HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mainar, A. Articles by Fernández, J. A. Search for Related Content PubMed PubMed Citation Articles by Mainar, A. Articles by Fernández, J. A.

Acute Colorectal Obstruction: Treatment with Self-expandable Metallic Stents before Scheduled Surgery—Results of a Multicenter Study

¹ Radiology Service, Hospital Central del Insalud de Soria, Spain (A.M.)
² Departments of Interventional Radiology (M.A.D.G.A., E.A., J.A.F.)
³ Surgery (E.T.), Hospital Clínico Universitario de Zaragoza, San Juan Bosco 15, 50-009 Zaragoza, Spain
⁴ Interventional Radiology Section, Hospital Uiversitario de Getafe, Madrid, Spain (I.P.)
⁵ Interventional Radiology Section, Clínica La Zarzuela, Madrid, Spain (R.T.)
⁶ Radiology Service, Louisiana State University Medical Center, New Orleans (M.H.).

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To evaluate the efficacy of treatment with self-expandable metallic stents for acute colonic obstruction before elective surgical resection.

MATERIALS AND METHODS: In 71 patients with malignant obstruction seen from October 1993 through December 1996, lesions were located in the transverse colon in one patient, in the descending colon in 22 patients, and in the rectosigmoid region in 48. A total of 72 self-expandable metallic stents were implanted within 24 hours of diagnosis.

RESULTS: Technical success was obtained in 64 patients (90%). In two cases (3%), it was not possible to advance across the obstructing mass. In five cases (7%), the prostheses were poorly positioned at the site of obstruction, requiring placement of a new stent in three cases. Clinical improvement and resolution of the obstruction were confirmed in 66 patients (93%) within 96 hours. Minor complications developed in nine cases (13%). One patient (1%) underwent surgery to resolve a colonic perforation caused by wires at the ends of the stent. The mean time between stent placement and surgery was 8.6 days (range, 6–16 days).

CONCLUSION: Implantation of colorectal stents is a safe treatment of acute malignant colonic obstruction before resection.

Index terms: Colon, interventional procedure, 75.1299 • Colon, neoplasms, 75.31, 75.32, 75.33 • Colon, stenosis or obstruction, 75.31, 75.32, 75.33 • Stents and prostheses, 755.1299, 756.1299

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
It has been estimated that between 8% and 29% of patients with colorectal cancer will have complete or partial intestinal obstruction (1,2). Moreover, only half of patients who undergo exploratory laparotomy are candidates for curative surgery with high rates of morbidity and mortality in emergency surgical intervention (3,4). Surgical alternatives for patients with acute colonic obstruction include (a) colostomy; (b) two- or three-stage surgery, including initial decompression with colostomy, mass resection, and colostomy closure; (c) tumor resection and colostomy; and (d) subtotal colectomy. Mortality rates decrease from 15%–20% to 0.9%–6.0% when patients undergo elective surgery (5,6). Consequently, ideal management obviates emergency surgery during the acute stage of obstruction.

Metallic endoprostheses have been used in recent years to manage the acute phase of large-bowel obstruction in patients with colonic malignancy (7–10).

We describe our experience in the treatment of acute neoplastic intestinal obstruction by placing self-expandable metallic stents as a stage before scheduled surgery.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
From October 1993 through December 1996, we developed a multicenter study at three European hospitals.

Seventy-one patients (24 women and 47 men; mean age, 63 years; age range, 42–87 years) with large-bowel carcinoma underwent metallic stent placement. Patients were eligible to be enrolled in the study if they presented with clinical signs and symptoms of intestinal obstruction.

All patients were admitted into our study. Evolution status of the intestinal obstruction at the time of admission ranged from 2 to 8 days. The procedures used to diagnose intestinal occlusion were plain abdominal radiography (100%), barium enema examination (100%), and colonoscopy (45%). Barium enema examination also revealed the location and morphology of the obstruction.

