Singapore Med J 2019; 60(7): 347-352

Original Article
https://doi.org/10.11622/smedj.2019010

Colonic stenting for malignant large bowel obstruction is

safe and effective: a single-surgeon experience
Man Hon Tang1, MBChB, MRCS, Talisa Ross2, MBChB, Shen Ann Yeo1, MBBS, FRCS, Chee Yung Ng1, MBBS, FRCS

INTRODUCTION Self-expanding metal stents (SEMS) can be used as a bridge to surgery (BTS) or for palliation in the
treatment of malignant large bowel obstruction. This case series evaluates the short-term outcomes of SEMS and success
rates over time.
METHODS A total of 75 consecutive patients who underwent colonic stenting for malignant colonic obstruction over a
period of six years were included. This time period was subdivided into two equal parts for analysis. The procedure was
carried out by a single surgeon from a tertiary institution in Singapore.
RESULTS Technical success was reported in 93.3% of cases and clinical success in 81.3% of cases, with better success
rates in the second half of the study (89.2% vs. 73.7%; p < 0.05). There were seven cases of inadequate decompression
and two cases of colonic perforation. The median duration from stent insertion to surgery was ten days, and the median
postoperative length of stay was six days.
CONCLUSION SEMS are a safe and effective way of relieving malignant large bowel obstruction, including those that
are proximal. The improvement in success over time reflects the importance of having an experienced endoscopist carry
out the procedure to ensure optimum success rates.

Keywords: colorectal neoplasms, colorectal surgery, intestinal obstruction, self-expandable metallic stents

INTRODUCTION stoma rates. There was, however, no advantage in terms of overall

Colorectal cancer is the third most common cancer in the world, mortality and long-term survival outcomes.(2,7,8) Furthermore,
with up to 1.4 million new cases diagnosed each year.(1) About colonic stenting had technical and clinical success rates of
7%–30% of colorectal cancers can present acutely with intestinal 70.7%–94.3% and 69.0%–96.0%, respectively, with higher rates
obstruction, especially if the tumour is located at or distal to the seen in single-operator series compared to data from pooled
splenic flexure.(2) randomised controlled trials.(8-10) The main adverse complication
Emergency surgery is the traditional approach in cases of colonic stenting is perforation: 6%–9% of stenting cases have
of malignant large bowel obstruction, to defunction or resect clinical evidence of perforation, while up to 14% of cases have
the affected bowel and prevent further bowel ischaemia or silent perforation. Two randomised controlled trials were stopped
perforation. The feasibility of primary anastomosis depends on prematurely for stent-related complications.(8,11) There is also
the condition of the colon as well as the patient’s haemodynamic increasing evidence that stenting should only be considered in
status. Stoma creation, either in the form of a diverting colostomy a selected group of patients.(12) The experience of the clinician
or an end colostomy, can occur at rates of up to 40% in the is crucial, both in terms of technicality, as colonic stenting is
emergency setting.(3) An Association of Coloproctology of Great considered an advanced endoscopic procedure, and clinical
Britain and Ireland audit in 2003, which included more than judgement in identifying suitable patients for stenting.(12)
8,000 patients, showed that emergency surgery for large bowel In this retrospective audit review, we aimed to evaluate a
obstruction carries a mortality of up to 20%.(4) In addition, there case series of patients who underwent colonic stenting in our
are also potential psychological consequences for the patient institution, performed by a single surgeon over a period of six
from the formation of a stoma.(5) years, from 2009 (when he first started performing the procedure
The introduction of colonic stenting over 20 years ago offered independently) to 2015. Our goal was to demonstrate that in
an alternative approach to dealing with malignant large bowel experienced hands, colonic stenting is safe and effective for
obstructions.(6) It can act as a bridge to surgery (BTS), allowing malignant large bowel obstruction. Our main outcomes were to
temporary bowel decompression by restoring luminal patency. review the success rate of stenting, rate of anastomosis and rate
Definitive surgical resection can then be performed in a more of stoma creation for this group of patients. The long-term and
elective setting and patients’ comorbidities can be further optimised. survival outcomes will be addressed in subsequent publications.
In addition, colonic stenting can also be used in a palliative setting.
Three separate meta-analyses comparing emergency surgery and METHODS
colonic stenting as BTS for obstructed colorectal cancer showed This was a retrospective case series of all consecutive patients
that stenting had higher primary anastomotic rates with lower from a prospectively collected electronic database who

Department of Colorectal Surgery, Singapore General Hospital, Singapore, 2School of Medicine, University of Birmingham, United Kingdom
1

Correspondence: Dr Man Hon Tang, Resident, Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169856. manhon_86@hotmail.com

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Table I. Patient demographics and surgical information.

