RESUMEN
BACKGROUND: Cervical anastomotic strictures after esophagectomy cause significant disease burden. We aimed to study the technical feasibility and safety of intensive endoscopic therapy. METHODS: In this pilot study, we included 15 patients with an untreated benign cervical anastomotic stricture after esophagectomy. Intensive endoscopic therapy comprised three endoscopic modalities: in- and excision using a needle-knife, intralesional steroid injections and bougie dilation. In two endoscopic procedures, the stricture was dilated up to a luminal diameter of 18 mm. Patients were followed up to 6 months. RESULTS: A luminal diameter of 18 mm was achieved in 13 of 15 patients (87%) after two endoscopic procedures. No major adverse events related to the investigational treatment occurred. Median dysphagia scores significantly improved from 2 (IQR, interquartile range, 2-3) at baseline to 0 (IQR 0-1) after 14 days (p < 0.001). Eleven (73%) patients developed recurrent symptoms of dysphagia requiring a median of 1 (IQR 0-3) additional endoscopic dilation procedure. CONCLUSIONS: Achieving a luminal diameter of 18 mm in two procedures with intensive endoscopic therapy was technically feasible and effective in reducing dysphagia rapidly in patients with a cervical anastomotic stricture after esophagectomy. No major adverse events related to the investigational treatment were observed.
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Trastornos de Deglución , Estenosis Esofágica , Humanos , Esofagectomía/efectos adversos , Esofagectomía/métodos , Constricción Patológica/etiología , Proyectos Piloto , Trastornos de Deglución/etiología , Trastornos de Deglución/terapia , Estenosis Esofágica/etiología , Estenosis Esofágica/terapia , Resultado del Tratamiento , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Dilatación/métodos , Estudios RetrospectivosRESUMEN
OBJECTIVE: The purpose of this population-based study was to compare decompressing stoma (DS) as bridge to surgery (BTS) with emergency resection (ER) for left-sided obstructive colon cancer (LSOCC) using propensity-score matching. SUMMARY BACKGROUND DATA: Recently, an increased use of DS as BTS for LSOCC has been observed in the Netherlands. Unfortunately, good quality comparative analyses with ER are scarce. METHODS: Patients diagnosed with nonlocally advanced LSOCC between 2009 and 2016 in 75 Dutch hospitals, who underwent DS or ER in the curative setting, were propensity-score matched in a 1:2 ratio. The primary outcome measure was 90-day mortality, and main secondary outcomes were 3-year overall survival and permanent stoma rate. RESULTS: Of 2048 eligible patients, 236 patients who underwent DS were matched with 472 patients undergoing ER. After DS, more laparoscopic resections were performed (56.8% vs 9.2%, P < 0.001) and more primary anastomoses were constructed (88.5% vs 40.7%, P < 0.001). DS resulted in significantly lower 90-day mortality compared to ER (1.7% vs 7.2%, P = 0.006), and this effect could be mainly attributed to the subgroup of patients over 70 years (3.5% vs 13.7%, P = 0.027). Patients treated with DS as BTS had better 3-year overall survival (79.4% vs 73.3%, hazard ratio 0.36, 95% confidence interval 0.20-0.65) and fewer permanent stomas (23.4% vs 42.4%, P < 0.001). CONCLUSIONS: In this nationwide propensity-score matched study, DS as a BTS for LSOCC was associated with lower 90-day mortality and better 3-year overall survival compared to ER, especially in patients over 70 years of age.
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Neoplasias del Colon/cirugía , Colostomía , Obstrucción Intestinal/cirugía , Anciano , Neoplasias del Colon/mortalidad , Descompresión Quirúrgica , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Femenino , Humanos , Obstrucción Intestinal/mortalidad , Masculino , Países Bajos , Complicaciones Posoperatorias/mortalidad , Puntaje de Propensión , Sistema de Registros , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. 1 : ESGE recommends colonic stenting to be reserved for patients with clinical symptoms and radiological signs of malignant large-bowel obstruction, without signs of perforation. ESGE does not recommend prophylactic stent placement.Strong recommendation, low quality evidence. 2 : ESGE recommends stenting as a bridge to surgery to be discussed, within a shared decision-making process, as a treatment option in patients with potentially curable left-sided obstructing colon cancer as an alternative to emergency resection.Strong recommendation, high quality evidence. 3 : ESGE recommends colonic stenting as the preferred treatment for palliation of malignant colonic obstruction.Strong recommendation, high quality evidence. 4 : ESGE suggests consideration of colonic stenting for malignant obstruction of the proximal colon either as a bridge to surgery or in a palliative setting.Weak recommendation, low quality evidence. 5 : ESGE suggests a time interval of approximately 2 weeks until resection when colonic stenting is performed as a bridge to elective surgery in patients with curable left-sided colon cancer.Weak recommendation, low quality evidence. 6 : ESGE recommends that colonic stenting should be performed or directly supervised by an operator who can demonstrate competence in both colonoscopy and fluoroscopic techniques and who performs colonic stenting on a regular basis.Strong recommendation, low quality evidence. 7 : ESGE suggests that a decompressing stoma as a bridge to elective surgery is a valid option if the patient is not a candidate for colonic stenting or when stenting expertise is not available.Weak recommendation, low quality evidence.