Colonoscopy was performed in only 32 patients because the colonoscopist service is not permanent in our hospitals. With this technique, histologic confirmation of malignancy was provided and, in six patients in whom the guide wire could not be progressed with fluoroscopic guidance, the guide wire reached the colonic stricture. Neither anesthesia nor analgesia were used for colonoscopy.

A total of 72 stents were implanted. Seventy-one were Wallstents (Schneider, Bülach, Switzerland) with diameters of 20–22 mm and lengths of 40–100 mm (nine were 40 mm long, 60 were 70 mm long, and two were 100 mm long). Two stents were required in three patients. In one patient, a 25-mm-diameter, 55-mm-long Memotherm stent (Angiomed, Karlsruhe, Germany) was used. A stent slightly longer than the lesion was always chosen.

The procedure we used has been described elsewhere (5–7,11) (Figs 1, 2). After the anal sphincter was lubricated, a 0.038-inch angled stiff hydrophilic guide wire (Radiofocus; Terumo, Tokyo, Japan) and a 7-F, 70–100-cm-long Berenstein type catheter (Positrol II; Bard, Billerica, Mass) were assembled. The guide wire and catheter were advanced with fluoroscopic guidance to pass through the area of obstruction. Nonionic contrast material could be flushed through the catheter to define the stenotic area and to rule out colonic perforation. Once the hydrophilic guide wire and catheter were advanced through the stenosis, the guide wire was replaced with a 260-cm-long Amplatz 0.0038-inch stiff guide wire (Medi-tech/Boston Scientific, Watertown, Mass) to straighten the tortuous rectosigmoid region. It was then easy to introduce the delivery system over the stiff guide wire with fluoroscopic guidance to assess the correct position of the stent (Fig 3). Balloon dilation was not performed in any of our patients.

View larger version (171K): [in this window] [in a new window]   Figure 1a. Illustrations depict placement of the stent. (a) The guide wire and catheter are advanced through the area of obstruction. (b) The guide wire is replaced by an Amplatz stiff guide wire to straighten the tortuous rectosigmoid region, and the delivery system is introduced. (c) The stent is initially deployed at the proximal portion of the lesion. (d) The stent is fully expanded and symmetric in diameter throughout its length.

View larger version (152K): [in this window] [in a new window]   Figure 1b. Illustrations depict placement of the stent. (a) The guide wire and catheter are advanced through the area of obstruction. (b) The guide wire is replaced by an Amplatz stiff guide wire to straighten the tortuous rectosigmoid region, and the delivery system is introduced. (c) The stent is initially deployed at the proximal portion of the lesion. (d) The stent is fully expanded and symmetric in diameter throughout its length.

View larger version (147K): [in this window] [in a new window]   Figure 1c. Illustrations depict placement of the stent. (a) The guide wire and catheter are advanced through the area of obstruction. (b) The guide wire is replaced by an Amplatz stiff guide wire to straighten the tortuous rectosigmoid region, and the delivery system is introduced. (c) The stent is initially deployed at the proximal portion of the lesion. (d) The stent is fully expanded and symmetric in diameter throughout its length.

View larger version (157K): [in this window] [in a new window]   Figure 1d. Illustrations depict placement of the stent. (a) The guide wire and catheter are advanced through the area of obstruction. (b) The guide wire is replaced by an Amplatz stiff guide wire to straighten the tortuous rectosigmoid region, and the delivery system is introduced. (c) The stent is initially deployed at the proximal portion of the lesion. (d) The stent is fully expanded and symmetric in diameter throughout its length.

View larger version (128K): [in this window] [in a new window]   Figure 2a. Barium enema studies in a 69-year-old man. (a) Right anterior oblique study shows a tight colorectal stenosis (arrow). (b) After the hydrophilic guide wire and an angiographic catheter were guided through the area of occlusion, nonionic contrast material was injected to define the anatomy of the proximal and distal regions of the lesion (arrows) and to rule out colonic perforation. (c) The guide wire is replaced by an Amplatz stiff guide wire, and the delivery system has been introduced. (d) Radiograph reveals deployment of the stent (arrows), which is fully expanded.

