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Thread: Colonic Stent Pictures - Atlas of Colon and Ileum

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    Default Colonic Stent Pictures - Atlas of Colon and Ileum

    The decision to preoperatively place a colonic stent in a patient with acute malignant colonic obstruction should be taken as part of a multidisciplinary discussion between surgeon and interventional endoscopist. The surgical team should be on stand by, in case of failure of the endoscopic stenting, due to the increased risk of bowel perforation caused by distension of the bowel above the stricture associated with endoscopic gas inflation.

    Recent technology improvements have been supported by the publication of clinical experiences with preoperative colon stenting and the development of laparoscopic surgical techniques in the management of malignant colonic obstruction.

    Most recent studies on the clinical use of colonic stenting in malignant colonic obstruction are single institution, retrospective case series describing technical and clinical outcomes associated with colon stent placement ( Table 2 ). As they include patients with both resectable (bridge-to-surgery colon stenting) and unresectable (palliative stenting) colonic malignancy, specific analysis of the former group is difficult.[32] Furthermore, the variety of stent-delivery techniques (fluoroscopy alone, combined endoscopy and fluoroscopy, and occasionally endoscopy alone) and the variety of stents used make comparisons between stent-delivery techniques and stent devices difficult.

    The promising technical and clinical results, but concerning complications, especially perforation, from these recent case series have been confirmed by published systematic reviews on the subject of safety and efficacy of colon stents.

    In a systematic review of cases series from January 1990 to December 2000, malignant left-sided obstruction composed the majority of the 598 patients analyzed.Technical success (stent placement and deployment) was accomplished for 551 stenting attempts (92%). Failure of stent placement was attributed to obstruction, malpositioning and, in two cases, perforation. Clinical success, defined as colonic decompression within 96 h without need for endoscopic or surgical reintervention, was achieved in 95% of technical successes (n = 525), giving an overall clinical success rate of 88%. When assessed by indication, clinical success was slightly lower in the bridge-to-surgery groups (85%, 223 of 262 patients). Of the clinically successful bridge-to-surgery patients, 95% (212 of 223 patients) went on to a one-stage colon resection within a mean of 8.9 days (range 2-115 days). Complications included perforation, migration, reobstruction, bleeding and pain. Perforation occurred in 4% of patients and was often associated with balloon predilatation of the stricture. An interventional mortality rate of 1% was reported (three of 598 patients). In patients in whom stent placement was initially successful, stent migration was observed in 10% (54 patients) and reobstruction was seen in 10% (52 patients).

    A more recent pooled analysis of the efficacy and safety of SEMS stenting in malignant colorectal obstruction looked at case series from January 1990 to May 2003.A systematic review of the efficacy and safety of these stents in the setting of malignant colorectal obstruction was performed after data were collected on technical success, clinical success, and safety parameters. Fifty-four studies reported the use of stents in a total of 1198 patients. A total of 407 patients included in 21 series of reports underwent stenting as a bridge-to-one-stage surgery. The procedure was technically successful in 374 (91.9%) patients. Clinical success in this subgroup, as defined as the ability to perform single-stage surgery with primary anastomosis, was achieved in 292 patients. The overall percentage of clinical success was 71.7%, but if the technical failures were excluded, 78.1% of patients underwent single-stage surgery. Overall, the major complications related to stent placement included perforation (3.76%), stent migration (11.81%), and reobstruction (7.34%). Factors related to an increased complication risk were identified and included predilation and use of laser recanalization. Stent-related mortality was 0.58%. In the group undergoing stenting as a bridge-to-surgery, the requirements for a colostomy stoma in the stented patients included locally advanced tumor , inadequate preparation , perforation and migration . There were 11 other stent migrations that did not affect outcome. The reason for clinical failure was not apparent in 14 patients.
    Colonic Stent Pictures Atlas Colon attachment.php?s=07dde559909cd36ad9948634bc318fd4&attachmentid=2725&d=1443374964

    The use of an SEMS can enhance the feasibility of a laparoscopic colectomy, avoiding the need for a colostomy and offering the advantages of two minimally invasive procedures. Since first described by Morino et al., this may represent a further improvement in the management of malignant colonic obstruction. Stent placement makes the laparoscopic procedure more difficult since stents make the colonic segment more bulky and more technically difficult to remove laparoscopically. This approach appears feasible, however, in the hands of well trained laparoscopic surgeons. Although no formal randomized clinical data are available comparing open with laparoscopic resection after colonic stenting, the initial case series data appear favorable.

