremin O, Hussey JK. Self-expanding metal stents in the management of colorectal carcinoma—a preliminary report. Clin Radiol 1998; 53: 251–4.[CrossRef][Medline]
  22. Egozi L, Sorrento JJ, Golub R, Schultz EH. Complication of the intracolonic bypass. Dis Colon Rectum 1993; 36: 191–3.[CrossRef][Medline]
  23. Corman ML. Colon and Rectal Surgery. 4th ed. Philadelphia: Lippincott-Raven, 1998: 684–93.
  24. Keighley MRB, Williams NS. Surgery of the Anus, Rectum, and Colon. 2nd ed. London: W.B. Saunders Co., 1999: 2185–8.
  25. Rupp KD, Dohmoto M, Meffert R, Holzgreve A, Hohlbach G. Cancer of the rectum—palliative endoscopic treatment. Eur J Surg Oncol 1995; 21: 644–7.[CrossRef][Medline]
  26. Sardi A, Ojeda H, Barco E. Cryosurgery: adjuvant treatment at the time of resection of a pelvic recurrence in rectal cancer. Am Surg 1999; 65: 1088–91.[Medline]
  27. Choo IW, Do YS, Suh SW, et al. Malignant colorectal obstruction: treatment with a flexible covered stent. Radiology 1998; 206: 415–21.[Abstract/Free Full Text]
  28. Saida Y, Sumiyama Y, Nagao J, Takase M. Stent endoprosthesis for obstructing colorectal cancers. Dis Colon Rectum 1996; 39: 552–5.[CrossRef][Medline]
  29. Arnell T, Stamos M, Takahashi P, et al. Colonic stents in colorectal obstruction. Am Surg 1998; 10: 986–8.
  30. Turegano-Fuentes F, Echenagusia-Belda A, Simo-Muerza G, et al. Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the colon. Br J Surg 1998; 85: 232–5.[CrossRef][Medline]
  31. Binkert CA, Ledermann H, Jost R, et al. Acute colonic obstruction: clinical aspects and cost-effectiveness of preoperative and palliative treatment with self-expanding metallic stents–a preliminary report. Radiology 1998; 206: 199–204.[Abstract/Free Full Text]
  32. Canon CL, Baron TH, Morgan DE, Dean PA, Koehler RE. Treatment of colonic obstruction with expandable metal stents: radiological features. AJR Am J Roentgenol 1997; 168: 199–205.[Abstract/Free Full Text]
  33. Lobato RF, Pinto I, Maillo C, et al. Rectovesical fistula treated by covered self-expanding prosthesis. Dis Colon Rectum 1999; 42: 812–5.[CrossRef][Medline]



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