View larger version (149K): [in this window] [in a new window]   Figure 2b. Barium enema studies in a 69-year-old man. (a) Right anterior oblique study shows a tight colorectal stenosis (arrow). (b) After the hydrophilic guide wire and an angiographic catheter were guided through the area of occlusion, nonionic contrast material was injected to define the anatomy of the proximal and distal regions of the lesion (arrows) and to rule out colonic perforation. (c) The guide wire is replaced by an Amplatz stiff guide wire, and the delivery system has been introduced. (d) Radiograph reveals deployment of the stent (arrows), which is fully expanded.

View larger version (159K): [in this window] [in a new window]   Figure 2c. Barium enema studies in a 69-year-old man. (a) Right anterior oblique study shows a tight colorectal stenosis (arrow). (b) After the hydrophilic guide wire and an angiographic catheter were guided through the area of occlusion, nonionic contrast material was injected to define the anatomy of the proximal and distal regions of the lesion (arrows) and to rule out colonic perforation. (c) The guide wire is replaced by an Amplatz stiff guide wire, and the delivery system has been introduced. (d) Radiograph reveals deployment of the stent (arrows), which is fully expanded.

View larger version (146K): [in this window] [in a new window]   Figure 2d. Barium enema studies in a 69-year-old man. (a) Right anterior oblique study shows a tight colorectal stenosis (arrow). (b) After the hydrophilic guide wire and an angiographic catheter were guided through the area of occlusion, nonionic contrast material was injected to define the anatomy of the proximal and distal regions of the lesion (arrows) and to rule out colonic perforation. (c) The guide wire is replaced by an Amplatz stiff guide wire, and the delivery system has been introduced. (d) Radiograph reveals deployment of the stent (arrows), which is fully expanded.

View larger version (153K): [in this window] [in a new window]   Figure 3. Digitalized radiograph obtained in a 71-year-old woman immediately after stent deployment shows an "apple-core" configuration of the lesion (arrows). The stent was delivered in an adequate location that allowed retrograde opacification of the descending colon.

Follow-up plain abdominal radiography was performed 24, 48, and 72 hours after the procedure.

Presurgical treatment stages to improve the general condition of the patients included mechanical preparation of the colon with orally administered polyethylene glycol, treatment of electrolytic imbalance, and intravenous administration of fluids.

Once the obstruction decompressed, tumor sizing and staging procedures were performed by means of chest radiography, colonoscopy, abdominal ultrasonography, computed tomography (CT) of the thorax and abdomen, bone scintigraphy, and tumor markers to determine whether the patient was a good surgical candidate.

After disseminated disease (Dukes stage D) was ruled out, patients underwent sched- uled surgical resection of the tumor with creation of a primary anastomosis. In the group of patients with Dukes stage D disease, the stent was kept in place as a permanent palliative treatment.

The study protocol was approved by the investigational review board of the hospitals included in our multicenter study, and informed consent was obtained from all patients before stent placement.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Stent placement was successful in 64 patients (90%). The prosthesis could not be implanted in two patients (3%). In one case, the tumor was located in the transverse colon and no carrier was long enough to deliver the stent; in the other, the delivery system could not negotiate a tortuous rectosigmoid region after the stiff guide wire had crossed the obstruction. In both cases, surgical intervention was necessary to resolve the acute intestinal obstruction.

The stent was poorly positioned at the site of obstruction in five cases, and implantation of another prosthesis was required in three cases. In the remaining two patients, a wait-and-see attitude was adopted. Follow-up findings showed correct function of all stents.

In 60 patients (84%), the clinical signs (including normalization of blood ions and relief of symptoms) and radiographic findings of bowel obstruction resolved within 24 hours after stent placement. The other six patients (8%) experienced relief between 24 and 96 hours. One patient from this group, who was in good general condition and had marked small-bowel dilatation, experienced bowel movements at 96 hours after stent implantation.

