Use of self-expanding metal stents to treat malignant colorectal obstruction in general endoscopic practice (with videos)

ORIGINAL ARTICLE: Clinical Endoscopy

Use of self-expanding metal stents to treat malignant colorectal obstruction in general endoscopic practice (with videos) ´lez-Huix, MD, Diego Juzgado, MD, Francisco Igea, MD, ´ s Garcı´a-Cano, MD, PhD, Ferran Gonza Jesu ´rez-Miranda, MD, Leopoldo Lo ´ pez-Rose ´s, MD, Antonio Rodrı´guez, MD, Manuel Pe ´lez-Carro, MD, Luis Yuguero, MD, Jorge Espino ´ s, MD, Julio Duco ´ ns, MD, PhD, Pedro Gonza Vı´ctor Orive, MD, Santiago Rodrı´guez, MD Cuenca, Girona, Madrid, Palencia, Valladolid, Lugo, Salamanca, Alca´zar de San Juan, Burgos, Terrassa, Huesca, Bilbao, Zamora, Spain

Background: Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction (MCRO). Patients can then either undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. The majority of reports on the use of SEMS in MCRO come from single centers; therefore, its use in general endoscopic practice is not clearly known. Objective: To study the use of SEMS for MCRO in a wide endoscopic practice. Design: Retrospective study. Setting: A survey was carried out among endoscopists in 13 hospitals in Spain (6 tertiary referral centers and 7 community hospitals). Patients: Those who presented with MCRO. Interventions: A total of 175 attempts to insert colorectal SEMS were made during a 12-month period (October 2003 to September 2004). Main Outcome Measures: Technical and clinical success and possible differences according to the type of hospital. Results: There was a mean of 1.2 attempts/mo per center (range, 2-0.5 attempts/mo per center). Insertion success was achieved in 162 (92.6%) and acceptable colonic decompression in 138 of 175 (78.8%) attempts and in 138 of 162 (85.1%) of successfully inserted stents. SEMS served as a bridge to scheduled surgery in 72 of 175 (41%) and as a palliative definitive treatment in 66 of 175 (37.7%). The major complication was perforation, which occurred in 7 of 175 occasions (4%) and led to death in 2 patients (1%). There were other less severe complications (25 [14%]). No significant differences in outcome of stent placement procedures were found between both categories of centers. Limitations: Retrospective study involving many centers and the possibility of bias for different assessments of outcomes. Conclusions: In this study, success rates for SEMS placement and colonic decompression in MCRO were acceptable, without substantial differences according to the type of hospital. This procedure appeared to be feasible in general endoscopic practice. (Gastrointest Endosc 2006;64:914-20.)

Self-expanding metal stents (SEMS) are currently used to treat malignant obstruction in different sites of the GI tract and biliary tree.1 In 1991, Dohmoto2 described, for the first time, the use of a SEMS to solve a malignant Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.06.034

colorectal obstruction (MCRO). Since then, an increasing number of endoscopic interventions have been reported,3-9 and dedicated enteral or specific colorectal stents have been manufactured. Insertion (technical) success rates and figures of clinical decompression of the colorectum are, on average, about 80% or higher, with an acceptable morbidity and mortality. After solving the acute colonic obstruction, patients can then either

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undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. In patients with acute MCRO and who are candidates for surgery, placement of a preoperative stent can prevent a large number of colostomies, because patients can be stabilized, and the large bowel can be adequately cleaned before the elective operation. Besides, a lower severe complication rate, as well as a shorter hospital stay, can be achieved.10 Also, stent insertion in MCRO followed by elective surgery appears to be more effective and less costly than emergency surgery under base-case conditions.11 In addition, insertion of SEMS for MCRO has been shown to be a good palliative alternative to colostomy in patients unfit for surgery, avoiding unnecessary operations and providing a better quality of life, as well as being cost effective.12 Despite the increasingly widespread use of SEMS for MCRO and the detailed description of endoscopic techniques,13 the majority of reports come from single centers. Therefore, its use in general endoscopic practice is not clearly known. Our aim was to perform a study for this purpose.

Self-expanding metal stents to treat malignant colorectal obstruction

Capsule Summary What is already known on this topic d

SEMS are being used in malignant colorectal obstruction to avoid emergency surgery, to provide either a bridge to elective surgery or definitive palliative treatment.

