- Email: [email protected]
The impact of stenting obstructing colorectal tumours in a district general hospital
International Journal of Surgery 9 (2011) 165e168
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
The impact of stenting obstructing colorectal tumours in a district general hospital N.J. Phillips a, *, S.J. Arnold b, J. Elford c, A.J.G. Miles d a
Hants County Hospital, Romsey Road, Winchester, UK North Hampshire County Hospital, Basingstoke, UK c Department of Radiology, Royal Hants County Hospital, Romsey Road, Winchester, Hants, UK d Royal Hants County Hospital, Romsey Road, Winchester, Hants, UK b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 September 2010 Accepted 23 October 2010 Available online 5 November 2010
Introduction: The technique of stenting malignant obstructing colorectal lesions is established as an acceptable treatment with a low morbidity and mortality. This paper reviews our experience in stenting malignant colorectal obstruction and compares this group with those who underwent emergency surgery as their primary intervention. Methods: A retrospectively kept database over four years was reviewed and patients who had undergone either stenting or emergency surgery for a malignant colorectal obstruction were identified. These patients’ notes were retrieved and reviewed. Results: During the duration of study, a total of 29 stents were placed in 28 patients, with a mean age of 78 y (range 59e96 years). Patients generally had significant co-existing morbidity, with a median ASA score of 2.5. The timing of stent placement was a mean of 3.4 days (1e9 days) after presentation, including time for relevant investigation and diagnosis. Mean length of hospital stay was 9.8 days (2e36 days). In the emergency operation category, during the period of study, a total of 38 patients had operations for large bowel obstruction, either because the lesion was not suitable for stenting, or the personnel for stenting were not available. These patients ranged in age from 45 to 96 years, with a mean age of 72.4 years. Patients in this group were generally a little fitter than the stented group, with a median ASA grade of 2, and 14/38 patients were ASA1 (the largest group). Despite this Post-operative recovery was slow with these patients, the average length of stay being 16 days (range 8e66 days). Conclusions: In this study, we report our data on the first four years of stenting malignant bowel obstruction. It is a feasible and acceptable means of treatment, and we have demonstrated comparable morbidity and mortality to that reported in medical literature. The technique may avoid the need for emergency operation with its concomitant risks, lengthy in-patient stay, and high likelihood for a stoma. We would advocate the use of self expanding metal stents where appropriate in the management of large bowel obstruction. Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Stenting Malignant large bowel obstruction Endoscopy
1. Introduction The technique of stenting malignant obstructing colorectal lesions is established as an acceptable treatment since it was first described in 1991.1 Approximately 50% of patients in this challenging category are aged 70e89years2 and they carry a significant 30-day mortality and morbidity.3,4 Expanding metal stents are placed across an obstructing tumour giving relief from their symptoms. This procedure either allows time for the patient to be optimised for definitive surgery (bridge)
* Corresponding author. E-mail addresses: [email protected] (N.J. Phillips), Julian.elford@ wehct.nhs.uk (J. Elford), [email protected] (A.J.G. Miles).
