Endoscopic Stenting Versus Emergency Surgery in Patients With Metastatic Colorectal Cancers Presenting With Acute Intestinal Obstruction.

Ker-kan Tan, FRCS Edin, Tian-zhi Lim, MBBS, Charles B Tsang, FRCS Edin FRCS Glasg, Dean C Koh, FRCS Edin FRCS Glasg. National University Health System

Background
Operating in patients with obstructed colorectal cancers is associated with numerous morbidities. Self expanding metallic stents provide a promising alternative. The aim of this study was to compare the outcomes of endoscopic stenting versus emergency surgery in patients with metastatic colorectal cancers presenting with acute intestinal obstruction.

Methods
A retrospective review of all patients with metastatic colorectal cancers who underwent either endoscopic stenting or emergency surgery for acute intestinal obstruction was performed.

Results
Over a 4-year period from June 2007 to June 2011, 31 patients, median age, 68 (42 – 96) years formed the study group. The two commonest sites of the primary malignancy were the sigmoid colon (n = 11, 35.5%) and the rectosigmoid junction (n = 8, 25.8%). Hepatic and pulmonary metastases were seen in 25 (80.6%) and 8 (25.8%) patients, respectively.

Eighteen (58.1%) patients had endoscopic stenting attempted. It was successful in only 12 (66.7%) patients. The other 6 (33.3%) patients who failed endoscopic stenting required immediate surgery to relieve the obstruction. The remaining 13 (41.9%) patients underwent immediate surgery with no prior attempt at endoscopic stenting.

Patients who failed stenting (4/6) had worse grades of complications than those who were successfully stented (1/12) (p: 0.022). This trend was also observed when compared to those patients who were operated immediately (4/13), although the difference was not statistically significant. In addition, the median length of stay (5, range, 3 – 12, days) was shorter in the successful stented group (p: 0.005) compared to the operated group (11, range, 5- 40, days).

Twenty-eight patients were discharged well. Only 16 (57.1%) underwent subsequent chemotherapy. The group that was successful stented had earlier commencement of chemotherapy (median: 3, range: 1-6, weeks) than the operated group (median: 10, range: 2- 48 weeks). There was no difference in the overall survival between the groups.

Two major stent-related complications were encountered 4 and 5 months after the stent was inserted. Perforation at the tumour site was seen in both patients and required immediate surgery.

Conclusion
Self expanding metallic stents for intestinal obstruction in patients with metastatic colorectal cancers are associated with superior outcomes and earlier commencement of subsequent chemotherapy. However, patients who fail endoscopic stenting may encounter significant complications.
 

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