Lo stent nelle occlusioni neoplastiche del Colon - Gastrolearning®

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Gastrolearning II modulo/2a lezione
Lo stent nelle occlusioni neoplastiche del Colon
Prof. G. Costamagna - Università Cattolica Sacro Cuore (Roma).

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  • Cumulative incidence of hospitalization for bowel obstruction over time in the baseline cohort of 12 553 patients with stage IV colon cancer in the Surveillance, Epidemiology, and End Results and Medicare claims linked databases for January 1, 1991, through December 31, 2005, stratified by tumor histological type. For reference, the median survival of each group is given. We found no significant difference in survival experience by histological type (P = .29) in a multivariable model of survival since the cancer diagnosis that included age at and year of diagnosis, sex, marital status, patient comorbidity score, primary tumor surgery, chemotherapy after diagnosis, tumor site and grade, and lymph node status. IQR indicates interquartile range.
  • Lo stent nelle occlusioni neoplastiche del Colon - Gastrolearning®

    1. 1. Lo Stent nelle Occlusioni Neoplastiche del Colon Guido Costamagna Catholic University – “A. Gemelli” Hospital European Endoscopy Training Center (EETC) Rome - Italy
    2. 2. Colorectal Cancer Obstruction Presenting symptom in 8-29% of cases
    3. 3. 1991: Esophageal Stents sporadically used for palliation in CRC obstruction 1991 First (esophageal) stent implantation for palliative treatment Dohmoto M, Rupp KD (1991) Dtsch Med Wochenschr 115: 943
    4. 4. Esophageal vs Colorectal Wall Thickness 5-6 mm 3-4 mm
    5. 5. Esophageal vs Colorectal Lumen
    6. 6. 2000: Specifically designed Colorectal Stents
    7. 7. Indications to Colorectal Stents Bridge to Surgery  Acute colonic obstruction Palliation  CR cancer stage IV patients  Unresectable extracolonic neoplasms  Patients unfit for surgery  Patients who refuse colostomy
    8. 8. Literature on CRC and Stents  Multiple retrospective studies   Variability in case-mix  Selection biases   Shortcomings of the published literature Vast heterogeneity in the technical success rates and risk profiles 5 RCT’s
    9. 9. CRC and Stents in 2013 Still No Evidence Based !
    10. 10. Endoscopic Treatment of Advanced CR Carcinoma Bridge-to-Surgery
    11. 11. Bridge-to-Surgery Rationale  To avoid emergency surgery  Allow normal preoperative bowel preparation followed by a one-stage elective procedure  Allows time for resuscitation, re-hydration, and hyper-alimentation  To decrease the rate of stoma formation  Overall lower morbidity and mortality  If Stage IV  Palliation
    12. 12. Bridge-to-Surgery Emergency surgery vs Elective surgery Morbidity 10% - 36% Morbidity 4% - 14% Mortality 6% - 38% Mortality 1% - 13% Often 2-stage procedure with temporary colostomy Colostomy reversal only in 60% Colostomy associated with morbidity and QoL implications Data from Literature
    13. 13. Malignant Colonic Obstruction: Literature Review on CR Stents (1992-2004) 54 Series* 1198 Pts Palliation Bridge to Surgery 791 (66%) 407 (34%) * Technique: Endo-Rx Rx Endo 37 16 1 Sebastian. Am J Gastroenterol 2004; 99: 2051-57
    14. 14. Literature Review on Bridge to Surgey Technical Success 91.9% Clinical Success 78.1%* *Causes of clinical failure: • Locally advanced tumor • Poor preparation • Stent migration • Perforation Am J Gastroenterol 2004
    15. 15. Bridge to Surgery vs Emergency Surgery: Long-Term Prognosis Early complications 14% 12% 10% P<0.05 8% Emerg. Surg. Stent 6% 4% 2% 0% Infections Anast. Leak Saida et Al. Dis Colon Rectum 2003
    16. 16. Bridge to Surgery vs Emergency Surgery: Long-Term Prognosis Survival rate 40% 5 years fu 44% 48% 3 years 0% Emerg. Surg. Stent 50% 20% 40% 60% Saida et Al. Dis Colon Rectum 2003
    17. 17. Cost Analysis of Bridge to surgery vs 2-stage surgical procedure 6000 Cost in GBP (£) 5000 Bridge to surgery and elective resection (n=5) 4000 3000 Hartmann’s operation and reversal (n = 6) 2000 1000 0 Hospital Stent stay Material Theatre/ (excl. radiology stent) suite Total Osman H.S. et al. Colorectal Dis 2000
    18. 18. 2002: A role for Lap Surg Malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic resection Morino et Al. Surg Endosc 2002
    19. 19. Endoscopic Treatment of Advanced CR Carcinoma Palliation
    20. 20. From: Incidence and Predictors of Bowel Obstruction in Elderly Patients With Stage IV Colon Cancer: A Population-Based Cohort Study JAMA Surg. 2013;148(8):715-722. doi:10.1001/jamasurg.2013.1 Copyright © 2012 American Medical Association. All rights reserved.
