Self-Expanding Metal Stenting for Malignant Colonic Tumours: A Prospective Study

doi:10.4236/ss.2011.23032

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Surgical Science, 2011, 2, 151-154

doi:10.4236/ss.2011.23032 Published Online May 2011 (http://www.scirp.org/journal/ss)

Self-Expanding Metal Stenting for Malignant Colonic

Tumours: A Prospective Study

Wissam Al-Jundi, Sameer Kadam, Ioakim Giagtzidis, Feras Ashouri, Kunal Chandarana,

Mark Downes, Amjad Khushal

Kent and Canterbury Hospital, Canterbury, United Kingdom

E-mail: [email protected]

Received February 7, 2011; revised April 12, 2011; accepted April 21, 2011

Abstract

Background: self-expanding metal stents (SEMS) have been used in the management of malignant colorectal

obstruction for palliation or as a bridging tool to single-stage surgery. We present the clinical results of a se-

ries of patients with colonic cancer in whom SEMS were inserted endoscopically under radiological guid-

ance. Methods: between September 2007 and January 2010, prospectively collected data from 21 patients

who underwent SEMS insertion was analysed. This data includes demographics, indication for stenting, stent

size, technical success, clinical success, complications, survival and duration of hospitalisation. Results: 14

male and 7 female patients with malignant colonic obstruction underwent SEMS insertion: 19 requiring pal-

liation and 2 bridging to surgery. The rate of technical success was 100% and of initial clinical success was

100%. In 16/19 (84.2%) of the palliation group, clinical success was maintained at mean follow up of 3.4

months (1 - 6 months), while 3/19 (15.8%) died, two with functioning stents and one with stent occlusion.

The two patients with operable tumours were successfully bridged to one-stage elective surgery at 1 month

and 4 months following stenting. Post-procedure complications occurred in 5 patients: 1 perforation, 2 pain,

1 migration and 1 stent occlusion. All patients were discharged alive and the median hospital stay was 1 day

(range: 1 to 13 days). Conclusion: SEMS provides an effective and safe option in the palliation of malignant

colorectal obstruction. In operable patients, it provides a useful option to avoid colostomy, by facilitating

safer single-stage surgery. In this prospective study of SEMS insertion, high rates of technical and initial

clinical success were achieved. This could be attributed to performing the procedure under combined endo-

scopic and radiological guidance.

Keywords: Self-Expanding Metal Stent; Stent; Colon/Colonic Obstruction

1. Introduction

Primary or recurrent adenocarcinoma, pelvic malignan-

cies, and metastatic diseases can lead to the development

of malignant colorectal strictures. Up to 85% of acute

colonic obstructions are due to malignancy and between

8% and 28% of patients with colonic cancer present with

obstructive symptoms [1]. Traditional management of

symptomatic malignant colorectal obstruction involves

emergency colostomy. However, patients with acute or

chronic large bowel obstruction are usually high-risk

surgical candidates due to poor general health. The di-

lated bowel wall proximal to the obstruction is often fri-

able, which complicates emergency surgical interven-

tions [2].

In 1991, Dohmoto [3] reported the first use of self-

expanding metallic stents (SEMSs) for palliation of

colorectal cancer. Since then, a growing number of re-

ports and reviews have demonstrated the effectiveness

of SEMSs for palliation in patients with advanced non-

resectable carcinoma and as a bridge to surgery in those

patients with resectable disease [4-7].

This is a report of our experience with one type of

SEMS for palliation of 19 inoperable patients and

bridging of 2 operable patients with colorectal cancer.

2. Methods

This prospective study was conducted at a single centre

between September 2007 and January 2010. A total of

21 patients (mean age 72 years; range 32 - 93; 14 men)

with left sided (descending colon, sigmoid or rectum)

W. AL-JUNDI ET AL.

152

cancer were treated by endoscopic insertion of SEMSs

under radiological guidance in a prospective series.

Treatment recommendations were made by a colorectal

surgery/interventional radiology/oncology multidiscipli-

nary team. Inclusion criteria were the presence of pri-

mary or recurrent malignant left-sided colon cancer with

obstructive symptoms (abdominal pain and distension,

passage of small-calibre stools, or constipation that re-

quired stool softeners) confirmed by abdominal radio-

graphs or computed tomography (CT) scan. No patient

had complete bowel obstruction.

