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COLONIC STENTING: A BRIDGE TO SURGERY ? Joint hospital surgical grand round Fiona Ka Man Chan Kwong Wah Hospital.

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Presentation on theme: "COLONIC STENTING: A BRIDGE TO SURGERY ? Joint hospital surgical grand round Fiona Ka Man Chan Kwong Wah Hospital."— Presentation transcript:

1 COLONIC STENTING: A BRIDGE TO SURGERY ? Joint hospital surgical grand round Fiona Ka Man Chan Kwong Wah Hospital

2 Acute malignant colonic obstruction  Occur in 8% to 29% of all colorectal malignancies  70% are left sided  5 year survival in obstructed carcinoma of colon 20%  Right sided obstruction are dealt with by emergency right hemicolectomy with ileocolic anastomosis  No optimal treatment for left sided colonic obstruction Deans et al. Br J Surg ; 81:1270–1276 Serpell et al. Br J Surg. 1989; 76: Phillips et al. Br J Surg. 1985; 72: 296–302 Finan et al. Colorectal Disease. 2007;9:1-17

3 What are the options for obstructive left sided colonic cancer (OLCC) ? Ansaloni et al. WSES guidelines 2010

4 Emergency surgery  High morbidity 40-50% and mortality 15-20%  Primary resection and anastomosis carried a mortality rate of 10%, wound infection 25-60%, and high clinical leakage rate of 18% compared with 6% in elective surgery Tekkis et al. Ann Surg. 2004, 350:76-81 Deans et al. Br J Surg. 1994, 39: Phillips et al. Br J Surg. 1985, 72: 296–302

5 Impact of stoma  Emergency surgery resulted in high stoma rates  Stoma creation is associated with high complication of 34% and impaired quality of life  Up to 40% of stomas were not reversed  Stoma closure is associated with mortality of 7%, morbidity 37%, leakage 3% Park et al. Dis Colon Rectum. 1999; 42:1575–1580 Nugent et al. Dis Colon Rectum. 1999; ;42:1569 Deans et al. Br J Surg. 1994, 39:

6 Potential benefits of self expanding metallic stents (SEMS)  Increase one stage operation with resection and primary anastomosis  Decrease stoma rate  Decrease morbidity and mortality

7 Recent evidence Tan et al Br J Surg. 2012; 99: 469–476

8

9 Primary anastomosis  Overall successful primary anastomosis in favour of SEMS group  Significant difference in 1 stage operation with primary anastomosis in SEMS group 67% Vs 38% in emergency surgery group Tan et al Br J Surg. 2012; 99: 469–476 Martinez et al. Dis Colon Rectum.2002; 45:401–406 Cheung et al. Arch Surg. 2009; 144:1127–1132

10 Stoma rates  Overall stoma rates in favour of SEMS group Tan et al Br J Surg. 2012; 99: 469–476

11 Success rate  Technical success rate 92-96%, clinical % in previous systemic reviews on uncontrolled data  Drop in technical success rate of % and clinical success of 40-83% in recent randomized controlled trails  One trial terminated due to high rate of technical failure (53%) Khot et al. Br J Surg. 2002; 89:1096–1102 Watt et al. Ann Surg. 2007; 246:24–30 Tan et al Br J Surg. 2012; 99: 469–476

12 Complications  Overall complication rates %  Mortality 0.5-1%  Early  Perforation 3-5%  Bleeding 0-5%  Misplacement  Late  Migration 11%  Reocclusion 10%  Erosion Khot et al. Br J Surg. 2002; 89:1096–1102

13 Fracture Migration

14 Perforation  One Dutch randomized controlled trial reported a high perforation risk up to 9%, up to 20% when silent perforations were included  Another also report perforation rate of 7% with silent perforation adding on to 35% perforation rate  Potential of tumour dissemination leading to compromise of oncological safety  No survival and local recurrence data on these patients so far Cheung et al. Arch Surg. 144:1127–1132 Pirlet et al. Surg Endosc. 25(6):1814–1821 Van Hooft et al Lancet Oncol Apr;12(4):344-52

15 Mortality and morbidity  One trial terminated for increased 30-day morbidity in colonic stenting group  No significant difference in mortality and morbidity in subsequent analysis  In contrast, another trial terminated for high anatomsotic leakage rates in emergency arm  Mortality rate 6.9% in SEMS group Vs 5.9% in emergency surgery  No significant difference in in-hospital mortality Tan et al Br J Surg. 2012; 99: 469–476

16 Anastomotic leakage  Significantly lower rate in stenting group in the single centered RCTs  0% in stent group Vs % in emergency group  No significant difference in meta-analysis Zhang et al. Surg Endosc. 2012;26:110–119 Tan et al Br J Surg 2012; 99: 469–476

17 Validity of this meta analysis?  Small sample size in each RCT  Contradicting results between studies  Endoscopist / radiologist experience  Multi-center participation

18 Oncological safety  No difference in 3 and 5 year survival  Elevated level of CK20 mRNA with endoscopic colonic stenting  14% of silent perforations in histological examination of resected specimens in stented group  Safety has yet to be further explored with survival studies Saida et al. Dis Colon Rectum 2003; 46:S44–S4 Maruthachalam et al. Br J Surg 2007; 94:1151–1154 Tan et al Br J Surg 2012; 99: 469–476

19 Cost effectiveness  12%-20% reduction in cost in SEMS group due to shorter hospital stay, lower complication rates and operative cost  23% less surgery per patient Osman et al. Colorectal Dis. 2000;2:233–7 Binkert et al. Radiology 1998;206:199–204 Targownik et al. Gastrointest Endosc. 2004;60:865–74

20 Conclusion  Colonic stents can be considered as a bridge to surgery in patient with acute colonic obstruction  Stenting should be performed by high volume centers with careful patient selection  Further survival analysis is needed to evaluate the impact of silent perforations on patient survival

21 Reference 1. Martinez-Santos C, Lobato RF, Fradejas JM, Pinto I, Ortega-Deballon P, Moreno-Azcoita M (2002) Self- expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum 45:401– Tilney HS, Lovegrove RE, Purkayastha S, Sains PS, Weston-Petrides GK, Darzi AW, Tekkis PP, Heriot AG (2007) Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 21:225– Khot UP, Lang AW, Murali K, Parker MC (2002) Systematic review of the efficacy and safety of colorectal stents. Br J Surg 89:1096– Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ (2007) Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 246:24–30 5. Cheung HY, Chung CC, Tsang WW, Wong JC, Yau KK, Li MK (2009) Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial. Arch Surg 144:1127– Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL (2011) Emergency preoperative stenting versus surgery for acute leftsided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 25(6):1814– van Hooft JE, Bemelman WA, Breumelhof R, Siersema PD, Kruyt PM, van der Linde K, Veenendaal RA, Verhulst ML, Marinelli AW, Gerritsen JJ, van Berkel AM, Timmer R, Grubben MJ, Scholten P, Geraedts AA, Oldenburg B, Sprangers MA, Bossuyt PM, Fockens P (2007) Colonic stenting as bridge to surgery versus emergency surgery for management of acute leftsided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study). BMC Surg 7:12 8. Sebastian S, Johnston S, Geoghegan T, TorreggianiW,Buckley M. Pooled analysis of the efficacy and safety of self- expanding metal stenting in malignant colorectal obstruction. Am J Gastrenterol 2004; 99: 2051– Tan, C. J., Dasari, B. V. M. and Gardiner, K. (2012), Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg, 99: 469–476. doi: /bjs Zhang Y, Shi J, Shi B, et al. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc. 2012;26:110–119

22 THANK YOU


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