or is used as an effective palliative procedure for inoperable cancers. Since Tejero et al. first coined the term ‘bridge to surgery’ in 19946 larger studies have reported patients being treated in this two-stage procedure.7,8 A meta-analysis of studies has shown that stenting has a low mortality rate (1%) and a successful palliation rate (90%) in patients thus treated.5 In the bridge to surgery group, complication rates are low (perforation rate 0e5%, stent migration 0e9.5%, and re-obstruction prior to surgery 0e4.7%).7e9 Up to 95% of patients had a primary anastomosis at subsequent operation, negating the need for a stoma.8 In recent times, laparoscopic-assisted surgery for colorectal cancer resections has gained increasingly widespread acceptance, with lower rates of morbidity. A recent study showed that blood loss and post-operative pain was less following laparoscopic
1743-9191/$ e see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2010.10.013
166
N.J. Phillips et al. / International Journal of Surgery 9 (2011) 165e168
resection, along with faster return of bowel function and earlier eating.10 This resulted in the hospital stay being, on average, 2 days shorter. Initial concerns, however, centred around the oncological clearance and long-term outcomes using this technique.11 More recently, however, data has been produced showing there appears to be no significant difference in overall or disease-free survival, with one study demonstrating a recurrence rate of 23% in both open and laparoscopic groups.12 This paper reviews our experience in stenting malignant colorectal obstruction and compares this group with those who underwent emergency surgery as their primary intervention. 2. Methods Between 2002 and 2006 a retrospective database of all patients undergoing emergency bowl surgery or endscopic stenting has been kept by the hospital colorectal co-ordinator and the department of radiology respectively. These databases have recorded patient demographics and technical details concerning the relevant procedure. These patients’ records were retrieved and data concerning age, sex, ASA grade, site of tumour, type of operation, formation of stoma, ITU admission, overall length of stay and complications were recorded as appropriate. Additionally, similar data was obtained concerning second elective procedures (such as reversal of stoma or those requiring operation after failure of stenting). Patients undergoing a laparotomy for bleeding or perforation were excluded from this study.
3. Results During the duration of study, a total of 29 stents were placed in 28 patients, with a mean age of 78 y (range 59e96 years). Patients generally had significant co-existing morbidity, with a median ASA score of 2.5. The timing of stent placement was a mean of 3.4 days (1e9 days) after presentation, including time for relevant investigation and diagnosis. Mean length of hospital stay was 9.8 days (2e36 days); see Fig. 1. The commonest anatomical site (Fig. 2) for an obstructing lesion was the sigmoid colon (64%), with other sites including rectosigmoid (7%), descending colon (18%), and transverse colon (11%). 15/28 patients died during the course of the study. The mean survival post-stenting was 10.7 months (range 5 dayse28 months). 13 patients were still alive at the end of the study. Six patients (21%) had complications related to their admission. One patient was unable to be stented due to the inability to cross the obstruction with a guide wire. He underwent a Hartmann’s procedure, and died of multi-organ failure and sepsis on the fifth post-operative day on ITU. This was the only in-patient death. The only other patient admitted to ITU during this time (for a total of 10 days) developed pneumonia, but responded well to treatment, was discharged on day 28, and subsequently underwent successful laparoscopic resection. One stent migrated, causing obstruction,
Fig. 2. Distribution of sites of obstructing colonic cancer.
necessitating a subtotal colectomy, whilst one patient re-presented with obstruction due to tumour growth around the end of the stent. This patient had a second stent inserted with good symptom relief. Two stent perforations occurred, both in the palliative group. One was initially discharged well on day 4, but returned two weeks later and was found to have a pericolic abscess at the tip of the stent where the proximal end had caused a small contained perforation. He was treated conservatively with i.v. antibiotics and made a good recovery. The other patient developed peritonitis within 12 h of stenting, and was taken for a Hartmann’s procedure. Nine patients subsequently underwent elective surgery. One open left hemicolectomy was performed, and two patients had an open extended right hemicolectomy, although one was found to be palliative at operation. This patient had a further laparotomy six months later for obstructive symptoms, where an ileo-transverse bypass was performed. One patient had a Hartmann’s procedure. Five patients had a laparoscopic anterior resection with primary anastomosis and no stoma. This subset of patients, who were found to have no metastatic disease, had a mean age of 79 years (range 71e88), and was operated on 69 days after being stented (range 29e135). Peri-operative stay for these patients was 9 days (range 7e12). No major morbidity was seen in these five patients, although one developed a minor chest infection requiring antibiotics and chest physiotherapy. During the period of study, a total of 38 patients had operations for large bowel obstruction, either because the lesion was not suitable for stenting, or the personnel for stenting were not available. These patients ranged in age from 45 to 96 years, with a mean age of 72.4 years. Patients in this group were generally a little fitter than the stented group, with a median ASA grade of 2, and 14/38 patients were ASA1 (the largest group). Despite this, three patients (7.9%) died in hospital, within two weeks of surgery. One patient
Fig. 1. Total length of stay for stented patients.
