Outcomes of the combined application of ultrathin endoscope and guidewire replacement for self-expandable metal stent placement in colorectal carcinoma with intestinal obstruction: A retrospective analysis

doi:10.21203/rs.3.rs-2742088/v1

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Outcomes of the combined application of ultrathin endoscope and guidewire replacement for self-expandable metal stent placement in colorectal carcinoma with intestinal obstruction: A retrospective analysis

https://doi.org/10.21203/rs.3.rs-2742088/v1

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Background: Self-expandable metal stent (SEMS) placement with an emergency colonoscope has been gradually applied to treat colorectal carcinoma with intestinal obstruction (CCIO). We proposed a new technique based on current SEMS placement with the combined application of ultrathin endoscope and guidewire replacement to solve previous technical difficulties. This study evaluated its feasibility, efficacy, and safety for SEMS placement in CCIO.

Methods: We retrospectively analyzed data of 31 CCIO patients, who received the novel SEMS placement technique at Wuhan No.1 Hospital between June 2019 and October 2022. Technical and clinical success rates, adverse events, prognosis, and follow-up were evaluated. Inter-group differences between bridge to surgery (BTS) and palliative treatment (PT) groups and clinical feasibility of this technique were analyzed.

Results: Overall technical and clinical success rates were 100% (31/31) and 96.8% (30/31), respectively, without adverse events. There was no significant difference in procedure time and technical/clinical success rates among three attending physicians(p>0.05). Fourteen BTS patients (14/31, 45.2%) underwent SEMS with a post-placement confined operation, which had a 100% success rate (14/14) and no ostomy. Median follow-up time was 67.5 days, and four patients (4/14, 28.6%) had postoperative adverse events of inflammatory anastomotic changes. Seventeen PT patients had a median follow-up time of 30 days, without adverse events. Two patients (2/17, 11.8%) underwent follow-up colonoscopywith no post-placement stent migration/obstruction.

Conclusions: The combined application of ultrathin endoscope with guidewire replacement for SEMS placement to treat CCIO could avoid X-ray-induced medical radiation damage and reduce cross-infection risk, making it clinically safe, effective, and promotion suitable.

ultrathin endoscope

self-expandable metal stent

colorectal carcinoma

intestinal obstruction

Intestinal obstruction is one of the most common acute abdomen adverse events, mechanical intestinal obstruction due to colon tumor represents the primary cause [1–4]. Currently, for the treatment of colorectal carcinoma with intestinal obstruction (CCIO), self-expandable metal stent (SEMS) placement assisted by an emergency colonoscope has been an effective bridge to surgery (BTS) [5–9]. Mergency colonoscopy requires the support of a digital X-ray imaging machine to assess the intestinal obstruction stenosis length and the success of stent release. Emergency endoscopic SEMS placement in the gastroenterology department usually requires shared imaging equipment and interventional operating room used for endoscopic retrograde cholangiopancreatography (ERCP) treatment, which increases the possibility of nosocomial cross-infection. In clinical practice, it is difficult to overcome the reliance of endoscopic SEMS on digital interventional equipment. Our center has achieved initial clinical results by applying the ultrathin endoscope to replace the measurement and positioning function of interventional imaging in the emergency endoscopic SEMS treatment of CCIO. Particularly, the innovative guidewire replacement method between the ultrathin endoscope and therapeutic colonoscopy was proposed, which overcame the difficulties of ultrathin endoscope application for SEMS placement in the colon. A retrospective analysis of the relevant clinical data was presented in this study.

General information

From June 2019 to October 2022, at Wuhan No.1 Hospital, 31 patients diagnosed with CCIO, who underwent SEMS placement assisted by ultrathin endoscope combined with guidewire replacement were retrospectively collected (Fig. 1). This study was reviewed and approved by the Ethics Committee of Wuhan No.1 Hospital. All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Inclusion criteria were as follows: (1) diagnosis of CCIO; (2) eligible for emergency colonoscopy; and (3) consent for endoscopic SEMS placement provided with signed corresponding written informed consent.

