Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors

Abstract

Background: Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively.

Objective: Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction.

Design: Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008.

Setting: Tertiary-care center.

Patients: This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a "bridge to surgery."

Intervention: Colonic SEMS placement.

Main outcome measurements: Stricture location, stent-induced complications, time to adverse events, need for reintervention.

Results: Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter < or = 22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation.

Limitations: Retrospective analysis, single institution.

Conclusion: Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.