Clinical symptoms of obstruction were not relieved in three patients (4%) despite having bowel movements and successful deployment of the stent, and they required emergency surgery. A herniated McBurney incision was observed during surgical intervention in one case, and adhesions on the wall of the sigmoid colon adjacent to the proximal end of the stent with compression of the lumen were evident in the other two cases.

The ability for intestinal transit with abundant defecation was recovered immediately in 49 patients (69%) and within 24 hours in 11 cases (15%), seven of which were related to incomplete opening of the stent. Follow-up plain radiography of the abdomen at 24 hours showed full opening of the stent (Fig 4).

View larger version (189K): [in this window] [in a new window]   Figure 4. Follow-up radiograph obtained at 24 hours after stent implantation reveals increased expansion of the stent (arrow). The 75-year-old man later underwent scheduled surgical resection of the tumor and creation of a primary colorectal anastomosis.

Mean duration of the procedure was 75 minutes (range, 28–180 minutes), depending on the location of the lesion and the degree of difficulty in negotiating the tortuous rectosigmoid region.

The stent placement procedure was painless, and neither anesthesia nor analgesia was provided. The patients were kept under medical observation for 6–8 days.

Complications were seen in 10 cases (14%). In nine cases, complications were minor and required no further treatment. In five patients who experienced mild rectal bleeding before stent placement, bleeding worsened after manipulation and advancing of the delivery system; all five recovered uneventfully after 48 hours.

Four patients reported minimal anorectal pain that lasted 2 days after stent placement. This symptom was well tolerated, and no analgesia was required.

Only one severe complication was observed. Peritonitis due to perforation of the colon by wires at the ends of the stent was detected and treated surgically. Two other focal perforations were discovered during surgical resection, but no symptoms have been reported.

The mean time for colonic preparation before surgery was 8.6 days (range, 6–16 days).

Sixty-five patients underwent elective single-stage surgery with partial colonic resection and creation of a primary end-to-end anastomosis without major complications. The stents were easily identified during surgery, and the affected colon segments were removed without complications. No evidence of tumor growth into the stent lumen was observed.

The postoperative course was uneventful in 58 patients (82%). These patients were discharged within 8 days after surgery with no complications. The other seven patients (10%) were discharged within 12 days. Mean postoperative hospital stay was 10.3 days (range, 6–35 days).

In all cases, findings in pathologic studies revealed adenocarcinoma with several degrees of differentiation.

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Self-expandable metallic stents have been used successfully for several years to relieve neoplastic obstruction of the biliary tract, trachea, and main bronchi. They have been used in the digestive tract to provide palliative treatment of cancer of the esophagus (11,12).

Several articles have described the use of metallic stents to treat colon stenosis, and satisfactory results have been documented (13,14). The treatment of acute colorectal obstruction before surgery has been reported recently (7–10,15).

The rates of morbidity and mortality in surgical treatment of colorectal carcinoma decrease when elective surgery is scheduled and the colon is adequately prepared (5,6). By obviating emergency surgery, our procedure enables the acute phase of neoplastic colon obstruction to be overcome and allows a patient with nonobstructive colon neoplasia to benefit from suitable general and intestinal preparation.

An acute colonic obstruction can be treated by placing metallic stents. Thus, colostomy for evacuation can be avoided, with consequent physical, psychologic, and economic advantages for the patient.

Our results support the placement of metallic stents to relieve an acute colonic obstruction. Clinical signs and symptoms and radiologic evidence of intestinal obstruction resolved within 96 hours of stent placement in 93% of the patients.

Once the problem of acute bowel obstruction is solved, this technique allows staging of disease, even on an outpatient basis, and scheduling of elective surgery after optimal colonic preparation.

Surgery is generally not an option for patients at high risk with general anesthesia, in poor general health, or with disseminated neoplastic disease. In patients with metastatic disease, metallic stents have been used as a primary palliative treatment (11,12). Our published experience supports the placement of a metallic stent as a definitive palliative treatment that provides good results and clear benefits to the patient (16).