Exclusion criteria were as follows: (1) severe abdominal infection and unstable vital signs; (2) the presence of contraindications, including severe cardiocerebral underlying diseases, that would render the patient unable to tolerate colonoscopy; and (3) refusal to undergo endoscopic intervention and failure to sign the corresponding written informed consent.

Operation steps and methods

Endoscopic equipment and instruments included the Fujinon VP7000 mainframe (Fujinon@ Japan), Fujinon EG-530 endoscope (Fujinon@ Japan channel 2.0 mm), EC-760R endoscope (Fujinon@ Japan channel 3.8 mm) (Fig. 2), a 0.25-mm diameter guidewire (Boston Scientific®, Jagwire guide wire ST 450 mm), and Nanjing minimally invasive bowel stent MTN-CG-S-20 (MT@ Japan, diameter: 2.6 cm, length specifications: 8 cm, 10 cm, 12 cm). The procedures were performed by three physicians engaged in endoscopy, and the third physician cooperated as an assistant to complete five endoscopic SEMS placement operations before performing the procedures independently.

Surgical procedures were conducted as follows (Fig. 3, video attachment). (a) An endoscopic operation was performed under local anesthesia with the patient in the left lateral position. (b) The operator operated the ultrathin endoscope to enter the stenotic segment of the CCIO. The ultrathin endoscope entered the obstruction’s distal end and then passed through the lumen stenosis to the obstruction’s proximal end under guidance of the guidewire, and it was confirmed that the guidewire of sufficient length was left in the lumen under direct vision. (c) While leaving the guidewire in the lumen, the ultrathin endoscope was retracted, and the stenosis length was measured. (d) The assistant used biopsy forceps to pass through the colonoscope’s clamp channel. The guidewire was clamped by biopsy forceps at the colonoscope’s front end and was replaced by pulling back the biopsy forceps, and then the guidewire was placed from the ultrathin endoscope to the therapeutic colonoscope. (e) The attending physician operated the colonoscope guided by the guidewire to the colorectal carcinoma stenosis. The assistant pushed the appropriate length of the SEMS release device through the guidewire to the intestinal obstruction site. The SEMS was released and placed under direct endoscopic vision. (f) After the operation, the ultrathin endoscope was reintroduced to determine whether the SEMS release site was appropriate and whether the ultrathin endoscope could pass through the stent smoothly. The abdominal plain film was reviewed 24 hours later to assess stent fixation and relief of the dilated intestinal cavity.

Observation index

Primary outcomes

Primary outcomes were technical and clinical successes. Technical success was defined as successful SEMS placement through the combined application of an ultrathin endoscope and guidewire replacement, with appropriate stent placement to cover the entire stenosis and self-expandable stent expansion on reinspection by ultrathin endoscope. Clinical success was defined as the relief or elimination of clinical symptoms and the presence of anal venting or defecation within 48 hours after technical success without requiring additional intervention or emergency surgery. Clinical failure was considered if the bowel lumen pressure and obstruction symptoms did not resolve within 48 hours after SEMS placement. We recorded the procedure time and evaluated technical and clinical success rates.

Secondary outcomes

Secondary outcomes included patient sex, age, tumor location, intestinal obstruction stenosis length, SEMS specifications, ultrathin endoscope passage rate, tumor differentiation degree, pathological classification and staging (AJCC Cancer Staging Manual, 8th Edition), prognosis and follow-up after stent placement, and imaging data of some patients.

Security and other observation indexes

Security indices included postoperative patient signs and adverse events, such as gastrointestinal bleeding, intestinal perforation, stent displacement, inflammatory anastomotic changes, and reobstruction. Other observation indices included 30-day mortality after stent placement, follow-up colonoscopy rate, and follow-up time.

