for many years , surgery was the only conventional treatment for colorectal obstruction , with a price of high rates of mortality and morbidity .
surgical treatment options included decompressing colostomy or large bowel resection with or without a stoma .
however , since the introduction of colorectal stenting in 1990 by dohmoto et al , large bowel obstruction relief may be achieved with better outcomes , especially in palliative patients . by alleviating the need for emergency surgery , stenting also enables preoperative comorbidity evaluation , proximal large bowel assessment , and staging of cancer , if needed . after the emergency treatment of obstruction and in cases when surgery is indicated , stenting enables laparoscopic colorectal resection with better short - term outcomes .
the aim of this study was to assess morbidity and mortality in elderly patients undergoing stenting for large bowel obstruction at darent valley hospital from 1997 to 2010 .
a retrospective case review was performed of all patients registered in a prospective database who underwent self - expanding metal stent ( sems ) insertion for colorectal obstruction within the colorectal unit at darent valley hospital ( dartford , uk ) between january 1997 and december 2010 .
data including demographic details , stricture location , indication for the procedure , success , failure , and complications of the procedure were collected .
data related to perforation , stent migration , reobstruction , fracture of the stent , and other major complications were included .
stenting - related mortality was defined as death caused by direct stenting - related complications ( mainly perforation ) .
calculation of mortality during the same admission and poststenting 30-day mortality rates were recoded on the basis of the national health service 's computerized system .
patients were divided into 3 groups : those < 70 years of age ( group i ) , those aged 70 to 79 years ( group ii ) , and those > 80 years of age ( group iii ) .
colorectal stenting was carried out in the interventional radiology room under light sedation and appropriate monitoring , with the patient placed in the left lateral decubitus position . in most cases ,
sems were inserted as a joint procedure between a colorectal surgeon and a radiologist using the  over - the - wire  method .
the colonoscope was introduced to the lesion site , and a flexible guidewire was inserted to bypass the stricture .
the scope was then retracted to enable introduction of the stent , which later was positioned and deployed .
method , predominantly for proximal tumors , whereby the stent was introduced through the colonoscope .
fluoroscopy was required to ensure successful wire placement and to delineate the size of the tumor for the assessment of stent length .
final assessment of stent positioning was made using water - soluble contrast material , ensuring colon decompression .
we used 2 types of stent : the metallic wallflex colonic stent ( boston scientific corporation , natick , ma ) and the memotherm colonic stent ( bard medical , covington , ga ) . in all cases of the through - the - scope method ,
undisclosed data were collected on a personal computer , using microsoft excel software ( microsoft corporation , redmond , wa ) .
continuous variables such as age were categorized into subgroups and compared using student t tests or mann - whitney u tests , depending on their distribution .
we constructed probability curves using the kaplan - meier method and compared them using the log - rank test .
statistical analysis was performed using statsdirect version 2.7.8 ( statsdirect ltd , cheshire , uk ) .
colorectal stenting was carried out in the interventional radiology room under light sedation and appropriate monitoring , with the patient placed in the left lateral decubitus position . in most cases ,
sems were inserted as a joint procedure between a colorectal surgeon and a radiologist using the  over - the - wire  method .
the colonoscope was introduced to the lesion site , and a flexible guidewire was inserted to bypass the stricture .
the scope was then retracted to enable introduction of the stent , which later was positioned and deployed .
method , predominantly for proximal tumors , whereby the stent was introduced through the colonoscope .
fluoroscopy was required to ensure successful wire placement and to delineate the size of the tumor for the assessment of stent length .
final assessment of stent positioning was made using water - soluble contrast material , ensuring colon decompression .
we used 2 types of stent : the metallic wallflex colonic stent ( boston scientific corporation , natick , ma ) and the memotherm colonic stent ( bard medical , covington , ga ) . in all cases of the through - the - scope method ,
undisclosed data were collected on a personal computer , using microsoft excel software ( microsoft corporation , redmond , wa ) .
continuous variables such as age were categorized into subgroups and compared using student t tests or mann - whitney u tests , depending on their distribution .
we constructed probability curves using the kaplan - meier method and compared them using the log - rank test .
statistical analysis was performed using statsdirect version 2.7.8 ( statsdirect ltd , cheshire , uk ) .
during the study period , 132 sems were deployed in a similar number of patients for treatment of colorectal pathology , with an average age of 72.1 years . of these
, 53 were included in group i ( average age , 59.7 years ; range , 2869 years ) , 42 were in group ii ( average age , 75.2 years ; range , 7079 years ) , and 37 were in group iii ( average age , 86.3 years ; range , 8095 years ) .
similar diversity of gender , indication for the procedure , and colonic stricture location was found ( table 1 ) . there were no significant differences in the technical success rates of the procedure ( 88.7% , 76.2% , and 78.4% , p = .23 ) and clinical success rates ( 88.7% , 73.8% , and 78.4% , p = .16 ) .
