Annals of Coloproctology

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Original Articles

Colorectal cancer

Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution: Michelle Shi Qing Khoo, Frederick H. Koh, Sharmini Su Sivarajah, Leonard Ming-Li Ho, Darius Kang-Lie Aw, Cheryl Xi-Zi Chong, Fung Joon Foo, Winson Jianhong Tan; Ann Coloproctol. 2024;40(6):555-563. Published online August 5, 2024; DOI: https://doi.org/10.3393/ac.2023.00738.0105

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Abstract PDF: Purpose
In patients with acute left-sided colonic obstruction, stenting can convert an emergency operation into a semi-elective procedure. However, its use continues to be debated. We performed a cost-effective analysis using our institution’s experiences.
Methods
Endoscopic, surgical, and financial details were prospectively collected for patients who presented with acute colonic obstruction and underwent stenting between 2019 and 2022. Outcomes were defined as technical/clinical success and successful surgical resection. The financial cost of stenting was compared with the expected cost without stenting.
Results
Forty patients were included, with 29 undergoing definitive resection. The most common pathology was primary colon cancer (27 patients, 93%). Endoscopic stenting had high technical (90%) and clinical (83%) success rates, with low rates of complications such as perforation (2 patients, 7%) and migration (0 patients, 0%). As a bridge to surgery, the median procedure time was 226 minutes and the surgical outcomes also showed a low rate of complications (3 patients, 11%), such as anastomotic leakage (0 patients, 0%), intraabdominal abscesses (2 patients, 7%), and 30-day postoperative mortality (0 patients, 0%). The cumulative costs with colonic stenting were $32,900, while the expected costs with emergency surgery, including stoma reversal, were $40,700 (healthcare cost-savings of $7,800 per person). The difference was mainly due to the avoidance of upfront emergency surgery. The incremental cost-effectiveness ratio was 0.81, favoring colonic stenting over upfront emergency surgery.
Conclusion
Colonic stenting as a bridge to surgery is safe and cost-effective for treating left-sided colonic obstruction with high success rates and low complication rates.

Colorectal cancer

Obstructing colorectal cancer: a population-based review of colonic stenting in Queensland, Australia: Cian Keogh, Julie Moore, Danica Cossio, Nick Smith, David A. Clark; Ann Coloproctol. 2024;40(3):268-275. Published online June 25, 2024; DOI: https://doi.org/10.3393/ac.2023.00640.0091

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Abstract PDF: Purpose
Stenting is a useful treatment option for malignant colonic obstruction, but its role remains unclear. This study was designed to establish how stents have been used in Queensland, Australia, and to review outcomes.
Methods
Patients diagnosed with colorectal cancer in Queensland from January 1, 2008, to December 31, 2014, who underwent colonic stent insertion were reviewed. Primary outcomes of 5-year survival, 30-day mortality, and overall length of survival were calculated. The secondary outcomes included patient and tumor factors, and stoma rates.
Results
In total, 319 patients were included, and distant metastases were identified in 183 patients (57.4%). The 30-day mortality rate was 6.6% (n=21), and the 5-year survival was 11.9% (n=38). Median survival was 11 months (interquartile range, 4–27 months). A further operation (hazard ratio [HR], 0.19; P<0.001) and chemotherapy and/or radiotherapy (HR, 0.718; P=0.046) reduced the risk of 5-year mortality. The presence of distant metastases (HR, 2.052; P<0.001) and a comorbidity score of 3 or more (HR, 1.572; P=0.20) increased mortality. Surgery was associated with a reduced risk of mortality even in patients with metastatic disease (HR, 0.14; P<0.001). Twenty-two patients (6.9%) ended the study period with a stoma.
Conclusion
Colorectal stenting was used in Queensland in several diverse scenarios, in both localized and metastatic disease. Surgery had a survival advantage, even in patients with metastatic disease. There was no survival difference according to whether patients were socioeconomically disadvantaged, diagnosed in a major city or not, or treated at private or public hospitals. Stenting proved a valid treatment option with low stoma rates.

Case Report

Benign bowel disease

A case report of a colouterine fistula treatment: when the patient chooses the steeplechase: Stefano Pontone, Pier Giorgio Nardis, Chiara Eberspacher, Domenico Mascagni; Ann Coloproctol. 2023;39(4):366-370. Published online August 9, 2021; DOI: https://doi.org/10.3393/ac.2021.00318.0045

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Abstract PDF: Colouterine fistula is a rare disease that is primarily treated using surgical approaches. Although invasive surgery is controversial in terms of techniques and results, minimally invasive endoscopic treatments have not been widely described. However, because it is rare for these fistulas to close spontaneously, surgical treatment is often mandatory. Appropriate management of colouterine fistula is complicated, especially when the patient refuses surgery. In this case study, we provide the first description of a minimally invasive endoscopic treatment of an iatrogenic colouterine fistula using a self-expandable metallic stent after an over-the-scope clip malposition.

Original Article

Obstructive Left Colon Cancer Should Be Managed by Using a Subtotal Colectomy Instead of Colonic Stenting: Chung Ki Min, Hyung Ook Kim, Donghyoun Lee, Kyung Uk Jung, Sung Ryol Lee, Hungdai Kim, Ho-Kyung Chun; Ann Coloproctol. 2016;32(6):215-220. Published online December 31, 2016; DOI: https://doi.org/10.3393/ac.2016.32.6.215

6,152 View
78 Download
14 Web of Science
10 Citations

Abstract PDF

Purpose

This study compared a subtotal colectomy to self-expandable metallic stent (SEMS) insertion as a bridge to surgery for patients with left colon-cancer obstruction.

