Safety of self expandingSafety of self expanding metal stents metal stents

for left sided large bowel for left sided large bowel obstruction obstruction

V Rao, R.S HUSSEIN, S I V Rao, R.S HUSSEIN, S I Haider, Haider,

T M Hunt,T M Hunt,R Orme, M SmithR Orme, M Smith

Colorectal Surgery UnitColorectal Surgery Unit Royal Shrewsbury HospitalRoyal Shrewsbury Hospital

UK SERIESUK SERIES

Systematic review ofSystematic review of

the clinical evidence onthe clinical evidence on

colorectal self expandingcolorectal self expanding

metal stents metal stents

Published in BJSPublished in BJS

2002;89:1096-102-M C2002;89:1096-102-M C

Parker et al-DartfordParker et al-Dartford

598 cases were 598 cases were stentedstented

Technical failure in Technical failure in 47(8%)47(8%)

Main reasons Main reasons

1.1. Access failure 86% Access failure 86%

2.2. Malposition 9% Malposition 9%

3.3. Perforation 5%Perforation 5%

UK SERIES (Contd)UK SERIES (Contd)

Mortality in 3 patients (0.5%) Mortality in 3 patients (0.5%) Perforation in 22 (0.4%)Perforation in 22 (0.4%) Stent migration in 54 patients (10%)Stent migration in 54 patients (10%) Bleeding in 27 (5%)Bleeding in 27 (5%) Pain in 31 (5%)Pain in 31 (5%) Reobstruction in 52 (10%)Reobstruction in 52 (10%)

AIM OF THE STUDYAIM OF THE STUDY

To find out the indications of stent placementTo find out the indications of stent placement

To review the complications and difficulties in stentingTo review the complications and difficulties in stenting

Its outcomeIts outcome

Patients requiring surgery following stentingPatients requiring surgery following stenting

Duration of stent in situDuration of stent in situ

METHODSMETHODS

Retrospective review of all patients who Retrospective review of all patients who underwent colonic stenting,our initial experience underwent colonic stenting,our initial experience

Total 21 case notes were reviewedTotal 21 case notes were reviewed

Proforma designed , data compiled and Proforma designed , data compiled and

interpreted .interpreted .

Results - Age groupResults - Age group

0

1

2

3

4

5

6

7

8

50-60 yrs 61-70 yrs 71 to 80 > 80 yrs

INVESTIGATIONS PERFORMEDINVESTIGATIONS PERFORMED

0

5

10

15

20

25

BAE FS CT USG HPstudy

INVESTIGATION (contd)INVESTIGATION (contd)Histopathological Histopathological confirmation achieved in confirmation achieved in 18 cases ( 86% )18 cases ( 86% )

15 proved to be adeno 15 proved to be adeno carcinomacarcinoma

Inflamed tissue – 1 case Inflamed tissue – 1 case –diverticular stricture–diverticular stricture

Liver bx in one case Liver bx in one case showed microacinar showed microacinar adeno caadeno ca

Omental bx – taken in a Omental bx – taken in a case of Ovarian cancercase of Ovarian cancer

3 cases did not have 3 cases did not have histological confirmation as histological confirmation as in two cases there was in two cases there was radiological evidence of radiological evidence of metastatic disease and in metastatic disease and in the other it was based on the other it was based on clinical diagnosis based on clinical diagnosis based on flexible sigmoidoscopy. flexible sigmoidoscopy.

Presently we are Presently we are performing contrast enema performing contrast enema for everyone to know the for everyone to know the anatomy of the large bowel anatomy of the large bowel before stentingbefore stenting

SITE OF TUMOURSITE OF TUMOUR

20 cases were left sided tumours-95 %20 cases were left sided tumours-95 %

Extrinsic compression – 1 case – Ovarian Extrinsic compression – 1 case – Ovarian

tumour with peritoneal metstumour with peritoneal mets

INDICATIONS OF STENTINDICATIONS OF STENT

16 Cases were palliative 16 Cases were palliative with obstructive with obstructive symptoms – 76%symptoms – 76%

One case extrinsic One case extrinsic obstruction of large bowel obstruction of large bowel from ovarian cancerfrom ovarian cancer

one case was acutely one case was acutely obstructed and was obstructed and was stented temporarily to stented temporarily to relieve obstruction prior to relieve obstruction prior to elective sigmoid elective sigmoid colectomy after colectomy after

1 month of stent insertion1 month of stent insertion

In one case stent was In one case stent was attempted as he was attempted as he was having a synchronous having a synchronous primary lung cancer along primary lung cancer along with recto sigmoid tumourwith recto sigmoid tumour