Statistical analysis

Statistical analyses were performed using the SPSS software package (version 25.0; IBM Corp, USA). Classified data were analyzed using Fisher’s exact test and expressed as the number of cases (percentage). Normally distributed continuous data were expressed as mean ± standard deviation and analyzed using single-factor analysis of variance and the least significant difference (LSD) pairwise comparison. Data without a normal distribution were expressed as median [quartile]; the Mann-Whitney U test was used to compare two groups, and the Kruskal-Wallis H test was used for multiple-group comparisons. P-value < 0.05 was considered statistically significant.

Baseline characteristics

Thirty-one CCIO patients were included in this study, including 14 (45.2%) men and 17 (54.8%) women, with an average age of 72.13 ± 9.80 years (range, 50–94). Thirty tumors (30/31, 96.8%) occurred in the left hemicolon, and one (1/31, 3.2%) occurred in the right hemicolon. The stenosis length at the obstruction site was 5.65 ± 0.95 cm. The therapeutic colonoscope (EC-760R endoscope) could not pass through the obstructed lumen stenosis in any patients. In contrast, the passage rate of the ultrathin endoscope (FujinonEG-530) was 96.8% (30/31). Baseline characteristics were shown in Table 1.

Table 1

Baseline characteristics of the patients
Characteristics	Value/Number of cases	Percentage (%)
Age (years)
Mean ± SD [range]	72.13 ± 9.80 [50–94]
Sex
Male	14	45.2
Female	17	54.8
Tumor location
Rectum	3	9.7
Rectosigmoid colon	6	19.4
Sigmoid colon	11	35.5
Descending colon	6	19.4
Splenic flexure	1	3.2
Transverse colon	3	9.7
Right hemicolon	1	3.2
Stenosis length (cm)
Mean ± SD [range]	5.65 ± 0.95 [4–8]
Ultrathin endoscope passage rate
No	1	3.2
Yes	30	96.8
SD: standard deviation

Technical and clinical outcomes and safety

SEMS were successfully placed in all patients, with a technical success rate of 100% (31/31). No adverse events or adverse events occurred postoperatively. Median procedure time was 24 minutes (range, 14–58 minutes). Thirty patients experienced significant relief of abdominal symptoms after stent placement, with a clinical success rate of 96.8% (30/31). One patient (1/31, 3.2%) showed no improvement in abdominal pain or distension after stent placement, which was considered a clinical failure. The patient underwent a follow-up colonoscopy 15 days after the procedure, which showed good stent positioning and bowel patency. After treatment with oral simethicone oil, abdominal distension symptoms disappeared. The results were shown in Table 2.

Table 2

Technical and clinical outcomes and safety
Variables	Value/Number of cases	Percentage (%)
Operation time (minutes)
Median [Q25, Q75]	24 [20, 30]
Range	14–58
SEMS specifications (cm)
8 cm	15	48.4
10 cm	12	38.7
12 cm	4	12.9
Technical success
Yes	31	100.0
No	0	0.0
Clinical success
Yes	30	96.8
No	1	3.2
Abdominal pain and distension	1	3.2
Adverse events
Bleeding, perforation, stent displacement, etc.	0	0.0
None	31	100.0
Q: quartile; SEMS: self-expandable metal stem

We compared the endoscopic operative outcomes of three physicians (Table 3, Fig. 4). Two had clinical experience with X-ray-assisted intestinal metal stent placement and completed the endoscopic treatments in 12 cases (38.7%) and 16 cases (51.6%), respectively. The third physician did not have clinical experience with X-ray-assisted endoscopic stent placement. All three physicians completed stent placement with a 100% technical success rate and no associated adverse events. There was no statistically significant difference in the procedure time among the three physicians (24 minutes vs. 22 minutes vs. 34 minutes, p = 0.155) and postoperative clinical remission among the patients (91.67% vs. 100% vs. 100%, p = 0.484).