What this study adds to our knowledge d

d

In this retrospective survey of 13 hospitals, SEMS insertion was attempted in 175 patients, was successful in 162 (92.6%), and achieved acceptable colonic decompression in 138 (78.8%). SEMS served as a bridge to scheduled surgery in 72 patients (41%) and as a palliative definitive treatment in 66 patients (37.7%).

A survey was carried out among endoscopists in 13 Spanish hospitals on the use of SEMS in MCRO during a 12-month period (October 2003 to September 2004). There were 6 tertiary referral centers and 7 community hospitals, belonging to 7 different Spanish regions. Within the Spanish National Health Service, level II hospitals can be considered community hospitals. These centers usually have approximately 200 to 400 inpatient beds and cover a population of about 150,000 people. There are general surgeons who also perform colorectal surgery, but there are no specialized coloproctologists. Often a general surgeon is on call at the hospital for the entire day. Endoscopic procedures and therapeutic endoscopy (eg, dilations, PEGs) are performed. If an endoscopist is on call for the whole day, he or she is at home after the normal working hours and only performs procedures for GI bleeding and esophageal foreign bodies. These centers seldom have interventional radiology. The participant endoscopists met on September 2004 and decided to investigate the use of SEMS for MCRO in general endoscopic practice. They also decided to set up a group for the study of GI stents inserted by endoscopists ´tesis Endosco ´picas Di(GEPED [Grupo de Estudio de Pro gestivas]). This study was conceived as a retrospective survey but was limited to the previous 12 months. In this way, data collection was presumed to be more accurate. Clinical records and databases from the different endoscopic units were the main sources of information on interventions and patient outcomes.

All stent-placement procedures were performed by means of an endoscope with or without fluoroscopic monitoring. A through-the-scope (TTS) intervention was considered as such when the undeployed stent was inserted through the working channel of a therapeutic endoscope, over a guidewire placed beyond the stricture, also by endoscopic means (Video 1, available online at www.giejournal. org). In a non-TTS procedure, the guidewire was, in the same way, inserted endoscopically, but the stent was placed parallel to the endoscope (Video 2, available online at www. giejournal.org). Acute colonic obstruction was diagnosed by the classical clinical and radiographic findings. A complete obstruction was defined if the patient was unable to pass stools and air. If some air could be expelled through the rectum or if there was pseudodiarrhea from overflow incontinence because of fecal impaction, the obstruction was deemed to be partial. A prophylactic stent insertion was considered in patients with no obstructive symptoms at the time of diagnosis but who had tumoral strictures so narrow that they did not allow the passage of a routine colonoscope and in whom no other short-term therapeutic measure was planned. In general, patients underwent bowel cleansing by means of enemas. But oral preparation was sometimes used when the clinical situation appeared less severe. In the majority of centers where this study was performed, colonoscopy is the first diagnostic procedure used to rule out colonic obstruction. Insufflation is used as little as possible to prevent further damage to the obstructed bowel. But, according to individual standards of practice and in some clinical situations, a barium enema was sometimes previously performed. It was considered to be a technical success if the SEMS had been properly deployed within the tumoral stricture. It was considered to be a clinical success if the satisfactorily placed stent produced an acceptable colonic decompression, enough to solve the obstructive symptoms.

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PATIENTS AND METHODS

Garcı´a-Cano et al

Self-expanding metal stents to treat malignant colorectal obstruction

Figure 1. Outcomes after stent placement in tumoral colorectal obstruction.

Other outcomes of patients who underwent stent placement during the study period, such as complications or surgery, were also recorded. Endoscopists working in these community hospitals that participated in this study did not receive any special training in colorectal SEMS insertion in tertiary referral centers. Nevertheless, at the beginning of the study, the learning curve for SEMS insertion was considered to have been accomplished by the majority of them. According to Spanish law, no special approval for this data recording is necessary. All patients gave informed consent before the procedure. Comparisons between categorical variables were made by using either the c2 test or the Fisher exact test, when appropriate. Means were compared by using the t test. Two-tailed P values were measured and a P ! .05 was considered significant.

