Introduction Colonic stenting of proximal Colorectal Cancers (CRC) (lesions at splenic flexure or beyond) is technically challenging and currently out-favour as surgical techniques allow safe primary anastomosis on unprepared dilated colon. Consequently, randomised trials (RCTs) have only compared colonic self-expandable metal stent (SEMS) with emergency surgery for acute left sided obstruction. However, emergency surgery is associated with substantial morbidity and mortality.
Aim: To assess the safety and effectiveness of colonic SEMS for obstruction caused by proximal CRC.
Methods Retrospective case series by 2 Consultant Gastroenterologists between 2005 to 2012 was audited. All procedures were performed using Through the Scope (TTS) technique and fluoroscopic guidance. End-points were technical success (correct SEMS placement confirmed radiologically at time of procedure), clinical success (resolution of patient symptoms within 48 hrs), re-intervention, patient discharge and mortality.
Results Demographics 31 patients (Male: Female ratio 2.1:1); median age 85.5 years (range 40–92), mean ASA score 2.5. Indications: 84% (n = 26) were palliative and 16% (n = 5) were bridge to surgery. 48% patients had subacute obstruction, 10% had total obstruction, and extent of obstruction was unknown in 42%. Lesions were located at Splenic flexure (n = 15), Distal Transverse (n = 7), Proximal Transverse (n = 3), Hepatic flexure (n = 4), Ascending (n = 1) & caecum (n = 1).
Procedural Success Technical success was 100%. Clinical Success was 81% (n = 25) with these patients being successfully discharged without requiring any further procedures during their hospital stay. Re-intervention was required in 5 patients (16%) due to SEMS dysfunction; managed by re-stenting in 1 and colostomy in 3 patients (Bridge group). The remaining was a colostomy for the only perforation in series (3%). Further surgery was only required in the 2 patients within the bridge group who went onto have uncomplicated elective surgery with primary anastomosis.
Mortality There was no procedure related mortality (0%). All cause 30 & 90 day mortality was 13% & 38% respectively, all of which were in palliative group. Over a third were alive at 1 year (1 year survival of 35%) and a further 2 patients are alive but yet to reach the 1 year end point.
Conclusion Colonic stenting by experienced operators for proximal CRC using TTS can be performed successfully and safely. It negated the need for emergency surgery with successful discharge of 81% of patients. These results are important when interpreting the RCT, when considering palliation and the developments of neo-adjuvant chemotherapy strategies in Bridge group.
Disclosure of Interest None Declared.
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.