    21. 21. Effect of primary tumor resection on survival in CRC stage IV Patients Palliative Surgery vs CR Stenting Palliative resection of primary CRC should be pursued in stage IV patients, as this prolongs survival In these pts new schedules of chemotherapy has improved the median survival from around 11 months with conventional regimes to over 20 months with the new ones Cochrane Database Syst Rev 2000 Costi R et al. Ann Surg Oncol 2007 Konyalian VR et al. Colorectal Dis 2007
    22. 22. Malignant Colonic Obstruction: Literature Review on CR Stents Technical Success 93.2% CR tumors 93.5% Extrinsic group 78% Am J Gastroenterol 2004; 99: 2051-57
    23. 23. Stents for Colonic vs Extracolonic Malignancy Colon stenting for large-bowel obstruction from ECM is seldom successful and is associated with a significantly higher risk of complications in comparison with patients with CRC Keswani RN. Gastrointest Endosc 2009
    24. 24. Malignant Colonic Obstruction: Literature Review on CR Stents Clinical Success 88.5% Am J Gastroenterol 2004; 99: 2051-57
    25. 25. Malignant Colonic Obstruction: Literature Review on CR Stents Complications  Stent Migration 11.8%  Re-obstruction 7.3%  Perforation 3.7%  Mortality 0.6% Am J Gastroenterol 2004
    26. 26. Colonic perforation after stent placement for malignant colorectal obstruction – causes and contributing factors Datye A, Hersh J. Minim Invasive Ther Allied Technol. 2011 2287 pts from 82 articles Overall perforation rate: 4.9% Perf rates for P and BTS not significantly different (4.8% vs. 5.4%, p = 0.66); Over 80% of perf occurred within 30 days of stent placement Mortality rate related to perforation: 0.8% Mortality of patients with perforation: 16.2%. No significant difference (p = 0.78) in the mortality rates between the P and the BTS group 
    27. 27. Premature Closure of the Dutch Stent-in I Study Multi -centre, prospective, randomised controlled trial WallFlex stent VS surgery in patients with incurable CRC Study stopped by the Safety Monitoring Committee 21 patients included. 10 patients treated with stenting. Hooft EJ and Dutch Stent-in Study Group. Endoscopy 2008
    28. 28. Premature Closure of the Dutch Stent-in I Study 60% Perforation Rate ! Hooft EJ and Dutch Stent-in Study Group. Lancet 2006
    29. 29. Premature Closure of the Dutch Stent-in I Study Of the seven stented patients who were treated with chemotherapy, four developed a (late) perforation Hooft EJ and Dutch Stent-in Study Group. Lancet 2006
    30. 30. The 11.1% mortality following colonic stenting for obstructing cancers was higher than in published cases and may need further study The Association of Coloproctology of Great Britain and Ireland
    31. 31. Palliative SEMS: Look Out for Perforations ! 3/19 pts (16%) died within a week after the insertion of an Ultraflex Precision Stent Surg Laparosc Endosc Percutan Tech, 2008
    32. 32. CR stents in palliative situation  Complications rates*: 25 - 50 %  Perforation :  Obstruction :  Migration : 5-20 %  5-10 % Ulceration : <5% 10-15 % * 50% of complications are observed after the 1st week Ceze, JFHOD 2007 Fernandez-Esparrach, Am J Gastro 2010 Small, GIE 2011
    33. 33. CR Stents: Risk of Perforation Risk factors for perforation  Chemotherapy  Steroids  Radiotherapy Datye A, Hersh J. Minim Invasive Ther Allied Technol. 2011
    34. 34. Stents vs Surgery: 5 RCT’s van Hooft JE Lancet 2006 van Hooft JE Lancet Oncology 2011 Pirlet IA Surgical Endoscopy 2011 Alcántara M World Journal of Surgery 2011 Ho KS International Journal of Colorectal Disease 2012
    35. 35. Stents vs Surgery: 5 RCT’s  Four were interrupted by the respective ethics committee:    One for the high incidence of perforations (6/11) Other two for the high perforation rate (13% and 6.6%), and for the lack of benefit with regard to quality of life and stoma formation. Only the Study of Alcantara has been discontinued for the high rate of anastomotic dehiscence in one-stage surgery
    36. 36. … consider placing a SEMS to initially manage a left-sided complete or near-complete colonic obstruction Only a healthcare professional experienced in placing colonic stents who has access to fluoroscopic equipment and trained support staff should insert colonic stents If a SEMS is suitable attempt insertion urgently and no longer than 24 hours after patients present with colonic obstruction.
