Sergio Bronze1, 2, Carlos Noronha Ferreira1, 2
1.Serviço de Gastroenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte
2. Clínica universitária de Gastroenterologia, Faculdade de Medicina de Lisboa, Universidade de Lisboa.
1. Search for true indications for colonic stent placement.
Up to 8-13% of patients with colorectal cancer present with acute colonic obstruction.(1) Colonic occlusion can be managed surgically with emergency colostomy (EC) or endoscopically with a self-expandable metallic stent (SEMS) as a bridge-to-surgery (BTS).(2) BTS as an alternative to emergency surgery may be considered after discussing therapeutic options with the patient.(2)
2. It is a common error to assume that the only strategy for management of left colorectal cancer presenting with colonic occlusion is surgery.
The BTS strategy in left sided tumors provides time for optimization of patients clinical condition, tumor staging and bowel preparation, prevents high risk emergency surgeries and improves oncological resections and primary anastomosis rates.(1)(2)(3) SEMS placement is the preferred therapeutic option for palliation of malignant colonic obstruction.(2)
3. Colonic stents aren’t always the solution.
SEMS are not indicated in patients with colonic perforation, in those with peritoneal carcinomatosis and where bowel obstruction is due to extrinsic compression (gynecological tumors).(3).
4. Interventions before and during the procedure not to be overlooked or performed.
An enema to clean the left colon prior to endoscopy facilitates stricture visualization and stent placement. (2) Endoscopic dilatation of malignant stricture should not be performed before colonic stenting.(2)(3)
5. Choosing the best stent.
Uncovered SEMS are preferred and the stent length should be adjusted to the length and location of the stricture, preferably extending by 1.5 to 2 cm beyond both edges.(2)
6. Choose an experienced team.
Expertise significantly predicts success in urgent colonic stent placement in acute occlusion, and should be performed or supervised by an experienced interventional endoscopist assisted by an endoscopy nurse and imaging technician.(2)(3)
7. When to perform the surgery and when to initiate chemotherapy.
An interval of up to 2 weeks after SEMS placement as BTS in patients with curable left-sided colon cancer is recommended.(2) Chemotherapy is safe in patients who have undergone palliative colonic stenting and antiangiogenic therapy may be considered.(2) Patients already receiving antiangiogenic therapy (bevacizumab) should probably not undergo colonic stenting for palliation of malignant obstruction.(2) Prophylactic stent placement in patients with colon cancer is not recommended.(2) 3