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Neoplasias del Colon , Obstrucción Intestinal , Stents Metálicos Autoexpandibles , Neoplasias del Colon/complicaciones , Neoplasias del Colon/cirugía , Colonoscopía , Endoscopía Gastrointestinal , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , StentsRESUMEN
BACKGROUND AND STUDY AIMS: Sealing esophageal leaks by stent placement allows healing in 44â%â-â94â% of patients. We aimed to develop a prediction rule to predict the chance of successful stent therapy. PATIENTS AND METHODS: In this multicenter retrospective cohort study, patients with benign upper gastrointestinal leakage treated with stent placement were included. We used logistic regression analysis including four known clinical predictors of stent therapy outcome. The model performance to predict successful stent therapy was evaluated in an independent validation sample. RESULTS: We included etiology, location, C-reactive protein, and size of the leak as clinical predictors. The model was estimated from 145 patients (derivation sample), and 59 patients were included in the validation sample. Stent therapy was successful in 55.9â% and 67.8â% of cases, respectively. The predicted probability of successful stent therapy was significantly higher in success patients compared with failure patients in both the derivation (Pâ<â0.001) and validation (Pâ<â0.001) samples. The area under the receiver operating characteristic curve was 74.1â% in the derivation sample and 84.7â% in the validation sample. When the model predictedâ≥â70â% chance of success, the positive predictive value was 79â% in the derivation sample and 87â% in the validation sample. When the model predictedâ≤â50â% chance of success, the negative predictive value was 64â% and 86â%, respectively. CONCLUSIONS: This prediction rule, consisting of four clinical predictors, could identify patients with esophageal leaks who were likely to benefit from or fail on stent therapy. The prediction rule can support clinical decision-making when the predicted probability of success isâ≥â70â% orâ≤â50â%.
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Fuga Anastomótica/cirugía , Endoscopía Gastrointestinal/métodos , Fístula Esofágica/cirugía , Perforación del Esófago/cirugía , Esófago/cirugía , Stents , Fuga Anastomótica/diagnóstico , Fístula Esofágica/diagnóstico , Perforación del Esófago/diagnóstico , Esófago/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Patients with therapy-resistant benign esophageal strictures (TRBES) suffer from chronic dysphagia and generally require repeated endoscopic dilations. For selected patients, esophageal self-dilation may improve patient's autonomy and reduce the number of endoscopic dilations. We evaluated the clinical course and outcomes of patients who started esophageal self-dilation at our institution. METHODS: This study was a retrospective case series of patients with TRBES who started esophageal self-dilation between 2012 and 2016 at the Academic Medical Center Amsterdam. To learn self-dilation using Savary-Gilliard bougie dilators, patients visited the outpatient clinic on a weekly basis where they were trained by a dedicated nurse. Endoscopic dilation was continued until patients were able to perform self-bougienage adequately. The primary outcome was the number of endoscopic dilation procedures before and after initiation of self-dilation. Secondary outcomes were technical success, final bougie size, dysphagia scores, and adverse events. RESULTS: Seventeen patients started with esophageal self-dilation mainly because of therapy-resistant post-surgical (41%) and caustic (35%) strictures. The technical success rate of learning self-bougienage was 94% (16/17). The median number of endoscopic dilation procedures dropped from 17 [interquartile range (IQR) 11-27] procedures during a median period of 9 (IQR 6-36) months to 1.5 (IQR 0-3) procedures after the start of self-dilation (p < 0.001). The median follow-up after initiation of self-dilation was 17.6 (IQR 11.5-33.3) months. The final bougie size achieved with self-bougienage had a median diameter of 14 (IQR 13-15) mm. All patients could tolerate solid foods (Ogilvie dysphagia score ≤ 1), making the clinical success rate 94% (16/17). One patient (6%) developed a single episode of hematemesis related to self-bougienage. CONCLUSIONS: In this small case series, esophageal self-dilation was found to be successful 94% of patients when conducted under strict guidance. All patients performing self-bougienage achieved a stable situation where they could tolerate solid foods without the need for endoscopic dilation.
