|Year : 2018 | Volume
| Issue : 1 | Page : 17-21
Acute obstructing left-sided colonic lesions: Role of preoperative endoscopic colonic stent insertion
Wael Al-shelfa1, Mohamad S Marie2, Ahmed Hashem2, Shymaa Yahia3, Salah Mansour4, Salina Saddick5, Amr Ibrahim4
1 Department of Surgery, Zagazig University, Zagazig, Egypt; Saudi-German Hospital, Jeddah, KSA
2 Department of Endemic Medicine and Hepatogastroentrology, Cairo University, Cairo, Egypt
3 Saudi-German Hospital, Jeddah, KSA; Department of Microbiology, Zagazig University, Zagazig, Egypt
4 Department of Surgery, Zagazig University, Zagazig, Egypt
5 Department of Biology and Science, King Abduaziz University, Jeddah, KSA
|Date of Web Publication||27-Feb-2018|
Dr. Wael Al-shelfa
Department of Surgery, Zagazig University, Zagazig
Source of Support: None, Conflict of Interest: None
Background: Malignant obstruction due to left-sided colonic malignant lesions is an acute emergent situation which is always dealt with by emergent celiotomy and colostomy for salvage of patient life. Colostomy is considered life-saving in such situations, yet it is of undesirable psychological feedback impressions for patients. The aim of this work is to describe our experience with the use of colonic stent in left-sided malignant obstruction, as a good step to relieve the obstruction, and hence to proceed for one-step resection anastomosis with primary repair without the need for colostomy, which is in itself of good impact for psychological satisfaction and salvage of patient.
Patients and Methods: Out of 20 patients with left-sided colonic obstruction, 9 patients were dealt with colonic stent, of them 7 patients had one-step procedure with either left hemicolectomy or sigmoidectomy, and 11 had emergent surgical interference with colostomy.
Results: Seven of nine patients had a successful laparoscopic colonic stent, and followed by a successful one-step surgical procedure, two of nine patients had unsuccessful laparoscopic stent with emergent exploration and colostomy.
Conclusion: Colonic stent for the left malignant obstruction represents a valuable procedure for one-step resection and primary anastomosis without the need for colostomy.
Keywords: Colostomy, obstruction, stent
|How to cite this article:|
Al-shelfa W, Marie MS, Hashem A, Yahia S, Mansour S, Saddick S, Ibrahim A. Acute obstructing left-sided colonic lesions: Role of preoperative endoscopic colonic stent insertion. Saudi Surg J 2018;6:17-21
|How to cite this URL:|
Al-shelfa W, Marie MS, Hashem A, Yahia S, Mansour S, Saddick S, Ibrahim A. Acute obstructing left-sided colonic lesions: Role of preoperative endoscopic colonic stent insertion. Saudi Surg J [serial online] 2018 [cited 2018 Mar 23];6:17-21. Available from: http://www.saudisurgj.org/text.asp?2018/6/1/17/226231
| Introduction|| |
Cancer colon represents the 3rd cancer in males and females. Patients with left-sided colonic lesions may presents with acute obstruction in 8% to 26% of cases which carries a risk of colonic perforation and high morbidity and mortality.
Resection and primary anastomosis of nonobstructing left- or right-sided colonic tumors is the main way of management. However, for obstructing left-sided lesions, majority of patients are not amenable for primary anastomosis because of distended colon and they are offered stoma.
Preoperative insertion of colonic stent was evaluated in several studies and offered a bridge to surgery, and the patients can be offered primary anastomosis without the need for stoma.
Beside, preoperative self-expandable metal stent (SEMS) insertion offers less morbidity and mortality when compared to those undergoing emergency surgery and stoma construction [Figure 1], [Figure 2], [Figure 3], [Figure 4].
On the other hand, based on other studies, the European Society of Gastrointestinal Endoscopy did not recommend SEMS insertion in patients with acute obstructing malignant colonic lesions as it carries a risk of perforation, tumor seedling, and no significant effect on overall survival.
In our study, we aimed at evaluating the role of preoperative placement of colonic stent and its impact on postoperative outcomes.
| Patients and Methods|| |
We conducted this prospective study in Saudi German Hospital, Jeddah, and Zagazig University Hospital, between January 2014 and December 2016. We recruited patients presenting with features of colonic obstruction Secondary to left-sided colonic lesions. Diagnosis was based on clinical criteria of bowel obstruction (abdominal pain, vomiting, and failure to pass stool), evidence of fluid level by abdomen X-ray, and computed tomography abdomen showing left-sided colon mass. We excluded patients with evidence of peritonitis, locally advanced disease and those with other causes of bowel obstruction.
All patients were put on initial management by bowel decompression, intravenous fluids, and antibiotic therapy.
All patients were offered trial of colonic metal stent insertion; those with successful insertion (9 patients) were included as Group 1 and those in whom stent insertion not done were named Group 2 (11 patients).