Table 3

Endoscopic operative outcomes of three physicians
Variables	Physician 1	Physician 2	Physician 3	F/H	p-value
Operative cases	12 (38.7%)	16 (51.6%)	3 (9.7%)
Age (years)				0.158	0.855
Mean ± SD	72.92 ± 6.97	71.19 ± 11.78	74 ± 10.81
Gender				0.514	0.880
Male	5 (41.7%)	8 (50.0%)	1 (33.3%)
Female	7 (58.3%)	8 (50.0%)	2 (66.7%)
Operation time (minutes)				3.761	0.155
Median [Q25,Q75]	24 [23,29]	22 [19,27.75]	34 [26,-]
Scope	19–54	14–58	26–36
Technical success
Success	12 (100.0%)	16 (100.0%)	3 (100.0%)
Failure	0 (0.0%)	0 (0.0%)	0 (0.0%)
Clinical success				2.234	0.484
Yes	11 (91.7%)	16 (100.0%)	3 (100.0%)
No	1 (8.3%)	0 (0.0%)	0 (0.0%)
Adverse events
Bleeding, perforation, infection, stent displacement, etc.	0	0	0
None	12 (100.0%)	16 (100.0%)	3 (100.0%)
Q: quartile, SD: standard deviation

Treatment options after SEMS placement

Fourteen patients (14/31, 45.2%) underwent a confined operation after stent placement, 17 patients (17/31, 54.8%) chose palliative treatment (PT), such as radiotherapy and chemotherapy after stent placement, and none underwent stoma or two-stage surgery. The mean interval between stent placement and surgery was 18.79 ± 6.97 days, and all patients successfully underwent the confined operation without intraoperative adverse events. The main reasons for not performing surgery were advanced age, a combination of underlying diseases that contraindicated surgery, and stage IV tumors. Regarding relevant tumor characteristics of PT vs. BTS patients, there was no significant difference between the two groups in terms of patient sex, tumor location, intestinal obstruction stenosis length, and follow-up time after stent placement (p > 0.05). There was a significant difference in age between the two groups (75.82 ± 10.25 years vs. 67.64 ± 7.28 years, p < 0.05). The results were presented in Table 4.

Table 4

Treatment options after self-expandable metal stem (SEMS) placement
Variable	PT group	BTS group	t/Z	p-value
Number of cases	17 (54.8%)	14 (45.2%)
Interval before surgery (days)
Mean ± SD	-	18.79 ± 6.97
[Scope]	-	[9–40]
Age (years)			-2.506	0.018
Mean ± SD	75.82 ± 10.25	67.64 ± 7.28
Sex				0.473
Male	9 (52.9%)	5 (35.7%)
Female	8 (47.1%)	9 (64.3%)
Part				0.838
Rectum	2 (11.8%)	1 (7.1%)
Rectosigmoid colon	4 (23.5%)	2 (14.3%)
Sigmoid colon	5 (29.4%)	6 (42.9%)
Descending colon	4 (23.5%)	2 (14.3%)
Splenic flexure	1 (5.9%)	0 (0.0%)
Transverse colon	1 (5.9%)	2 (14.3%)
Right hemicolon	0 (0.0%)	1 (7.1%)
Stenosis length (cm)			-0.386	0.702
Mean ± SD	5.71 ± 0.92	5.57 ± 1.01
BTS: bridge to surgery; PT: palliative treatment; SD: standard deviation

Pathological characteristics of the lesions

Among 31 lesions, 22 cases (22/31, 71.0%) were pathologically diagnosed as moderately differentiated adenocarcinoma, 2 cases (2/31, 6.5%) were low differentiated adenocarcinoma, 1 case (1/31, 3.2%) was moderately and poorly differentiated adenocarcinoma, 5 cases (5/31, 16.1%) had adenocarcinoma with undefined differentiation, and 1 case (1/31, 3.5%) was mucinous adenocarcinoma. All 14 BTS patients underwent postoperative biopsy for histopathological examination, and postoperative pathological findings were consistent with endoscopic biopsy results. Tumor stages were all above stage II, with 2 cases (2/14, 14.3%) of stage IIa, 6 cases (6/14, 42.9%) of stage IIb, 2 cases (2/14, 14.3%) of stage IIIb, 3 cases (3/14, 21.4%) of stage IVa, and 1 case (1/14, 7.1%) of stage IVb. The results were shown in Table 5.

