- Email: [email protected]
Stent for palliation of advanced colorectal cancer
Techniques in Gastrointestinal Endoscopy ] (2014) ]]]–]]]
Contents lists available at ScienceDirect
Techniques in Gastrointestinal Endoscopy journal homepage: www.techgiendoscopy.com/locate/tgie
Stent for palliation of advanced colorectal cancer Søren Meisner, MD Endoscopy Unit, Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23 Entr 7B, 2400 Copenhagen NV, Denmark
a r t i c l e in fo
Keywords: Colorectal obstruction SEMS palliation advanced cancer
a b s t r a c t In palliation of advanced colorectal cancer, self-expanding metal stent (SEMS) can be an alternative to surgical resection for malignant obstruction proximal to the splenic flexure. SEMS is recommended as the preferred treatment for palliation of left-sided advanced malignant colonic obstruction with a high quality of evidence, except in patients (1) with a presumed long life expectancy ( 4 1 year) and (2) treated or considered for treatment with antiangiogenic drugs (ie, bevacizumab). The validity of the recommendation that palliative stenting is contraindicated in patients with a presumed long life expectancy ( 4 1 year) because of late stent-related complications is debatable and might be an erroneous conclusion. It is recommended that each institution should decide a clear strategy for this palliative group of long-term survivors. Understanding the risks of surgery is important for both patients and surgeons in the shared decision-making process, and it is recommended to implement a surgical risk prediction system. Patients who have undergone palliative stenting can be safely treated with chemotherapy without antiangiogenic agents. Given the high risk of colonic perforation, it is not recommended to use SEMS as palliative decompression of obstructions if a patient is being treated or considered to be treated with antiangiogenic therapy (ie, bevacizumab). & 2014 Elsevier Inc.. All rights reserved.
1. Introduction Colorectal cancer is one of the most common cancers worldwide, particularly in the economically developed world [1]. Overall, 8%-13% of patients with advanced colonic cancer develop large bowel obstruction [2,3]. There is still some controversy regarding the management of this severe clinical condition, and multiple articles have been published on the subject of colonic stenting for malignant colonic obstruction, including randomized controlled trials and systematic reviews [4]. Evaluation of treatment outcomes in patients with incurable or advanced colorectal cancer is different from that in curable patients. In patients with advanced cancer, minimal invasive therapy, hospital stay, interval to chemotherapy, risk of complications, life expectancy, and quality of life are important criteria when offering treatment. Decision making in patients with advanced cancer is important, but the task remains difficult. Prediction of survival or life expectancy is necessary to make the best decision in the treatment of patients with advanced cancer. It has been shown that performance status, American Society of Anesthesiologists class, carcinoembryonic antigen level, metastatic load, extent of primary tumor, and chemotherapy are
The author did consultancy work for Olympus Europe, Olympus Denmark, Boston Scientific, and Coloplast Denmark. E-mail address: [email protected] http://dx.doi.org/10.1016/j.tgie.2014.09.002 0049-0172/& 2014 Elsevier Inc.. All rights reserved.
important variables to include in the prediction especially in patients symptomatic with obstruction [5,6]. This article summarizes the indications, therapeutic efficacy, and outcomes of self-expanding metal stents (SEMSs) for the palliation of advanced colorectal cancer.
2. Palliation of advanced (incurable) colorectal cancer obstruction in proximal colon In a curative setting, surgical resection is the treatment of choice for malignant obstruction of the proximal colon. In a palliative setting, SEMS can be an alternative. Stenting malignant strictures proximal to the splenic flexure have been shown to be feasible in retrospective series [7,10,12-14]. However, these data show conflicting results regarding SEMS outcome when compared with stent placement in the left colon [7-12,15,16]. Considering the relative low risk and favorable outcome of a primary ileocolic anastomosis, right hemicolectomy is still the treatment of choice for proximal malignant colonic obstruction (Figure) [4,17,18]. Several factors could indicate that surgical resection is the best option even in a palliative setting. If patients with incurable colorectal cancer have a low surgical risk score, have a presumed long life expectancy ( 41 year), and are considered for treatment with antiangiogenic drugs (ie, bevacizumab), then surgery should be considered.
