Introduction

Self-expandable metal stents (SEMS) are the preferred treatment of malignant large bowel obstruction in those individuals who are not likely to have a curative resection (ESGE recommendations 2020). The differentiation between palliative and surgical candidacy may not be possible at presentation. We wished to measure the stoma-free prognosis of palliative patients, who do not have a surgical resection.

Aims & Methods

We analysed all patients undergoing SEMS at our centre over 10 years, collecting data on stoma formation, significant events and survival. Palliative stenting was defined in those who never underwent a resection of their primary obstructing cancer. All patients who had a technically successful SEMS were followed (a stent was placed across the stricture) so cases where there was early clinical failure were included. In our centre, we opt to attempt SEMS in all areas of the colon including the right colon.

Results

171 patients with malignant large bowel obstruction (mean age 72.6, 57% male, 31% right-sided with obstruction beyond the splenic flexure) were referred for SEMS and no resection of the primary cancer was undertaken (this was 80% of total patients referred for SEMS). In 31% of patients, a stated plan for curative or palliative intent was amended in later decision-making. Where a stent was successfully deployed (150 patients, 88% technical success), 96% of patients avoided a stoma at any time in their palliation and median stoma-free survival was 283 days (9.4 months). Palliative chemotherapy was administered in 38.4% of cases. In those 21 cases where stenting was unsuccessful, 15 had surgery with a stoma formed and 6 were palliated. No procedural perforations occurred. Re-stenting of the primary cancer was required in 15 cases out of 150 (10%) at a median time of 6.5 months. Long term survival showed 33% of patients lived at least 1 year, 16% of patients survived more than 2 years, and 3.6% more than 3 years. Four patients (2.7%) were found to have incidental stent migration on CT to assess response to chemotherapy, but no further intervention (re-stenting or surgery) was required. Three patients may have died prematurely from COVID. Factors associated with significantly lower rate of re-intervention were obstruction in the proximal colon and older age.

Conclusion

In palliative SEMS management of malignant bowel obstruction, 96% of patients can avoid lifetime stoma surgery and can expect a median survival of 283 days.

Disclosure

No conflicts of interest

Introduction

There is minimal data to support a recommendation to perform colonic stenting (SEMs) in the right colon, but particularly in malignancy in the region of the ileocaecal valve, where only small bowel dilatation results from obstruction. This scenario poses technical challenges in endoscopic access in unprepared proximal colon, and relating to the anatomy of the ileocaecal valve. One recent case series included 13 patients with reported success rate and equivalent outcomes to left-sided stents with median survival of 4 months, although a two-step procedure was described¹.

Aims & Methods

In our centre we attempt self-expanding metal stent insertion (SEMs) in cases of malignant ileocaecal obstruction, which constitutes ~9% of our overall SEMs caseload. We report our outcomes and, as an important metric for palliative patients, stoma-free survival in the context of colorectal cancer management. We perform stenting using colonoscopy to access the stricture and fluoroscopy for wire and stent deployment, with both over the wire and through the scope techniques.

Results

25 patients, median age 77 years, underwent intention to stent for colorectal malignancy at the ileocaecal junction, where stent deployment into the ileum would be necessary to overcome the obstruction. Clinical success with life-time avoidance of surgery or stoma was 68% without any adverse events from attempting SEMs. Median survival was 206 days, compared to 167 days in those where stenting was unsuccessful. This was not significantly different to median stoma-free survival of 272 days for all SEMs patients in our database. One patient, after technically successful stent deployment, re-obstructed within 7 days and underwent surgery. There were no other early or late complications in either group. Reasons for technical failure in 6 cases was inability to pass a wire into the ileum, bowel preparation in 1 case, and failure to adequately resolve obstruction in the aforementioned patient.

Conclusion

Stenting malignant colonic obstruction of the ileocaecal region is more technically challenging but does not appear to disadvantage patients after an unsuccessful procedure. Stoma or surgery is avoided in 68% cases in intention to treat analysis of 25 patients and median survival of 206 days is equivalent to other colonic stent locations.