N.J. Phillips et al. / International Journal of Surgery 9 (2011) 165e168
developed pneumonia and then suffered a myocardial infarction in the post-operative period, one succumbed to multi-organ failure, and one patient was septic, almost moribund on arrival (ASA 5), and died on ITU on day 9 post-operatively. Timing of surgery was a mean of 3 days after presentation, (range 1e7 days), allowing for resuscitation and diagnostic testing. 23/38 patients had a right hemicolectomy to resect right sided or transverse colon lesions, while one patient had a palliative bypass. Two trephine colostomies were brought out in elderly patients with significant co-morbidity, and two subtotal colectomies performed in patients whose caecum was critically distended at operation. Ten left sided lesions were resected, six of whom had a Hartmann’s procedure, leaving four with a primary resection and anastomosis, two with a covering stoma, and one with a caecostomy. Seventeen patients required an ITU bed post-operatively, for an average of 4 days (range 1e10 days). Of these, eight were ventilated post-operatively for an average of 2 days (range 1e5 days). Ten patients had stomas, and stoma training alone extended the hospital stay by an average of 3.3 days per patient, after they were otherwise considered fit for surgical discharge. Post-operative recovery was slow with these patients, the average length of stay being 16 days (range 8e66 days). Significant morbidity was seen in 12/38 patients (32%). Three had a myocardial infarction, five had septic or infective complications, and one patient went into retention and required a TURP as an in-patient. Two patients were re-operated on during their index admission, one for a dehiscence, and one for revision of stoma. Three patients were admitted for further surgery at a later date: one for resection of a liver metastasis after 32 weeks (at a different hospital), and two for reversal of stoma, one of which developed a fistula at the closure site, necessitating ITU admission for 11 days and eventually discharged after 7 weeks. As expected, pathological staging of the resected tumours was advanced, with 13 classified as Dukes B, and 25 classified as Dukes C. 21 patients were considered to have had a curative procedure (55%), and were still alive at the end of the study, up to 4 years later.
167
associated with a new technique. Despite this, our figures are comparable to those achieved in the medical literature. The average length of stay for stented patients was 9 days, allowing for investigation, treatment and resolution of their symptoms. A longer period of 16 days was required for those patients who underwent surgery. Whilst the two groups can not be compared directly, it is clear that stented patients are discharged around a week earlier than those who had surgery. If we had looked at a matched population, comparing stents against left sided resection, then this difference may have been even greater, with more patients requiring stoma training prior to discharge. 17 patients required ITU stay for a cumulative total of 69 days. With an ITU bed costing approximately £1100e£1400 per day (government figures), this represents a total cost of over £86,000 on intensive care treatment for this group of patients alone. Any treatment which may allow for faster discharge from hospital should be considered for its potential. Stenting malignant bowel obstruction may have a significant impact on hospital bed occupancy, compared to emergency operation, at a time when bed shortages are an increasing problem. It has been suggested that the cost of occupying an NHS bed for a day can be calculated at over £300. Whilst stenting may allow for faster discharge, the cost of equipment will offset this to some extent. One study estimated that the cost of materials for stenting worked out at an average of just over €1700 (£1150 approx) per patient.16 Overall, this group found that defunctioning alone was cheaper by €132 (£91) per inpatient episode compared to stenting, but did not look at the ongoing costs and morbidity of stoma care once discharged from hospital. In this study, we report our data on the first four years of stenting malignant bowel obstruction. It is a feasible and acceptable means of treatment, and we have demonstrated comparable morbidity and mortality to that reported in medical literature. The technique may avoid the need for emergency operation with its concomitant risks, lengthy in-patient stay, and high likelihood for a stoma. We would advocate the use of self-expanding metal stents where appropriate in the management of large bowel obstruction.
