Original article
Results of a National Survey on the Use of Stents for the Treatment of Colonic ObstructionResultados de una encuesta nacional sobre el uso de stent para el tratamiento de la obstrucción de colon

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Abstract

Introduction

We distributed a survey in order to determine the current indications for the use of colonic stents to treat colonic obstruction in Spain and its compliance with international guidelines.

Methods

Descriptive study of a survey distributed by the Spanish Association of Surgeons (Asociación Española de Cirujanos), the Catalan Society of Surgery (Societat Catalana de Cirurgia) and the Spanish Society of Digestive Endoscopy (Sociedad Española de Endoscopia Digestiva).

Results

340 valid responses were received: 25% from gastrointestinal specialists, and 75% from general surgeons. During the last year, 44.4% of respondents assessed between 10 and 20 COC. Of these, 52.2% indicated less than 5 stents/year, 75% of which were indicated as a prior step to preferential surgery and only 25% were performed with palliative intent. 55.3% of the participants reported knowing the official guidelines, and 64% of respondents would use the stent as a step prior to surgery in elderly patients with localized disease. 75.9% would place stents as palliative therapy in young patients with carcinomatosis, and 61.8% would use them in stage IV malignancies under treatment with chemotherapy. Only 18.1% knew of the risk of colon perforation after stent placement in patients undergoing treatment with antiangiogenics.

Conclusions

In Spain, the indication for colonic stents is reserved for selected cases and varies according to the specialty and the years of experience of the respondent. The compliance with international guidelines of most respondents is moderate. It is important to insist on the high risk of perforation after angiogenics, which is unknown to most surgeons.

Resumen

Introducción

Difundimos una encuesta con el objetivo de conocer las indicaciones actuales para la utilización del stent de colon para el tratamiento de la obstrucción colónica en España y su adecuación a las guías internacionales.

Métodos

Estudio descriptivo de una encuesta distribuida por la Asociación Española de Cirujanos, la Societat Catalana de Cirurgia y la Sociedad Española de Endoscopia Digestiva.

Resultados

Se recibieron 340 respuestas válidas, un 25% de médicos digestólogos, y el 75% de cirujanos generales. Durante el último año el 44,4% de los encuestados valoró entre 10 a 20 COC. Un 52,2% indicó menos de 5 stents/año, y de estos el 75% se indicó como paso previo a una cirugía preferente y solo el 25% se realizó con intención paliativa. Un 55,3% de los participantes refirió conocer las guías oficiales. El 64% de los encuestados utilizaría el stent como paso previo a cirugía en ancianos con enfermedad localizada. El 75,9% colocaría stent con fines paliativos en jóvenes con carcinomatosis, y un 61,8% los utilizaría en neoplasias estadio IV en tratamiento con quimioterapia. Solo un 18,1% conocía el riesgo de perforación de colon tras stent en pacientes en tratamiento con antiangiogénicos.

Conclusiones

En España la indicación del stent de colon se reserva para casos seleccionados y varía según la especialidad y los años de experiencia del encuestado. La adecuación a las guías internacionales para la mayoría de los encuestados es moderada. Es importante insistir en el alto riesgo de perforación tras angiogénicos, pues la mayoría de profesionales lo desconocen.

Introduction

It is estimated that some 41,411 new cases of colon cancer are diagnosed in Spain each year, and 10%-30% begin with clinical signs of colon obstruction.1

Treatment of the obstruction differs according to the hospital in which it is treated. Decision-making is influenced by both patient characteristics—tumor location, extension of the oncological disease, age and comorbidities—as well as the characteristics of the healthcare setting—the surgeon's or gastroenterologist's preferences, caseload and availability of resources. For these reasons, different management options include: urgent surgery, decompression with colonic stent prior to preferential surgery (CS-S), and colonic stent as palliative therapy or to initiate neoadjuvant therapy (CS-P).

The objective of this study was to determine the indications for colonic stents (CS) as a treatment for obstructive colon cancer (OCC) performed in Spanish hospitals. As secondary objectives, we analyzed whether there was agreement between these indications and the recommendations of official European and American guidelines (compliance with guidelines) and whether knowing these official guidelines influenced the responses of the participants.2

Section snippets

Methods

A descriptive study was conducted with data collected through an online survey sent to the members of the Spanish Association of Surgeons (Asociación Española de Cirujanos), Catalan Society of Surgery (Societat Catalana de Cirurgia) and the Spanish Society of Digestive Endoscopy (Sociedad Española de Endoscopia Digestiva). The email of each respondent was registered to avoid duplicate responses.

The survey was carried out from March to May 2017 using Google Forms (Appendix B, Annex 1). It

Statistical Analysis

The statistical analysis was carried out with the SPSS computer software from 2008, version 16.0. The descriptive analysis of the variables was carried out, including means and medians, as well as the proportions for the categorical variables of the main results.

Surveys that did not have complete epidemiological and workplace data were excluded.

Results

We received 388 surveys, 340 of which were complete. The epidemiological data of the respondents, as well as the data referring to their usual clinical situation, are summarized in Table 1. In terms of the main national societies, 4.5% of AEC members and 10.5% of SEED associates responded.

The majority of those surveyed (65%) worked in medium-sized hospitals (300–600 beds) or regional hospitals (less than 300 beds). Only 8.8% were employed at hospitals with more than 1000 beds.

When we analyzed

Clinical Cases

The responses given by the respondents to the different clinical cases with colon obstruction are summarized in Table 2.

65.2% of the respondents’ responses followed the recommendations of the official guidelines. Compliance did not change with the years of experience of the respondents.

We compared the specialists who reported knowing the guidelines versus those who did not, without observing differences in the overall number of responses according to the guideline recommendations between the 2

Discussion

Since the appearance of CS, several official guidelines have been published for the treatment of OCC,2, 3, 4, 5 which coincide in the majority of their recommendations. In other European countries like France, Sweden, Norway and the Netherlands, CS have been all but abandoned.3 Meanwhile, stents continue to be the standard treatment for many surgeons in the United Kingdom, who are themselves responsible for their placement. In Spain, the situation and compliance with guidelines had not been

Limitations of Our Study

As it is a survey, the responses provided about previous activities may be influenced by subjective perceptions of the respondent, and therefore differ from the use of CS and its actual indications due to memory bias. Similarly, there may be a certain participation bias in the survey, and those who have responded are mainly those most interested in the use of the stent, altering the representativeness of its use. These biases could be avoided through a national registry on CS use, which would

Conclusion

Colonic stents are an established therapeutic option for the treatment of colon obstruction in Spain. The vast majority of participants used it only in selected cases, and we observed heterogeneous indications and a greater tendency of its use by gastroenterologists than by surgeons.

The compliance with international guidelines reported by most participants was moderate.

A high percentage of respondents did not act in accordance with the recommendations, and we have observed a tendency to reserve

Conflict of Interests

The authors have no conflict of interests to declare.

Acknowledgements

The authors would like to thank the Asociación Española de Cirujanos, Societat Catalana de Cirurgia and the Sociedad Española de Endoscopia Digestiva for their approval and distribution of the survey, as well as all the participants for their responses.

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Please cite this article as: Alonso-Hernández N, Segura-Sampedro JJ, Soldevila Verdeguer CM, Ochogavía Seguí A, Olea Martinez-Mediero JM, Fernández Isart M, et al. Resultados de una encuesta nacional sobre el uso de stent para el tratamiento de la obstrucción de colon. Cir Esp. 2020. https://doi.org/10.1016/j.ciresp.2020.02.006

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