Methods

Ninety-four consecutive patients with left colon-cancer obstruction underwent an emergency subtotal colectomy or elective SEMS insertion between January 2007 and August 2014. Using prospectively collected data, we performed a retrospective comparative analysis on an intention-to-treat basis.

Results

A subtotal colectomy and SEMS insertion were attempted in 24 and 70 patients, respectively. SEMS insertion technically failed in 5 patients (7.1%). The mean age and rate of obstruction in the descending colon were higher in the subtotal colectomy group than the SEMS group. Sex, underlying disease, American Society of Anesthesiologists physical status, and pathological stage showed no statistical difference. Laparoscopic surgery was performed more frequently in patients in the SEMS group (62 of 70, 88.6%) than in patients in the subtotal colectomy group (4 of 24, 16.7%). The overall rate of postoperative morbidity was higher in the SEMS group. No Clavien-Dindo grade III or IV complications occurred in the subtotal colectomy group, but 2 patients (2.9%) died from septic complications in the SEMS group. One patient (4.2%) in the subtotal colectomy group had synchronous cancer. The total hospital stay was shorter in the subtotal colectomy group. The median number of bowel movements in the subtotal colectomy group was twice per day at postoperative 3–6 months.

Conclusion

A subtotal colectomy for patients with obstructive left-colon cancer is a clinically and oncologically safer, 1-stage, surgical strategy compared to SEMS insertion as a bridge to surgery.

Citations

Citations to this article as recorded by

Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution
Michelle Shi Qing Khoo, Frederick H. Koh, Sharmini Su Sivarajah, Leonard Ming-Li Ho, Darius Kang-Lie Aw, Cheryl Xi-Zi Chong, Fung Joon Foo, Winson Jianhong Tan
Annals of Coloproctology.2024; 40(6): 555. CrossRef
Short- and long-term outcomes of subtotal/total colectomy in the management of obstructive left colon cancer
Jung Tak Son, Yong Bog Kim, Hyung Ook Kim, Chungki Min, Yongjun Park, Sung Ryol Lee, Kyung Uk Jung, Hungdai Kim
Annals of Coloproctology.2023; 39(3): 260. CrossRef
Outcomes After Colonic Self-Expanding Metal Stent Insertion Without Fluoroscopy: A Surgeon-Led 10-Year Experience
Tara M. Connelly, Jessica Ryan, Niamh M. Foley, Helen Earley, Shaheel M. Sahebally, Carl O'Brien, Peter McCullough, Peter Neary, Fiachra Cooke
Journal of Surgical Research.2023; 281: 275. CrossRef
Which treatment strategy is optimal for acute left-sided malignant colonic obstruction? A Bayesian meta-analysis
Kaibo Ouyang, Zifeng Yang, Yuesheng Yang, Junjiang Wang, Deqing Wu, Yong Li
International Journal of Colorectal Disease.2023;[Epub] CrossRef
New Challenges in Surgical Approaches for Colorectal Cancer during the COVID-19 Pandemic
Dragos Serban, Geta Vancea, Catalin Gabriel Smarandache, Simona Andreea Balasescu, Gabriel Andrei Gangura, Daniel Ovidiu Costea, Mihail Silviu Tudosie, Corneliu Tudor, Dan Dumitrescu, Ana Maria Dascalu, Ciprian Tanasescu, Laura Carina Tribus
Applied Sciences.2022; 12(11): 5337. CrossRef
Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis
Sanne J. Verkuijl, Jara E. Jonker, Monika Trzpis, Johannes G.M. Burgerhof, Paul M.A. Broens, Edgar J.B. Furnée
European Journal of Surgical Oncology.2021; 47(5): 960. CrossRef
Short-term outcomes of stents in obstructive rectal cancer
Nora H. Trabulsi, Hajar M. Halawani, Esraa A. Alshahrani, Rawan M. Alamoudi, Sama K. Jambi, Nouf Y. Akeel, Ali H. Farsi, Mohammed O. Nassif, Ali A. Samkari, Abdulaziz M. Saleem, Nadim H. Malibary, Mohammad M. Abbas, Luca Gianotti, Antonietta Lamazza, Jin
Saudi Journal of Gastroenterology.2021; 27(3): 127. CrossRef
Fluoroscopic Stenting as a Bridge to Surgery versus Emergency Management for Malignant Obstruction of the Colon
Fan Xue, Feng Lin, Jun Zhou, Ning Feng, You-Gang Cui, Xu Zhang, Yu-Peng Yi, Wen-Zhi Liu
Emergency Medicine International.2020; 2020: 1. CrossRef
Safety of subtotal or total colectomy with primary anastomosis compared to Hartmann procedure for left-sided colon cancer obstruction or perforation
Eun-Do Kim, Jin-Kwon Lee, Jin-Kyu Cho, Jae-Myung Kim, Ji-Ho Park, Ju-Yeon Kim, Sang-Ho Jeong, Young-Tae Ju, Chi-Young Jeong, Eun-Jung Jung, Young-Joon Lee, Soon-Chan Hong, Seung-Jin Kwag
Korean Journal of Clinical Oncology.2019; 15(2): 106. CrossRef
Laparoscopic assisted insertion of a colonic self-expandable metallic stent
Y. M. Ho, V. Shenoy, J. Alberts, N. Ward
Techniques in Coloproctology.2018; 22(10): 809. CrossRef

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