4. Discussion Malignant large bowel obstruction remains a challenging clinical problem in the 21st century, with high levels of morbidity and mortality. The ACPGBI audit of over 8000 patients showed that emergency operations for this range of conditions resulted in a mortality rate of 20%.13 This retrospective audit does not directly compare a matched population for patients undergoing stenting versus operation. We have studied all patients treated for large bowel obstruction over four years, with what we considered the best means available to each patient at the time of presentation. Our mortality rate for patients who underwent operation was 7.9%; this was despite being a group with better ASA grading compared to those who were stented. A significant number of this group, however, had a right hemicolectomy, perhaps imparting less insult to patients than those undergoing left sided resections. These patients are not amenable to stenting by current techniques. Despite, this however, it still demonstrates that operative intervention has its risks in terms of mortality and morbidity, with a complication rate of 32%. Set against this is our procedural complication rate of 18% for the stented group. This includes problems such as migration, tumour overgrowth, failure to stent (each one patient, 4%), and perforation (7% - two patients). Such figures are comparable to those quoted in large systematic reviews, with rates of migration and reobstruction of about 10%, and perforation and bleeding around 5%.14,15 Our series looks at the first four years of practice of stenting in a district general hospital, and encompasses the ‘learning curve’
Ethical approval Not required. Funding None. Conflict of interest None to declare.
References 1. Dohmoto M. New method e endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endoscopia Digestiva 1991;3:1507e12. 2. Stamatakis J, Thompson M, Chave H. National audit of bowel obstruction due to colorectal cancer, Apr 1998eMar 1999. London: Association of Coloproctology of Great Britain and Ireland; 2000. 3. Riedl S, Wiebelt H, Bergmann U, Hermanek Jr P. Post-operative complications and fatalities in the surgical therapy of colon carcinoma. Results of the German multicentre stucy by the colorectal carcinoma study group. Chirurgia 1995 Jun;66(6):597e606. 4. Irvin 3rd GL, Horsley 3rd JS, Caruana Jr JA. The morbidity and mortality of emergent operations for colorectal disease. Ann Surg 1984 May;199(5): 598e603. 5. Khot UP, Wenk Lang A, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002 Sept;89:1096e102. 6. Tejero E, Mainar A, Fernandez L, Tobio R, De Gregorio MA. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum 1994 Nov;37(11):1158e9. 7. Mainar A, De Gregorio MA, Tejero E, Tobio R, Alsonso E, Pinto I, et al. Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery e results of a multicentre trial. Radiology 1999; 210:65e9.
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8. Saida Y, Sumiyama Y, Nagao J, Uramatsu M. Long term prognosis of preoperative ‘bridge to surgery’ expandable metallic stent insertion for obstructive colorectal cancer: comparison with emergency operation. Dis Colon Rectum 2003 Oct;46(Suppl. 10):S44e9. 9. Knopfle E, Mayer H, Wamser G, Bohndorf K, Witte J. Ileus in colorectal carcinoma. Pre-operative implantation of self-expanding metal stents and early elective surgery as an alternative to emergency surgery. Chirurgia 2001 Oct;72 (10):1137e43. 10. Reza MM, Blasco JA, Andradas E, Cantero R, Mayol J. Systematic review of laparoscopic versus open surgery for colorectal cancer. Br J Surg 2006 July;93(8):921e8. 11. Cohen SM, Wexner SD. Laparoscopic colorectal resection for cancer: the cleveland clinic Florida experience. Surg Oncol 1993;2(Suppl. 1):35e42. 12. Nakamura T, Mitomi H, Ohtani Y, Kokuba Y, Sato T, Ozawa H, et al. Comparison of long-term outcome of laparoscopic and conventional surgery for advanced
13.
14. 15.