Colonic metal stent insertion
After written consent, nine patients underwent colonic stenting using ELLA fully covered stents. Procedure was done under fluoroscopic and colonoscopic guidance.
Two patients in whom stent insertion failed (failure to pass guidewire) or had peritonitis after colon stent were candidate for surgery. Out of eleven patients, three of them refuse colon stent and eight require immediate surgical interference. Type, extent of resection, and whether to construct stoma or not were decided by the surgeon.
Seven patients of nine after colon stent had short hospital stay (2 days after stent) and had primary resection anastomosis, 4 patients had left hemicolectomy, and 3 patients had sigmoidectomy. Eleven patients without stent with two patients after unsuccessful stent were subjected to colostomy with Hartmann pouch.
All patients had open exploratory laparotomy to assess local and distant metastasis. For cases underwent left hemicolectomy, inferior mesenteric vessels were ligated close to the aorta and inferior border of the pancreas, for cases underwent sigmoidectomy, ligation of sigmoid branches with lymphadenectomy for all procedures.
One case after unsuccessful stent presented with peritonitis with marked fecal contamination had emergent laparotomy, colostomy and mucous fistula were done, after peritoneal lavage, and excision of the tumor was done at a later date.
In healthy individuals, due to the effect of gastric acid and because the intestinal contents constantly move forward and are replaced by new ones under the effect of peristalsis, only a handful of bacteria exist in the small intestine. In patients with simple mechanical intestinal obstruction, the bacteria and toxins, if exist, cannot pass through the mucosal barrier and therefore will not cause notable harm. However, if the obstruction is long-standing or transmural wall necrosis (as in cancer colon), fluids in the affected intestinal canal will contain a large number of bacteria (e. g., Clostridium, Streptococcus, and Escherichia More Details coli), blood, and necrotic tissues, among which the bacterial toxins and necrotic tissue decomposition products are highly toxic. After these fluids enter the abdominal cavity through the damaged or perforated intestinal wall, they can cause severe irritation and infections; when absorbed by the peritoneum, they can cause sepsis. Severe peritonitis and sepsis is the leading cause of death in patients with intestinal obstruction. In addition to these three major pathophysiological changes, patients with malignant intestinal obstruction can also be associated with hemorrhage on intestinal wall, in intestinal canal, and/or abdominal cavity. The longer bowel malignant obstruction is associated with larger blood loss, which is also one of the causes of death among patients with intestinal obstruction. In patients with prolonged intestinal obstruction, a variety of intestinal and peritoneal bacterial (such as E. coli, Clostridium, and Streptococcus) infections can occur. Broad-spectrum antibiotic therapies mainly targeting Gram-negative bacilli and anaerobic bacteria are particularly important. Animal experiments and clinical studies have proved that antibiotic treatment can significantly reduce intestinal obstruction-related deaths. Peritoneal fluid culture was performed on standard bacteriological media (sheep blood agar, MacConkey agar, chocolate agar, and Sabouraud dextrose agar. Two culture sets were done aerobically and anaerobically. Further microbiologic testing was performed for organism identification, including Gram stain and other standard techniques, such as coagulase and oxidase testing. Antibiotic sensitivity was done by disc diffusion Kirby-Bauer method.
The isolates were E. coli and viridans group streptococci.
Patient outcomes and statistical analysis
All values are presented as mean, median (range), or percentage. The primary outcomes of this study were to evaluate the success, and complication rates between cases had colon stent and those had emergent surgery with colostomy with 1–3 years follow-up. Continuous data were compared using the unpaired t- test or Mann–Whitney tests. Categorical variable was evaluated using Chi-square test. Survival analysis was performed as the lesion was Life-threatening condition. Statistical significance was determined a prior at ≤0.05.
| Results|| |
We recruited 20 patients with acute obstructing left-sided colon malignant mass and divided into Group 1 with SEMS insertion and Group 2 with emergency surgery.
We tried stent insertion for all patients, but we were able to insert colonic stents in nine patients only. Bowel perforation complicated 1 procedure, 5 patients refused to sign consent for procedure, and finally, we were not able to pass wire in 6 patients (tight lesions).
Demographic and laboratory features of both groups are illustrated in [Table 1]; both groups were matched regarding age and sex.
Patients underwent expandable metal stent insertion
Out of nine patients with successful SEMS insertion, seven patients (78%) had successful decompression of the bowel and underwent elective surgery with interval time (time between stent insertion and elective surgery) 7 ± 3 days. No patients needed stoma construction. One patient had persistent clinical and radiological evidence of obstruction (failed to decompress the bowel) despite colon stent and underwent immediate surgery with stoma construction.
| Discussion|| |
Colonic obstruction represents a surgical emergency associated with a high degree of morbidity and mortality because of the generally poor condition of these patients. Colonic stenting is an alternative method for the treatment of obstructive left-sided colon cancer. However, its use as a preoperative bridge to surgery remains controversial because of significant heterogeneity between studies in relation to tumor location, staging, study design, follow-up, and overall morbidity.
