International Journal of Surgery 12 (2014) 1198e1202

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International Journal of Surgery

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Original research

Short-term outcomes following the use of self-expanding metallic

stents in acute malignant colonic obstruction e A single centre
experience
Shaheel M. Sahebally, Azhar Sarwar, Fiachra Cooke*
Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland

h i g h l i g h t s

Management of obstructing colorectal cancer is challenging.

Successful SEMS deployment obviates need for emergency surgery.

Other benefits include shorter hospital stay and lower rates of permanent stomas.

a r t i c l e i n f o a b s t r a c t

Article history: Background: Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malig-
Received 31 July 2014 nant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery
Received in revised form (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term out-
10 September 2014
comes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution
Accepted 19 September 2014
Available online 6 October 2014
over a 3-year period. Methods: A prospectively maintained database was reviewed to identify all pa-
tients who presented to our institution with AMCO between August 2010 and 2013 and who were
treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews
Keywords:
Self-expanding metallic stent
and operation notes. Results: Sixteen patients (12 males, 4 females) each had a single stent inserted
Colorectal cancer during the study period, either palliatively (n ¼ 11) or as a BTS (n ¼ 5). The technical and clinical success
Malignant colorectal obstruction rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and
Bridge to surgery required emergency surgery while five patients with curable disease proceeded to elective resections.
Palliative There was no procedure-related mortality or stent-related perforations. The mean (standard deviation)
length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All
patients in the BTS group were stoma-free post-operatively, while both patients who had emergency
surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary
to migration. Conclusions: Although limited by a small sample size, the study shows that SEMS have
favourable short-term outcomes. Further adequately powered trials are needed to confirm those
findings.
© 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

1. Introduction
Colorectal cancer is the second most common cause of cancer in
women, and the third most common in men [1]. Acute malignant
colorectal obstruction is a common surgical emergency, with a
reported incidence of 8e29 % [2,3]. A population-based study [4]
showed that one in four (i.e. 25%) postoperative deaths following
* Corresponding author. Department of Colorectal Surgery, University Hospital
Waterford, Dunmore Road, Waterford, Ireland.
E-mail address: fiachra.cooke@hse.ie (F. Cooke).
surgery for colorectal cancer arises from patients who originally
presented with obstruction. Sequelae of large bowel obstruction
include colonic dilatation, bacterial translocation, metabolic de-
rangements as well as an increased risk of colonic perforation [5].
Consequently, urgent surgical decompression is needed. Whilst the
treatment of acute right-sided malignant colonic obstruction is
widely accepted as resection with primary anastomosis [6], there is
ongoing debate among the surgical community regarding the
optimal treatment for acute left-sided obstruction. Indeed, the
latter can be treated with a colonic resection with primary anas-
tomosis, with or without a diverting stoma or a Hartmann's

http://dx.doi.org/10.1016/j.ijsu.2014.09.010
1743-9191/© 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
 S.M. Sahebally et al. / International Journal of Surgery 12 (2014) 1198e1202 1199

procedure, with a later reversal of colostomy and restoration of

luminal continuity [2,7]. Irrespective of the technique used, emer-
gency surgery is associated with significantly higher mortality rates
(14.9%) compared to elective surgery (<6%) [8e11] as well as worse
oncological outcomes [12]. In addition, a curative resection is not
possible for one-third of patients presenting with acute malignant
colonic obstruction due to locally advanced disease, distant me-
tastases or severe comorbidities [13].
Colorectal stents provide an alternative to emergency surgery
for the management of obstructing colorectal cancer. Over the last
twenty years, self-expanding metallic stents (SEMS) have emerged
as a favourable therapeutic approach, both as a palliative option (in
patients with advanced or unresectable cancer) [14e16] and as a
bridge to surgery measure (in patients with potentially curable
disease) [17,18]. In both instances, the use of SEMS relieves the
obstruction and obviates the need for emergency surgery, while
enabling correction of fluid and electrolyte abnormalities and
completion of pre-operative staging [19]. This report describes a
single surgeon's stenting experience in a cohort of patients who
Fig. 1. Intrao-perative fluoroscopic image demonstrating an obstructing sigmoid
presented with acute malignant colonic obstruction in a tertiary
tumour treated with a SEMS, with flaring evident at both ends consistent with satis-
referral centre in Ireland. factory placement.