16.
colon and recto-sigmoid cancer. Hepatogastroenterology 2006 May-Jun;53 (69):351e3. Tekkis PP, Poloniecki JD, Thompson MR, Stamatakis JD. Operative mortality in colorectal cancer: prospective national study. BMJ 2003 Nov 22;327(7425): 1196e201. Khot UP, Wenk Lang A, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096e102. Sebastian S, Johnston S, Geoghegan T, Torregiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051e7. Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, Tsamakidis K, Bitsakou G, Plataniotis G, et al. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis. Surg Endosc 2004 Mar;18(3):421e6.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
The impact of stenting obstructing colorectal tumours in a district general hospital N.J. Phillips a, *, S.J. Arnold b, J. Elford c, A.J.G. Miles d a
Hants County Hospital, Romsey Road, Winchester, UK North Hampshire County Hospital, Basingstoke, UK c Department of Radiology, Royal Hants County Hospital, Romsey Road, Winchester, Hants, UK d Royal Hants County Hospital, Romsey Road, Winchester, Hants, UK b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 September 2010 Accepted 23 October 2010 Available online 5 November 2010
Introduction: The technique of stenting malignant obstructing colorectal lesions is established as an acceptable treatment with a low morbidity and mortality. This paper reviews our experience in stenting malignant colorectal obstruction and compares this group with those who underwent emergency surgery as their primary intervention. Methods: A retrospectively kept database over four years was reviewed and patients who had undergone either stenting or emergency surgery for a malignant colorectal obstruction were identified. These patients’ notes were retrieved and reviewed. Results: During the duration of study, a total of 29 stents were placed in 28 patients, with a mean age of 78 y (range 59e96 years). Patients generally had significant co-existing morbidity, with a median ASA score of 2.5. The timing of stent placement was a mean of 3.4 days (1e9 days) after presentation, including time for relevant investigation and diagnosis. Mean length of hospital stay was 9.8 days (2e36 days). In the emergency operation category, during the period of study, a total of 38 patients had operations for large bowel obstruction, either because the lesion was not suitable for stenting, or the personnel for stenting were not available. These patients ranged in age from 45 to 96 years, with a mean age of 72.4 years. Patients in this group were generally a little fitter than the stented group, with a median ASA grade of 2, and 14/38 patients were ASA1 (the largest group). Despite this Post-operative recovery was slow with these patients, the average length of stay being 16 days (range 8e66 days). Conclusions: In this study, we report our data on the first four years of stenting malignant bowel obstruction. It is a feasible and acceptable means of treatment, and we have demonstrated comparable morbidity and mortality to that reported in medical literature. The technique may avoid the need for emergency operation with its concomitant risks, lengthy in-patient stay, and high likelihood for a stoma. We would advocate the use of self expanding metal stents where appropriate in the management of large bowel obstruction. Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Stenting Malignant large bowel obstruction Endoscopy
1. Introduction The technique of stenting malignant obstructing colorectal lesions is established as an acceptable treatment since it was first described in 1991.1 Approximately 50% of patients in this challenging category are aged 70e89years2 and they carry a significant 30-day mortality and morbidity.3,4 Expanding metal stents are placed across an obstructing tumour giving relief from their symptoms. This procedure either allows time for the patient to be optimised for definitive surgery (bridge)
* Corresponding author. E-mail addresses: [email protected] (N.J. Phillips), Julian.elford@ wehct.nhs.uk (J. Elford), [email protected] (A.J.G. Miles).
or is used as an effective palliative procedure for inoperable cancers. Since Tejero et al. first coined the term ‘bridge to surgery’ in 19946 larger studies have reported patients being treated in this two-stage procedure.7,8 A meta-analysis of studies has shown that stenting has a low mortality rate (1%) and a successful palliation rate (90%) in patients thus treated.5 In the bridge to surgery group, complication rates are low (perforation rate 0e5%, stent migration 0e9.5%, and re-obstruction prior to surgery 0e4.7%).7e9 Up to 95% of patients had a primary anastomosis at subsequent operation, negating the need for a stoma.8 In recent times, laparoscopic-assisted surgery for colorectal cancer resections has gained increasingly widespread acceptance, with lower rates of morbidity. A recent study showed that blood loss and post-operative pain was less following laparoscopic
1743-9191/$ e see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2010.10.013
166
N.J. Phillips et al. / International Journal of Surgery 9 (2011) 165e168
resection, along with faster return of bowel function and earlier eating.10 This resulted in the hospital stay being, on average, 2 days shorter. Initial concerns, however, centred around the oncological clearance and long-term outcomes using this technique.11 More recently, however, data has been produced showing there appears to be no significant difference in overall or disease-free survival, with one study demonstrating a recurrence rate of 23% in both open and laparoscopic groups.12 This paper reviews our experience in stenting malignant colorectal obstruction and compares this group with those who underwent emergency surgery as their primary intervention. 2. Methods Between 2002 and 2006 a retrospective database of all patients undergoing emergency bowl surgery or endscopic stenting has been kept by the hospital colorectal co-ordinator and the department of radiology respectively. These databases have recorded patient demographics and technical details concerning the relevant procedure. These patients’ records were retrieved and data concerning age, sex, ASA grade, site of tumour, type of operation, formation of stoma, ITU admission, overall length of stay and complications were recorded as appropriate. Additionally, similar data was obtained concerning second elective procedures (such as reversal of stoma or those requiring operation after failure of stenting). Patients undergoing a laparotomy for bleeding or perforation were excluded from this study.