data concerning complications were available for 124 of 132 patients and were comparable for the different groups ( 25.5% , 30.0% , and 12.1% , p = .17 ) .
the mortality rate during the same admission was significantly higher in the older groups ( 4.0% , 15.0% , and 22.2% , p = .027 ) , but stent - related mortality and 30-day mortality were similar .
kaplan - meier 30-day survival curves showed a similar tendency of probability of survival for the 2 older groups ( 7080 and 80 years ) compared with the young group ( 1870 years ) , with a log - rank p value of .19 ( figure 1 ) .
colonic stenting : data per age group complications : data per age group * percentages were calculated from known data .
kaplan - meier 30-day survival curve per age group ( log - rank p = .1904 ) . of all stented patients , 48 ( 36.4% )
underwent surgery . of these , 27 ( 20.4% of all patients ) were operated on urgently because of failure of stent insertion , failure to achieve bowel decompression , or stent complications .
twenty - one patients ( 15.9% ) underwent planned surgery , of whom 11 ( 8.3% ) underwent laparoscopic surgery .
when comparing age groups , it is notable that the younger groups had more surgery ( 50.9% , 38.1% , and 13.5% , respectively , p = .0013 ; figure 2 ) , though there was no statistical difference between the indication for surgery ( planned vs urgent ) or the surgical approach ( laparoscopic vs open ) .
ratio ( % ) of surgery versus no surgery per age group ( p = .0013 ) .
stoma prevention was achieved in 105 of 132 patients ( 79.4% ) , and only 27 patients ( 20.6% ) had stomas .
a significant difference in stoma rate was discovered when comparing age groups , with a higher rate of stoma among the young group ( 17 of 53 [ 32.1% ] , 7 of 42 [ 16.7% ] , and 3 of 37 [ 8.1% ] , p = .0147 ) .
the risk for a patient < 70 years of age to have a stoma was 5.5 times higher than that of a patient > 80 years of age .
colorectal cancer accounts for about 1 million new cases per year worldwide , with 15% of all cases presenting as acute colonic obstructions , making it the leading cause of large bowel obstruction .
colonic obstruction necessitates urgent decompression that traditionally required surgery , which carries high risk for mortality and morbidity , as well as high stoma rates .
however , in recent years , the use of colorectal stenting proved to be a successful method for relief of symptoms of large bowel obstruction .
it also enables management and correction of fluid and electrolyte imbalance , cardiac arrhythmias , and respiratory complications .
sems insertion can also be used in benign strictures such as diverticular disease , postradiation , and anastomotic stricture .
the array of colonic stenting technical success rates in the literature is wide , with a mean of 92% ( range , 66.6%100% ) .
clinical success rates are slightly lower , reaching a mean of 88% ( range , 46%100% ) .
technical failure is due mainly to the inability to place a guidewire through the stricture .
a recent systematic review and meta - analysis of randomized clinical trials of sems insertion versus emergency surgery by tan et al found lower technical and clinical success rates of 70.7% and 69.0% , respectively , which were linked partially to complete large bowel obstruction .
tight strictures , such as in complete obstruction , can cause marked abdominal distension and difficulties in guidewire placement , leading to lower rates of stent deployment .
it demonstrates a technical stent placement success rate of 81.8% and a clinical success rate of 81.1% , both within reported ranges . with the increase in life expectancy and the link between colorectal cancer and age
, there is a higher likelihood that an elderly population will exhibit acute mechanical colonic obstruction due to advanced cancerous disease .
previous strategies for the treatment of colonic obstruction were associated with high mortality rates of 15% to 34% . in an association of coloproctology of great britain and ireland study of large bowel obstruction that included data on nearly 8000 patients , the average mortality rate was 16.5% , but when adding risk factors such as age > 85 years and american society of anesthesiologists score of iii , the mortality rate has reached 50% .
the results of our study outline a tendency toward a higher proportion of 30-day mortality rates among the different age groups ( 13.2% , 23.8% , and 27.0% , p = .153 ; 12.7% overall ) .
although this difference might be linked to a small sample size , it also indicates better outcomes for sems insertion compared with surgery .
higher rates of mortality during the same admission for the older groups , ii and iii , were found ( 4.0% , 15.0% , and 22.2% , p = .027 ; 20.4% overall ) , even though similar bowel decompression rates were achieved , with comparable complication rates .
an additional effect was the different curvature tendency shown in the kaplan - meier diagram regarding the 30-day probability of survival , which was similar for groups ii and iii compared with group i ( figure 1 ) .
we believe that the disturbance of homeostasis , which is caused by colonic obstruction including dehydration due to shift of fluids , electrolyte imbalance , reduced intestinal blood flow , and mucosal edema with bacterial translocation , causes a physiologic  insult  that is more challenging for the aged population , thus influencing survival rates . alleviating obstruction with stent insertion
buchanan et al published their experience in stenting elderly patients ( median age , 82 years ; range , 6996 years ) , with successful sems placement in 9 of 11 patients and a median survival time of 5 months . when analyzing outcomes in a population > 70 years of age with colorectal obstructions , guo et al compared stent insertion and primary surgery , with better results for the stenting group in terms of primary anastomosis and 30-day mortality rate .