During the 12-month study period, there were 175 attempts to insert colorectal SEMS (mean, 1.2 attempts/ mo per center; range, 2-0.5). There were 112 men (64%). Mean age was 73.8 years (standard deviation, 12 years; range, 33-97 years). Colonic obstruction was complete in 73 patients (41.7%) and partial in 94 (53.7%), and, in 8 occasions (4.6%), SEMS were inserted prophylactically. Primary colonic cancer accounted for the majority of obstructions (167 [95.4%]). Other tumoral causes were ovaric (5), cervix (1), prostate (1), and bladder (1). Strictures were located at the rectosigmoid in 129 patients (73.7%), descending colon in 27 (15.4%), splenic flexure in 4 (2.3%), transverse colon in 8 (4.6%), hepatic flexure in 5 (2.9%), and ascending colon in 2 (1.1%). Referral physicians in charge of the patients were surgeons in 110 cases (62.9%), gastroenterologists in 33

(18.9%), oncologists in 14 (8%), internists in 13 (7.4%) and other in 5 (2.8%). After proper clinical assessment, a stent-placement procedure was planned to treat MCRO. For SEMS placement, both endoscopic and fluoroscopic monitoring was used in 134 occasions (76.6%), and, in 41 (23.4%), only endoscopic methods were used, without fluoroscopic guidance. Strictures were not dilated before stent placement. Only 39 patients (22.3%) had a barium enema before the procedure. Interventions were attempted without sedation in 46 patients (26.3%), general anesthesia was used in 13 (7.4%), deep sedation in 25 (14.3%), and conscious sedation in 91 (52%). Therefore, any type of sedation was used in 129 of 175 patients (73.7%). Successful insertion was achieved in 162 of 175 patients (92.6%). There were 13 failures (7.4%): inability to traverse the stricture with a guidewire (7); iatrogenic colonic perforation during the procedure (3); proximal stent migration, without another stent inserted (2); and poor patient compliance (1). Eleven of these patients underwent emergency surgery: 6 diverting colostomies with tumoral resection, 3 colostomies that left the tumor in place, and 2 tumoral resections with primary anastomosis (Fig. 1). There was no surgical mortality. In 133 of 162 successful attempts (82%), TTS stents were inserted. In 110 cases, the stent chosen was an enteral Wallstent (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass), and, in 23 cases, a Hanarostent (M.I. Tech, Seoul, Korea) was used. Twenty-nine Ultraflex Precision stents (Microvasive) were inserted in a nonTTS method. This kind of SEMS was inserted exclusively in rectosigmoid strictures. No differences were found in terms of success according to type of stent (Table 1). Complete clinical success, with an acceptable colonic decompression, was achieved in 138 of 175 attempts

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RESULTS

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(78.8%) and in 138 of 162 of successfully inserted stents (85.1%). In 24 patients, good results were not achieved. Five MCRO because of malignancies other than nonprimary colonic carcinoma (4 ovaric and 1 bladder) had incomplete decompression, and 1 of them, with ovarian cancer, had to undergo a diverting colostomy. In this group of patients without adequate decompression, 3 colonic perforations occurred after stent placement. Two patients underwent surgery, and the other patient received only palliative support. Another perforation was seen, but, after careful revision of the pre–stent-placement radiographs, it was decided that the perforation had taken place before the procedure. This patient also underwent surgery. Nine patients had surgery before the scheduled date because of malfunctioning of the stent. All underwent resection with primary anastomosis. Therefore, the primary goal to avoid colostomy was achieved. Finally, 6 more patients with carcinomatosis for colonic carcinoma continued to have intermittent episodes of obstruction. Seventy-two of 138 patients (52%) with acceptable decompression were deemed to be candidates for elective surgery. Median time for surgery was 11 days (range, 1-149 days). At the end of the study, 8 patients were still awaiting surgery. Fifty-seven patients had tumoral resection with primary anastomosis, and 7 patients received a stoma, with different kinds of operative procedures. Surgical mortality was 4.6% (3/64). While waiting for surgery, 2 stent migrations occurred. Only 1 was reinserted. SEMS served as palliative definitive treatment in 66 of 138 patients (47.8%), with clinical success, because they were not fit for surgery because of a high surgical risk or advanced disease. Complications observed in this group were sepsis (1 patient), mild tenesmus (4 patients), migration (3 patients), stent reobstruction (3 patients), and rectal hemorrhage (1 patient). An abscess in the psoas muscle, with colonic perforation by the stent, was seen at follow-up of an ovaric carcinoma. This patient underwent uncomplicated surgery with stoma creation. The remaining patients were managed with conservative measures, and 4 new stents were reinserted. Median survival time after stent insertion was 100 days (range, 5-246 days). At the end of the study, 16 patients were still alive, with a median survival time of 34 days (range, 12-72 days). On an intention-to-treat basis, 26 of 175 procedures (14.8%) ended up in unplanned surgery. Only 16 (8%) had to be performed urgently (Fig. 1). When success and other characteristics of stent insertion were compared between tertiary referral centers and community hospitals (Table 2), only 2 significant differences were found. The first one was that the range of attempted procedures per month was greater in tertiary referral centers than in community hospitals. The variance was higher in these hospitals and this made the means significantly different. And, the second one was that patients with MCRO in tertiary centers were more prone to suffer a complete obstruction. On the contrary, a higher number www.giejournal.org