In our experience, we encountered only one major complication due to colonic perforation and associated peritonitis that required surgical treatment. In only three cases was implantation of a new prosthesis necessary to resolve a malpositioning of the stent. The other 11 complications required no further treatment.

The stents do not induce excessive artifacts on CT scans (Fig 5) but do allow adequate tumor staging.

View larger version (144K): [in this window] [in a new window]   Figure 5. CT scan obtained in a 68-year-old man shows a patent stent (arrow) and allows adequate staging of the tumor. The stent does not induce artifacts.

Stent implantation with endoscopic techniques may be more uncomfortable for a patient, who is likely to experience more bleeding (15) as a result of trauma caused by manipulation of nonhydrophilic guide wires, which in turn increases the risk of perforation. In six of our cases, colonoscopic techniques helped guidance of the guide wire in the area of the tumor. We think fluoroscopic guidance alone provides adequate assessment of the point of obstruction in most cases, but endoscopic guidance may be useful when it is difficult to locate the stenosis.

In conclusion, implantation of a colorectal stent before scheduled surgery is an excellent alternative to emergency surgery in cases of acute intestinal obstruction caused by tumors in the rectosigmoid or descending colon. We think that stent placement offers clear benefits to the patient. It is minimally invasive, well tolerated, obviates emergency surgery, and offers fast relief of symptoms.

	Footnotes

 
Address reprint requests to M.A.D.G.A.

Author contributions: Guarantor of integrity of entire study, A.M.; study concepts, M.A.D.G.A.; study design, A.M., M.A.D.G.A.; definition of intellectual content, E.T.; literature research, E.A., A.M., M.A.D.G.A.; clinical studies, R.T., I.P., M.H., J.A.F.; experimental studies, M.H., M.A.D.G.A.; data acquisition, E.A.; data analysis, D.T., A.M., M.A.D.G.A.; manuscript preparation, E.A.; manuscript editing, A.M.; manuscript review, E.A., M.A.D.G.A., A.M.

Received August 19, 1997; revision requested November 12, 1997; revision received June 11, 1998; accepted August 20, 1998.

	References

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 

1. Goligher I, Hafner CD. The treatment of acute obstruction or perforation with carcinoma of the colon and rectum. Br J Surg 1957; 450:270-274.
2. Regland JJ, Londe AM, Spratt JS. Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathologic variables. Am J Surg 1971; 121:552-556.[Medline]
3. Lofler I, Hafner CD. Survival rate in obstructing carcinoma of the colon. Arch Surg 1964; 89:716-718.
4. Leitman IM, Sullivan JD, Brams D, Decosse JJ. Multivariate analysis of morbidity and mortality from the initial surgical management of obstructing carcinoma of the colon. Surg Gynecol Obstet 1992; 174:513-518.[Medline]
5. Witzig JA, Morel P, Erne M, Egeli R, Borst F, Rohner A. Chirurgie des cancers digestifs des patients de plus de 80 ans. Helv Chir Acta 1993; 59:767-769.[Medline]
6. Messmer P, Thoni F, Ackermann C, Herzog U, Schuppiser JP, Tondelli P. Perioperative morbidity and mortality of colon resection in colonic carcinoma. Scheweiz Med Wochenschr 1992; 122:1011-1014.
7. Tiger E, Mainar A, Fernandez L, Tobio R, De Gregorio MA. New procedure for the treatment of the colorectal neoplastic obstructions. Dis Colon Rectum 1994; 37:1158-1159.[Medline]
8. Mainar A, Tiger E, Tobio R, De Gregorio MA, Eguizabal C, Saiz P. Resolución de las oclusiones agudas neoplásicas colorectales mediante el uso de stents metálicos. Radiologia 1994; 36:647-651.
9. Tiger E, Mainar A, Fernandez L, Tieso A, Cuezva JF, San Jose A. New procedure for relief of malignant obstruction of the left colon. Br J Surg 1995; 82:34-35.[Medline]
10. Mainar A, Tiger E, Maynar M, Ferral H, Castaneda-Zuniga W. Colorectal obstruction: treatment with metallic stents. Radiology 1996; 198:761-764.[Abstract/Free Full Text]
11. Knrym K, Wagner HJ, Bethge N, Keymling M, Vakil N. A controlled trial of an expansible metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329:1302-1307.[Abstract/Free Full Text]
12. Cwikiel W, Stridbeck H, Tranberg KG, et al. Malignant esophageal strictures: treatment with a self-expanding nitinol stent. Radiology 1993; 187:661-665.[Abstract/Free Full Text]
13. Cwikiel W, Andren-Sandberg A. Malignant stricture with colovesical fistulla stent insertion in the colon. Radiology 1993; 186:563-564.[Abstract/Free Full Text]
14. Itabashi M, Hamano K, Kameoka S, Asahina K. Self expanding stainless steel stent application in rectosigmoid stricture. Dis Colon Rectum 1993; 36:508-511.[Medline]
15. Yoshihisa S, Yoshinobu S, Jiro N, Makoto T. Stent endoprosthesis for obstructing colorectal cancers. Dis Colon Rectum 1996; 39:552-555.[Medline]
16. De Gregorio MA, Mainar A, Tiger E, et al. Acute colorectal obstruction: stent placement for palliative treatment—results of a multicenter study. Radiology 1998; 209:117-120.[Abstract/Free Full Text]