although without discussing the issue of age , other studies of large bowel obstruction have published better results for sems insertion compared with urgent surgery in terms of primary anastomosis and stoma rates , with comparable complications and mortality results . on the other hand , elderly patients undergoing urgent colorectal surgery have worse 1-year survival rates . in a study by mamidanna et al , patients were classified into 3 age groups : 70 to 75 , 76 to 80 , and > 80 years .
thirty - day mortality rates were 17.0% , 23.3% , and 31.0% , respectively ( p < .001 ) .
advanced age was an independent risk factor for mortality in risk - adjusted regression analyses .
surgery for octogenarians with colorectal cancers was also linked to significant morbidity and mortality rates in a study by tan et al .
an association between advanced age , emergency surgery , and comorbidity was found . in our opinion
, the data in the literature suggest that elderly patients would probably have difficulties in regaining homeostasis after an incident of large bowel obstruction , but they would probably do better with stenting than with emergency surgery .
another remarkable issue is the significant difference between the proportions of patients undergoing surgery among the different age groups , with higher rates in younger patients causing higher rates of stoma ( figure 2 ) .
we can not fully explain this difference , because of the retrospective nature of our study .
nevertheless , we suspect that this difference might be linked to patients ' comorbidity issues ( discussed earlier in this article ) as well to patients ' and surgeons ' preferences relating to end - of - life decision making .
we believe that surgeons have a greater reluctance to pursue aggressive management in the poststenting period , although in some cases , patients were probably too sick to undergo surgery .
we also think that older patients , as well as surgeons treating the elderly , tend to prefer less invasive techniques such as sems insertion and avoid the choice of surgery . 
failure to rescue  in those cases is partially a consequence of attitude rather than a result of disease and aggressive management .
similar tendencies are found in other areas of colorectal cancer treatment . a study by serra - rexach et al examined differences in therapeutic approach in 503 patients with colorectal malignancies who were divided into a young group ( age < 75 years ) and an older group ( age  75 years ) .
although no differences were observed between the groups in terms of tumor differentiation , extension , tumor stage , or comorbidities , young patients were more likely to receive surgery , radiotherapy , and chemotherapy and were less likely to receive palliative care .
similar attitudes toward the elderly are found when observing research in the field of chemotherapy , in which the elderly are underrepresented in clinical trials .
our study demonstrates similar indications and stricture locations when comparing sems placement in young and elderly patients . comparable success , failure , and complication rates were found , with a higher same - admission mortality rate among the older patients .
we believe that this dissimilarity represents the significant divergence in the disease burden due to large bowel obstruction , especially in elderly patients .
we also observed a relationship between age and the tendency to operate , with aging patients less likely to undergo surgery for large bowel obstruction .
this , we believe , reflects on the different attitudes of both patients and surgeons in terms of decision making .
prospective randomized trials are needed to better determine the benefits of sems compared with emergency surgery .
 background and objectives : emergency surgery for large bowel obstruction is associated with high morbidity and mortality rates , especially in elderly patients . 
 colonic self - expanding metal stents may provide temporary relief of obstructions and enable preoperative evaluation . 
 the aim of this retrospective study was to assess the clinical outcomes of emergency stenting in elderly patients with large bowel obstructions.methods:between 1997 and 2010 , patients presenting with large bowel obstructions were treated predominantly with self - expanding metal stent insertion . 
 clinical data , including age , site of obstruction , success rate , and surgery and mortality rates , were collected . 
 patients were divided into 3 groups ( i , ii , and iii ) according to age : < 69 , 70 to 79 , or > 80 years.results:one hundred thirty - two consecutive patients underwent stent implantation , with a mean age of 72.1 years ( range , 2895 years ) . 
 similar diversity of sex , indication , and stricture location was found . 
 there were no significant differences in clinical success ( 88.7% , 73.8% , and 78.4% , p = .16 ) and stent - related mortality ( 2.1% , 3.3% , and 3.6% , p = 1.00 ) . 
 similar rates of stoma creation were also found ( 59.3% , 46.7% , and 60.0% , p = .76 ) . 
 in contrast , rates of surgery were lower in older patients ( 50.9% , 38.1% , and 13.5% , p = .0013 ) , and mortality during the same admission was significantly higher in patients > 70 years of age ( 4.0% , 15.0% , and 22.2% , p = .027 ) . 
 kaplan - meier 30-day survival curves for the 3 groups showed a trend toward earlier death among patients > 70 years of age.conclusions:this study demonstrates that stenting provides similar success rates in all age groups but is associated with higher mortality rates in older patients . 
INTRODUCTION
METHODS
Technical Considerations
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSIONS