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OCCLUSIONE COLICA: LO STENT VS. L’INTERVENTO CHIRURGICO IN URGENZA

18 Novembre 2011 – Università Milano-Bicocca GIORNATA DELLA RICERCA. OCCLUSIONE COLICA: LO STENT VS. L’INTERVENTO CHIRURGICO IN URGENZA N Tamini , L Gianotti, L Nespoli, E Bolzonaro, R Frego, A Redaelli, A Ardito, A Nespoli, M Dinelli Dipartimento di Chirurgia Università Milano – Bicocca

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OCCLUSIONE COLICA: LO STENT VS. L’INTERVENTO CHIRURGICO IN URGENZA

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  1. 18 Novembre 2011 – Università Milano-Bicocca GIORNATA DELLA RICERCA OCCLUSIONE COLICA: LO STENT VS. L’INTERVENTO CHIRURGICO IN URGENZA N Tamini, L Gianotti, L Nespoli, E Bolzonaro, R Frego, A Redaelli, A Ardito, A Nespoli, M Dinelli Dipartimento di Chirurgia Università Milano – Bicocca Ospedale S. Gerardo Monza

  2. BACKGROUND • Up to 20% of patients with colonic cancer are admitted with symptoms of acute obstruction • The majority of cases of acute colonic obstruction is due to colorectal cancer • Emergency surgery for acute colonic obstruction is associated with a significant risk of mortality and morbidity and with a high percentage of stoma creation (either temporary or permanent) • Colon stenting may represent a valuable option both for palliation and as a bridge to elective surgery. Phillips RK - Br J Surg 1985. Ansaloni - World Journal of Emergency Surgery 2010 Mella J - Br J Surg 1997 Khot UP - Br J Surg 2002 Serpell JW - Br J Surg 1989. Breitenstein S. - Br J Surg 2007 Umpleby HC - Dis Colon Rectum 1984 Villar JM - Surg Today 2005

  3. Excluded from analysis for perforation-peritonitis n = 23 Patients admitted with large bowel obstruction n = 157 January 2005-April 2011 Clinical evaluation and staging n = 134 Non resectable n = 34 Resectable n = 100 Surgeon judgment SEMS SEMS attempt as a bridge to elective operation n = 51 Emergency operation n = 49+2 Successful n = 32 Unsuccessful n = 2 Unsuccessful n = 2 Successful n = 49 Emergency operation with palliative intent Elective operation n = 49 Oncology Oncology

  4. Non resectable patients (palliation) • Bilobar multiple liver metastasis or involving the hepatic hileum or veins • Lung metastasis • Peritoneal carcinomatosis • ASA > 4 • Karnofsky < 30 • Child C

  5. Baseline characteristics of patients with SEMS placement (n=81)

  6. Short-term complications of SEMS (n=81)

  7. Long-term complications of SEMS (n=32) Median follow-up: 19 months (95%CI 16-22)

  8. Long-term survival (Kaplan-Meier curve) Palliation

  9. Stent “bridge” V.S. Chirurgia d’urgenza: 3 RCT

  10. Results PRIMARY OUTCOME STOMA PLACEMENT: ES n=17 (57%) versus SEMS n=13 (43%) (p=0.30) STOMA CLOSURE: ES n=9 (30%) versus SEMS n=4 (13%) (p=0.12) SECONDARY OUTCOME No statistically significant ENDOSCOPIC PROCEDURE Successo Tenico n=14 (47%) Successo clinico n=12 (40%) Technical failure  n=16 (53%) - 13 impossibile superare la stenosi con filo guida - 1 malfuzionamento stent - 2 perforazioni These major side effects, associated with the unexpected high rate of technical failures, led the steering committee to interrupt the trial after 65 patient inclusions.

  11. Results • PRIMARY OUTCOME: no difference in global health status between the treatment groups • SECONDARY OUTCOMES: no differences in the secondary outcomes of mortality and morbidity between study groups STOMA RATE: After the first operation: SEMS 24/48 vs ES 38/51 (p=0.016) After 6 months fup: SEMS 27/47 vs ES 34/51 (p=0.35) • STENTING PROCEDURE: - Technical success 33/47 (70.2%) = clinical success - SEMS-related perforations: 6/47 (12.8%)

  12. Baseline characheristics of resectable patients who underwent surgery

  13. Short-term outcomes of resectable patients who underwent surgery

  14. ROC curve on surgical complications and time interval from SEMS placement to operation

  15. Long-term complications of patients who underwent surgery (median follow-up = 43.5 months)

  16. Long-term survival (Kaplan-Meier curve) SEMS NO SEMS Log-rank

  17. Conclusioni • L’uso di SEMS per trattare l’occlusione colica è sicuro, fattibile ed efficace (esperienza endoscopista) • SEMS per palliazione sembra promettente ma sono necessari ulteriori dati • SEMS “as a bridge to elective surgery” dovrebbe essere considerata l’opzione ottimale.

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