2. Materials and methods 2.3. Study end-points

2.1. Patient population
A prospectively maintained database of all colorectal cancer
patients was analysed to identify all patients who presented to our
service with acute malignant colorectal obstruction and who were
treated with a SEMS between August 2010 and 2013. Malignant
large bowel obstruction was diagnosed by clinical examination
(through a combination of obstipation or decrease in stool fre-
quency, vomiting, abdominal pain and distension) and confirmed
radiologically with plain abdominal radiographs and contrast-
enhanced computed tomography (CT) scans. Patient selection
criteria for stenting were location of the obstruction at or distal to
the hepatic flexure and absence of clinical or radiographic evidence
of perforation. Patients with obstructions proximal to the hepatic
flexure were excluded because of poor site accessibility. However,
age, general physical condition or disease stages were not consid-
ered exclusion criteria. Stents were inserted to either palliate or
alleviate acute malignant colonic obstruction.
2.2. Stent insertion
Colonic SEMS were deployed in an operating theatre under both
endoscopic and fluoroscopic guidance (Fig. 1), with the patient in
the left lateral position using a combination of intravenous mid-
azolam (Roche, UK) and fentanyl (Janssen, UK). A contrast study
was performed to confirm the anatomical site and length of the
stricture and to exclude bowel perforation. A 450 cm, super stiff
0.038 JAG guide wire (Boston Scientific Corporation, Galway,
Ireland) was used to negotiate the stricture and subsequently the
stent delivery system was deployed over this guide wire. Uniform
size (25  90 mm) WallflexTM colonic stents (Boston Scientific
Corporation, Galway, Ireland) were used in all patients. Balloon
dilatation was not performed in any patients either before or after
SEMS insertion. A single colorectal surgeon deployed all stents.
Antero-posterior abdominal radiographs were taken afterwards
to check that the stent had fully deployed and the colon had
decompressed. After the obstruction had resolved, pre-operative
staging was completed and patients with potentially curable dis-
ease were offered elective resections, while those with evidence of
distant metastases were referred for consideration of palliative
chemotherapy.
Technical success (TS) was defined as successful stent deploy-
ment across the obstructing tumour with radiographic confirma-
tion of flaring of the stent both proximally and distally and visible
stool passage. Clinical success (CS) was defined as colonic decom-
pression with resolution of obstructive symptoms, without the
need for further intervention during the hospital stay [20]. Stent
complications were defined as those leading to new symptoms,
characterized by perforation, reobstruction and stent migration
[21,22]. Thirty-day procedure mortality was defined as death
within 30 days of SEMS insertion, or within 30 days of elective or
emergency/unplanned surgery. Hospital stay related to the number
of days spent in hospital following either SEMS insertion or surgery.
2.4. Sources of data
Theatre registries and patient records were reviewed and the
following information collected: patient demographics, location of
obstruction, maximal extent of disease, number of stents inserted,
TS and CS rates, details of further interventions performed after
stenting (such as surgery, palliative chemotherapy, or stent re-
insertion), length of time between SEMS insertion and elective/
emergency surgery, stent complications, 30-day mortality and
morbidity, length of hospital stay post stent placement or surgery
and overall patient survival.
2.5. Statistical analysis
Data was analyzed using SPSS v21 (SPSS Inc., Chicago, IL) and
presented as mean (standard deviation) or median (interquartile
range) depending on their distribution. Categorical variables were
summarised as frequency and percentage. As n < 20, no p value was
calculated.
3. Results
Sixteen patients (12 males, 4 females) presented with acute
malignant colorectal obstruction during the study period and they
all had a single SEMS inserted, either as a temporizing measure or as
a definitive intervention. Data was available on all of them and their
demographics are outlined in Table 1. Five patients (i.e. 31.2%) had
1200 S.M. Sahebally et al. / International Journal of Surgery 12 (2014) 1198e1202

