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Enteral stents for the management of malignant colorectal obstruction

Author
Todd H Baron, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

Enteral stents are used increasingly as a non-surgical alternative for the palliation of luminal gastrointestinal neoplasms, particularly in the esophagus and biliary tract [1]. They also have an emerging role in the treatment of obstruction in other segments of the gastrointestinal tract such as the stomach, proximal small bowel, and colon.

This topic will review the role of expandable metal stents in the management of colonic obstruction. Stenting of other portions of the gastrointestinal tract is discussed elsewhere. (See "Use of expandable stents in the esophagus" and "Enteral stents for the palliation of malignant gastroduodenal obstruction" and "Overview of pancreatic stenting and its complications" and "Treatment options for locally advanced cholangiocarcinoma", section on 'Stenting'.)

INDICATIONS

There are two major indications for colonic stenting in patients with colorectal cancer: palliation of advanced disease and preoperative decompression [2]. In the latter case, placement of a stent can convert a surgical procedure from an emergent two-step procedure (including a colostomy) into an elective one-step resection with a primary anastomosis, which can be performed laparoscopically. However, studies suggest increased morbidity compared with surgery, so we suggest that it be reserved for patients who are at increased risk for complications of emergency surgery (eg, patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery. (See 'Stenting for acute obstruction' below.)

Colonic stenting can be performed in many patients with a partial obstruction or with complete obstruction if there are no signs of systemic toxicity. However emergency surgery is recommended in patients with complete colonic obstruction with evidence of systemic toxicity, as these patients may have ischemia and/or a perforation. (See "Overview of the management of primary colon cancer".)

Morbidity and mortality are substantially higher for emergent surgery than for elective surgery. In one review, morbidity and mortality for patients requiring emergency operation were approximately 39 and 12 percent, respectively, compared with 23 and 3.5 percent for patients who were treated on an elective basis [3]. In other reports, more than one-half of patients undergoing emergency surgery for colon cancer required a stoma [3-5]. Even with contemporary surgical procedures, mortality rates are approximately 4 percent [6], and are even higher in patients with advanced tumor stage and those with comorbidities [7]. In addition, patients who undergo surgery with a primary anastomosis appear to have a higher survival rate than those treated by initial tumor resection and subsequent reversal of the diverting colostomy, such as may be required after emergency surgery in the unprepared bowel [8]. A cost-effectiveness analysis concluded that colonic stent insertion followed by elective surgery was more effective and less costly than emergency surgery [9].

                

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Literature review current through: Nov 2016. | This topic last updated: Wed Jan 21 00:00:00 GMT+00:00 2015.
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