Self-expanding metal stents to treat malignant colorectal obstruction

TABLE 1. Outcomes according to the type of stent used endoscopically to solve malignant colorectal obstruction* Ultraflex Wallstent, Hanarostent, Precision, no. of no. of no. of procedures/ procedures/ procedures/ total (%) total (%) total (%) Failure in stent insertiony

9/119 (7.6)

3/26 (11.5)

1/30 (3.3)

1/23 (4.3)

5/29 (17.2)

92/110 (83.6)

22/23 (95.6)

24/29 (82.7)

Overall 22/119 (18.5) complications rate

4/26 (15.3)

6/30 (20)

No clinical 18/110 (16.3) success after stent insertion Clinical success after stent insertion

*No significant difference was found among the 3 types of stent used. yIn 7 occasions failure was because of an inability to traverse the stricture with a guidewire and in 1 patient because of poor compliance. Reported here is the stent that would have been inserted.

of partial obstructions were observed in small centers. MCRO caused by tumors other than from primary colonic cancer responded worse to stent placement. Good results were achieved in 3 of 8 of noncolonic cancer versus 116 of 135 in colonic cancer, odds ratio 0.09, 95% confidence interval 0.09-0.5, P Z .003. Complications for the entire series are shown in Table 3. The most severe complication was perforation, occurring in 7 patients (4%) and leading to death in 2 patients (procedure-related mortality 2/175 [1%]). There were another 25 less severe complications (14%), which were managed conservatively or by endoscopic reintervention.

DISCUSSION The usefulness of SEMS to palliate MCRO has been previously shown in several series,3-9 each time with a higher number of procedures (Table 414-21). These reports come from single centers, which may have special dedication and interest in this intervention. Furthermore, these studies usually are of a longer period, more than 1 year. The current study presents the experience of 13 hospitals during a 12-month period and also shows that a large number of patients who had tumoral obstruction of the large bowel can benefit from stent placement. Volume 64, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 917

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Self-expanding metal stents to treat malignant colorectal obstruction

TABLE 2. Characteristics of self-expanding metal stents used to treat malignant colorectal obstruction in 13 hospitals in Spain* Complete series

Tertiary hospitals

Community hospitals

No. of patients

175

93

82

Insertion success, no. (%)

162 (92.6)

83 (89)

79 (96)

N.S.

Complete clinical success, no. (%)

138 (78.8)

72 (77.4)

66 (80.4)

N.S.

Perforation, no. (%)

7 (4)

5 (5.3)

2 (2.4)

N.S.

Mortality, no. (%)

2 (1)

1 (1)

1 (1.2)

N.S.

0.97 (1.25-0.5)

P value

Attempts per month, mean (range)

1.2 (2-0.5)

1.3 (2-0.5)

Obstruction in the left colon, no. (%)y

156 (89)

84 (90)

72 (87)

N.S.

!.001

Type of obstruction, no. (%) Complete

73 (41)

47 (50.5)

26 (31.7)

.01

Partial

94 (53.7)

42 (45.2)

52 (63.4)

.02

8 (4.6)

4 (4.3)

4 (4.9)

N.S.