Parameter No. (%) p‑value
Overall (n = 75) 2009–2012 (n = 38) 2012–2015 (n = 37)
Male 46 (61.3) 22 (57.9) 24 (64.9) 0.81
Age* 68.8 ± 14.7 (36–102) 70.3 ± 15.1 (36–102) 67.6 ± 14.2 (37–91) 0.37
Tumour location
Sigmoid 38 (50.7) 20 (52.6) 18 (48.6) 0.61
Descending 18 (24.0) 9 (23.7) 9 (24.3) 0.57
Splenic 9 (12.0) 3 (7.9) 6 (16.2) 0.48
Transverse 4 (5.3) 1 (2.6) 3 (8.1) 0.11
Hepatic flexure 1 (1.3) 1 (2.6) 0 (0) 0.38
Rectosigmoid 5 (6.7) 4 (10.5) 1 (2.7) 0.20
Stent intent 0.09
Bridge to surgery 57 (76.0) 25 (65.8) 32 (86.5)
Palliative 18 (24.0) 13 (34.2) 5 (13.5)
Success rate
Technical 70 (93.3) 35 (92.1) 35 (94.6) 0.31
Clinical 61 (81.3) 28 (73.7) 33 (89.2) < 0.05
*Data presented as mean ± standard deviation (range).

underwent attempted colonic stenting by a single surgeon for All colonic stents were performed in the institution’s
malignant colorectal cancer. The inclusion criteria were: (a) dedicated endoscopy suite under sedation. A guidewire was
aged over 18 years; and (b) underwent treatment with a metallic first passed through the stenotic tumour under fluoroscopic
stent for malignant large bowel obstruction in any part of the guidance before deploying the SEMS. After the procedure, all
colon. Most patients were admitted as emergency cases with patients were monitored clinically and radiologically for evidence
clinical evidence of large bowel obstruction but without clinical of bowel decompression to determine clinical success. Final
and radiological evidence of perforation or bowel infarction. histopathological reports were also examined post resection to
Patients who had a bowel obstruction from a benign cause or an determine cancer stage and evidence of microscopic perforations.
extracolonic malignancy were excluded.
Patient demographics were recorded, including age, RESULTS
gender, past medical history and ASA (American Society of Colonic SEMS insertion was attempted on a total of 75 patients
Anesthesiologists) grade. Included disease characteristics were during the study period (Table I). Their mean age was 68.8 (range
site of tumour, presence of metastases and degree of obstruction. 36–102) years and the majority were male (61.3%). The vast
Intervention variables were date of stent, intention (i.e. palliative majority of the tumours stented were distal tumours, and half of
or BTS), duration from diagnosis to stent insertion, and the size them (50.7%) were located in the sigmoid colon. Stenting was a
and type of self-expanding metal stent (SEMS) deployed. Patients BTS for 57 (76.0%) patients and for palliation in the remainder
classified as having an impending obstruction were those who (24.0%, n = 18). The majority (n = 69) of stented patients
had a very narrow lumen on endoscopy, to the extent that the presented with acute intestinal obstruction and stenting was
scope could not be passed through. Although these patients did performed within a median time of 15 ± 12.5 (range 2–60) hours
not have any clinical or radiological evidence of obstruction, they from diagnosis. A small number of patients (n = 6) had stenting
usually had non-resectable metastatic disease, and therefore, the for impending tumour obstruction despite not exhibiting any
objective of stenting was palliation. For patients with subsequent clinical symptoms of obstruction. For these patients, the median
surgical resection, details of surgery such as anastomosis, stoma time lapse to stenting was 3 ± 12.4 (2–30) days from diagnosis.
creation, postoperative complications and length of hospital stay The length of the stent used in each case was decided
were also recorded. The cases were subdivided into two equal based on the length of the obstructive lesion seen on computed
time periods, 2009–2012 and 2012–2015, for the purpose of tomography. The majority of the stents were the WallFlex™
comparison to assess if there was an improvement in success rates colonic stent (Boston Scientific, Marlborough, MA, USA). Three
over time. A p-value < 0.05 was considered statistically significant. patients had insertion of the Niti-S™ enteral colonic stent
The primary outcome was the number of clinical and (Taewoong Medical Co Ltd, Gimpo-si, Gyeonggi-do, South Korea)
technical successes after the placement of a SEMS. Technical (Table II).
success was defined as the successful placement of the stent in situ The overall technical success rate was 93.3%; in four cases,
across the length of the obstruction. Clinical success was defined the guidewire could not be passed through safely, and in one
as the absence of complications, with clinical and radiological case, the stent migrated proximally immediately after it was
evidence of bowel decompression. deployed. The overall clinical success rate was 81.3%, with

