Final Stent[1]


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Final Stent[1]

  1. 1. Safety of self expanding metal stents for left sided large bowel obstruction V Rao, R.S HUSSEIN, S I Haider, T M Hunt, R Orme, M Smith Colorectal Surgery Unit Royal Shrewsbury Hospital
  2. 2. UK SERIES <ul><li>Systematic review of </li></ul><ul><li>the clinical evidence on </li></ul><ul><li>colorectal self expanding </li></ul><ul><li>metal stents </li></ul><ul><li>Published in BJS </li></ul><ul><li>2002;89:1096-102-M C </li></ul><ul><li>Parker et al-Dartford </li></ul><ul><li>598 cases were stented </li></ul><ul><li>Technical failure in 47(8%) </li></ul><ul><li>Main reasons </li></ul><ul><li>Access failure 86% </li></ul><ul><li>Malposition 9% </li></ul><ul><li>Perforation 5% </li></ul>
  3. 3. UK SERIES (Contd) <ul><li>Mortality in 3 patients (0.5%) </li></ul><ul><li>Perforation in 22 (0.4%) </li></ul><ul><li>Stent migration in 54 patients (10%) </li></ul><ul><li>Bleeding in 27 (5%) </li></ul><ul><li>Pain in 31 (5%) </li></ul><ul><li>Reobstruction in 52 (10%) </li></ul>
  4. 4. AIM OF THE STUDY <ul><li>To find out the indications of stent placement </li></ul><ul><li>To review the complications and difficulties in stenting </li></ul><ul><li>Its outcome </li></ul><ul><li>Patients requiring surgery following stenting </li></ul><ul><li>Duration of stent in situ </li></ul>
  5. 5. METHODS <ul><li>Retrospective review of all patients who underwent colonic stenting,our initial experience </li></ul><ul><li>Total 21 case notes were reviewed </li></ul><ul><li>Proforma designed , data compiled and </li></ul><ul><li>interpreted . </li></ul>
  6. 10. Results - Age group
  8. 12. INVESTIGATION (contd) <ul><li>Histopathological confirmation achieved in 18 cases ( 86% ) </li></ul><ul><li>15 proved to be adeno carcinoma </li></ul><ul><li>Inflamed tissue – 1 case –diverticular stricture </li></ul><ul><li>Liver bx in one case showed microacinar adeno ca </li></ul><ul><li>Omental bx – taken in a case of Ovarian cancer </li></ul><ul><li>3 cases did not have histological confirmation as in two cases there was radiological evidence of metastatic disease and in the other it was based on clinical diagnosis based on flexible sigmoidoscopy. </li></ul><ul><li>Presently we are performing contrast enema for everyone to know the anatomy of the large bowel before stenting </li></ul>
  9. 13. SITE OF TUMOUR <ul><li>20 cases were left sided tumours-95 % </li></ul><ul><li>Extrinsic compression – 1 case – Ovarian </li></ul><ul><li>tumour with peritoneal mets </li></ul>
  10. 14. INDICATIONS OF STENT <ul><li>16 Cases were palliative with obstructive symptoms – 76% </li></ul><ul><li>One case extrinsic obstruction of large bowel from ovarian cancer </li></ul><ul><li>one case was acutely obstructed and was stented temporarily to relieve obstruction prior to elective sigmoid colectomy after </li></ul><ul><li>1 month of stent insertion </li></ul><ul><li>In one case stent was attempted as he was having a synchronous primary lung cancer along with recto sigmoid tumour </li></ul><ul><li>One case had diverticular stricture and had potential medical problems and was therefore stented </li></ul><ul><li>Palliative obstructive symptoms in a psychiatric patient who refused treatment </li></ul>
  11. 15. DURING STENTING <ul><li>Well placed in 17 cases – 81 % </li></ul><ul><li>Failure of the guide wire through the tumour – 4 cases – 19 % </li></ul><ul><li>3 had loop stomas and one refused surgery </li></ul><ul><li>Two Perforations occurred during guide wire insertion which were conservatively managed </li></ul>
  12. 16. FOLLOWING STENTING <ul><li>Technical success achieved in 17 cases-81% </li></ul><ul><li>Good position achieved in 12 cases – 71% </li></ul><ul><li>Stent migrated in 3 cases – in less than 4 </li></ul><ul><li>weeks(17.6%) </li></ul><ul><li>Failed to relieve obstruction(clinical and radiological failures) in 2 cases </li></ul><ul><li>both of them had loop colostomies </li></ul><ul><li>These 5 cases 4 had loop stomas and one had elective resection </li></ul>
  14. 18. DURATION STENTS LASTED <ul><li>Short term duration (less than 4 weeks) – </li></ul><ul><li>5 cases </li></ul><ul><li>Long term duration (more than 4 weeks) – </li></ul><ul><li>12 cases </li></ul><ul><li>Duration of patency was from 2 weeks to 16 </li></ul><ul><li>months </li></ul>
  15. 19. DURATION OF STENT (CONTD) <ul><li>Successful stenting was achieved in 12 cases </li></ul><ul><li>4 still have it – 23.5% – 2 months to 14 months </li></ul><ul><li>One had elective Surgery </li></ul><ul><li>Died unrelated to stent with stent in situ – </li></ul><ul><li>6 cases – 3 days to 16 months </li></ul><ul><li>Tumour growth within stent at 5 months – 1 case </li></ul>
  16. 20. SURGERY FOLLOWING ATTEMPTED STENTING <ul><li>10 patients required surgery following attempted stenting – 47.6% </li></ul><ul><li>2 had definitive surgery </li></ul><ul><li>8 had loop colostomies </li></ul>
  17. 21. SUMMARY <ul><li>Technical success achieved in 17 / 21 cases – 81% </li></ul><ul><li>Short term failures – seen in 5 cases – early migration or no relief from obstruction. </li></ul><ul><li>Long-term success achieved in 12 cases(52%) </li></ul><ul><li>One patient had elective surgery following successful stenting </li></ul><ul><li>and in another the stent migrated who also had elective resection. </li></ul><ul><li>One had tumour growth within the stent after 5 months –had loop stoma . </li></ul><ul><li>Out of 21 cases 8 had loop stomas formed </li></ul>
  18. 22. SUMMARY (CONTD) <ul><li>Mortality in one patient with diverticular stricture </li></ul><ul><li>who died of massive Rectal bleed after 3 weeks </li></ul><ul><li>of insertion of stent </li></ul><ul><li>Morbidity was none </li></ul>
  19. 23. CONCLUSION <ul><li>This audit shows that colonic stenting is safe and provides an alternative to palliative colostomy . </li></ul><ul><li>There was no major morbidity. </li></ul><ul><li>Better results may be produced with patient selection , further technical development and more experience . </li></ul><ul><li>Cost of SEMS for palliative cases is less than half of the cost of surgical decompression </li></ul><ul><li>SEMS appear to be a favourable option to consider rather than or prior to surgery </li></ul>
  20. 24. THANK YOU ALL .