Self‐expanding metallic stents for large bowel obstruction

Sir,

We thank Mr Thorlacius for his interest in our article. The point raised is an important one and as mentioned seven of our patients undergoing stenting as a bridge to surgery had benign disease. As such we advised caution in interpretation of results related to adverse events in stents inserted as a bridge to surgery due to the presence of patients with benign pathology. With regard to time to stent migration we do not agree that this was related to a reduction in inflammatory swelling. Three of the stents migrated within the first few days and the other two experienced complications shortly after the first week post insertion. In our centre we no longer use stents routinely for benign obstruction in view of prior experience.

We agree that four patients with malignant disease is too small a number to draw any solid conclusions regarding utilization of stents as a bridge to surgery in malignant disease. We advised caution in interpreting our results here for the reasons outlined above. We recognize the absence of high quality evidence, in particular, randomized trials to clarify the role of self expandable metallic stents when used as a bridge to surgery in malignant disease.

Yours sincerely

Craig Mackay
Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
cmackay@doctors.org.uk

• Commentor: Craig Mackay - Aberdeen Royal Infirmary, UK
• Date: Nov 10, 2011

Sir

The authors conclude that the relative risk of an adverse event is increased in the group of patients undergoing ”bridge to surgery” stenting. However, this group of patients constituted 11 patients of which seven had benign disease. Adverse events are well-known to be increased in patients with benign compared to malignant disease undergoing colorectal stenting (1, 2). If a self-expanding metallic stent is used in a patient with benign disease, the planned bowel resection should not be delayed more than four weeks. It is not surprising that as the inflammatory response subsides the benign stricture will widen and increase the risk of stent migration. The time to operation after stenting was not presented making it difficult for the reader to know whether this time factor played a role in the present study. Moreover, the group of patients with malignant disease stented with the intention as “bridge-to-surgery” consisted of only four patients of which 50% required a stoma at the planned colonic resection. This is not only too few patients for solid conclusions about the risks associated with the “bridge to surgery” approach but also a relatively high percentage of patients needing stoma compared to data in the literature ranging between 0-17% (3-5). Thus, to conclude that the risk of adverse events associated with the use of self-expanding metallic stents in “bridge to surgery” is not substantiated in the present study especially when considering that this indication should be restricted to patients with malignant colonic obstruction.

Henrik Thorlacius
Skåne University Hospital, Malmö
henrik.thorlacius@med.lu.se

References

1. Keränen I, Lepistö A, Udd M, Halttunen J, Kylänpää L. Outcome of patients after endoluminal stent placement for benign colorectal obstruction. Scand J Gastroenterol 2010; 45: 725-731.

2. Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008; 22: 454-462.

3. Lepsenyi M, Santen S, Syk I, Nielsen J, Nemeth A, Toth E, Thorlacius H. Self-expanding metal stents in malignant colonic obstruction: experiences from Sweden. BMC Res Notes 2011; 4: 274.

4. Iversen LH, Kratmann M, Bøje M, Laurberg S. Self-expanding metallic stents as bridge to surgery in obstructing colorectal cancer. Br J Surg 2011; 98: 275-281.

5. Saida Y, Enomoto T, Takabayashi K, Otsuji A, Nakamura Y, Nagao J et al. Outcome of 141 cases of self-expandable metallic stent placements for malignant and benign colorectal strictures in a single center. Surg Endosc 2011; 25: 1748-1752.

• Commentor: Henrik Thorlacius - Skåne University Hospital, Malmö
• Date: Oct 24, 2011