2
S. Meisner / Techniques in Gastrointestinal Endoscopy ] (2014) ]]]–]]]
Fig. Decision algorithm for SEMS treatment of advanced colonic cancer.
3. Palliation of advanced (incurable) colorectal cancer obstruction in left colon Owing to the high mortality and morbidity in emergency surgery for colonic obstruction, SEMSs have been recommended as the preferred treatment for incurable colorectal cancer obstruction. However, the published literature from the past 2-3 years indicate that this is not completely true. As for right-sided obstructions, several factors could indicate that surgical resection in some cases might be a better choice even in a palliative setting. SEMS is recommended as the preferred treatment for palliation of left-sided malignant colonic obstruction with a high quality of evidence, except in patients (1) with a presumed long life expectancy ( 4 1 year) and (2) treated or considered for treatment with antiangiogenic drugs (ie, bevacizumab). There are 2 meta-analyses, including randomized and nonrandomized comparative studies, that have compared SEMS (n ¼ 195 and 404) and surgery (n ¼ 215 and 433) in the setting of palliation for malignant colonic obstruction [20,21]. The technical success of stent placement ranged from 88%-100% [22,23]. Initial clinical success (relief) of obstruction was significantly higher after palliative surgery compared with stent placement at approximately 100% vs 93%, respectively [10,21]. Both meta-analyses showed a lower 30-day mortality rate for SEMS, but it was statistically significant only in the meta-analysis that included the highest number of patients (4% vs 11%) [21]. There was no difference in overall survival. As expected, stent placement was significantly associated with a lower rate of stoma formation (13% vs 54%) and a shorter hospital stay (10 vs 19 days) [20,21]. Overall morbidity was the same: 34% in the stent
group compared with 38% for surgery in the largest meta-analysis [21]. Short-term complications occurred more often in the palliative surgery group, whereas late complications were higher in the SEMS group. Stent-related complications mainly include colonic perforation (10%), stent migration (9%), and reobstruction (18%) [21]. The results from the meta-analysis are supported by other recently published literature, including a randomized controlled trial that was not included in meta-analyses [8,19,24-30]. The recommendation that palliative stenting is contraindicated in patients with a presumed long life expectancy because of late stent-related complications seems to based on a relative high level of evidence but should be accepted as true with caution. It might be a misleading conclusion, because the SEMS itself may have contributed to the prolonged life expectancy. The absolute 6% initial difference in hospital mortality with the significant differences in hospital stay ( 50% days) and intensive care unit admission ( 17%) in favor of stent placement are probably more important than the small long-term risk of perforation (stent migration and reobstruction is not a severe complication and is usually easy resolved by revisional stenting). Chemotherapy administration is started much earlier after SEMS placement, which may also contribute to increased life expectancy.
4. Palliation of advanced (incurable) colorectal cancer obstruction due to peritoneal carcinomatosis Some studies have investigated the clinical outcomes of SEMS between patients with colorectal cancer and those with
S. Meisner / Techniques in Gastrointestinal Endoscopy ] (2014) ]]]–]]]
extracolonic malignancy. SEMS can be used to alleviate the symptoms of obstruction in patients with extracolonic malignancy with almost equal results as SEMS for obstruction due to colorectal cancer. Patients with extracolonic malignancy may have more than one site of obstruction, which may explain the poorer outcome in some patients. Few studies have presented data on SEMS treatment of colorectal obstruction by extracolonic malignancy with peritoneal carcinomatosis. The expected outcome is probably not as good compared with colorectal cancer obstruction, but SEMS insertion can be a reasonable first-treatment option in patients with malignant colorectal obstruction by extracolonic malignancy with peritoneal carcinomatosis, mainly owing to very short life expectancy [15,31].