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Dilatación/métodos , Estenosis Esofágica/terapia , Autocuidado , Adulto , Anciano , Dilatación/instrumentación , Endoscopía/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto , Estudios RetrospectivosRESUMEN
BACKGROUND: The optimal target of endoscopic dilation of postsurgical esophageal strictures is unknown. Our aim was to compare the dilation-free period of patients who underwent dilation up to 16 mm with patients who were dilated up to 17 or 18 mm. METHODS: We retrospectively analyzed adult patients who received bougie/balloon dilation for a benign anastomotic stricture after esophagectomy. An anastomotic stricture was defined as dysphagia in combination with a luminal diameter of ≤13 mm at endoscopy. We analyzed the dilation-free period using Kaplan-Meier and multivariable Cox regression analysis. RESULTS: Eighty-eight patients were dilated up to a maximum diameter of 16 mm and 91 patients to a diameter >16 mm. The stricture recurrence rate was 79.5 % in the 16 mm group and 68.1 % in the >16 mm group (p = 0.083). The overall dilation-free period had a median of 41.5 (range 8-3233) days and 92 (range 17-1745) days, respectively (p < 0.001). For patients who developed a stricture recurrence, the median dilation-free period was 28 (range 8-487) days and 63 (range 17-1013) days, respectively (p = 0.001). Cox regression analysis showed a reduced risk of stricture recurrence for patients who were dilated up to >16 mm: crude hazard ratio (HR) 0.57 (95 % confidence interval (CI) 0.41-0.81) and adjusted HR 0.48 (95 % CI 0.33-0.70). CONCLUSIONS: Endoscopic dilation over 16 mm resulted in a significant prolongation of the dilation-free period in comparison with dilation up to 16 mm in patients with benign anastomotic strictures after esophagectomy.
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Dilatación/métodos , Estenosis Esofágica/terapia , Esofagectomía , Esofagoscopía/métodos , Esófago/cirugía , Complicaciones Posoperatorias/terapia , Adulto , Anciano , Anastomosis Quirúrgica , Estenosis Esofágica/etiología , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Recurrencia , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement. OBJECTIVE: To identify risk factors for perforation from colonic stenting. DESIGN: A meta-analysis of 86 studies published between 2005 and 2011. SETTING: Multicenter review. PATIENTS: All patients who underwent colorectal stent placement. INTERVENTION: Colorectal stent placement. MAIN OUTCOME MEASUREMENTS: The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab. RESULTS: A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%). LIMITATIONS: Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis. CONCLUSIONS: The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.
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Colon/lesiones , Enfermedades del Colon/cirugía , Obstrucción Intestinal/cirugía , Perforación Intestinal , Complicaciones Intraoperatorias , Medición de Riesgo/métodos , Stents/efectos adversos , Salud Global , Humanos , Incidencia , Perforación Intestinal/diagnóstico , Perforación Intestinal/epidemiología , Perforación Intestinal/etiología , Factores de RiesgoRESUMEN
This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. 1 Prophylactic colonic stent placement is not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation (strong recommendation, low quality evidence). 2 Colonic self-expandable metal stent (SEMS) placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction (strong recommendation, high quality evidence). 3 For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, I. e. American Society of Anesthesiologists (ASA) Physical Status ≥ III and/or age > 70 years (weak recommendation, low quality evidence). 4 SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction (strong recommendation, high quality evidence), except in patients treated or considered for treatment with antiangiogenic drugs (e. g. bevacizumab) (strong recommendation, low quality evidence).