This article has been cited by other articles:

				R Lewis, A Flynn, M E Dean, A Melville, A Eastwood, and A Booth Management of colorectal cancers Qual. Saf. Health Care, October 1, 2004; 13(5): 400 - 404. [Abstract] [Full Text] [PDF]

				T. H. Baron Expandable Metal Stents for the Treatment of Cancerous Obstruction of the Gastrointestinal Tract N. Engl. J. Med., May 31, 2001; 344(22): 1681 - 1687. [Full Text] [PDF]

				T. Ahmad and A. S Mee Expandable metal stents in malignant colorectal obstruction BMJ, September 9, 2000; 321(7261): 584 - 585. [Full Text]

				F. Camúñez, A. Echenagusia, G. Simó, F. Turégano, J. Vázquez, and I. Barreiro-Meiro Malignant Colorectal Obstruction Treated by Means of Self-expanding Metallic Stents: Effectiveness before Surgery and in Palliation Radiology, August 1, 2000; 216(2): 492 - 497. [Abstract] [Full Text]

				T. E. Velling, L. D. Hall, and F. J. Brennan Colonic Stent Placement Facilitated by Percutaneous Cecostomy and Antegrade Enema Am. J. Roentgenol., July 1, 2000; 175(1): 119 - 120. [Full Text] [PDF]

				M. A. Mauro, R. E. Koehler, and T. H. Baron Advances in Gastrointestinal Intervention: The Treatment of Gastroduodenal and Colorectal Obstructions with Metallic Stents Radiology, June 1, 2000; 215(3): 659 - 669. [Abstract] [Full Text]

				W. Z. Tamim, A. Ghellai, T. C. Counihan, R. S. Swanson, J. M. Colby, and W. B. Sweeney Experience With Endoluminal Colonic Wall Stents for the Management of Large Bowel Obstruction for Benign and Malignant Disease Arch Surg, April 1, 2000; 135(4): 434 - 438. [Abstract] [Full Text] [PDF]

				G. W. Stevenson 1998 RSNA Annual Oration in Diagnostic Radiology : Colorectal Cancer Imaging: A Challenge for Radiologists Radiology, March 1, 2000; 214(3): 615 - 621. [Full Text]

This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mainar, A. Articles by Fernández, J. A. Search for Related Content PubMed PubMed Citation Articles by Mainar, A. Articles by Fernández, J. A.