Table 5

Pathological characteristics of the lesions
Variables	Number of cases	Percentage (%)
Degree of differentiation
Moderately differentiated adenocarcinoma	22	71.0
Moderately and poorly adenocarcinoma	1	3.2
Low differentiated adenocarcinoma	2	6.5
Unspecified differentiation adenocarcinoma	5	16.1
Mucinous adenocarcinoma	1	3.2
AJCC Stage	Numbers of cases/surgeries
IIA	2/14	14.3
IIB	6/14	42.9
IIIB	2/14	14.3
IVA	3/14	21.4
IVB	1/14	7.1
T stage	Numbers of cases/surgeries
T3	2/14	14.3
T4	12/14	85.7
N stage	Numbers of cases/surgeries
N0	10/14	71.4
N1	2/14	14.3
N3	2/14	14.3
M stage	Numbers of cases/surgeries
M0	10/14	71.4
M1	3/14	21.4
Liver metastases	2/14	14.3
Pulmonary metastases	1/14	7.1
M2	1/14	7.1
Liver and lung metastases	1/14	7.1

Follow-up and prognosis

Routine follow-up was scheduled 4–6 weeks after stent placement or earlier if adverse events arose. Thirty-one patients were followed up within 6 months of stent placement, with no postoperative restenosis or death within 30 days. We evaluated the follow-up and prognosis of 17 PT patients (17/31, 54.83%) and 14 BTS (14/31, 45.16%) and found a significant difference in follow-up time between the two groups (30 days vs. 67.5 days, p < 0.05). PT patients were predominantly followed up by telephone (12/17, 70.6%) with a median follow-up time of 30 days, and none showed clinical symptoms of intestinal obstruction. In the BTS group, 6 patients (6/14, 42.8%) underwent follow-up colonoscopy, and 4 patients (4/14, 28.6%) underwent computed tomography (CT) review, with a median follow-up time of 67.5 days. Four patients (4/14, 28.6%) were diagnosed with concomitant anastomotic inflammatory changes by colonoscopy, and no tumor recurrence was detected. The results were presented in Table 6.

Table 6

Follow-up and prognosis
Variable	PT group	BTS group	p-value
Number of cases	17	14
Follow-up assessment method			0.053
Follow-up colonoscopy	2 (11.8%)	6 (42.9%)
Computed tomography review	3 (17.6%)	4 (28.6%)
Telephone follow-up	12 (70.6%)	4 (28.6%)
Follow-up time (days)			0.017
Median [Q25,Q75]	30 [30,30]	67.5 [30,180]
Range	[2-180]	[30–180]
Adverse events
None	17 (100.0%)	10 (71.4%)
Inflammatory changes in the anastomosis	0 (0.0%)	4 (28.6%)
Prognosis
No recurrence or metastasis	16 (94.1%)	14 (100.0%)
Liver metastases with seroperitoneum and pelvic effusion	1 (5.9%)	0 (0.0%)
Reobstruction	0 (0.0%)	0 (0.0%)
Death within 30 days	0 (0.0%)	0 (0.0%)
BTS: bridge to surgery; PT: palliative treatment; Q: quartile

Surgery is the recommended CCIO treatment [10, 11]. However, CCIO is primarily detected in the older adults, most of whom have contraindications to surgery [10]. Additionally, emergency surgery for intestinal obstruction usually requires a temporary bowel stoma and elective two-stage surgery, which reduces the quality of patient survival. Endoscopic SEMS placement for CCIO is safe and provides an opportunity for further treatment [6]. After stent placement, performing adequate preoperative evaluation of the patients for the next treatment option is possible, which can significantly reduce the stoma rate [4, 5, 8, 12]. It also has a significantly lower complication rate than emergency surgery [13–15]. The success rate of confined operation after SEMS placement was significantly higher and the treatment cost was lower than that of emergency surgery [3, 16–18]. SEMS offers a good treatment option for patients who are unable to undergo surgery [19, 20].

