[Standardization of surgical care for malignant colonic obstruction]. / Standartizatsiia khirurgicheskoi pomoshchi pri kolorektal'nom rake, oslozhnennom obturatsionnoi kishechnoi neprokhodimost'iu.

AIM: To standardize surgical care for malignant colonic obstruction. MATERIAL AND METHODS: There were 572 patients with malignant colonic obstruction: 247 of them were hospitalized in 2011-2013 (I group); 325 - in 2014-2017 (group II). Forty-six patients underwent medication; 302 - acute resection; 141 - stoma construction; 83 - stent deployment. Elective surgery and radiation or chemotherapy was performed after 0.5-6 months in 110 patients of group II. Acute resection was more common in I group, elective resection - in group II. Early and long-term results including Kaplan-Meier 3-year overall survival were compared in both groups. RESULTS: Complications occurred in 46.69% (group I) and 21% (group II). Postoperative mortality was significantly higher in group I compared with II group: 26.11 and 10.33%, respectively. Three-year overall survival was higher in group I compared with group II: 0.82 and 0.69, respectively. CONCLUSION: Advisability of new two-stage surgical standard is confirmed for malignant colonic obstruction. Stoma formation and stenting may be a valid alternative in some patients with malignant colonic obstruction due to significantly lower postoperative mortality.

[The optimal terms of the second stage of treatment of patients with malignant colonic obstruction]. / Optimal'nye sroki vypolneniia vtorogo étapa lecheniia bol'nykh kolorektal'nym rakom, oslozhnennym obturatsionnoi tolstokishechnoi neprokhodimost'iu.

AIM: To determine the optimal terms of the second stage of treatment of patients with malignant colonic obstruction. MATERIAL AND METHODS: There were 110 patients with colorectal cancer stage T3-4N0M0 (groups I-III, n=69) and T3-4N0-2M0-1 (group IV, n=41). Everybody has been previously treated for colonic obstruction 0,5-6 months ago: stoma in 62 cases, stenting - in 48 cases. Elective radical surgery and radiotherapy and/or chemotherapy were applied in 2 (I group, n=23), 3 (II, n=23), 4 (III, n=23) weeks or 4-6 months (IV, n=41) after colonic decompression. The optimal terms of radical surgery are determined depending on CT-data, histological examination. RESULTS: Bowel wall thickness was significantly higher in I-II groups compared with III-IV groups: 3.7; 2.5; 1.9; 1.7, respectively (p≤0,5). The maximum number of tumor emboli was found in III-IV groups. Signs of focal colitis were absent in III-IV groups. CONCLUSION: The expediency of the new surgical standard is confirmed. Bridging strategy (stenting and stoma) may be a valid alternative in some patients with malignant colonic obstruction due to reduced postoperative mortality. The optimal terms for resection in patients with local cancer is 4 weeks after colonic decompression, in locally advanced cancer - 4-6 months.

[Managerial and methodological aspects of emergency surgery for malignant colonic obstruction]. / Organizatsionnye i metodologicheskie aspekty okazaniia neotlozhnoi khirurgicheskoi pomoshchi pri obstruktsionnoi kishechnoi neprokhodimosti opukholevogo geneza.

AIM: To determine the most feasible treatment strategy for malignant colonic obstruction. MATERIAL AND METHODS: There were 427 patients with malignant colonic obstruction who were hospitalized for emergency indications. 30 of them were treated with medical therapy; 286 - underwent acute resection; 43 - stoma construction; 68 - stents deployment. 64 out of 427 patients underwent elective restorative/radical surgery and radio- or chemotherapy in 1-8 months. 3-year Kaplan-Meier survival was assessed. RESULTS: Complications occurred in 58% after acute resection and in 32.6% and 8.8% after stoma and stent deployment, respectively. Postoperative mortality was significantly lower after palliative surgery (stent or stoma) compared with acute resection: 2.9%, 18.6%, 29.37%, respectively. 3-year survival was higher after elective resections compared with emergency resection group: 0,81 и 0,68 respectively. CONCLUSION: Bridging strategy (stoma/stents) may be a valid alternative in some patients with malignant colonic obstruction due to significantly reduced postoperative mortality. Acute surgery for malignant colonic obstruction should only be carried out by appropriately trained surgeons at multi-field hospital.

Structural optimization and in vivo evaluation of a colorectal stent with anti-migration and anti-tumor properties.