    37. 37. • Systematic review of five RCTs • Higher rates of clinical relief of obstruction in emergency surgery • CR stent has not been shown to be as effective as emergency surgery in malignant colorectal obstructions • Use of CR stent is associated with comparable mortality and morbidity with advantage of shorter hospital stay and procedure time and less blood loss. “Colonic stenting has no decisive advantages to Emergency surgery” Sagar Jayesh Colorectal stents for the management of malignant colonic obstructions 39 Cochrane Database of Systematic Reviews. 2011
    38. 38. UK ColoRectal Stenting Trial (CReST) 2009 –     Pts in emergency setting with left-sided neoplastic colonic obstruction who require urgent decompression Randomised to Stenting Stenting Surgical decompression Surgical decompression +/+/Resection Resection
    39. 39. To Stent or Not to Stent That Is the Question The question of stenting, therefore, remains unanswered. It seems a reasonable approach for patients with incurable cancer who have a left-sided obstruction or those who are not fit for an operation. Questions arise as to the need for stents as a bridge to surgical intervention given the high rate of stoma formation despite decompression with a stent. Any risk of perforation in a patient with a potentially curable obstruction is not acceptable because it converts a curable obstruction into one destined for
    40. 40. Possible worsening of QoL even after a successful SEMS insertion    … An elderly woman who presented with an obstructing metastatic rectal cancer underwent ‘successful’ insertion of SEMS and was subsequently managed by the palliative care team. She died peacefully after 6 months … The twist of the story was that she spent her remaining days mostly on the toilet as the stent made her incontinent… D. Debnath. Br J Surg 2004
    41. 41. Stent Palliation of Malignant Colonic Obstruction Bowel function is often poor in patients treated with CR stents  Functional outcome should be discussed fully during the consenting process for the procedure.  Colorectal Disease 2006, 7
    42. 42. Contraindications to Colorectal Stents  Long Life Expectancy  Right sided occlusions  Incomplete occlusion  Cancers ≤ 5 cm from the anal verge  Severe anemia by bleeding cancers  (Extracolonic Malignancies)
    43. 43. • The decision to insert a SEMS or to perform a colostomy involves multiple areas of uncertainty… • The longer a SEMS remains in place, the greater the amount of uncertainty surrounding its effectiveness and the higher the probability that surgery is the preferred alternative da Silveira E, Barkun AN. Gastrointest Endosc. 2008.
    44. 44. • Utilization of SEMS for conditions that have not been thoroughly investigated (ie, long-term palliation of CRC) cannot be recommended yet ... • … but short ‘‘bridges’’ from acute obstruction to surgery can be safely ‘‘crossed’’ with the endoscopic insertion of a colonic SEMS da Silveira E, Barkun AN. Gastrointest Endosc. 2008.
    45. 45. Stent Palliation of Malignant Colonic Obstruction Take Home Messages  Acute Occlusion = Bridge to Surgery  Palliation: Stent only if occlusion  If CT planned, consider resection  Discuss with the patient (Informed Consent) !

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