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Neoplasias del Colon/complicaciones , Obstrucción Intestinal/terapia , Cuidados Paliativos/métodos , Stents , Colonoscopía , Humanos , Obstrucción Intestinal/etiología , Selección de Paciente , Implantación de Prótesis/métodosRESUMEN
BACKGROUND: Temporary placement of self-expandable stents has been increasingly used for the management of benign esophageal diseases. OBJECTIVE: To evaluate the safety of endoscopic removal of esophageal self-expandable stents placed for the treatment of benign esophageal diseases. DESIGN: Multicenter retrospective study. SETTING: Six tertiary care centers in the United States and Europe. PATIENTS: A total of 214 patients with benign esophageal diseases undergoing endoscopic stent removal. INTERVENTION: Endoscopic stent removal. MAIN OUTCOME MEASUREMENTS: Endoscopic techniques for stent removal, time to stent removal, and adverse events related to stent removal. RESULTS: A total of 214 patients underwent a total of 329 stent extractions. Stents were mainly placed for refractory strictures (49.2%) and fistulae (49.8%). Of the removed stents, 52% were fully covered self-expandable metal stents (FCSEMSs), 28.6% were partially covered self-expandable metal stents (PCSEMSs), and 19.5% were self-expandable plastic stents. A total of 35 (10.6%) procedure-related adverse events were reported, including 7 (2.1%) major adverse events. Multivariate analysis revealed that use of PCSEMSs (P < .001) was a risk factor for adverse events during stent removal. Favorable factors for successful stent removal were FCSEMSs (P ≤ .012) and stent migration (P = .010). No significant associations were found for stent indwelling time (P = .145) and stent embedding (P = .194). LIMITATIONS: Retrospective analysis, only tertiary care centers. CONCLUSIONS: With an acceptable major adverse event rate of 2.1%, esophageal stent removal in the setting of benign disease was found to be a safe and feasible procedure. FCSEMSs were more successfully removed than self-expandable plastic stents and PCSEMSs. Adverse events caused by stent removal were not time dependent.
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Remoción de Dispositivos/métodos , Enfermedades del Esófago/terapia , Stents , Remoción de Dispositivos/efectos adversos , Seguridad de Equipos , Esofagoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents/efectos adversosAsunto(s)
Enfermedades del Colon/terapia , Neoplasias Colorrectales/complicaciones , Obstrucción Intestinal/terapia , Stents Metálicos Autoexpandibles , Enfermedades del Colon/etiología , Enfermedades del Colon/cirugía , Neoplasias Colorrectales/cirugía , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Recurrencia Local de Neoplasia/etiología , Recurrencia Local de Neoplasia/prevención & control , Stents Metálicos Autoexpandibles/efectos adversosRESUMEN
Importance: Bridge to elective surgery using self-expandable metal stent (SEMS) placement is a debated alternative to emergency resection for patients with left-sided obstructive colon cancer because of oncologic concerns. A decompressing stoma (DS) might be a valid alternative, but relevant studies are scarce. Objective: To compare DS with SEMS as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer using propensity score matching. Design, Setting, and Participants: This national, population-based cohort study was performed at 75 of 77 hospitals in the Netherlands. A total of 4216 patients with left-sided obstructive colon cancer treated from January 1, 2009, to December 31, 2016, were identified from the Dutch Colorectal Audit and 3153 patients were studied. Additional procedural and intermediate-term outcome data were retrospectively collected from individual patient files, resulting in a median follow-up of 32 months (interquartile range, 15-57 months). Data were analyzed from April 7 to October 28, 2019. Exposures: Decompressing stoma vs SEMS as a bridge to surgery. Main Outcomes and Measures: Primary anastomosis rate, postresection presence of a stoma, complications, additional interventions, permanent stoma, locoregional recurrence, disease-free survival, and overall survival. Propensity score matching was performed according to age, sex, body mass index, American Society of Anesthesiologists score, prior abdominal surgery, tumor location, pN stage, cM stage, length of stenosis, and year of resection. Results: A total of 3153 of the eligible 4216 patients were included in the study (mean [SD] age, 69.7 [11.8] years; 1741 [55.2%] male); after exclusions, 443 patients underwent bridge to surgery (240 undergoing DS and 203 undergoing SEMS). Propensity score matching led to 2 groups of 121 patients each. Patients undergoing DS had more primary anastomoses (104 of 121 [86.0%] vs 90 of 120 [75.0%], P = .02), more postresection stomas (81 of 121 [66.9%] vs 34 of 117 [29.1%], P < .001), fewer major complications (7 of 121 [5.8%] vs 18 of 118 [15.3%], P = .02), and more subsequent interventions, including stoma reversal (65 of 113 [57.5%] vs 33 of 117 [28.2%], P < .001). After DS and SEMS, the 3-year locoregional recurrence rates were 11.7% for DS and 18.8% for SEMS (hazard ratio [HR], 0.62; 95% CI, 0.30-1.28; P = .20), the 3-year disease-free survival rates were 64.0% for DS and 56.9% for SEMS (HR, 0.90; 95% CI, 0.61-1.33; P = .60), and the 3-year overall survival rates were 78.0% for DS and 71.8% for SEMS (HR, 0.77; 95% CI, 0.48-1.22; P = .26). Conclusions and Relevance: The findings suggest that DS as bridge to resection of left-sided obstructive colon cancer is associated with advantages and disadvantages compared with SEMS, with similar intermediate-term oncologic outcomes. The existing equipoise indicates the need for a randomized clinical trial that compares the 2 bridging techniques.