5. Chemotherapy after palliative SEMS placement Chemotherapy plays an increasing important role in the treatment of advanced colorectal cancer, and there has been concern that stent treatment in combination with chemotherapy might lead to severe complications. The published results show that patients who have undergone palliative stenting can be safely treated with chemotherapy without antiangiogenic agents. Given the high risk of colonic perforation, it is not recommended to use SEMS as palliative decompression of obstruction if a patient is being considered or being treated with antiangiogenic therapy (ie, bevacizumab). It has been debated that chemotherapy after stent placement might induce stent-related complications, mainly perforation. Several retrospective series have reported an increased risk of stent perforation in patients treated with the antiangiogenesis inhibitor bevacizumab [9,19,32]. A meta-analysis of risk factors of stent perforation in a heterogeneous population found a significantly increased perforation rate of 12.5% in patients receiving bevacizumab compared with patients who received no concomitant therapy during colorectal stenting (9.0%), whereas chemotherapy without bevacizumab was not associated with an increased risk of stent perforation (7.0%) [33]. There is no hard evidence, but an increased perforation risk can be anticipated as well for the newer antiangiogenic agents, aflibercept and regorafenib, owing to a similar therapeutic mechanism. With the present evidence, SEMS placement is strongly discouraged for patients who are being treated or considered for further treatment with antiangiogenic therapy. Palliative chemotherapy after stent placement is associated with prolonged survival [34,35] and might therefore result in more patients being exposed to the risk of late complications. There seems to be a correlation between chemotherapy and the occurrence of stent migration probably owing to tumor shrinkage [36,37].
6. Conclusions In the palliation of advanced colorectal cancer, SEMS can be an alternative to surgical resection for malignant obstruction proximal to the splenic flexure. SEMS is recommended as the preferred treatment for palliation of left-sided malignant colonic obstruction with a high quality of evidence, except in patients (1) with a presumed long life expectancy (41 year) and (2) treated or considered for treatment with antiangiogenic drugs (ie, bevacizumab). The validity of the recommendation that palliative stenting is contraindicated in patients with a presumed long life expectancy (41 year) because of late stent-related complications is debatable and might be a misleading conclusion. It is recommended that each institution should decide a clear strategy for this palliative group of long-term survivors. Understanding the risks of surgery is important for both patients and surgeons in the shared decision-making
3
process, and it is recommended to implement a surgical risk prediction system. Patients who have undergone palliative stenting can be safely treated with chemotherapy without antiangiogenic agents.
References [1] Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69–90. [2] Winner M, Mooney SJ, Hershman DL, et al. Incidence and predictors of bowel obstruction in elderly patients with stage IV colon cancer: a population-based cohort study. JAMA Surg 2013;148:715–22. [3] Jullumstro E, Wibe A, Lydersen S, et al. Colon cancer incidence, presentation, treatment and outcomes over 25 years. Colorectal Dis 2011;13:512–8. [4] Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg 2014;207:127–38. [5] Stelzner S, Hellmich G, Koch R, Ludwig K. Factors predicting survival in stage IV colorectal carcinoma patients after palliative treatment: a multivariate analysis. J Surg Oncol 2005;89:211–7. [6] Chew M-H, Teo J-Y, Kabir T, Koh P-K, Eu K-W, Tang C-L. Stage IV colorectal cancers: an analysis of factors predicting outcome and survival in 728 cases. J Gastrointest Surg 2012;16:603–12. [7] Yoon JY, Jung YS, Hong SP, et al. Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011;74:858–68. [8] Abbott S, Eglinton TW, Ma Y, et al. Predictors of outcome in palliative colonic stent placement for malignant obstruction. Br J Surg 2014;101:121–6. [9] Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of selfexpandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560–72. [10] Geraghty J, Sarkar S, Cox T, et al. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis 2014;16(6):476–83. [11] Selinger CP, Ramesh J, Martin DF. Long-term success of colonic stent insertion is influenced by indication but not by length of stent or site of obstruction. Int J Colorectal Dis 2011;26:215–8. [12] Cho YK, Kim SW, Lee BI, et al. Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction. Gut Liver 2011;5:165–70. [13] Yao LQ, Zhong YS, Xu MD, et al. Self-expanding metallic stents drainage for acute proximal colon obstruction. World J Gastroenterol 2011;17:3342–6. [14] Repici A, Adler DG, Gibbs CM, et al. Stenting of the proximal colon in patients with malignant large bowel obstruction: techniques and outcomes. Gastrointest Endosc 2007;66:940–4. [15] Kim JY, Kim SG, Im JP, et al. Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction. Surg Endosc 2013;27:272–7. [16] Dronamraju SS, Ramamurthy S, Kelly SB, et al. Role of self-expanding metallic stents in the management of malignant obstruction of the proximal colon. Dis Colon Rectum 2009;52:1657–61. [17] Gainant A. Emergency management of acute colonic cancer obstruction. J Visc Surg 2012;149:e3–10. [18] Cuffy M, Abir F, Audisio RA, et al. Colorectal cancer presenting as surgical emergencies. Surg Oncol 2004;13:149–57. [19] Manes G, de Bellis M, Fuccio L, et al. Endoscopic palliation in patients with incurable malignant colorectal obstruction by means of self-expanding metal stent: analysis of results and predictors of outcomes in a large multicenter series. Arch Surg 2011;146:1157–62. [20] Liang TW, Sun Y, Wei YC, et al. Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: a self-expanding metallic stent or surgery? A system review and meta-analysis. Surg Today 2014;44:22–33. [21] Zhao XD, Cai BB, Cao RS, et al. Palliative treatment for incurable malignant colorectal obstructions: a meta-analysis. World J Gastroenterol 2013;19: 5565–74. [22] Carne PW, Frye JN, Robertson GM, et al. Stents or open operation for palliation of colorectal cancer: a retrospective, cohort study of perioperative outcome and long-term survival. Dis Colon Rectum 2004;47:1455–61. [23] Fiori E, Lamazza A, De Cesare A, et al. Palliative management of malignant rectosigmoidal obstruction. Colostomy vs. endoscopic stenting. A randomized prospective trial. Anticancer Res 2004;24:265–8. [24] Fiori E, Lamazza A, Schillaci A, et al. Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial. Am J Surg 2012;204:321–6. [25] Gianotti L, Tamini N, Nespoli L, et al. A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction. Surg Endosc 2013;27:832–42. [26] Yoshida S, Watabe H, Isayama H, et al. Feasibility of a new self-expandable metallic stent for patients with malignant colorectal obstruction. Dig Endosc 2013;25:160–6.
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[27] Huhtinen H, Varpe P, Karvonen J, et al. Late complications related to palliative stenting in patients with obstructing colorectal cancer. Minim Invasive Ther Allied Technol 2013;22:352–8. [28] Angenete E, Asplund D, Bergstrom M, et al. Stenting for colorectal cancer obstruction compared to surgery—a study of consecutive patients in a single institution. Int J Colorectal Dis 2012;27:665–70. [29] Meisner S, Gonzalez-Huix F, Vandervoort JG, et al. Self-expanding metal stenting for palliation of patients with malignant colonic obstruction: effectiveness and efficacy on 255 patients with 12-month's follow-up. Gastroenterol Res Pract 2012;2012:296347. [30] Yoon JY, Park SJ, Hong SP, et al. Outcomes of secondary self-expandable metal stents versus surgery after delayed initial palliative stent failure in malignant colorectal obstruction. Digestion 2013;88:46–55. [31] Kim JH, Ku YS, Jeon TJ, Park JY, Chung J-W, Kwon KA, et al. The efficacy of selfexpanding metal stents for malignant colorectal obstruction by noncolonic malignancy with peritoneal carcinomatosis. Dis Colon Rectum 2013;56:1228–32. [32] Cennamo V, Fuccio L, Mutri V, et al. Does stent placement for advanced colon cancer increase the risk of perforation during bevacizumab-based therapy? Clin Gastroenterol Hepatol 2009;7:1174–6.