Currently, relevant guidelines [4–8, 11] recommend endoscopic SEMS placement as a BTS for the treatment of colorectal tumors with intestinal obstruction. For conventional X-ray-assisted SEMS placement, the X-ray imaging machine is used for guiding the guidewire and confirming its position to avoid intestinal wall penetration, evaluating the stenosis length, and assessment of the appropriateness of the postoperative stent release position and shape. While it is a must-use device, most medical institutions currently do not have a standalone digital X-ray imaging machine available for endoscopic SEMS placement. In China, most emergency SEMS placements are performed in the ERCP operating room with aseptic requirements, which could lead to cross-infection. Additionally, the physician should have experience in both endoscopy and imaging reviews to perform SEMS treatment. Whether a more straightforward procedure that physicians can follow exists and whether a solution for avoiding radiation damage for physicians and patients could be provided remain to be explored.

We have applied a SEMS placement assisted by an ultrathin endoscope without relying on a digital X-ray imaging machine, that can solve the above problems. The ultrathin endoscope with a small outer diameter of only 5.8 mm allows it to pass through the stenosis of colorectal tumors with intestinal obstruction that the colonoscope cannot pass. It can completely replace digital X-ray imaging machine during the entire operation. SEMS release requires the support of a colonoscope clamp channel for precise release into the stenotic segment. If the guidewire is not placed from the ultrathin endoscope channel to the therapeutic colonoscope channel and is only used as a guide to push the metal stent, successful stent placement is likely to be compromised. The use of an ERCP catheter to complete the guidewire placement method has been reported; however, this method has an additional cost [21]. We innovatively proposed a simple guidewire replacement method using biopsy forceps to clamp and pull back the guidewire and ensured smooth performance of the endoscopic procedure. Regarding the avoidance of the anesthetic risk, another advantage of the ultrathin endoscope is that it can reduce patient discomfort so that SEMS treatment can be performed without anesthesia. Additionally, some studies reported the occurrence of adverse events, such as perforation and permanent stoma, during SEMS placement [22–24]. The inability to operate the guidewire through the stenotic segment and inability to visualize the tumor are factors contributing to the failure [14, 25–27]. Most aforementioned reasons are due to non-endoscopic direct-view operations. As such, retaining the guidewire under direct view of the ultrathin endoscope and placing the stent under direct view of the colonoscope after guidewire replacement reduce the incidence of adverse events.

We have clinically addressed the difficulties associated with ultrathin endoscopy in intestinal stent placement. Since colon tumors are mostly detected in the left hemicolon, and endoscopic surgery in the left hemicolon has good conduction, even for ultrathin endoscopes. If the bowel lumen was twisted and the ultrathin endoscope could not enter, a guidewire could be placed in the endoscopic clamped channel to increase the endoscope stiffness. If the ultrathin endoscope could not pass through the stenosis directly, the guidewire’s hydrophilic end could be used to explore the opening of the obstructed part of the intestinal obstruction and push the guidewire through the stenosis. Since the clamp channel of the ultrathin endoscope is only 2.0 mm and cannot complete the suction well, and inflation, such as CO₂, is the main method to dilate the bowel after the endoscope has entered. Additionally, a biopsy should be performed after guidewire placement but not earlier. There are usually two types of stenosis openings: the central type and the eccentric type. While accurately searching for intestinal lumen opening, mucosal damage should be avoided as much as possible, which is vital to maintaining a good view. If the ultrathin endoscope could not successfully find the stenosis opening, the steps of conventional intestinal stent placement could be followed. We could use the colonoscope to place the guidewire, retain the guidewire and retract the colonoscope, and then replace the guidewire retrogradely with the ultrathin endoscope clamp channel, which enters through the stenotic segment guided by the guidewire to confirm the presence of the guidewire’s front end in the intestinal lumen. Lastly, regarding the requirements for SEMS selection, SEMS is usually chosen to be 1–2 cm longer than the ends of the stenosis, in line with guideline recommendations [8]. The stent length should not exceed 12 cm to ensure complete dilatation of the stenosis, which will reduce adverse events due to embedding of the stent ends in the intestinal mucosa.