References

1. Fujisawa et al. J. Clin. Med. 2025, 14(3), 826

Introduction

Self-expandable metallic stent (SEMS) placement for palliation (PAL) of malignant colorectal obstruction due to unresectable advanced colorectal cancer or metastases from other organs is a noninvasive treatment option that prevents emergency surgery or colostomy. However, there are concerns that a satisfactory success rate may not be attained.

Aims & Methods

Therefore, this study investigated the efficacy and safety of colorectal stenting for PAL at our institution. We retrospectively analyzed the cases of 94 patients who underwent colorectal stent placement for PAL out of 191 patients at our institution from June 2012 to February 2024, a period during which 111 stent placement procedures were performed. We collected data on patient characteristics, details of the obstruction site, outcomes of stent placement (technical success, clinical success), complications, the 1-year overall survival rate, the cumulative stent patency rate, and risk factors for perforation.

Results

The median was 76.5 (IQR, 67–87) years, and there were 53 males. The ECOG Performance Status was 0–1 in 36 cases and 2–4 in 58 cases. Obstruction was caused by primary colorectal cancer in 48 cases, local recurrence after colorectal cancer surgery in 6 cases, and metastases from other organs in 40 cases. The ColoRectal Obstruction Scoring System (CROSS) before stenting was 0 in 33 cases, 1 in 46 cases, and 2 in 15 cases. Lesions were located in the rectum, sigmoid colon, descending colon, transverse colon, ascending colon, and cecum in 19, 29, 21, 12, 9, and 4 cases, respectively. The mean stenosis length was 5.6 ± 2.4 cm. The technical success rate was 97.9% (92/94), and the clinical success rate was 85.1% (80/94). Early (within 7 days) complications included perforation in 6 cases (6.4%), migration in 2 cases (2.1%), and inadequate dilation in 2 cases (2.1%), all of which required surgery. Late complications included perforation in 8 cases (8.5%), migration in 1 case (1.1%), and stent occlusion in 11 cases (11.7%). In all cases of stent occlusion, the stents used were 22 mm-diameter stents, and ingrowth was the main cause of obstruction. In all cases of stent occlusion, stent-in-stent procedures were successfully performed to re-open the stents. Complication-related mortality occurred in 3 cases (3.2%). The one-year overall survival rate was 29.3% (mean follow-up period: 221 ± 248 days), and the one-year stent patency rate was 75.5% (mean follow-up period: 168 ± 198 days). Per our univariate analysis, the stent length, stent diameter, chemotherapy, and anti-VEGF antibody use after stent placement were not risk factors. Our multivariate analysis showed that only a stent diameter of 25 mm tended to be an independent risk factor for perforation.

Conclusion

SEMS replacement for PAL was effective in cases of colorectal obstruction. The incidence of complications and the complication-related mortality rate were within acceptable limits, suggesting that colonic stent placement is a promising palliative treatment option for malignant colorectal obstruction that helps maintain the quality of life of patients.

Introduction

Emergency surgery (ES) is associated with higher morbidity and mortality for acute left colonic malignant obstruction. Since the first application of self-expandable metallic stent (SEMS), the technique has been popularly applied as “bridge to surgery (BTS)”. The short-term clinical outcomes and long-term oncologic prognosis remain controversial.

Aims & Methods

This retrospective study aimed to compare the performance for managing acute left colonic malignant obstruction by ES or BTS. The medical records were collected from May 2015 to December 2019 in two tertiary hospitals in Eastern China. Patients were followed up after surgery every 6 months for 3 years and once a year afterwards. Clinical success was defined as resumption of intestinal function for 30 days without morbidity or mortality after surgical procedure. All demographics, intervention procedures and follow-up were analyzed for short-term and long-term outcomes. Risk factors for long-term survival were discussed as well.