[33] van Halsema EE, van Hooft JE, Small AJ, et al. Perforation in colorectal stenting: a meta-analysis and a search for risk factors. Gastrointest Endosc 2014;79(6): 970–82. [34] Luigiano C, Ferrara F, Fabbri C, et al. Through-the-scope large diameter selfexpanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: a single center experience with a long-term follow-up. Scand J Gastroenterol 2011;46:591–6. [35] Lee HJ, Hong SP, Cheon JH, et al. Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc 2011;73:535–42. [36] Canena JM, Liberato M, Marques I, et al. Sustained relief of obstructive symptoms for the remaining life of patients following placement of an expandable metal stent for malignant colorectal obstruction. Rev Esp Enferm Dig 2012;104:418–25. [37] Fernandez-Esparrach G, Bordas JM, Giraldez MD, et al. Severe complications limit long-term clinical success of self-expanding metal stents in patients with obstructive colorectal cancer. Am J Gastroenterol 2010;105:1087–93.
Contents lists available at ScienceDirect
Techniques in Gastrointestinal Endoscopy journal homepage: www.techgiendoscopy.com/locate/tgie
Stent for palliation of advanced colorectal cancer Søren Meisner, MD Endoscopy Unit, Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23 Entr 7B, 2400 Copenhagen NV, Denmark
a r t i c l e in fo
Keywords: Colorectal obstruction SEMS palliation advanced cancer
a b s t r a c t In palliation of advanced colorectal cancer, self-expanding metal stent (SEMS) can be an alternative to surgical resection for malignant obstruction proximal to the splenic flexure. SEMS is recommended as the preferred treatment for palliation of left-sided advanced malignant colonic obstruction with a high quality of evidence, except in patients (1) with a presumed long life expectancy ( 4 1 year) and (2) treated or considered for treatment with antiangiogenic drugs (ie, bevacizumab). The validity of the recommendation that palliative stenting is contraindicated in patients with a presumed long life expectancy ( 4 1 year) because of late stent-related complications is debatable and might be an erroneous conclusion. It is recommended that each institution should decide a clear strategy for this palliative group of long-term survivors. Understanding the risks of surgery is important for both patients and surgeons in the shared decision-making process, and it is recommended to implement a surgical risk prediction system. Patients who have undergone palliative stenting can be safely treated with chemotherapy without antiangiogenic agents. Given the high risk of colonic perforation, it is not recommended to use SEMS as palliative decompression of obstructions if a patient is being treated or considered to be treated with antiangiogenic therapy (ie, bevacizumab). & 2014 Elsevier Inc.. All rights reserved.
1. Introduction Colorectal cancer is one of the most common cancers worldwide, particularly in the economically developed world [1]. Overall, 8%-13% of patients with advanced colonic cancer develop large bowel obstruction [2,3]. There is still some controversy regarding the management of this severe clinical condition, and multiple articles have been published on the subject of colonic stenting for malignant colonic obstruction, including randomized controlled trials and systematic reviews [4]. Evaluation of treatment outcomes in patients with incurable or advanced colorectal cancer is different from that in curable patients. In patients with advanced cancer, minimal invasive therapy, hospital stay, interval to chemotherapy, risk of complications, life expectancy, and quality of life are important criteria when offering treatment. Decision making in patients with advanced cancer is important, but the task remains difficult. Prediction of survival or life expectancy is necessary to make the best decision in the treatment of patients with advanced cancer. It has been shown that performance status, American Society of Anesthesiologists class, carcinoembryonic antigen level, metastatic load, extent of primary tumor, and chemotherapy are
The author did consultancy work for Olympus Europe, Olympus Denmark, Boston Scientific, and Coloplast Denmark. E-mail address: [email protected] http://dx.doi.org/10.1016/j.tgie.2014.09.002 0049-0172/& 2014 Elsevier Inc.. All rights reserved.