Exclusion criteria were perforation, peritonitis, or

other serious complications demanding urgent surgery

and the presence of rectal stenosis less than 5 cm from

the anal sphincter. All patients had symptoms related to

the stenosis, including abdominal pain and distension,

tenesmus, passage of small-calibre stools, or constipation

that required stool softeners.

Lesions were located in the rectum in 3 patients, in the

rectosigmoid junction/sigmoid colon in 12 patients and

in the descending colon in 5 patients. In 1 patient the

stenosis was caused by an anastomotic recurrence after

sigmoid colectomy.

Each patient gave written informed consent for the

treatment. Phosphate enemas were administered in the

morning of the procedure. Stenting procedures were per-

formed by a colorectal surgeon (AK) and an interven-

tional radiologist (MD). Self-expanding metal stents

(Niti-S Enteral Colonic Stent, Taewoong Medical Co.,

Ltd, Korea) were inserted endoscopically across the le-

sions under fluoroscopic control. The stricture was trav-

ersed with the endoscope, which was inserted into the

left colon or more proximally. A stainless steel guidewire

with a spring tip was inserted thro ugh the co lono scope as

far as possible into the left colon. The length of the le-

sion was measured during withdrawal of the endoscope.

The appropriately sized stent was loaded onto the distal

tip of the introducer and the pusher was inserted through

the introducer until it reached the stent. The introducer,

which contained the stent and the pusher, was passed

over the guidewire beside the endoscope and through the

stenotic segment. After proper positioning, the introdu cer

was withdrawn keeping the pusher firmly against the

stent, thereby allowing the prosthesis to expand.

The whole procedure was performed without p remedi-

cation in less than 30 minutes. Treatment success was

considered the restoration of asymptomatic defecation

with the disappearance of obstructive symptoms. Seven-

teen patients (81%) were discharged on the same day

with laxatives, wh ile 4 patients (19%) remained in hosp i-

tal for longer duration due to other medical or social rea-

sons.

Post stenting assessments were performed in specialist

clinics where treatment success was determined by ask-

ing patients at each follow-up visit about stool number,

abdominal pain and distension, the need for laxatives,

and the presence of diarrhoea, or constipation. All com-

plications and deaths were recorded up to 6 months fol-

lowing stenting. Patients missing or , “lost to follow up”,

were traced and contacted by telephone. Deaths were

confirmed from medical records, or death certificates

were obtained from the General Register Office (www.gro.

gov.uk).

3. Results

Twenty-one consecutive patients were included in this

study. Indications for stenting and stents’ characteristics

are summarized in Table 1. SEMSs were placed with

palliative intent in 19 patien ts and as a bridge to surgery

in 2 (Table 1).

Two SEMSs were placed in 4 patients, because of

long strictures/malpositioning of first stent. Metal stents

were placed correctly in all patients achieving a techni-

cal success rate of 100%. No patient underwent balloon

dilatation, either before or after stent placement. All

patients tolerated the procedure well and no complica-

tion was obser ve d with in 24 hours of stent placem ent.

Table 1. Characteristics of the colonic stents used in the

study.

Parameter No. Pa-

tients %

Palliation 19 91

Indication for stent

placement Bridge to surgery 2 9

1 17 81

No. Stents placed per

patient 2 4 19

80 3 14.3

120 14 66.6

Two 120 2 9.5

120 and 60 1 4.8

Stent length (mm)

120 and 80 1 4.8

20 3 14.3

24 12 57.1

28 2 9.5

Two 24 3 14.3

Stent diameter (mm)

Two 28 1 4.8

W. AL-JUNDI ET AL. 153

Table 2. Post-procedural complications.

Complication Type No. Patients %

Perforation 1 4.8

Stent Occlusion 1 4.8

Stent Migration 1 4.8

Pain 2 9.5

Rectal Bleeding 0 0

Tenesmus 0 0

The patients were followed for a median of 3.5 months

(range 1-6 months).

During follow-up after SEMS placement for palliative

treatment, complications resulted in 1 clinical failure

(4.8%) (Table 2). A 32-year-old woman with metastatic

adenocarcinoma of the sigmoid colon was readmitted

with complete intestinal obstruction due to stent occlu-

sion 2 weeks following stenting and died soon after ad-

mission. One patient, an 82-year-old man developed de-

layed perforation. This was concealed perforation at the

stent site that was treated conservatively and the patient

had no further complicati ons.

Late distal migration of the stent was observed in 1

case two months after insertion. Overall the incidence of

complications was 23.8% (5/21), with one mortality

(4.8%) following stent occl usion.