Table 1 (interquartile range) of 64 (20e147), days [mean (SD) of 79.6 ± 64.3,

Demographics and clinicopathological parameters of all patients who underwent days] following SEMS insertion. Two of these patients had rectal
SEMS insertion for acute malignant colonic obstruction.
cancer and underwent neoadjuvant chemo-radiotherapy to
Parameter Palliative stent Bridge to surgery downstage their tumours. Of these, one patient had delayed me-
(n ¼ 11) stent (n ¼ 5) chanical bowel preparation, completion colonoscopy and during an
Gender, male/female (%) 9/2 (82/18) 3/2 (60/40) examination under anaesthesia underwent removal of her rectal
Mean (SD) age, years 71.3 ± 13.2 67.4 ± 10.8 SEMS and elective defunctioning loop ileostomy. Their character-
Location of tumour, n (%)
istics and outcomes are summarized in Table 2. Three patients had a
- Transverse colon 1 (9) 0 (0)
- Splenic flexure 1 (9) 1 (20) laparoscopic anterior resection, one had a laparoscopic converted
- Descending colon 0 (0) 1 (20) to open anterior resection because the ureter could not be
- Sigmoid colon 5 (45) 1 (20)
- Recto-sigmoid 1 (9) 0 (0) Table 2
- Rectum 3 (27) 2 (40) Comparison of ASA grades, operative procedures and outcomes, hospital stay,
Differentiation, n (%) mortality/morbidity, pathological staging and duration of follow-up between pa-
- Well 1 [9] 0 (0) tients undergoing emergency and elective surgery.
- Moderate 10 (91) 5 (100)
- Poor 0 (0) 0 (0) Parameter Acute unplanned Elective
Abdominal CT prior to SEMS insertion surgery due to failed bridge-to-surgery
- No 0 (0) 0 (0) SEMS (n ¼ 2) (n ¼ 5)
- Yes 11 (100) 5 (100)
ASA grade, n (%)
Technical success, n (%) 9 (82) 5 (100)
- I 0 (0) 0 (0)
Clinical success, n (%) 9 (82) 5 (100)
- II 0 (0) 1 (20)
Mean (SD) hospital stay 4.8 ± 2.2 4.8 ± 1.5
- III 2 (100) 4 (80)
post SEMS insertion, days
- IV 0 (0) 0 (0)
Stent perforation, n (%) 0 (0) 0 (0)
Mean (SD) age, years 57.0 ± 2.8 67.4 ± 10.8
Chemotherapy after 4 (36) 2 (40)a
Surgical approach, n (%)
SEMS insertion, n (%)
- Open 2 (100) 1 (20)
30-day mortality, n (%) 0 (0) 0 (0)
- Laparoscopic 0 (0) 3 (60)
SD ¼ Standard Deviation, CT ¼ Computed Tomography, SEMS ¼ Self-Expanding - Laparoscopic converted to open 0 (0) 1 (20)
Metallic Stent. Procedure, n (%)
a
Neoadjuvant chemo-radiotherapy for rectal cancer. - Anterior resection 0 (0) 4 (80)
- Total colectomy and 1 (50) 0 (0)
potentially curable disease on staging and were stented as a bridge ileorectal anastomosis
- Hartmann's procedure 1 (50) 0 (0)
to surgery. The remaining eleven patients (i.e. 68.8%) had evidence - Abdominoperineal resection 0 (0) 1 (20)
of metastatic disease and were stented with palliative intent. Most Mean (SD) interval from SEMS 0a 79.6 ± 64.3
cancers (15/16) were located at or distal to the splenic flexure. insertion to surgery, days
Mean (SD) hospital stay post 45.0 ± 21.2 15.8 ± 4.0
surgery, days
3.1. Technical and clinical success Defunctioning loop stoma, n (%) 0 (0) 1 (20)b
End ileostomy, n (%) 1 (50) 0 (0)
Technical and clinical success rates were similar and achieved in End colostomy, n (%) 1 (50) 1 (20)c
14 out of 16 (i.e. 87.5%) cases. In the two cases of failure, the stent Surgical morbidity, n (%)
- Anastomotic leak 1 (50) 0 (0)
was deployed proximal to the obstruction having successfully
- Wound complications 0 (0) 0 (0)
negotiated the malignant stricture with a guide wire. Both patients - Intra-abdominal collections 1 (50) 0 (0)
required immediate abdominal surgery to relieve the obstruction. General morbidity, n (%)
Both patients had metastatic sigmoid cancers and one had a - Cardio-cerebrovascular 0 (0) 1 (20)
Hartmann's procedure, while the other had a total colectomy and complications
- Pleural effusions 1 (50) 0 (0)
ileorectal anastomosis because of right-sided colonic ischaemia. - Urinary tract infection 0 (0) 0 (0)
There was no 30-day procedure mortality however. 30-day mortality, n (%) 0 (0) 0 (0)
Pathological staging
Tumour category
3.2. Stent complications
- pT3 0 (0) 3 (60)
- pT4 2 (100) 2 (40)
The stent complication rate was 6.2% (1/16) in our cohort and Nodal category
included migration in a patient stented palliatively. The patient had a - N0 0 (0) 2 (40)
distal sigmoid cancer that was acutely angulated and while the stent - N1 2 (100) 3 (60)
- N2 0 (0) 0 (0)
was endoscopically and radiographically confirmed to have been
Metastasis category
deployed successfully, it had migrated distally on day 1 post stent - M0 0 (0) 5 (100)
abdominal radiograph and was removed per rectum. The patient's - M1 2 (100) 0 (0)
obstructive symptoms, however, were alleviated and he did not un- R0 resection, n (%) 2 (100) 5 (100)
Adjuvant chemotherapy, 2 (100) 3 (60)
dergo a further attempted stenting. He subsequently (3 months later)
n (%)
underwent an elective palliative resection and primary anastomosis. Reoperation within 30 days, 1 (50) 0 (0)
n (%)
3.3. Elective surgery following bridge to surgery stent Mean (SD) duration of follow 30.0 ± 1.4 19.6 ± 11.4
up, months