important variables to include in the prediction especially in patients symptomatic with obstruction [5,6]. This article summarizes the indications, therapeutic efficacy, and outcomes of self-expanding metal stents (SEMSs) for the palliation of advanced colorectal cancer.
2. Palliation of advanced (incurable) colorectal cancer obstruction in proximal colon In a curative setting, surgical resection is the treatment of choice for malignant obstruction of the proximal colon. In a palliative setting, SEMS can be an alternative. Stenting malignant strictures proximal to the splenic flexure have been shown to be feasible in retrospective series [7,10,12-14]. However, these data show conflicting results regarding SEMS outcome when compared with stent placement in the left colon [7-12,15,16]. Considering the relative low risk and favorable outcome of a primary ileocolic anastomosis, right hemicolectomy is still the treatment of choice for proximal malignant colonic obstruction (Figure) [4,17,18]. Several factors could indicate that surgical resection is the best option even in a palliative setting. If patients with incurable colorectal cancer have a low surgical risk score, have a presumed long life expectancy ( 41 year), and are considered for treatment with antiangiogenic drugs (ie, bevacizumab), then surgery should be considered.
2
S. Meisner / Techniques in Gastrointestinal Endoscopy ] (2014) ]]]–]]]
Fig. Decision algorithm for SEMS treatment of advanced colonic cancer.
3. Palliation of advanced (incurable) colorectal cancer obstruction in left colon Owing to the high mortality and morbidity in emergency surgery for colonic obstruction, SEMSs have been recommended as the preferred treatment for incurable colorectal cancer obstruction. However, the published literature from the past 2-3 years indicate that this is not completely true. As for right-sided obstructions, several factors could indicate that surgical resection in some cases might be a better choice even in a palliative setting. SEMS is recommended as the preferred treatment for palliation of left-sided malignant colonic obstruction with a high quality of evidence, except in patients (1) with a presumed long life expectancy ( 4 1 year) and (2) treated or considered for treatment with antiangiogenic drugs (ie, bevacizumab). There are 2 meta-analyses, including randomized and nonrandomized comparative studies, that have compared SEMS (n ¼ 195 and 404) and surgery (n ¼ 215 and 433) in the setting of palliation for malignant colonic obstruction [20,21]. The technical success of stent placement ranged from 88%-100% [22,23]. Initial clinical success (relief) of obstruction was significantly higher after palliative surgery compared with stent placement at approximately 100% vs 93%, respectively [10,21]. Both meta-analyses showed a lower 30-day mortality rate for SEMS, but it was statistically significant only in the meta-analysis that included the highest number of patients (4% vs 11%) [21]. There was no difference in overall survival. As expected, stent placement was significantly associated with a lower rate of stoma formation (13% vs 54%) and a shorter hospital stay (10 vs 19 days) [20,21]. Overall morbidity was the same: 34% in the stent
group compared with 38% for surgery in the largest meta-analysis [21]. Short-term complications occurred more often in the palliative surgery group, whereas late complications were higher in the SEMS group. Stent-related complications mainly include colonic perforation (10%), stent migration (9%), and reobstruction (18%) [21]. The results from the meta-analysis are supported by other recently published literature, including a randomized controlled trial that was not included in meta-analyses [8,19,24-30]. The recommendation that palliative stenting is contraindicated in patients with a presumed long life expectancy because of late stent-related complications seems to based on a relative high level of evidence but should be accepted as true with caution. It might be a misleading conclusion, because the SEMS itself may have contributed to the prolonged life expectancy. The absolute 6% initial difference in hospital mortality with the significant differences in hospital stay ( 50% days) and intensive care unit admission ( 17%) in favor of stent placement are probably more important than the small long-term risk of perforation (stent migration and reobstruction is not a severe complication and is usually easy resolved by revisional stenting). Chemotherapy administration is started much earlier after SEMS placement, which may also contribute to increased life expectancy.