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Enfermedades del Colon/etiología , Enfermedades del Colon/cirugía , Neoplasias del Colon/complicaciones , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Stents Metálicos Autoexpandibles , Estomas Quirúrgicos , Anciano , Anciano de 80 o más Años , Enfermedades del Colon/mortalidad , Femenino , Humanos , Obstrucción Intestinal/mortalidad , Masculino , Persona de Mediana Edad , Periodo Preoperatorio , Puntaje de Propensión , Estudios Retrospectivos , Tasa de SupervivenciaAsunto(s)
Colon/cirugía , Enfermedades del Colon/cirugía , Colonoscopía/métodos , Obstrucción Intestinal/cirugía , Stents , Neoplasias Abdominales/complicaciones , Colon/diagnóstico por imagen , Enfermedades del Colon/diagnóstico por imagen , Enfermedades del Colon/etiología , Neoplasias del Colon/complicaciones , Colonografía Tomográfica Computarizada , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/etiología , Tomografía Computarizada por Rayos XAsunto(s)
Remoción de Dispositivos/métodos , Enfermedades del Esófago/terapia , Stents , Femenino , Humanos , MasculinoRESUMEN
Self-expanding metal stents can be considered as initial treatment for malignant large bowel obstruction in the palliative setting. It is suggested that systemic anti-angiogenic therapy increases the risk of stent perforation. We report a 65-year-old woman with a metastatic, obstructing colon tumor who has been successfully treated with stent placement and chemoimmunotherapy consisting of capecitabine and bevacizumab for 8 years.
RESUMEN
AIM: To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature. METHODS: The PubMed, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics. RESULTS: Fully covered self-expandable metal stents (FC SEMS) (n = 85), biodegradable (BD) stents (n = 77) and self-expandable plastic stents (SEPS) (n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major (17.7%) and minor (13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks (64.5%), iatrogenic perforations (19.6%), Boerhaave's syndrome (7.8%) and fistulae (3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major (7.8%) and minor (5.5%) complications. CONCLUSION: The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforations and fistulae is promising.
RESUMEN
AIM: To provide an overview of the clinical outcomes of self-expandable metal stent (SEMS) placement for malignant gastric outlet obstruction (MGOO). METHODS: A systematic literature search was performed in PubMed of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success, defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs (PCSEMSs) and uncovered SEMSs (UCSEMSs) using Fisher's exact test. RESULTS: A total of 19 studies, including 1281 patients, were included in the final analysis. Gastric (42%) and pancreatic (37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients, mainly caused by re-obstruction (12.6%) and stent migration (4.3%), and was comparable between PCSEMSs and UCSEMSs (21.2% vs 19.1%, respectively, P = 0.412). Re-obstruction was more common with UCSEMSs (14.9% vs 5.1%, P < 0.001) and stent migration was more frequent after PCSEMS placement (10.9% vs 2.2%, P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients, including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies. CONCLUSION: The clinical outcomes in this large population showed that enteral stent placement was feasible, effective and safe. Therefore, stent placement is a valid treatment option for the palliation of MGOO.
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Obstrucción de la Salida Gástrica/terapia , Gastroscopía/instrumentación , Metales , Neoplasias/complicaciones , Cuidados Paliativos , Stents , Migración de Cuerpo Extraño/etiología , Obstrucción de la Salida Gástrica/diagnóstico , Obstrucción de la Salida Gástrica/etiología , Hemorragia Gastrointestinal/etiología , Gastroscopía/efectos adversos , Humanos , Diseño de Prótesis , Falla de Prótesis , Radiografía Intervencional , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
When choosing a treatment for obstructing left-sided colonic carcinoma, a distinction is made between patients with increased surgical risk and patients without increased surgical risk. Patients with increased surgical risk (age > 70 years or ASA class ≥ 3) do have an indication for stent placement as a bridge to elective surgery, or as an alternative, a decompressing colostomy. Acute resection is the treatment of choice in patients without increased surgical risk, given the oncological risk associated with guidewire-related or stent-related perforation. Stent placement is recommended as the palliative treatment for patients with malignant colonic obstruction, unless the patient is simultaneously being treated with angiogenesis inhibitors (e.g. bevacizumab) as these increase the risk of stent perforation. Expertise of at least 20 colonic stent procedures is required for stent placement.