Sedation during the procedure, no. (%)

129 (73.7)

63 (67.7)

66 (80)

N.S.

Endoscopic insertion with fluoroscopic monitoring, no. (%)

134 (76.6)

74 (79.5)

60 (73)

N.S.

Bridge to scheduled surgery, no. (%)

72 (41)

37 (39.7)

35 (42.6)

N.S.

Stent as palliative definitive treatment, no. (%)

66 (37.7)

35 (37.6)

31 (37.8)

N.S.

Prophylaxis

N.S., Not significant. *All percentages are in intention-to-treat basis, thus taking into account all attempts. yLeft colon: rectum, sigmoid, and descendent before the splenic flexure.

TABLE 3. Complications of stents During the insertion procedure (n Z 175)

Group of patients with no acceptable decompression (n Z 24)

Perforation

3

3*

Migration

2z

Malfunction

Group of patients with clinical success and bridge to surgery (n Z 72)

2

Group of patients with clinical success and definitive palliation (n Z 66)

Overall

1y

7/175 (4%)

3

7/175 (4%)

9

9/162 (5.5%)x

Obstruction

3

3/162 (1.8%)

Hemorrhage

1

1/162 (0.6%)

Tenesmus

4

4/162 (2.4%)

Sepsis

1

1/162 (0.6%)

13/66 (19.7%)

32/175 (18.2%)

5/175 (2.8%)

12/24 (50%)

2/72 (2.8%)

*Another patient had a preexisting perforation before the stent placement procedure and is not considered a complication. yThis patient had a perforation and an abscess in the psoas muscle. zUpstream migration during stent deployment. xThe number (162) of successfully inserted stents after 13 failures had occurred in the initial attempts.

Therefore, SEMS insertion for MCRO in general endoscopic practice appears to be feasible. Furthermore, this series is, until now, to our knowledge, the largest one published.

Our results, with a technical success rate of 92% and a clinical success rate of 78.8%, lie within the range of previously reported data. We believe that these figures can represent the outcome of stent placement in the

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TABLE 4. Experience with endoscopically placed SEMS in malignant colorectal obstruction in some published series with at least 20 patients*

Y

No. of patients

Insertion success, no. (%)

Clinical success, no. (%)

Perforation rate, no. (%)

1998

27

25 (94)

23 (85)

4 (15)

2001

37

36 (97)

28 (75.6)

2 (5.4)

2003

23

19 (82)

18 (78.2)

0

2003

22

20 (91)

20 (91)

2 (9)

2004

89

84 (94.3)

76 (85.3)

0

Suzuki and Saunders

2004

42

36 (85.7)

35 (83.3)

2 (4.7)

20

2004

52

51 (98)

50 (96.1)

1 (1.9)

Carne et al

2004

25

22 (88)

20 (80)

0

Current study

2005

175

162 (92.6)

138 (78.8)

Study 14

Baron et al

15

Spinelli and Mancini 16

Smedh et al

17

Lambertini et al 18

Meisner et al

19

Law et al

21

7 (4)

*All are single-center studies and extended several years, except the current series, which is multicentric and during only 1 year. Success and perforation rates are calculated according to the initial number (no.) of attempted procedures. In some series, a small proportion of benign strictures (most of them diverticular disease) are also included, and its outcomes are difficult to extract from the entire series, composed, in its vast majority, of malignant strictures.

community, because, in this study, different levels of expertise and even dissimilar stages in the learning curves for SEMS insertion were involved. Moreover, we have found no significant differences between tertiary referral centers and community hospitals in terms of success or severe complications. However, it is not clear why there is a different type of acute colonic obstruction between the 2 kinds of centers. In community hospitals, fewer complete acute obstructions were found (no passing of stools per rectum but more or less capable of expelling air). Perhaps in these centers, because they had less availability of endoscopists during the evening and night hours, more patients were considered to have a less severe acute colonic obstruction and stayed with nothing by mouth and nasogastric tube aspiration until the next morning. It cannot be excluded that in community hospitals, complete obstructions were more easily sent to surgery, whereas less ill patients were referred for stent placement. In the same way, because different hospitals were involved in the study, some findings that correspond only to individual characteristics of some patients, practice criteria in several centers, or nonstandard surgical or oncologic approaches can be found. For instance, although the average time to undergo surgery in the ‘‘bridge to surgery’’ group was 11 days, a few patients waited almost 5 months. Besides, the minority of patients (13 [7.4%]) received, in some centers, general anesthesia to undergo stent insertion. It can be argued that this type of sedation is disproportionate for a minimal invasive decompression. But in those few cases, the attending anesthesiologists