Clinically, colorectal stents can only palliatively relieve obstruction caused by colorectal cancer (CRC), with a high incidence of stent migration and tumor-related re-obstruction. To overcome these shortcomings, we developed a colorectal stent composed of a structure-optimized nitinol braided stent and a tubular film including an inner layer of poly (ethylene-co-vinyl acetate) (EVA) and a segmental outer layer of EVA with paclitaxel (PTX). The braiding pattern, segment number, and end shape of the stent were optimized based on the mechanical properties, ex vivo and in vivo anti-migration performance, and tissue response of the stent. The optimized nitinol stent had a structure of one middle segment in a hook-pattern and two end segments in a cross-pattern with two studs on each end in a staggered arrangement. Structure-optimized colorectal stents were prepared and evaluated in vivo. PTX released from the stent was mostly distributed in the rabbit rectum in contact with it. The biosafety of the colorectal stent was evaluated using blood tests, biochemical analysis, anatomical observation, and pathological analysis. The anti-tumor effect of the stent was also evaluated by endoscopy, anatomical observation, and pathological and immunohistochemical analyses in rabbits with orthotopic CRC. The results demonstrate that the optimized colorectal stents have effective anti-migration ability and anti-tumor effects with good biosafety. STATEMENT OF SIGNIFICANCE: In order to overcome the most common disadvantages of migration and re-obstruction of colorectal stents clinically, a colorectal stent composed of a structure-optimized nitinol stent and a tubular film including an inner layer of EVA and a segmental outer layer of EVA with PTX was put forward in this study. The optimized nitinol stent had a structure of one middle segment in hook-pattern and two end segments in cross-pattern with two studs on each end in staggered arrangement. The resulting colorectal stent has been proved with good anti-migration ability, anti-tumor effects, and biosafety in vivo, which provides a safe and effective potential treatment modality for patients with colorectal cancer.

Technical and Clinical Outcomes After Colorectal Stenting in Malignant Large Bowel Obstruction: A Single-Center Experience.

PURPOSE: Malignant large bowel obstruction is a surgical emergency that requires urgent decompression. Stents are increasingly being used, though reported outcomes are variable. We describe our multidisciplinary experience in using stents to manage malignant large bowel obstruction. METHODS: All patients undergoing colorectal stent insertion for acute large bowel obstruction in a teaching hospital were included. Outcomes, complications, and length of stay (LOS) were recorded. RESULTS: Over a 7-year period, 73 procedures were performed on 67 patients (37 male, mean age of 76 years). Interventional radiology was involved in all cases. Endoscopic guidance was required in 24 cases (32.9%). In 18 patients (26.9%), treatment intent was to bridge to elective surgery; 16 had successful stent placement; all had subsequent curative resection (laparoscopic resection, 8 of 18; primary anastomosis, 14 of 18). Overall LOS, including both index admission and elective admission, was 16.4 days. Treatment intent was palliative in 49 patients (73.1%). In this group, stents were successfully placed in 41 of 49 (83.7%). Complication rate within 30 days was 20%, including perforation (2 patients), per rectal bleeding (2), stent migration (1), and stent passage (5). Nineteen patients (38.8%) required subsequent stoma formation (6, during same admission; 13, during subsequent admission). Overall LOS was 16.9 days. CONCLUSION: In our experience colorectal stents can be used effectively to manage malignant large bowel obstruction, with only selective endoscopic input. As a bridge to surgery, most patients can avoid emergency surgery and have a primary anastomosis. In the palliative setting, the complication rate is acceptable and two-thirds avoid a permanent stoma.

Efficacy of uncovered self-expandable metallic stent for colorectal obstruction by extracolonic malignancy.

BACKGROUND: Self-expandable metallic stent (SEMS) is widely used for malignant colorectal obstruction. Recently, SEMS has been used for palliative option for colorectal obstruction caused by extracolonic malignancy (ECM). AIM: To evaluate the efficacy of SEMS for colorectal obstruction caused by ECM, and to identify the factors associated with stent occlusion. METHODS: Seventy-two patients who were treated with uncovered SEMS insertion for malignant colorectal obstructions caused by colorectal metastasis or peritoneal seeding of ECM at Samsung Medical Center between April 2012 to March 2016 were enrolled. We analyzed technical and clinical outcomes of stent insertion, the factors associated with stent occlusion and long term outcomes after stent insertion. RESULTS: Technical success rate was determined as 90.3% with a clinical success rate of 87.7%. Stent occlusion developed in 28.1%, with a median duration of 51 d. Further, 81.3% with stent occlusion could be treated with secondary stent insertion. Clinical failure was observed to be related to the male sex (P = 0.020) and right colon obstruction (P = 0.017). Stent length ≤ 10 cm was found to be associated with stent occlusion (P = 0.003). Median survival time after stent insertion was 4.7 mo and 40.4% were able to receive their oncological treatments after stent insertion without surgery. CONCLUSION: Uncovered SEMS is effective for the treatment of colorectal obstruction caused by ECM, considering life expectancy of patients with ECM.