3. Results During the duration of study, a total of 29 stents were placed in 28 patients, with a mean age of 78 y (range 59e96 years). Patients generally had significant co-existing morbidity, with a median ASA score of 2.5. The timing of stent placement was a mean of 3.4 days (1e9 days) after presentation, including time for relevant investigation and diagnosis. Mean length of hospital stay was 9.8 days (2e36 days); see Fig. 1. The commonest anatomical site (Fig. 2) for an obstructing lesion was the sigmoid colon (64%), with other sites including rectosigmoid (7%), descending colon (18%), and transverse colon (11%). 15/28 patients died during the course of the study. The mean survival post-stenting was 10.7 months (range 5 dayse28 months). 13 patients were still alive at the end of the study. Six patients (21%) had complications related to their admission. One patient was unable to be stented due to the inability to cross the obstruction with a guide wire. He underwent a Hartmann’s procedure, and died of multi-organ failure and sepsis on the fifth post-operative day on ITU. This was the only in-patient death. The only other patient admitted to ITU during this time (for a total of 10 days) developed pneumonia, but responded well to treatment, was discharged on day 28, and subsequently underwent successful laparoscopic resection. One stent migrated, causing obstruction,
Fig. 2. Distribution of sites of obstructing colonic cancer.
necessitating a subtotal colectomy, whilst one patient re-presented with obstruction due to tumour growth around the end of the stent. This patient had a second stent inserted with good symptom relief. Two stent perforations occurred, both in the palliative group. One was initially discharged well on day 4, but returned two weeks later and was found to have a pericolic abscess at the tip of the stent where the proximal end had caused a small contained perforation. He was treated conservatively with i.v. antibiotics and made a good recovery. The other patient developed peritonitis within 12 h of stenting, and was taken for a Hartmann’s procedure. Nine patients subsequently underwent elective surgery. One open left hemicolectomy was performed, and two patients had an open extended right hemicolectomy, although one was found to be palliative at operation. This patient had a further laparotomy six months later for obstructive symptoms, where an ileo-transverse bypass was performed. One patient had a Hartmann’s procedure. Five patients had a laparoscopic anterior resection with primary anastomosis and no stoma. This subset of patients, who were found to have no metastatic disease, had a mean age of 79 years (range 71e88), and was operated on 69 days after being stented (range 29e135). Peri-operative stay for these patients was 9 days (range 7e12). No major morbidity was seen in these five patients, although one developed a minor chest infection requiring antibiotics and chest physiotherapy. During the period of study, a total of 38 patients had operations for large bowel obstruction, either because the lesion was not suitable for stenting, or the personnel for stenting were not available. These patients ranged in age from 45 to 96 years, with a mean age of 72.4 years. Patients in this group were generally a little fitter than the stented group, with a median ASA grade of 2, and 14/38 patients were ASA1 (the largest group). Despite this, three patients (7.9%) died in hospital, within two weeks of surgery. One patient
Fig. 1. Total length of stay for stented patients.