    In a study of 23 colon resections after colonic stent decompression, 19 were performed laparoscopically and four by open laparotomy. Mean postoperative stay was 18.5 (range 9-35) days for the open group and 12 (range 9-20) days for the laparoscopic group. In another study, seven of 11 cases of left colonic obstruction due to cancer were initially treated with colonic stenting preoperatively and underwent definitive laparoscopy resection to attempt the definitive colectomy. The seven patients were operated on an average of 8 days (range 6-14 days) after insertion of the stent. Conversion to open surgery was necessary in one case for reasons not related to the stent.

    Finally, a more comprehensive study looked at the clinical outcomes of SEMS placing followed by laparoscopic resection and primary anastomosis for the treatment of acute colonic obstruction in 14 patients with acute and complete colonic obstruction, treated with endoscopic colonic stenting as a bridge to an elective one-stage laparoscopic resection. Three patients were excluded from the analysis due to an inoperable tumor. Ninety-three per cent technical and clinical success was achieved. The stent insertion-related perforation rate was 7% (1/14). Mean operating time was 132 ± 38 min. No cases required conversion to open laparotomy and there were no intraoperative complications. One case of anastomotic leakage was observed and was treated by laparoscopic drainage and protective ileostomy. Ambulation time after operation was 1.8 ± 0.6 days and total hospital-stay length was 16.4 ± 5.0 days. During a period of 11 ± 7 months of follow-up, neither recurrences nor port-site metastases were observed.

    While the previously described data support the good technical and clinical success associated with the placement of colonic stents preoperatively, the important question remains about whether this is truly advantageous to the patient presenting with acute malignant colonic obstruction. Unfortunately, there are no randomized clinical data available to answer this question. We are reliant on case control cohort studies comparing preoperative stenting with no stenting ( Table 3 ), as well as cost-effectiveness studies.

    Collectively, the published case cohort series studies appear to suggest that preoperative stenting is associated with improved primary anastomosis rates, shorter hospital stays, and fewer postoperative complications ( Table 3 ).[39-43] One of the concerns raised is that preoperative colon stenting could spread malignancy in otherwise curable colonic malignancy. One study reviewed the long-term prognosis of patients with resectable colorectal cancers treated surgically with and without preoperative SEMS as a bridge to surgery. There is no significant difference in 3-year survival (50% compared with 48%) or 5-year survival (44% compared with 40%) rates between the two groups. These data suggest that implanted stents do not lead to spread of malignancy or any adverse effects on the course of the disease.

    When compared to colostomy, in one study from Switzerland, stent placement cost 29% less when used as a bridge-to-surgery, due to the shorter hospital stay in the stent group. A British study compared the costs of patients managed with stents with unselected patients managed by surgical decompressions. It found that the use of stents caused a significant reduction in total hospital stay when compared with colostomized patients with an average saving of £1760.
    Colonic Stent Pictures Atlas Colon attachment.php?s=07dde559909cd36ad9948634bc318fd4&attachmentid=2726&d=1443375007

    Recently, a decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: first, emergent colonic stent followed by elective surgical resection and re-anastomosis; second, emergent surgical resection followed by diversion (Hartmann’s procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective, and included both inpatient costs and outpatient community costs. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures. Colonic stent resulted in 23% fewer operative procedures per patient (1.01 compared with 1.32 operations per patient), an 83% reduction in stoma requirement (7% compared with 43%), and lower procedure-related mortality (5% compared with 11%). Colonic stent was associated with a lower mean cost per patient ($45 709 compared with $49 941). Most of the cost saving was attributed to avoiding a second colon operation to re-establish bowel continuity. The findings remained robust over a wide range of assumptions for clinical inputs in sensitivity analysis.

    For preoperative colon stenting, advances in technique and stent technology have resulted in a good technical and clinical success rate, with modest but significant complications. Several retrospective case series and systematic reviews have confirmed a positive experience with preoperative colonic stenting. In the absence of randomized clinical-trial information, data from case cohort studies and cost-effectiveness studies suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

    References:
    Medscape: Medscape Access











    Last edited by Medical Photos; 09-27-2015 at 05:30 PM.

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