Results

A total of 136 patients were eligible for the study, 67 in BTS group and 69 in ES group. No significant differences concerning demographics were found, including age, sex, body-mass index (BMI), symptoms, coexisting disorders, laboratory tests, preoperative radiotherapy or chemotherapy, previous history of abdominal surgery, cancer location, obstructive degree and TNM stage. Technical success of SEMS insertion was achieved in 64 patients (95.5%). The interval from SEMS placement to elective surgery was 16 days. Minor perforation was detected on 4 patients during the elective surgery, while no symptomatic complaint was recorded.
BTS group showed better short-term performance, including less intraoperative decompressive intervention (85.1% vs. 69.6%, p=0.045), more complete decompression (64.2% vs. 27.5%, p＜0.001), more primary anastomosis (65.7% vs. 17.4%, p＜0.001), less temporary and permanent stoma (34.3% vs. 82.6%, 13.4% vs. 58.7%, both p＜0.001), less intensive care unit requirement (10.4% vs. 27.5%, p=0.011), less intraoperative complications (3.0% vs. 13.0%, p=0.031) and reduced 30-day mortality (0 vs. 8.7%, p=0.028). Longer hospitalization was observed in the BTS group (21.7±13.3 days vs. 14.9±7.6 days, p＜0.001). Postoperative hospitalization and total cost were comparable between the two groups. No significant difference was observed about clinical success (73.1% vs. 63.8%, p=0.240), overall mortality (53.7% vs. 64.4%, p=0.247) or long-term survival (52.0 months vs. 35.0 months, p=0.121). TNM stage Ⅳ, permanent stoma and postoperative complication were the independent risk factors for long-term survival.

Table.1 Operation related characteristics

Conclusion

SEMS served as a safe and effective bridge to elective surgery for acute left colonic malignant obstruction, without adverse effect on long-term survival. It significantly improved short-term outcomes by reducing perioperative complication, 30-day mortality and stoma. More prospective studies are necessary for further evaluating the clinical values of SEMS, and weighing its benefits against potential complications.

References

1. Manfredi S, Sabbagh C, Vanbiervliet G, et al. Place of colorectal stents in therapeutic management of malignant large bowel obstructions. Endoscopy. 2014;46:546-552.
2. Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg. 2014;207:127-138.
3. Arezzo A, Passera R, Lo Secco G, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc. 2017;86:416-426.
4. van Hooft JE, van Halsema EE, Vanbiervliet G, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Gastrointest Endosc. 2014;80:747-761 e741-775.
5. Pisano MA-O, Zorcolo L, Merli C, et al. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. 2017.
6. Kawachi J, Kashiwagi H, Shimoyama R, et al. Comparison of efficacies of the self-expandable metallic stent versus transanal drainage tube and emergency surgery for malignant left-sided colon obstruction. Asian J Surg. 2018;41:498-505.

Introduction

Endoscopic colonic stenting is a treatment method in which a colonoscope is used to insert a self-expandable metal stent (SEMS) into a stenotic site and allow its expansion to alleviate colonic obstruction and permit urgent colonic decompression. It is an effective and extensively practiced minimally invasive procedure compared with emergency surgery. However, perforation, stent migration, and reocclusion may occur. Perforation is particularly a serious adverse event with a mortality rate of 50%. There are three possible causes of perforation:
(1) Local perforation due to stimulation of the stent itself directly into the intestinal tract;
(2) Perforation due to guidewire or catheter manipulation during stent insertion; and
(3) Perforation due to increased pressure in the intestinal tract at the oral side of the obstruction (especially in the cecum) caused by air supply during colonoscopy insertion.
For the first possible cause, an improved colonic stent was developed to reduce irritation to the intestinal tract, and for the second possible cause, a strategy for safe stent insertion was established.
However, perforation due to the third possible cause remains a concern, and appropriate countermeasures should be urgently developed.
In endoscopic colonic stenting, we hypothesized that colonoscope insertion using the gel immersion method, which uses a recently developed endoscopic view-securing gel, would allow safe and rapid access to the lesion without increasing intestinal pressure, thereby decreasing the incidence of perforation.