In the current study, bridge to surgery was defined as scheduled ASA ¼ American Society of Anesthesiologists, SD ¼ Standard Deviation, SEMS ¼ Self-
elective surgery after optimisation of physiological parameters and Expanding Metallic Stent, R0 ¼ No residual tumour.
a
Both patients with failed SEMS underwent emergency surgery within 12 h of
recovery of normal bowel function, regardless of the length of time attempted stenting.
between SEMS insertion and surgery. Five patients had evidence of b
Reversed.
c
localized disease and proceeded to elective surgery after a median Abdominoperineal resection (APR).
 S.M. Sahebally et al. / International Journal of Surgery 12 (2014) 1198e1202
identified properly intra-operatively and the anatomy was unfav-
ourable, while the last operation was an open abdomino-perineal
resection for a low rectal tumour. There was no 30-day mortality
in any of the patients. However, one patient suffered a cerebro-
vascular accident peri-operatively despite appropriate bridge
anticoagulation from warfarin to therapeutic low molecular weight
heparin (for a mechanical mitral valve) but was not thrombolysed.
3.4. Hospital stay
The mean (SD) length of stay (LOS) following successful SEMS
insertion was similar in both palliative and BTS groups [4.8 ± 2.2
and 4.8 ± 1.5, days] while the mean (SD) LOS following emergency
unplanned surgery (for failed stents) was longer than scheduled
elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. Both patients who
underwent emergency surgery had prolonged hospital stays sec-
ondary to post-operative complications; one had bilateral pleural
effusions and pneumonia while the other suffered an anastomotic
dehiscence eight days after the index resection (requiring a take
back to theatre for revision of the anastomosis and formation of an
end stoma) and an intra-abdominal abscess (necessitating percu-
taneous drainage).
3.5. Short-term outcomes
All patients who had an elective operation were stoma-free
post-operatively [including one patient whose stent was replaced
with an interval elective loop ileostomy prior to neoadjuvant che-
moradiotherapy (CRT) and who underwent a reversal of ileostomy
three months post laparoscopic ultra low anterior resection (ULAR)
and colon J pouch anal anastomosis], while both patients who
proceeded to emergency surgery ended up with a permanent
stoma. A curative outcome was achieved in all five patients (i.e.
100%) who underwent elective surgery after BTS stent, whilst both
patients who had acute surgery had a palliative resection.
3.6. Follow-up
At last review (November 30th 2013), with a mean (SD) follow up
of 22.6 ± 11.3 months, 8 of the 11 (72.7%) patients with metastatic
disease had passed away, while 4 out of 5 (80%) patients who un-
derwent curative resection were still alive. The mean (SD) survival
post SEMS insertion in the palliative group was 11.8þ/11.2, months.
4. Discussion
The current case series demonstrates that immediate manage-
ment of obstructing colorectal cancer with SEMS is associated with
a shorter length of hospital stay, as well as lower rates of permanent
stomas in comparison to emergency surgery in a cohort of 16 pa-
tients followed up for a mean duration of 22.6 ± 11.3 months in a
single Irish tertiary referral centre. The management of acute ma-
lignant colonic obstruction is challenging because the patients are
frequently elderly with substantial co-morbidities, biochemically
deranged and present with advanced disease. Emergency surgery is
associated with higher mortality and morbidity rates, lengthy
hospital stays, higher frequency of stoma creation, decreased
quality of life and considerable financial costs [8e11,23,24]. This
provides the rationale for the use of SEMS, both as a palliative
measure in unresectable disease and as a bridge to surgery in
potentially curable disease. Colorectal stents allow decompression
of the obstruction non-operatively, optimization of the patient's