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better success rates in the later cohort in 2012–2015 (89.2% vs. with a temporary ileostomy, while the remaining 11 patients
73.7%; p < 0.05). The causes of clinical failure were inadequate had primary anastomosis without stoma creation. Our intention-
decompression (n = 7) and colonic perforation (n = 2). For the two to-treat analysis showed that 93.0% of patients had primary
cases of perforation from stent insertion, both patients underwent anastomosis after colonic resection and only 10.5% required
emergency laparotomy and Hartmann’s procedure. Fig. 1 depicts stoma creation. The anastomotic rate was higher for patients with
the radiological findings in some of the unsuccessful cases. successful stenting, although the difference was not statistically
For the 57 patients who had surgery, the median duration significant (95.3% vs. 85.7%; p = 0.22). The stoma creation rate
from stenting to surgical resection was 10 (range 0–21) days was significantly lower in patients who were successfully stented
(Table III). 63.2% of the surgical resections were performed (4.7% vs. 28.6%; p = 0.03) (Table III).
as open procedures, although there was a trend towards Among the 18 patients who received palliative stenting, there
laparoscopic surgeries in the second half of the study period. was only one case of unsuccessful stenting, which eventually
All patients with successful stenting underwent subsequent required a colostomy. There were two cases of subsequent stent
surgery with primary anastomosis without stoma, except one blockage, one at four months and the other at two years after
patient who had an elective Hartmann’s procedure due to his initial stent placement. The remaining patients did not require
age and comorbidities. Emergency surgeries were performed on further intervention after initial colonic stenting.
all patients who had unsuccessful stent insertion; two patients The final tumour grading from histopathological examination
had a Hartmann’s procedure and one had colonic resection is shown in Table IV. As expected, there was a higher percentage
of more advanced disease among obstructed tumours.
Table II. Details of the self‑expanding metal stents used.
No microscopic perforations were found on pathological
Stent type No. examination. The median length of hospital stay was four days
WallFlex™ (mm) after colonic stenting, and six days after interval surgical resection
22 × 60 10 of colorectal cancer.
22 × 90 8 A cumulative sum (CUSUM) chart was plotted to show the
25 × 60 22 trend in clinical success over time (Fig. 2). As shown by the
25 × 90 33 upward slope of the graph, there were increasing rates of clinical
25 × 120 1 success after 35 cases.
Niti‑S™ (mm)
24 × 80 2 DISCUSSION
24 × 100 3 Since colonic SEMS was introduced in the 1990s, many studies
Total no. of stents does not add up to 75, as there were some cases in which the have examined its role in the treatment of malignant colonic
stent was unable to be deployed and some patients needed more than 1 stent. obstruction. Watt et al(13) showed that stenting is less risky than

Table III. Surgical details of patients who underwent surgical resection after stenting.
Parameter No. (%)
Overall (n = 57) 2009–2012 (n = 25) 2012–2015 (n = 32)
Duration till surgery* (day) 10 ± 6 (0–21) 11 ± 6 (0–21) 10 ± 5 (0–20)
Method
Open 36 (63.2) 22 (88.0) 14 (43.8)
Laparoscopic 18 (31.6) 2 (8.0) 16 (50.0)
Laparoscopic assistance 3 (5.3) 1 (4.0) 2 (6.3)
Primary anastomosis
Overall intention to treat 53 (93.0) 22 (88.0) 31 (96.9)
Successful stenting† 41/43 (95.3) 14/15 (93.3) 27/28 (96.4)
Unsuccessful stenting† 12/14 (85.7) 8/10 (80.0) 4/4 (100.0)
Stoma creation
Overall intention to treat 6 (10.5) 5 (20.0) 1 (3.1)
Successful stenting† 2/43 (4.7) 1/15 (6.7) 1/28 (3.6)
Unsuccessful stenting †
4/14 (28.6) 4/10 (40.0) 0/4 (0)
Length of stay* (day)
Post stenting 4 ± 2 (1–10) 5 ± 3 (2–8) 3 ± 2 (1–10)
Post resection 6 ± 5 (3–25) 6 ± 5 (3–68) 6 ± 4 (3–25)
Total (stent and resection) 11 ± 12 (5–76) 11 ± 13 (3–76) 10 ± 11 (5–32)
*Data presented as median ± standard deviation (range). †Value of n is provided for patients who were included in analysis, and percentages are calculated
according to this value.

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1a 1b 1c

Fig. 1 (a) Radiograph shows persistent large bowel and caecal dilatation with pneumoperitoneum after stenting of an obstructing rectosigmoid tumour
on Day 3 despite adequate decompression, with liquid stools seen after stent insertion. The patient had abdominal pain, was noted to have perforation
at the caecum intraoperatively, and underwent an open right hemicolectomy and anterior resection. (b) Radiograph shows stent in situ but evidence of
pneumoperitoneum (Rigler’s sign) ten days after stenting of an obstructing sigmoid tumour with clinical success on discharge. The patient presented
with abdominal pain and underwent a Hartmann’s procedure, which found a 5-mm perforation just proximal to the stent. (c) Radiograph shows stent
in situ but a distended caecum and small bowel 12 days after stenting of an obstructing transverse colon tumour with clinical evidence of decompression
thereafter. The patient had worsening abdominal distension and underwent an open extended right hemicolectomy, during which the colonic stent was
noted to be loose and able to freely slip in and out of the tumour.

Table IV. Final histopathology staging of resected specimens.

1.00
Stage No. (%) 0.50
Overall 2009–2011 2012–2015 0.00
1 6 11 16 21 26 31 36 41 46 51 56 61 66 71
(n = 75) (n = 36) (n = 39)
CUSUM value

-0.50
I 0 (0) 0 (0) 0 (0) -1.00
II 15 (20.0) 6 (16.7) 9 (23.1) -1.50
III 36 (48.0) 17 (47.2) 19 (48.7) -2.00
VI* 24 (32.0) 13 (36.1) 11 (28.2) -2.50

*Non‑resected tumours with radiological evidence of metastasis were considered -3.00

Stage VI. -3.50

emergency surgery, resulting in shorter hospital stays and lower Fig. 2 Cumulative sum graph shows the cumulative clinical success rates
(x-axis) plotted against consecutive cases of colonic stenting (y-axis).
postprocedural complication rates. In their study, clinical and
technical success rates were high, and there was little difference
between the BTS and palliation groups. The average technical which the majority of patients had laparoscopic surgery. A meta-
success rate was 96.2% and clinical success rate was 92.0%. Their analysis by Zhang et al concluded that stenting, as opposed to
results are comparable to those of the present series and suggest emergency surgery, in a BTS population reduces intensive care
that stenting is a successful procedure with promising outcomes length of stay, generates higher primary rates of anastomosis,
for the relief of malignant bowel obstruction and a low, acceptable and lowers both stoma and leak rates.(7) A recent Cochrane
rate of complications. Another pooled analysis by Sebastian review by Sagar of five randomised controlled trials found
et al(14) had largely similar results to Watt et al’s review, with 94% that SEMS reduces hospital stays and the duration of surgery,
technical success and 91% clinical success. Clinical success was although it found no difference in overall mortality or morbidity
substantially higher in the palliative group. Stent migration was when comparing stenting and surgery.(15) The first randomised
found to be the most common complication, occurring in 11.81% controlled trial from the University of Birmingham Clinical Trials
of included patients. The analysis also suggested that stents are a Unit, comparing endoluminal stenting to emergency surgery,
safe and effective alternative to emergency surgery. demonstrated in an early abstract publication that stenting as
SEMS has important advantages over emergency surgery. BTS decreases the rate of stoma formation without affecting
Not only can the patient undergo a significantly less invasive overall mortality.(16)
procedure (especially salient to palliative patients who can avoid Despite the short-term advantages of colonic stenting in terms
surgery if possible), studies have shown that surgery is technically of shorter hospital stay, higher anastomotic rates and lower stoma
more successful after stenting.(14) This is due to the ability to rates, almost all reviews have shown that the long-term survival
optimise the patient’s comorbid state prior to the operation, outcomes are at best comparable to the traditional method,
including maximising their nutritional status, ensuring adequate emergency surgical resection of obstructed colorectal cancer.
bowel preparation and rectifying electrolyte disturbances. A BTS While emergency surgery almost guarantees successful bowel
technique also makes it possible for laparoscopic oncological decompression, the application of SEMS is associated with both
surgical resection to be performed after adequate bowel technical and clinical failure, which leads to inevitable emergency
decompression, as shown in the second half of our study during surgery. The associated risk of stent perforation is approximately