In our study, the overall stoma rate was lower and the primary anastomosis rate was higher in the SEMS group. These results support the hypothesis that SEMS placement as a bridge to surgery allows improvement of the patient's general condition creating the right conditions for a successful primary anastomosis. However, there was no significant difference in the rates of permanent stoma, and a conclusion also supported by a meta-analysis published by Grundmann et al. These authors suggest that evaluation of the stoma rate is essential when comparing the two different interventions because creation of a definitive stoma can have profound effects on the psychosocial well-being of patients and specialized counseling is needed to improve quality of life significantly.
The decision to create a stoma rather than to restore continuity is also related to the patient's overall condition and stability. Although we did not find any statistically significant difference in relation to the total hospital stay, there was a trend to a longer hospital stay in the SEMS group that may be due time needed for decompression after colonic stenting.
In contrast to some studies, we did not find any difference in postoperative complications using Clavien-Dindo classification. The therapy used to correct specific complication is the basis of this classification to rank a complication in an objective and reproducible manner. A systematic review and meta-analysis published by Guang-Yao Ye et al. also did not find any differences between the two groups regarding anastomotic leakage and intra-abdominal infection. This may be related to the emergency nature of the surgery, the type of surgeon or the time after colonic stenting. A series of studies showed that SEMS has an overall rate for relief of obstruction of 84%–94%, with complications such as perforation (4%), stent migration (10%–12%), and re-obstruction (7%–10%), causing a cumulative mortality of 1%. The technical and clinical success of SEMS varies in accordance to published studies. Sebastian et al. reported a technical success rate of 91.9% and a clinical success rate of 71.7% for SEMS placement as a bridge to elective surgery. Pirlet et al. had a 53% technical failure for stent insertion, two cases of stent perforation in the SEMS group and one perforation in a nonrandomized patient leading to closure of the trial. Van Hooft et al. also stopped their trial because they found an unexpectedly increased absolute risk of 30-day morbidity in the SEMS group, with almost 20% of stent-related perforations. A meta-analysis published by Grundmann et al. concluded that technical and clinical success rates for stenting were lower than expected (70% and 69%, respectively), with almost 20% of SEMS-related perforations. The stent-related technical failure could be related to the level of experience of the operator. In our study, we found 11% of stent-related perforations, with a technical and clinical success of 78% and 85.2%, respectively. All stents were placed by gastroenterologists with experience in SEMS placement for the treatment of colonic obstruction. Operator experience and technical expertise in stent placement has been shown to reduce significantly the number of stent-related complications. Although Van Hooft et al. reported that stent placement was performed by experienced endoscopists, Small et al. also suggested that the degree of occlusion is another risk factor for SEMS complications as the completely occluded bowel may result in friable microperforated tissue and present as a very tight stricture that makes stent deployment technically difficult. In our study, it was possible to assess the type of obstruction, and eventually, the type of obstruction could influence the rate of perforations. The oncological consequences of potential tumor dissemination caused by perforations are unclear, but the possibility of dissemination is worrisome. A recent retrospective study found that the 3-year overall survival (85.2 vs. 82.8%; P = 0.65) and recurrence-free survival (80.7 vs. 78.6%; P = 0.916) were not significantly different between the stent and surgery groups; however, in the stent group, perforation was identified as an independent risk factor for cancer recurrence (odds ratio 22.0; 95% P = 0.030) and seeded metastasis (odds ratio 46.0; 95%; P = 0.016). Another retrospective study found that SEMS had an adverse effect on 5-year overall and disease-free survival rates. The poorer outcomes in this group could have been due to patients with more advanced disease presenting with emergency bowel obstruction. On the other hand, one prospective study reported longer survival in patients who underwent SEMS placement (hazard ratio 0.412; 95%; P = 0.007). Considering the differences in published studies regarding tumor recurrence and survival, there are no proven differences in long-term outcomes between the two treatment approaches. In our study, we did not find any statistically significant difference in 1- and 3-year overall survival and in 3-year recurrence-free survival. Stent-related perforation and tumor stage did not influence tumor recurrence in the SEMS group. This study is limited by its retrospective design and the small number of patients. Small number of patients should be considered with caution when interpreting these results. Patients were not randomly assigned, and selection bias may have confounded our data. Some data could be missed, including postoperative complications and oncological recurrence. However, we analyzed a very important variable, not always explored in these types of studies: the oncologic recurrence. We think this is a strong point of our study. Furthermore, to the best of our knowledge, this is the first Portuguese study comparing SEMS as a bridge to surgery with emergency surgery in patients with obstructive left-sided colon cancer.
| Conclusion|| |
Our study shows that preoperative SEMS is safe and effective technique in selected patients with colonic malignant obstruction some advantages because it is associated with a lower overall stoma rate and a higher primary anastomosis rate. However, there are no differences in complications, overall survival, and recurrence-free survival. More studies to resolve these conflicting results regarding the treatment of left-sided obstructive cancer are needed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]