physiological parameters and comorbidities, assessment of the
entire colon for synchronous neoplasia and convert an emergent
operation into an elective one [15,16,23,25e27]. Furthermore,
1201
SEMS, when used as a bridge to surgery, are associated with a
higher rate of successful primary anastomosis and lower overall
stoma rates, compared to emergency surgery [5,28]. In addition to
shorter hospital stays and lower rates of serious adverse events
[17,29], palliatively stented patients were noted to have acceptable
quality of life [30] and could begin chemotherapy earlier than after
emergency surgery [14e16,24,26]. In our cohort, 11 out of 16
stented patients were found to have disseminated disease on
staging, and 9 of them avoided unnecessary major emergency
surgery following successful conservative management with SEMS.
Four patients proceeded to have palliative chemotherapy after a
mean (SD) of 41.0 ± 15.3, days following SEMS insertion.
Despite the aforementioned benefits, the use of SEMS carries
notorious risks and recognized or subclinical tumour perforation
remains a significant oncological adverse event. Indeed a poten-
tially curative resection could be compromised should perforation
and peritoneal tumour dissemination occur following SEMS inser-
tion. However, the literature regarding this is conflicting. A Danish
study [20] investigated the oncological outcomes of 34 patients
with curable obstructing colonic cancer who were initially treated
with SEMS prior to undergoing elective resections. Despite a
perforation rate of 12% (4 out of 34), a curative outcome was ach-
ieved in 88% (30 out of 34) of cases and the 3-year survival rate was
74%. The authors concluded that SEMS was an effective substitute
to emergency surgery and was not associated with any adverse
oncological consequences. In contrast, Gorissen et al. [31] recently
reported an increased local recurrence rate with SEMS compared to
emergency surgery, although there was no significant difference in
overall survival. Furthermore, the Dutch Stent-In Study [32] was
prematurely terminated because of an unacceptably high risk of
stent-related perforations. Whilst the rate of stent-related com-
plications was low in our series (6.2%), Watt et al. [29] reported
median stent migration rates of 11%, tumour overgrowth of 12% and
perforation of 4.5%.
Our study has several limitations, namely it is non-randomized,
has a small sample size, is conducted in a single centre, does not
assess quality of life of the patients and has a short follow-up.
However, the benefits of endoluminal stenting over emergency
surgery in the management of acute malignant colorectal
obstruction can be readily appreciated.
5. Conclusions
Acute malignant colonic obstruction poses significant chal-
lenges in management due to the frailty of the presenting patients
and the high mortality/morbidity rates associated with emergency
surgery. Although our study suffers from a small sample size, it
demonstrates that SEMS offer a favourable therapeutic alternative
to emergency surgery and are associated with promising short-
term outcomes as well as an acceptable safety profile. Further
larger scale studies looking at long-term survival and oncological
outcomes are awaited.
Ethical approval
N/A.
Sources of funding
None.
Author contribution
Shaheel M Sahebally: study design, data collection, data gath-
ering, data analysis, writing of manuscript.
1202 S.M. Sahebally et al. / International Journal of Surgery 12 (2014) 1198e1202
Azhar Sarwar: data collection, data analysis, proofreading.
Fiachra Cooke: study design, concept generation, manuscript
editing, draft development, proofreading final authorization of
article for submission.
Conflicts of interest
None to declare.
Acknowledgements
We would like to thank colorectal nurse coordinators Anne-
Marie Clarke and Catherine O'Neill for their help in data retrieval.
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