4. Palliation of advanced (incurable) colorectal cancer obstruction due to peritoneal carcinomatosis Some studies have investigated the clinical outcomes of SEMS between patients with colorectal cancer and those with
S. Meisner / Techniques in Gastrointestinal Endoscopy ] (2014) ]]]–]]]
extracolonic malignancy. SEMS can be used to alleviate the symptoms of obstruction in patients with extracolonic malignancy with almost equal results as SEMS for obstruction due to colorectal cancer. Patients with extracolonic malignancy may have more than one site of obstruction, which may explain the poorer outcome in some patients. Few studies have presented data on SEMS treatment of colorectal obstruction by extracolonic malignancy with peritoneal carcinomatosis. The expected outcome is probably not as good compared with colorectal cancer obstruction, but SEMS insertion can be a reasonable first-treatment option in patients with malignant colorectal obstruction by extracolonic malignancy with peritoneal carcinomatosis, mainly owing to very short life expectancy [15,31].
5. Chemotherapy after palliative SEMS placement Chemotherapy plays an increasing important role in the treatment of advanced colorectal cancer, and there has been concern that stent treatment in combination with chemotherapy might lead to severe complications. The published results show that patients who have undergone palliative stenting can be safely treated with chemotherapy without antiangiogenic agents. Given the high risk of colonic perforation, it is not recommended to use SEMS as palliative decompression of obstruction if a patient is being considered or being treated with antiangiogenic therapy (ie, bevacizumab). It has been debated that chemotherapy after stent placement might induce stent-related complications, mainly perforation. Several retrospective series have reported an increased risk of stent perforation in patients treated with the antiangiogenesis inhibitor bevacizumab [9,19,32]. A meta-analysis of risk factors of stent perforation in a heterogeneous population found a significantly increased perforation rate of 12.5% in patients receiving bevacizumab compared with patients who received no concomitant therapy during colorectal stenting (9.0%), whereas chemotherapy without bevacizumab was not associated with an increased risk of stent perforation (7.0%) [33]. There is no hard evidence, but an increased perforation risk can be anticipated as well for the newer antiangiogenic agents, aflibercept and regorafenib, owing to a similar therapeutic mechanism. With the present evidence, SEMS placement is strongly discouraged for patients who are being treated or considered for further treatment with antiangiogenic therapy. Palliative chemotherapy after stent placement is associated with prolonged survival [34,35] and might therefore result in more patients being exposed to the risk of late complications. There seems to be a correlation between chemotherapy and the occurrence of stent migration probably owing to tumor shrinkage [36,37].
6. Conclusions In the palliation of advanced colorectal cancer, SEMS can be an alternative to surgical resection for malignant obstruction proximal to the splenic flexure. SEMS is recommended as the preferred treatment for palliation of left-sided malignant colonic obstruction with a high quality of evidence, except in patients (1) with a presumed long life expectancy (41 year) and (2) treated or considered for treatment with antiangiogenic drugs (ie, bevacizumab). The validity of the recommendation that palliative stenting is contraindicated in patients with a presumed long life expectancy (41 year) because of late stent-related complications is debatable and might be a misleading conclusion. It is recommended that each institution should decide a clear strategy for this palliative group of long-term survivors. Understanding the risks of surgery is important for both patients and surgeons in the shared decision-making
3
process, and it is recommended to implement a surgical risk prediction system. Patients who have undergone palliative stenting can be safely treated with chemotherapy without antiangiogenic agents.
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