1. Role of colonic stent in the management malignant colonic obstruction Dr Eddy Lo TKOH JHSGR Aug 2011

2. Introduction Colorectal cancer is a common and important health issue in HK Rank 2 nd in the crude cancer incidence 2 nd commonest cause of cancer related death (HK cancer registry 2008)

3. RankSiteNew cases registered Relative frequency Crude incidence rate 1Lung423617.260.7 2Colorectum403116.457.8 RankSiteDeath registered Relative frequency Crude mortality rate 1Lung349728.150.1 2Colorectum168613.524.2

4. Introduction ~10%-30% of patients with colorectal cancer present with features of IO Deans GT et al. Malignant obstruction of the left colon. Br J Surg 1994;81:1270-76 70% occurs in left colon Philips RK et al. Malignant large bowel obstruction. Br J Surg 1985;72:296- 302 Poor 5-year OS for those presented with IO, ~20% Ohman U. Prognosis in patients with obstructing colorectal carcinoma. Am J 1982;143:742-7 Significant no. of patients will end up with a stoma Impact on QoL

5. Introduction Traditional Mx Surgery  Rt colon: colectomy + primary anastomosis  Lt colon: controversial two/three stage operation One stage operation + on-table colonic irrigation Colonic stenting +/- interval elective operation

7. Colonic stent First used by Dohomoto in 1990 to manage the acute phase of malignant colonic obstruction Dohomoto M et al. Endoscopically-implanted prosthesis in rectal carcinoma. Dtsch Med Wochenschr 1990;115:915 Self expandable metallic non-covered stent (nitinol or stainless steel) of various diameter and length e.g. Wallstent Covered stent has high rate of migration

8. Colonic stent Indications Temporary colonic decompression  Bridge to elective surgery  Palliation Contraindications Clinical/radiological evidence of perforation Unfavorable anatomy

11. Post-stenting Monitor vital signs Observe for any BO Take an AXR the next day to assess the stent position and expansion Check electrolytes +/- arrange elective operation in ~2-3 weeks after the patient is stabilized

13. Colonic stent Technical and clinical success rate ~90% Cause of failure Failure to negotiate through tumor due to complete obstruction Poor stent position Perforation Mean durations of stent patency ~106 days Watt AM et al. self-expanding metallic stents for relieving malignant colorectal obstruction. A systemic review. Ann Surg 2007;246:24-30

14. Complications Mild Radiation exposure PR bleeding Severe bleeding 2.5% Selinger CP et al. Long-term success of colonic stent insertion is influendced by indication but not by length of stent or site of obstruction. Int J Colorectal Dis 2011;26:215-8 Pain Temporary incontinence Faecal impaction Harris G et al. The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices. Am J Surg 2001;181:499-506

15. Complications Severe Perforation  4.5%  Procedure related  Unsuccessful decompression Migration 11% Obstruction after initial decompression  10%  Tumor ingrowth  Migration of stent Watt AM et al. self-expanding metallic stents for relieving malignant colorectal obstruction. A systemic review. Ann Surg 2007;246:24-30

16. Complications Stent fracture –IO –Perforation Khot U et al. Systemic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096-1102 Stent-related mortality –1% Sebastian S et al. Pooled analysis of the efficacy and safety of self- expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051-7

17. Perforation

18. Stent migration

19. Tumor overgrowth

20. Fracture stent

21. Limitations Distal rectal tumor Severe tenemus Faecal incontinence Turegano F et al. Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon. Br J Surg 1998;85:232-5

22. Why stenting? Emergency operation entails substantial operative mortality and morbidity Colonic stenting decreases mortality rate and medical complications Tilney HS et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 2007;21:225-233 No sig. difference in 3-yr (50% vs. 48%) or 5- yr (44% vs. 40%) OS Saida Y et al. Long-term prognosis of preoperative ‘ bridge to surgery ’ expandable metallic stent insertion for obstructive colorectal cancer: comparison with emergency operation. Dis Colon Rectum 2003;46:S44-49

23. Why stenting? No significant difference in recurrence Beltran JM et al. Left obstructive colonic carcinoma. Comparative study of short and middle-term results after a new therapeutic procedure based in self-expanding metallic stents placement. Zaragoza, Spain: Universidad de Zaragoza 2003 Prevent 84.6% of colostomies Decrease total hospital stay, ICU stay and lower complication rate Martinez C et al. 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 2002;45:401-406

24. Why stenting? Greater successful 1-stage operation Less cumulative blood loss Less wound infection Reduced incidence of anastomotic leak Greater LN harvest Higher rate of primary anastomosis Cheung HYS et al. Endolaparoscopic approach vs. convertional open surgery in the treatment of obstructing left-sided colon cancer. Arch Surg 2009;144(12):1127-32

25. Why stenting? Enable laparoscopic assisted operation –Less invasive to multistage operation –Faster recovery Stipa F et al. Management of obstructive colorectal cancer with endoscopic stenting followed by single-stage surgery: open or laparoscopic resection? Surg Endosc 2008;22:1477-1481 Allow early administration of chemotherapy in patients with disseminated diseases Karoui M et al. Stents for palliation of obstructive metastatic colon cancer. Arch Surg 2007;142(7):619-623

26. Cost SFI in HA, ~$8000 Lower mean cost per patient in stenting group than emergency operation –Fewer operative procedure/patient (1.01 vs. 1.32) –Shorter hospital stay –83% reduction in stoma requirement (7% vs. 43%) –Less complication Binkert CA 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 Targownik LE et al. Colonic stent vs. emergency for management of acute left- sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004;60:865-74

27. Recommendations Consensus conference of the world society of emergency surgery and peritoneum and surgery society 2010 –Colonic stent Preferred to colostomy for palliation of obstructing left colon cancer (2B) Used as a bridge to elective surgery (1B)

28. However …. Several recent RCTs showed in the stenting group –high Cx rate i.e. perforation –failed to demostrate benefits Van Hooft JE et al. Early closure of a multicenter randomized clincial trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy 2008 Mar; 40(3):184-91 Pirlet IA et al. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 2011;25:1814-21 Van Hooft JE et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: A multicentre randomized trial. Lancet Oncol 2011;12:344-52

29. However … Studies carried out in small volume centre, ~3 patients/yr/centre received colonic stents Comparing to previous reviews –Higher perforation rate –Highter technical failure rate

30. However … Risk factors for perforation –Chemotherapy –RT –Steroid –Dilatation Datye A et al. Colonic perforation after stent placement for malignant colorectal obstruction — causes and contributing factors. Minim Invasive Ther Technol 2011 May;20(3):133-40

31. Conclusion Colonic stent placement is a safe and effective measure in the management of malignant colonic obstruction Palliation Bridge to elective surgery Careful patient selection Yet to be proven by large scale RCT

32. Thank you