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ARE SEMS (SELF-EXPANDING METAL STENTS) A SAFE AND SUCCESSFUL BRIDGE TO SURGERY OR DEFINITIVE THERAPY FOR MALIGNANT COLORECTAL OBSTRUCTION (MCO), PARTICULARLY IN PATIENTS TREATED WITH BEVACIZUMAB, A VEGF INHIBITOR? A TERTIARY CANCER CENTER EXPERIENCE.
Jeffrey Lee*1, Ikenna K. Emelogu2, Emmanuel Coronel1, Graciela M. Nogueras-González1, Phillip Lum1, William A. Ross1, Gottumukkala S. Raju1, Patrick M. Lynch1, Selvi Thirumurthi1, John R. Stroehlein1, Yinghong Wang1, Y. Nancy You1, Brian R. Weston1
1MD Anderson Cancer Center, Houston, TX; 2University of Texas Health Science Center at Houston, Houston, TX
Introduction The aim of this study was to examine clinical outcomes and complications of SEMS in the management of MCO.
Methods Patients who had SEMS placed for MCO from 2007-2016 at our institution were included. Statistical analysis was performed using Stata/SE version 15.1. Clinical success was defined as patients successfully resuming resume oral intake post procedure. Technical success was defined as stent deployment across stricture in the desired location.
Results Of the 199 patients identified, mean age was 58, 54% male (n=107) and nearly all patients had stage IV cancer (99%, n=196). MCO was due to colorectal cancer (82%, n=164) extrinsic compression (17%, n=34) or other (0.5%, n=1). Mean duration of symptoms at presentation was 7 days (range 1-120 d). Technical success was achieved in 99.5% (n=198). Fluoroscopy was used in all but one case. Clinical success was achieved in 89% (n=177). SEMS were placed for palliation in 97% (n=192) and as a bridge to surgery in 4% (n=7). MCO was located in the left colon 90% (n=179) transverse colon 4.5% (n=9) and ascending colon 5.5% (n=11). SEMS were placed in curved segments 30% (n=59) but mostly in straight segments 70% (n=136). Mean stricture length 40 mm (range 10-180 mm). The 25 x 120 mm SEMS was used 56% of the time and the 25 x 90 mm 29%. Tandem SEMS were required in 27 patients.
Complications occurred in 23% (n=45, peri-procedure 2% n=1, post-procedure 16% n=7, delayed >72 hours 82% n=37) and included minor bleeding (n=2) major bleeding (n=3) perforations (n=4) abdominal pain (n=3) stent migration (n=9) stent occlusion (n=7) failure to decompress (n=1) failed stent expansion (n=7) persistent obstruction (n=1). Repeat procedure required in 21 of these 45 patients.
After SEMS, 47 patients underwent surgery (44 after stent placement) including resection with primary anastomosis (n=8) resection with definitive stoma (n=18) diverting stoma without resection (n=19). Mean time to surgery after SEMS was 175 days (3-1,345 d). Post surgical complications were seen in the 29 resected patients (leak n=2, infection n=2).
Some patients had been treated with bevacizumab (n=104) and 22% of them had complications (n=23, 4 post procedure, 23 delayed). One perforation occurred in this group compared to patients without bevacizumab (1% versus 3% n=3/95, p=0.549).
Mean overall survival was 5.6 months. Extrinsic compression strictures and curved strictures were associated with poor clinical success by univariate analysis, and etiology (non-colonic with poor outcome) only by multivariate analysis.
Conclusion SEMS for MCO has a high technical success rate, but clinical success is suboptimal. Curved strictures and those due to extrinsic compression are associated with poor outcome. Perforation rate in patients on bevacizumab was not higher than in patients with other or no chemotherapy.
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