This new endoscopic treatment method has proven to be safe, effective, and easy to learn. Our study revealed that the technical and clinical success rates of this endoscopic treatment were 100% and 96.8%, respectively, without adverse events. This is consistent with previous findings that conventional X-ray-assisted SEMS placement has a technical success rate of 75–100% and clinical success rate of 84–100% [8]. Many studies have recommended that SEMS placement be performed only by experienced endoscopists [5]. The risk of inadvertent perforation is increased because some operating physicians lack experience with imaging reviews. Hence, our technical procedure is more straightforward for physicians to follow. In our endoscopy center, three physicians specializing in endoscopy learned and used this procedure simultaneously, including one without clinical experience with conventional intestinal stent placement. No significant difference was observed in treatment outcomes among the three attending physicians, demonstrating that this procedure was suitable for doctors with varying endoscopic clinical experiences. In our study, 14 BTS patients underwent SEMS and a post-placement confined operation, with a 100% success rate and no ostomy. Many studies [5, 11] have discovered that confined operation after stent placement had similar overall and disease-free survival rates but a lower frequency of postoperative stomas and shorter postoperative hospital stay than emergency surgery. To some extent, SEMS treatment can convert emergency surgery into elective surgery, saving patients from stoma or two-stage surgeries. The technique was suitable for CCIO patients with varying tumor differentiation levels and stages (even stage IV) with successful endoscopic manipulation. Correcting the patient’s electrolyte disturbance, reducing mucosal edema and intestinal infections, and performing thorough colonic preparation are possible after stent placement. The incidence of postoperative adverse events in surgery-treated patients was 28.6%, similar to previous data in relevant literature [8], and this approach did not increase the risk of adverse events. In some PT patients who could not undergo surgery, our follow-up results showed that all patients had symptomatic relief, no reobstruction after stent placement, and no death within 30 days.

As this study was a single-center retrospective analysis with a small sample size of observed cases, studies with larger sample sizes are required to further assess the clinical efficacy and identify new technical difficulties of this method. Since we only performed a follow-up and prognostic evaluation within six months, the patient’s long-term prognosis, conversion, and quality of survival need to be further evaluated.

Acknowledgements

We thank the patients, doctors, and nurses for their friendly participation. We would also like to thank Editage (www.editage.cn)for English language editing.

Author contributions

Conception and design, Zhao-hong Shi and Lei Shu; Article arrangement and compilation, Chen Li; Analysis and interpretation of the data, Shuang-yi Li; Endoscopic operation, Lei Shu, Lin Yang, Song Liu; Endoscopic anesthesia, Li Zhang; All authors approved the submission of the article. Lei Shu, Shuang-yi Li, and Chen Li contributed equally to the article. All the authors have read and approved the study.

Competing Interests and Funding

None declared

Institutional review board statement:

This study has been reviewed and approved by the Ethics Committee of Wuhan No.1 Hospital.

Informed consent statement:

All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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No competing interests reported.

SupplementalDigitalContent1.mp4
Supplemental Digital Content Video, Supplemental Digital Content 1: The procedure of the self-expandable metal stent placement (SEMS) in colorectal carcinoma with intestinal obstruction. SEMS was released and placed by the colonoscope, confirming the distance between the mark and the stenosis. After completion of intestinal SEMS placement, a large amount of fecal water spillage could be observed. List of Supplemental Digital Content Supplemental Digital Content 1.mp4

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Outcomes of the combined application of ultrathin endoscope and guidewire replacement for self-expandable metal stent placement in colorectal carcinoma with intestinal obstruction: A retrospective analysis

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Observation index

Primary outcomes

Secondary outcomes

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Statistical analysis

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Technical and clinical outcomes and safety

Treatment options after SEMS placement

Pathological characteristics of the lesions

Follow-up and prognosis

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