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4%.(15) Whether this affects subsequent tumour recurrence is an followed by resection and those undergoing emergency bowel
area of great debate. Although SEMS is beneficial to patients resection.(15)
when it is successfully deployed with bowel decompression, the Colonic stenting remains an attractive alternative to
success rates are dependent on many factors. emergency surgery for malignant colonic obstruction, especially
It is important to identify the patients who are suitable for for patients with high operative morbidity and mortality. It allows
stenting based on characteristics such as patient factors and definitive surgical resection to be performed in an elective setting,
tumour location. Van Hooft et al have suggested that the subset with the option of laparoscopic surgery and potentially avoiding
of patients suitable for stenting should be defined further.(12) a stoma. While stenting for proximal lesions is considered
Blake et al carried out a United Kingdom-based case series on technically more challenging and not usually recommended,
54 patients that had lower success rates than in other studies.(9) we have shown that proximal stenting is feasible and can be
Technical success was 86% and clinical success was 84%, while considered in suitable patients. A large cohort study on stenting
complications occurred in one-fifth of patients. We may speculate for proximal lesions also showed very encouraging results.(18)
that clinician experience was more limited at this centre given Our study had some limitations. First, although a single
its status as a district general hospital, therefore accounting for surgeon placed the stents in all patients, different surgeons
its lower success rates than in other publications. performed the subsequent elective surgery. We did not examine
Technical failures are mostly due to the inability to locate the effect of this on our outcomes. Additionally, as with all
the lumen so that the guidewire can be safely passed through. retrospective studies projects, it is possible that a degree of
In three out of four cases in the present study, the tumour was selection bias may have been present.
at the curved portion of the colon. While this is not an absolute In conclusion, using SEMS appears to be a safe and effective
contraindication to stenting, it is important to note that there is a way of relieving large bowel obstruction caused by colorectal
higher failure rate in such cases. cancer, even for proximal lesions. The complication rate found
The main reasons for the clinical failures in our study were in our series was low and success rates were on par with those
inadequate decompression (seven cases) and perforation (two in the existing literature. After successful stent placement,
cases). The size of the stent plays an important role in the clinical patients were subsequently able to undergo surgical resection
success of SEM. Prior to 2012, the majority of stents used were those in an elective setting with minimal complications. We have also
with the larger 25-mm diameter. In addition to concern about a shown that the stoma rate is significantly lower in cases where
higher risk of perforation with the larger stents, we have also noted a stenting was successful and that the success rate correlates with
significant amount of intraoperative fibrosis, which makes resection experience. It is therefore imperative that colonic stenting is
more difficult. As such, we have more recently moved towards using performed by an experienced endoscopist, in terms of technical
the smaller 22-mm stents in selected patients. Although there were skill and knowledge of patient selection, due to the learning
cases of inadequate decompression due to very hard impacted stools curve required. This would generate a higher success rate with
proximally in our study cohort, there was no overall discernible fewer complications. We hope to see more high-quality studies
difference in clinical success rates between the two stent sizes. in this area.
Another crucial factor is the experience and skill level of the
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