were more confident acting in such a way. However, the vast majority of procedures (137 [78.2%]) were performed without sedation or with conscious sedation administered by the same endoscopists. Moreover, dissimilar criteria can be found in the manner in which some hospitals dealt with problems, eg, stent malfunction (new stent, surgery, or palliative measures). Despite this heterogeneity, sometimes seen in a real-life scenario of clinical practice, our aim was only to investigate the efficacy of SEMS in solving MCRO. Interestingly, the majority of patients in the current series were referred by surgeons, who called the endoscopists for SEMS insertion. Perhaps because our surgical colleagues were convinced of the efficacy of stents in MCRO, the average of 1.2 procedures per month in this study is slightly superior to the 0.77 reported as a mean in some published series.22 Nevertheless, in tertiary referral centers, a wider range of attempted procedures per month than in community hospitals was found, which can represent special approaches to MCRO by individual groups of surgeons. SEMS in MCRO are also inserted by interventional radiologists. The advantage of endoscopic placement of colorectal stents instead of interventional radiologic placement is the greater accessibility to obstructions proximal to the sigmoid colon and in patients with extremely angulated strictures. There is also an improved mechanical advantage of being able to pass some stents directly through the working channel of the endoscope.13 In our series, a fourth of the strictures (46 [26%]) were beyond the sigmoid colon. Although, until now, no randomized trial has been performed that compared both types of insertion, it

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Self-expanding metal stents to treat malignant colorectal obstruction

is assumed that regardless of the method of stent placement, the effectiveness is the same. Our results in palliation of MCRO caused by nonprimary colon cancers (ovaric, bladder, cervix, and prostate) have been disappointing. Good results were only achieved in 3 of 8 (37.5%). Pothuri et al23 reported an initial success in 4 of 6 gynecologic cancers (66.6%) causing MCRO. Besides, in the follow-up period, another patient had a contained sigmoid perforation 12 days after stent insertion, which was managed with conservative measures. Perhaps it should be considered that outcomes in this type of MCRO are worse than those obtained in obstructions caused by colonic carcinoma. Our series also shows that insertion of SEMS to treat MCRO is not a procedure without failures, complications, or mortality. Despite these drawbacks, there is an increasing amount of information that initial stent insertion compares favorably with emergency surgery, either in the setting of a bridge to elective operation11 or as definitive palliation.12,20 We believe that our results can help to spread this knowledge within the endoscopic community. DISCLOSURES The authors have no commercial associations (eg, equity ownership or interest, consultancy, patent and licensing agreement, or institutional and corporate associations) that might be a conflict of interest in relation to this article. There are not sources of funding in support of the work presented in the article.

REFERENCES 1. Baron TH. Expandable metal stents for the treatment of cancerous obstructions of the gastrointestinal tract. N Engl J Med 2001;344:1681-7. 2. Dohmoto M. New method: endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endoscopia Digestiva 1991; 3:1507-12. 3. Rey JF, Romanczyk T, Greff M. Metal stents for palliation of rectal carcinoma: a preliminary report on 12 patients. Endoscopy 1995;27:501-4. 4. Saida Y, Sumiyama Y, Nagao J, et al. Stents endoprosthesis for obstructing colorectal cancers. Dis Colon Rectum 1996;39:552-5. 5. Tack J, Gevers AM, Rutgeerts P. Self-expandable metallic stents in the palliation of rectosigmoidal carcinoma: a follow-up study. Gastrointest Endosc 1998;48:267-71. 6. Repici A, Reggio D, DeAngelis C, et al. Covered metal stents for management of inoperable malignant colorectal strictures. Gastrointest Endosc 2000;52:735-40. 7. Lieberman H, Adams DR, Blatchford GJ, et al. Clinical use of the selfexpanding metallic stent in the management of colorectal cancer. Am J Surg 2000;180:407-11. 8. Ben Sousan E, Savoye G, Hochain P, et al. Expandable metal stents in palliative treatment of malignant colorectal stricture. A report of 17 consecutive patients. Gastroenterol Clin Biol 2001;25:463-7. 9. Garcı´a-Cano J, Gonza´lez Martı´n JA, Redondo-Cerezo E, et al. Treatment of malignant colorectal obstruction by means of endoscopic insertion of self-expandable metallic stents [in Spanish with English abstract]. An Med Interna 2003;20:515-20.