N.J. Phillips et al. / International Journal of Surgery 9 (2011) 165e168
developed pneumonia and then suffered a myocardial infarction in the post-operative period, one succumbed to multi-organ failure, and one patient was septic, almost moribund on arrival (ASA 5), and died on ITU on day 9 post-operatively. Timing of surgery was a mean of 3 days after presentation, (range 1e7 days), allowing for resuscitation and diagnostic testing. 23/38 patients had a right hemicolectomy to resect right sided or transverse colon lesions, while one patient had a palliative bypass. Two trephine colostomies were brought out in elderly patients with significant co-morbidity, and two subtotal colectomies performed in patients whose caecum was critically distended at operation. Ten left sided lesions were resected, six of whom had a Hartmann’s procedure, leaving four with a primary resection and anastomosis, two with a covering stoma, and one with a caecostomy. Seventeen patients required an ITU bed post-operatively, for an average of 4 days (range 1e10 days). Of these, eight were ventilated post-operatively for an average of 2 days (range 1e5 days). Ten patients had stomas, and stoma training alone extended the hospital stay by an average of 3.3 days per patient, after they were otherwise considered fit for surgical discharge. Post-operative recovery was slow with these patients, the average length of stay being 16 days (range 8e66 days). Significant morbidity was seen in 12/38 patients (32%). Three had a myocardial infarction, five had septic or infective complications, and one patient went into retention and required a TURP as an in-patient. Two patients were re-operated on during their index admission, one for a dehiscence, and one for revision of stoma. Three patients were admitted for further surgery at a later date: one for resection of a liver metastasis after 32 weeks (at a different hospital), and two for reversal of stoma, one of which developed a fistula at the closure site, necessitating ITU admission for 11 days and eventually discharged after 7 weeks. As expected, pathological staging of the resected tumours was advanced, with 13 classified as Dukes B, and 25 classified as Dukes C. 21 patients were considered to have had a curative procedure (55%), and were still alive at the end of the study, up to 4 years later.
167
associated with a new technique. Despite this, our figures are comparable to those achieved in the medical literature. The average length of stay for stented patients was 9 days, allowing for investigation, treatment and resolution of their symptoms. A longer period of 16 days was required for those patients who underwent surgery. Whilst the two groups can not be compared directly, it is clear that stented patients are discharged around a week earlier than those who had surgery. If we had looked at a matched population, comparing stents against left sided resection, then this difference may have been even greater, with more patients requiring stoma training prior to discharge. 17 patients required ITU stay for a cumulative total of 69 days. With an ITU bed costing approximately £1100e£1400 per day (government figures), this represents a total cost of over £86,000 on intensive care treatment for this group of patients alone. Any treatment which may allow for faster discharge from hospital should be considered for its potential. Stenting malignant bowel obstruction may have a significant impact on hospital bed occupancy, compared to emergency operation, at a time when bed shortages are an increasing problem. It has been suggested that the cost of occupying an NHS bed for a day can be calculated at over £300. Whilst stenting may allow for faster discharge, the cost of equipment will offset this to some extent. One study estimated that the cost of materials for stenting worked out at an average of just over €1700 (£1150 approx) per patient.16 Overall, this group found that defunctioning alone was cheaper by €132 (£91) per inpatient episode compared to stenting, but did not look at the ongoing costs and morbidity of stoma care once discharged from hospital. In this study, we report our data on the first four years of stenting malignant bowel obstruction. It is a feasible and acceptable means of treatment, and we have demonstrated comparable morbidity and mortality to that reported in medical literature. The technique may avoid the need for emergency operation with its concomitant risks, lengthy in-patient stay, and high likelihood for a stoma. We would advocate the use of self-expanding metal stents where appropriate in the management of large bowel obstruction.