Aims & Methods

This study aimed to clarify the usefulness of the gel immersion method during colonoscope insertion with endoscopic view-securing gel for colonic stenting. Eight patients in whom colorectal stenting was performed using the gel immersion method between May 2022 and January 2023 were included.
The primary endpoint was the endoscopic lesion reach rate, and the secondary endpoints were the technical and clinical success rates of SEMS deployment, colonoscope insertion time, total procedure time, and adverse event rate.

Results

Of the included patients, four were males (50%), and the mean age of patients was 67.6 ± 15.6 years. Seven patients (87.5%) had colorectal cancer and one patient (12.5%) had gastric cancer. The cancer was localized at the following sites: sigmoid colon in three patients, descending colon in three patients, transverse colon in one patient, and ascending colon in one patient. The purpose of SEMS deployment was bridge to surgery in four (50%) and palliation in four (50%) patients. In all cases, the endoscope was inserted without the preparation and insertion of the endoscope into the lesion at the origin of the obstruction without insufflation, and the endoscopic lesion reach rate was 100% (8/8). No worsening of intestinal dilatation was observed. The technical and clinical success rates each were 100% (8/8). The scope insertion time was 9.8 ± 5.2 min, total procedure time was 27.3 ± 6.5 min, and the adverse event rate was 0% (0/8).

Conclusion

For endoscopic colonic stenting, endoscope insertion using the gel immersion method could be performed safely and effectively and has the potential to become the standard method.

Introduction

Endoscopic self-expandable metallic stent (SEMS) placement for malignant colonic obstruction is commonly performed using the through-the-scope (TTS) technique. However, strategies to reduce radiation exposure remain a clinical concern. We developed a novel technique, Direct-Vision Stenting (DVS), using a new thin therapeutic scope (Fujifilm EG-840TP: outer diameter, 7.9 mm; working channel, 3.2 mm) for malignant rectosigmoid obstructions [1]. After advancing the scope through the stricture, the stent is partially expanded under direct vision, then anchored and gradually released under endoscopic visualization while withdrawing the scope. This technique may minimize radiation exposure by eliminating the need for fluoroscopic confirmation of guidewire placement and contrast injection.

Aims & Methods

This study aimed to evaluate the feasibility of the DVS technique. From January 2024 to March 2025, SEMS placement for malignant rectosigmoid obstructions was initially attempted using the DVS technique. If DVS was unsuccessful, conversion to the conventional TTS technique (without direct visualization of the oral lumen or beginning of the stent expansion) was permitted. Ten consecutive patients were prospectively evaluated for technical success, adverse events, fluoroscopy time, and total procedure time (from scope arrival at the lesion to stent deployment).

Results

The median age was 81 years, and 4 patients were men. The obstruction was located in the rectosigmoid colon in 3 patients and the sigmoid colon in 7. Five procedures were performed for palliative purposes. The technical success rate of the DVS technique was 60%. All unsuccessful cases were resolved by conversion to the conventional TTS technique. Reasons for DVS failure included poor bowel preparation (n = 1), failure of scope advancement (n = 2), and severe colonic angulation (n = 1). No adverse events were observed, and all patients experienced symptomatic relief. Among successful DVS cases, median procedure time was 17 minutes, and fluoroscopy time was 4 minutes. In comparison, in 17 cases treated with the conventional TTS technique prior to the study period, the median procedure and fluoroscopy times were 15 and 11 minutes, respectively, suggesting a trend toward reduced fluoroscopy time with the DVS technique.

Conclusion

The DVS technique using EG-840TP achieved a 60% success rate for malignant colonic obstructions in the rectum or sigmoid colon and allowed safe conversion to the TTS technique when necessary. In appropriate cases, this approach may reduce fluoroscopy time and overall radiation exposure.

References

[1] Sawai Y, Shimada T, Yamagata T, et al. Innovative techniques using a novel thin scope for stent placement in malignant colonic obstruction with severe angulation deformity. Endoscopy 2024; 56: E866–E867.