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10. Martinez-Santos C, Lobato RF, Fradejas JM, et al. Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum 2002;45:401-6. 11. Targownik LE, Spiegel BM, Sack J, et al. Colonic stent vs emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004;60:865-74. 12. Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, et al. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Surg Endosc 2004;18:421-6. 13. Baron TH. Colorectal stents. Tech Gastrointest Endosc 2003;5:182-90. 14. Baron TH, Dean PA, Yates MR, et al. Expandable metal stents for the treatment of colonic obstruction: technical outcomes. Gastrointest Endosc 1998;47:277-85. 15. Spinelli P, Mancini A. Use of self-expanding metal stents for palliation of rectosigmoid cancer. Gastrointest Endosc 2001;53:203-6. 16. Smedh K, Birgisson H, Raab Y, et al. Self-expanding stent in obstructing colorectal cancer. A new technique to avoid abdominal surgery [in Swedish with English abstract]. Lakartidningen 2003;100:1982-6. 17. Lambertini M, Tamburini A, Corinaldesi F, et al. Metal endoprosthesis in the treatment of acute neoplastic occlusion of the colon. Our experience [In Italian with English abstract]. Tumori 2003;89(Suppl 4):86-9. 18. Meisner S, Hensler M, Knop FK, et al. Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center. Dis Colon Rectum 2004;47:444-50. 19. Suzuki N, Saunders BP, Thomas-Gibson S, et al. Colorectal stenting for malignant and benign disease: outcomes in colorectal stenting. Dis Colon Rectum 2004;47:1201-7. 20. Law WL, Choi HK, Lee YM, et al. Palliation for advanced malignant colorectal obstruction by self-expanding metallic stents: prospective evaluation of outcomes. Dis Colon Rectum 2004;47:39-43. 21. Carne PWG, Frye JNR, 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. 22. Garcı´a-Cano J. Endoscopic insertion of self-expanding metal stents as first step to treat malignant colorectal obstruction [letter]. Am J Gastroenterol 2005;100:1203-4. 23. Pothuri B, Guirguis A, Gerdes H, et al. The use of colorectal stents for palliation of large-bowel obstruction due to recurrent gynecologic cancer. Gynecol Oncol 2004;95:513-7.

Received June 23, 2005. Accepted June 14, 2006. Current affiliations: Gastroenterology Department, Hospital Virgen de la Luz, Cuenca (J.G-C.), Gastroenterology Department, Hospital Josep Trueta, Girona (F.G-H.), Gastroenterology Department, Centro Me´dico Andersen, Madrid (D.J.), Gastroenterology Department , Hospital Rı´o Carrio´n, Palencia (F.I.), Gastroenterology Department, Hospital Rı´o Ortega, Valladolid (M.P-M.), Gastroenterology Department, Hospital Xeral, Lugo (L.L-R.), Gastroenterology Department, Hospital Clı´nico, Salamanca (A.R.), Gastroenterology Department, Hospital La Mancha-Centro, Alca´zar de San Juan (P.G-C.), Gastroenterology Department, Hospital General Yagu¨e, Burgos (L.Y.), Gastroenterology Department, Mutua de Terrassa, Terrassa (J.E.), Gastroenterology Department, Hospital San Jorge, Huesca (J.D.), Gastroenterology Department, Hospital de Basurto, Bilbao (V.O.), Gastroenterology Department, Hospital Virgen de la Concha, Zamora (S.R.), Spain. Presented at Digestive Disease Week, May 14-18, 2005, Chicago, Illinois (Gastrointest Endosc 2005;61:AB251). Reprint requests: J. Garcı´a-Cano, MD, Gastroenterology Service, Hospital Virgen de la Luz, C/ Federico Mayor Zaragoza, 2, 5 A. 16002 Cuenca, Spain.

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