4. Discussion Malignant large bowel obstruction remains a challenging clinical problem in the 21st century, with high levels of morbidity and mortality. The ACPGBI audit of over 8000 patients showed that emergency operations for this range of conditions resulted in a mortality rate of 20%.13 This retrospective audit does not directly compare a matched population for patients undergoing stenting versus operation. We have studied all patients treated for large bowel obstruction over four years, with what we considered the best means available to each patient at the time of presentation. Our mortality rate for patients who underwent operation was 7.9%; this was despite being a group with better ASA grading compared to those who were stented. A significant number of this group, however, had a right hemicolectomy, perhaps imparting less insult to patients than those undergoing left sided resections. These patients are not amenable to stenting by current techniques. Despite, this however, it still demonstrates that operative intervention has its risks in terms of mortality and morbidity, with a complication rate of 32%. Set against this is our procedural complication rate of 18% for the stented group. This includes problems such as migration, tumour overgrowth, failure to stent (each one patient, 4%), and perforation (7% - two patients). Such figures are comparable to those quoted in large systematic reviews, with rates of migration and reobstruction of about 10%, and perforation and bleeding around 5%.14,15 Our series looks at the first four years of practice of stenting in a district general hospital, and encompasses the ‘learning curve’
Ethical approval Not required. Funding None. Conflict of interest None to declare.
References 1. Dohmoto M. New method e endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endoscopia Digestiva 1991;3:1507e12. 2. Stamatakis J, Thompson M, Chave H. National audit of bowel obstruction due to colorectal cancer, Apr 1998eMar 1999. London: Association of Coloproctology of Great Britain and Ireland; 2000. 3. Riedl S, Wiebelt H, Bergmann U, Hermanek Jr P. Post-operative complications and fatalities in the surgical therapy of colon carcinoma. Results of the German multicentre stucy by the colorectal carcinoma study group. Chirurgia 1995 Jun;66(6):597e606. 4. Irvin 3rd GL, Horsley 3rd JS, Caruana Jr JA. The morbidity and mortality of emergent operations for colorectal disease. Ann Surg 1984 May;199(5): 598e603. 5. Khot UP, Wenk Lang A, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002 Sept;89:1096e102. 6. Tejero E, Mainar A, Fernandez L, Tobio R, De Gregorio MA. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum 1994 Nov;37(11):1158e9. 7. Mainar A, De Gregorio MA, Tejero E, Tobio R, Alsonso E, Pinto I, et al. Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery e results of a multicentre trial. Radiology 1999; 210:65e9.
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N.J. Phillips et al. / International Journal of Surgery 9 (2011) 165e168
8. Saida Y, Sumiyama Y, Nagao J, Uramatsu M. Long term prognosis of preoperative ‘bridge to surgery’ expandable metallic stent insertion for obstructive colorectal cancer: comparison with emergency operation. Dis Colon Rectum 2003 Oct;46(Suppl. 10):S44e9. 9. Knopfle E, Mayer H, Wamser G, Bohndorf K, Witte J. Ileus in colorectal carcinoma. Pre-operative implantation of self-expanding metal stents and early elective surgery as an alternative to emergency surgery. Chirurgia 2001 Oct;72 (10):1137e43. 10. Reza MM, Blasco JA, Andradas E, Cantero R, Mayol J. Systematic review of laparoscopic versus open surgery for colorectal cancer. Br J Surg 2006 July;93(8):921e8. 11. Cohen SM, Wexner SD. Laparoscopic colorectal resection for cancer: the cleveland clinic Florida experience. Surg Oncol 1993;2(Suppl. 1):35e42. 12. Nakamura T, Mitomi H, Ohtani Y, Kokuba Y, Sato T, Ozawa H, et al. Comparison of long-term outcome of laparoscopic and conventional surgery for advanced
13.
14. 15.
16.
colon and recto-sigmoid cancer. Hepatogastroenterology 2006 May-Jun;53 (69):351e3. Tekkis PP, Poloniecki JD, Thompson MR, Stamatakis JD. Operative mortality in colorectal cancer: prospective national study. BMJ 2003 Nov 22;327(7425): 1196e201. Khot UP, Wenk Lang A, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096e102. Sebastian S, Johnston S, Geoghegan T, Torregiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051e7. Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, Tsamakidis K, Bitsakou G, Plataniotis G, et al. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis. Surg Endosc 2004 Mar;18(3):421e6.