One case had diverticular One case had diverticular stricture and had potential stricture and had potential medical problems and medical problems and was therefore stentedwas therefore stented

Palliative obstructive Palliative obstructive symptoms in a psychiatric symptoms in a psychiatric patient who refused patient who refused treatmenttreatment

DURING STENTINGDURING STENTINGWell placed in 17 cases Well placed in 17 cases – 81 %– 81 %

Failure of the guide wire Failure of the guide wire through the tumour – 4 through the tumour – 4 cases – 19 %cases – 19 %

3 had loop stomas and 3 had loop stomas and one refused surgeryone refused surgery

Two Perforations Two Perforations occurred during guide occurred during guide wire insertion which were wire insertion which were conservatively managedconservatively managed

02468

1012141618

wellplaced

failed

FOLLOWING STENTINGFOLLOWING STENTING

Technical success achieved in 17 cases-81%Technical success achieved in 17 cases-81%

Good position achieved in 12 cases – 71%Good position achieved in 12 cases – 71%

Stent migrated in 3 cases – in less than 4 Stent migrated in 3 cases – in less than 4 weeks(17.6%) weeks(17.6%)

Failed to relieve obstruction(clinical and radiological Failed to relieve obstruction(clinical and radiological failures) in 2 cases failures) in 2 cases

both of them had loop colostomiesboth of them had loop colostomies

These 5 cases 4 had loop stomas and one had elective These 5 cases 4 had loop stomas and one had elective resectionresection

FOLLOWING STENTINGFOLLOWING STENTING

0

2

4

6

8

10

12

good migrated failed

DURATION STENTS LASTEDDURATION STENTS LASTED

Short term duration (less than 4 weeks) – Short term duration (less than 4 weeks) –

5 cases5 cases

Long term duration (more than 4 weeks) – Long term duration (more than 4 weeks) –

12 cases12 cases

Duration of patency was from 2 weeks to 16 Duration of patency was from 2 weeks to 16

monthsmonths

DURATION OF STENT (CONTD)DURATION OF STENT (CONTD)

Successful stenting was achieved in 12 casesSuccessful stenting was achieved in 12 cases

4 still have it – 23.5% – 2 months to 14 months4 still have it – 23.5% – 2 months to 14 months

One had elective SurgeryOne had elective Surgery

Died unrelated to stent with stent in situ –Died unrelated to stent with stent in situ – 6 cases – 3 days to 16 months6 cases – 3 days to 16 months

Tumour growth within stent at 5 months – 1 case Tumour growth within stent at 5 months – 1 case

SURGERY FOLLOWING SURGERY FOLLOWING ATTEMPTED STENTINGATTEMPTED STENTING

10 patients required 10 patients required surgery following surgery following attempted stenting – attempted stenting – 47.6%47.6%

2 had definitive 2 had definitive surgery surgery

8 had loop 8 had loop colostomies colostomies

0

1

2

3

4

5

6

7

8

elective loop

SUMMARYSUMMARY

Technical success Technical success achieved in 17 / 21 achieved in 17 / 21 cases – 81%cases – 81%

Short term failures – seen Short term failures – seen in 5 cases – early in 5 cases – early migration or no relief migration or no relief from obstruction.from obstruction.

Long-term success Long-term success achieved in 12 achieved in 12 cases(52%) cases(52%)

One patient had elective One patient had elective surgery following surgery following successful stenting successful stenting

and in another the stent and in another the stent migrated who also had migrated who also had elective resection.elective resection.

One had tumour growth One had tumour growth within the stent after 5 within the stent after 5 months –had loop stoma .months –had loop stoma .

Out of 21 cases 8 had Out of 21 cases 8 had loop stomas formedloop stomas formed

SUMMARY (CONTD)SUMMARY (CONTD)

Mortality in one patient with diverticular stricture Mortality in one patient with diverticular stricture

who died of massive Rectal bleed after 3 weeks who died of massive Rectal bleed after 3 weeks

of insertion of stentof insertion of stent

Morbidity was none Morbidity was none

CONCLUSIONCONCLUSION

This audit shows that colonic stenting is safe This audit shows that colonic stenting is safe and provides an alternative to palliative and provides an alternative to palliative colostomy .colostomy .

There was no major morbidity.There was no major morbidity.

Better results may be produced with patient Better results may be produced with patient selection , further technical development and selection , further technical development and more experience . more experience .

Cost of SEMS for palliative cases is less than Cost of SEMS for palliative cases is less than half of the cost of surgical decompressionhalf of the cost of surgical decompression

SEMS appear to be a favourable option to SEMS appear to be a favourable option to consider rather than or prior to surgeryconsider rather than or prior to surgery