Colonic stenting is an endoscopic procedure used to relieve large bowel obstruction caused by malignant tumors. It allows for patient evaluation and staging, avoids emergency surgery and stomas, and can provide long-term palliation. While technically challenging, stenting has high rates of technical and clinical success for both bridge to surgery and palliative cases when performed by an experienced multidisciplinary team. However, there are risks of perforation and re-obstruction that require careful patient selection, especially for those receiving bevacizumab therapies.

1. Colonic Stenting Alessandro Repici, MD Digestive Endoscopy Unit Department of Gastroenterology IRCCS Istituto Clinico Humanitas, Milano, Italy

2. Large Bowel Obstruction (LBO)

12. Baron TH, Endoscopy 2010

13. first 25-30 cm Rest of colon OTW STENT TTS STENT

16. Pooled analysis of clinical and technical success rates (54 trials – 1198 patients) Sebastian S et al. Am J Gastroenterol 2004 Group Number Cumulative Range Technical success Overall 1198 93% 64-100 Palliative 791 93% 67-100 Bridge to surgery 407 92% 33-100 Clinical success Overall 1198 89% 55-100 Palliative 791 91% 62-100 Bridge to surgery 407 72% 45-84

17. Br J Surgery 2007

18. Arch Surg 2009

19. Repici A et al GIE 2008 Long-term palliation

21. There is concern about risk of perforation Van Hooft J et al Endoscopy 2008

22. Author Journal Pts Palliation/ BTS Type of stent Complications (%) Perforations (%) Law WL Colorectal Dis 2010 130 101/29 Esoph.Wallstent Colon Wallflex Choostent Enteral Wallstent Ultraflex 20 1,5 Baraza W. Colorectal Dis 2008 63 56/7 Niti-S Bard Memotherm 25 0 M. Alcantara Tech Coloproctol 2007 95 (103 SEMS) 28/67 Enteral Wallstent Esophacoil Hanaro stent Wallflex 13.7 4.2 Giovannini MD J clin Gastroenterol 2008 36 (52 SEMS) 36/0 Choostent Wallstent Hanaro stent 35 7.5 Brehant O Colorectal Dis 2009 30 0/30 Wallflex 23 7 Min Kyu Jung Surg Endosc 2009 39 39/0 Niti-S Hanarostent Wallflex Early 12.8 Late 11.8 Early 2.6 Late 2.9 S. Mucci-Hennekinne Surg Endosc 2007 67 55/12 Hanarostent ? 6,2 Repici A Gastroint Endosc 2008 42 23/19 Wallflex Early 9.5 Late 14.3 2.4 Jong Pil Im Int J Colorectal Dis 2008 49 pts (51SEMS) 49/0 Hanaro MI Tech 24 2

23. Small AJ et al. GIE 2010 Bevacizumab-based therapies and Colonic perforation after SEMS placement Is it time for a warning? Bevacizumab-based therapies Treated Untreated P 15.4% 6.8% 0.06

24. Cennamo V et al Clin Gastroenterol Hepatol 2009

25. 49 y old lady: Feb-July 2009 FOLFOX4 Sept 2009-Jan 2010 FOLFIRI+Bevacizumab Feb 02 2010 Feb 04 2010 March 11 2010

26. Hapani S, et al Lancet Oncology 2009