The remaining patients (76.2%) did not experience

pain, tenesmus, or bleeding during follow-up. All had

restoration of asymptomatic defecation and relief of ab-

dominal discomfort. Most used stool softeners.

The two patients with operab le tumours survived until

elective one stage surgery at 1 month and 4 months fol-

lowing stenting. In the palliative group, clinical success

was maintained in 15/19 patients (84.2%) at mean follow

up of 3.4 months (1 - 6 months), while 3/19 (15.8%) died,

two with functioning stents. Thus, for those patients,

stent placement had fulfilled its palliative purpose over

their entire remaining life span.

4. Discussion

In the UK, approximately 34,000 patients are diagnosed

with colorectal cancer each year [8]. Colonic obstruction

is almost exclusively associated with tumours in the

recto-sigmoid region, and acute colonic obstruction has a

high mortality (17%) and morbidity (39%) [8]. There is

no eviden ce that palliative resections prolong survival [9],

while the presence of a colostomy decreases the quality

of life [10]. For palliative treatment, it has been sug-

gested that SEMS provide a solution that combines good

results with short hospital stay, good tolerance and ac-

ceptance by the patients [4-7]. In patients who are suit-

able for curative surgery, colonic stenting creates an op-

portunity for resuscitation, correction of electrolytes

imbalance, optimising bowel preparation, improving the

nutritional status and planning for definitive elective

resection at a later date [11].

Colonic stenting, like any clinical intervention, is not

devoid of complications. However in our study we had

100% technical success in placement of stents in addi-

tion to low complication rates. The most serious com-

plication of this procedure is perforation of the colon. In

our study only one patient suffered with delayed perfo-

ration, which was treated conservatively and did not

affect the outcome of his stenting. One explanation for

the low number of post-procedural perforation is the

avoidance of balloon dilation of the stents during their

placement. The technique that was used and the col-

laboration of a colorectal su rgeon with an interven tional

radiologist can also explain the good technical success

across this cohort. As stenting devices and our skills

develop, endoscopic capabilities will continue to ex-

pand to involve more complicated cases and patients

with more advanced disease.

Our study was not without limitations. There was no

comparative group i.e. emergency surgery group, to

assess the effectiveness of stenting against surgery. In

addition, there was lack of randomisation and the num-

ber of patients involved was small, therefore, it is not

possible to assure the validity of the results. Involve-

ment of a larger number of patients could have defined

the technical and clinical success rates more accurately

and could have potentially identified more post-

procedural complications. Finally, there were no pa-

tients with transverse or ascending colon tumours and

the follow up was limited to a maximum of 6 months.

Despite the fact that 70% of bowel obstructions occur in

the left and sigmoid colon [7], future studies should also

investigate the use of colonic stents for more proximal

obstructing colonic tumours.

A systematic review by Sebastian et al. of 54 uncon-

trolled trials and case reports on placement of self-

expandable metal stents revealed a technical success

rate of 90% - 100%, a clinical success rate of 84% -

94% and clinical success when used as bridge to sur-

gery of 71.7%. Major complications related to stent

placement included perforation (4%), stent migration

(11.8%) and re-obstruction (7.3%), causing a cumula-

tive mortality of 0.58% [7]. A more recent review by

Watt et al. found median complication rates of stent

migration 11%, perforation 4.5%, and tumour over-

growth 12% [12]. Nevertheless insertion of SEMS for

acute malignant colonic obstruction was associated with

lower mortality rates, a lower mean number of opera-

tions per patient, and a reduction in the number of per-

manent and temporary stomas required compared with

W. AL-JUNDI ET AL.

154

either emergency resective surgery or emergency divert-

ing colostomy. Though the cost associated with colonic

stenting is higher than the cost of performing a diverting

colostomy for the initial management of acute, malignant

colonic obstruction, the incremental cost associated with

providing one additional improved patient outcome is

very reasonable [13].

Summarizing, the use of SEMS for palliation of ma-

lignant colorectal tumour is a safe and effective proce-

dure. As a bridge to a single stage surgery it appears a

promising method with good outcome, but no random-

ized controlled trial between stenting and primary sur-

gery has been carried out to date to provide the necessary

clinical proof [14]. A Cochrane review in 2002 con-

cluded that the limited number of randomised control

trials into the management of obstructing left-sid ed colo-

rectal carcinoma together with methodological weak-

nesses does not allow reliable assessment of the best

treatment strategy [15]. There is a clear need for further

large randomised studies.

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